内镜治疗食管胃静脉曲张破裂出血的地位

食管胃底静脉曲张是肝硬化门脉高压患者常见的临床表现之一,破裂出血是其主要危害和致死性并发症。近年来随着血管活性药物、内镜、介入技术等技术的进步,病死率较前下降。内镜检查与治疗在食管胃底静脉曲张患者的多学科治疗和个体化处理过程中均有不可替代的重要地位。现从食管胃底静脉曲张的筛查、预防初次出血、急诊止血、预防再出血等方面回顾近年来国内外的研究进展,阐述并评价内镜治疗在食管胃静脉曲张破裂出血方面的地位与存在的争议问题。     

急诊内镜下套扎治疗食管静脉曲张破裂出血

目的 总结急诊内镜下紧急套扎治疗食管静脉曲张破裂出血的经验。方法 对84例食管静脉曲张破裂出血病人在急诊情况下紧急内镜下套扎，观察止血效果。结果 急诊止血成功率98.8％，术中无并发症发生，近期再出血率4.76％。结论 急诊EVI，治疗食管静脉曲张破裂出血是一种安全、有效、快捷的止血方法。     

肝硬化食管胃底静脉曲张内科治疗进展

食管胃底静脉曲张破裂出血是肝硬化患者的严重并发症和主要死亡原因.防止原发性首次食管胃底静脉曲张破裂出血(FVB)和预防再出血十分重要.β-肾上腺素受体阻滞剂(β-Ab)列为首选防止FVB的一线药物,对高危性食管静脉曲张者主张行预防性治疗.β-Ab或与EVL合用亦是预防再出血的首选治疗方法.对急性食管胃底静脉曲张破裂出血,药物治疗仍为首选措施,内镜疗法用于药物疗法失败病例.     

食管静脉曲张破裂出血内镜下介入治疗

目的总结３６４例肝炎后肝硬化合并食管静脉曲张破裂出血患者进行内镜下介入疗法的经验。方法内镜下采用５％鱼肝油酸钠（ＳＭ）或１％乙氧硬化醇（ＡＳ）进行食管静脉曲张硬化治疗（ＥＶＳ），六连发圈套器结扎治疗（ＥＶＬ）和医ＭＴＨ胶或凝血酶食管静脉内栓塞治疗（ＥＶＥ）。结果三种介入方法平均急诊止血率为８９．９％；食管静脉消失率为７７．２％。结论内镜下介入疗法是控制食管静脉曲张出血，消除食管静脉曲张的有效方法，操作较容易，再出血率较低；ＥＶＬ可替代ＥＶＳ作为食管静脉曲张破裂出血首选方法。ＥＶＥ法有异位栓塞之虑，目前暂不宜广泛开展。     

重视食管胃静脉曲张出血的临床研究

我国各种病因的肝硬化食管胃静脉曲张出血患者众多，临床死亡率高。内镜治疗的多种方法能有效地控制出血，消除曲张静脉，降低再出血率。加强肝硬化食管胃静脉曲张出血的基础和临床研究，有利于选择合理的治疗方案，提高治疗效果。一、食管曲张静脉测压肝硬化食管和（或）胃静脉曲张破裂时往往出血量大，控制急性出血至关重要。应用血管活性药物能有效降低门静脉压力，在众多药物中，生长抑素及其类似物奥曲肽、特利加压素等的有效率约为７０％～９０％。为研究曲张静脉内压力与破裂出血的关系以及探索血管活性药物降压的有效性和相关机理，…     

川芎嗪预防内镜硬化疗法闭塞食管静脉曲张后复发的评价

肝硬化食管静脉曲张破裂出血的死亡率颇高,而再出血率约10%。在内镜硬化疗法闭塞食管静脉曲张后复发率约60%,复发绝大部分发生于初始闭塞后的12月内,有报道长期服用心得安可减少食管静脉破裂出血的复发。本研究观察内镜硬化治疗合并中药川芎嗪在首次闭塞食管静脉曲张后的复发率。对象和方法一、患者:21例患者均为肝硬化食管静脉曲张破裂出血第一次出血发作而住院,见表1,该次出血经急诊内镜硬化治疗而得到控制,此后患者每隔     

内镜外套管在辅助急诊内镜治疗食管胃静脉曲张出血中的作用研究

目的 探讨内镜外套管在辅助急诊内镜治疗食管胃静脉曲张破裂出血中的作用.方法 选择临床诊断为肝硬化门静脉高压食管胃静脉曲张破裂出血患者62例作为治疗组,采用外套管辅助急诊内镜注射硬化剂治疗.另选择同期行常规急诊内镜治疗的62例食管胃静脉曲张破裂出血患者作对照组,比较两组治疗效果.结果 治疗组62例患者在行急诊内镜止血中先用外套管压迫止血均获成功,止血效率为100%,显著高于对照组的80.65%（P＜0.05） 治疗组食管胃静脉曲张注射后消失率为59.32%显著高于对照组7.27%（P＜0.05）.胸痛和食管溃疡、总住院天数、总医疗费用,治疗组显著低于对照组（P＜0.05）.结论 应用外套管辅助急诊内镜注射硬化剂治疗食管胃静脉曲张出血可提高治疗效率,减少患者负担.     

内镜下硬化剂治疗食管静脉曲张破裂出血临床研究

目的观察食管静脉曲张破裂出血内镜下硬化剂治疗的疗效。方法对21例食管静脉曲张破裂出血并进行内镜下硬化剂治疗的患者进行回顾性分析。结果急诊硬化治疗8例,止血成功率87.5%,近期再次出血率12.5%,并发症发生率25%。择期硬化治疗13例,止血成功率92.3%,近期再次出血率8.3%,并发症发生率7.7%。结论内镜下硬化剂注射是食管静脉曲张破裂出血的有效治疗方法,更适合于预防再出血。     

特利加压素联合内镜静脉曲张套扎术预防急性食管静脉曲张破裂再出血的研究

背景：食管胃底静脉曲张破裂出血是肝硬化的危重并发症之一,内镜静脉曲张套扎术（EVL）是食管静脉曲张破裂出血的首选内镜治疗方案。对于急性食管静脉曲张破裂出血患者,推荐于EVL术后使用血管活性药物特利加压素3—5d以预防早期再出血。目的：明确特利加压素联合EVL对急性食管静脉曲张破裂再出血的预防作用。方法：96例急诊食管静脉曲张破裂出血患者行EVL后随机分为2组,对照组口服普萘洛尔10mg／d×5d,干预组静脉推注特利加压素1mg／d×5d,其后两组患者均以维持剂量长期服用普萘洛尔。记录术后5d内和3个月内的再出血发生情况。结果：干预组早期（5d内）再出血率显著低于对照组（2．1％对12．5％,P〈0．05）,两组近期（3个月内）再出血率无明显差异（4．2％对14．6％,P〉0．05）。结论：急诊EVL联合特利加压素预防急性食管静脉曲张破裂早期再出血的效果优于EVL联合普萘洛尔,远期结果尚需进一步随访观察。     

急诊内镜下硬化治疗食管静脉曲张破裂大出血12年回顾

目的探讨急诊内镜下硬化治疗食管静脉曲张破裂大出血近期止血效果,分析其术后相关并发症及可能机制。方法收集苏州大学第三附属医院2003年1月-2014年12月急诊内镜下硬化治疗食管静脉曲张破裂大出血523例次的临床资料,回顾性分析其止血率、再出血率及并发症情况。结果急诊内镜下硬化治疗523例次,483例次止血成功,急诊止血率92.4%。硬化治疗后72 h~1周再出血105例次,再出血率20.1%。急诊内镜下硬化治疗患者中,出现中-高热48例,胸痛者45例,早期并发症发生率17.8%。结论急诊内镜下硬化治疗简便、高效,近期并发症少,对于食管静脉曲张破裂大出血患者可作为急诊止血首选方案。     

Update on treatment of variceal hemorrhage

Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment. Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding. Prophylactic antibiotics are increasingly used for prevention of infection, notably spontaneous bacterial peritonitis. Follow-up endoscopic treatment is necessary in order to obliterate residual varices. The combination of a beta blocker and nitrate is an essential component of secondary prophylaxis for recurrent variceal bleeding. Transjugular intrahepatic portosystemic shunt or surgery offers the best salvage therapy in patients with failed hemostasis or breakthrough recurrent bleeding despite medical and endoscopic therapy. Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.     

A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding

BACKGROUND/AIMS: The currently recommended treatment for acute variceal bleeding is the association of vasoactive drugs and endoscopic therapy. However, which emergency endoscopic treatment combines better with drugs has not been clarified. This study compares the efficacy and safety of variceal ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin. METHODS: Patients admitted with acute gastrointestinal bleeding and with suspected cirrhosis received somatostatin infusion (for 5 days). Endoscopy was performed within 6h and those with esophageal variceal bleeding were randomized to receive either sclerotherapy (N=89) or ligation (N=90). RESULTS: Therapeutic failure occurred in 21 patients treated with sclerotherapy (24%) and in nine treated with ligation (10%) (RR=2.4, 95% CI=1.1-4.9). Failure to control bleeding occurred in 15% vs 4%, respectively (P=0.02). Treatment group, shock and HVPG >16 mmHg were independent predictors of failure. Side-effects occurred in 28% of patients receiving sclerotherapy vs 14% with ligation (RR=1.9, 95% CI=1.1-3.5), being serious in 13% vs 4% (P=0.04). Six-week survival probability without therapeutic failure was better with ligation (P=0.01). CONCLUSIONS: The use of variceal ligation instead of sclerotherapy as emergency endoscopic therapy added to somatostatin for the treatment of acute variceal bleeding significantly improves the efficacy and safety.     

Pharmacologic therapy of portal hypertension and variceal hemorrhage

Patients with large esophageal varices who are deemed compliant and have no contraindications to beta-blocker therapy should be started on nonselective beta-adrenergic blockers (Fig. 5). The dose should be titrated to a 25% decrease in resting heart rate, a resting heart rate of 55 to 60 beats per minute, or development of symptoms, in which case the dose should be decreased until the patient's symptoms abate. If available, measurements of the HVPG at baseline and 3 months can be very helpful in ascertaining the response to treatment and in making the appropriate adjustments (e.g., adding a second drug). Sclerotherapy or endoscopic variceal ligation are the preferred therapies for treatment of acute esophageal variceal bleeding. Concomitant use of vasoactive drugs can supplement endoscopic treatment. They offer the advantage of early administration as soon as the diagnosis is suspected while awaiting endoscopy. Unlike endoscopic treatment, they decrease portal pressure and are the only established treatment for nonvariceal sources of bleeding related to portal hypertension. Once the index bleed is controlled, the patient should be started on treatment to reduce the high risk of recurrent variceal hemorrhage (Fig. 6). For patients with well-compensated cirrhosis, pharmacologic therapy may be desirable. For less compliant patients or patients with decompensated cirrhosis, an endoscopic technique, such as variceal ligation, may be preferable. Combinations of pharmacologic agents or pharmacologic agents and endoscopic procedures may offer hope for better control, but their efficacy needs to be demonstrated in RCTs. For patients who rebleed despite maximal pharmacologic or endoscopic therapy, a TIPS procedure, surgically created shunt, or liver transplantation should be considered, with the decision based on the patient's condition and the local availability of these options.     

Bleeding caused by portal hypertension

Variceal bleeding is one of the dreaded complications of portal hypertension. Patients who have suspected or proven cirrhosis should undergo diagnostic upper endoscopy to detect medium and large gastro-esophageal varices. Patients with medium and large gastro-esophageal varices should be treated with non-selective beta-blockers (propranolol or nadolol), and these agents should be titrated to a heart rate of 55 beats per minute or adverse effects. If there are contraindications to or if patients are intolerant to beta-blockers, it is appropriate to consider prophylactic banding therapy for individuals with medium-to-large esophageal varices. When patients who have cirrhosis present with GI bleeding, they should be resuscitated and receive octreotide or other vasoactive agents. Endoscopy should be performed promptly to diagnose the source of bleeding and to provide endoscopic therapy (preferably banding). The currently available treatment for acute variceal bleeding provides hemostasis in most patients. These patients, however, are at significant risk for rebleeding unless secondary prophylaxis is provided. Although various pharmacological, endoscopic, radiological, and surgical options are available, combined pharmacological and endoscopic therapy is the most common form of secondary prophylaxis. TIPS is a radiologically placed portasystemic shunt, and if placed in suitable patients, it can provide effective treatment for patients with variceal bleeding that is refractory to medical and endoscopic therapy.     

内镜下急诊套扎治疗食管静脉曲张破裂出血的临床研究

[目的]探讨内镜下急诊套扎治疗食管静脉曲张破裂出血的疗效及安全性。[方法]选择2010年10月～2013年12月的69例食管静脉曲张出血患者,在急诊状态下行内镜套扎治疗,观察疗效、并发症、再出血率及套扎术对生命体征的影响。[结果]急诊止血成功率98.6%（68例）、并发症发生率1.4%（1例）、近期再出血率4.3%（3例）,套扎术过程对血压、心率、呼吸等生命体征无明显影响。[结论]急诊食管静脉曲张套扎术治疗食管静脉曲张破裂出血是一种有效、安全、快捷的止血方法。     

Endoscopic treatments for portal hypertension

Endoscopic treatments for bleeding gastroesophageal varices include injection sclerotherapy, variceal obturation with tissue adhesives, and variceal rubber band ligation. Acute injection sclerotherapy remains a quick and simple technique for the control of active bleeding from esophageal varices. Although few trials have been published so far, some evidence suggests that the early administration of vasoactive drugs (somatostatin, octreotide, or terlipressin) is safe and may increase the efficacy of endoscopic treatments. Banding ligation is the optimal endoscopic treatment for the prevention of rebleeding from esophageal varices. The use of tissue adhesives and thrombin as injectates to treat bleeding fundal gastric varices and esophageal varices not responding to vasoactive drugs or sclerotherapy is promising but needs further assessment by means of randomized controlled trials. As of today, endoscopic treatments are not recommended for the primary prophylaxis of variceal bleeding.     

Long-term follow-up of patients with liver cirrhosis after endoscopic esophageal varices ligation therapy: comparison with ethanol injection therapy

BACKGROUND/AIMS: Esophageal variceal hemorrhage is the most dreaded complication of liver disease. Prevention or emergency therapy of bleeding is important. METHODOLOGY: A group of 217 patients underwent endoscopic esophageal variceal therapy including endoscopic ethanol injection, endoscopic esophageal variceal ligation, or a combination of the two. RESULTS: Esophageal varices were eradicated by endoscopic esophageal variceal ligation with the least sessions required, and associated complications with endoscopic esophageal variceal ligation therapy were lower than with the other two approaches. However, the cumulative recurrence-free period of esophageal varices was significantly higher after endoscopic ethanol injection than after endoscopic esophageal variceal ligation and in some cases F3 varices were observed post-endoscopic esophageal variceal ligation hemorrhage. A combined endoscopic esophageal variceal ligation and endoscopic ethanol injection therapy had no advantage with respect to cumulative recurrence-free rate, session number, or complication frequency, relative to either therapy alone. CONCLUSIONS: While the combined observations indicate that endoscopic esophageal variceal ligation is safe and simple, we should consider additional therapy to achieve complete mucosal fibrosis of the esophagus after endoscopic esophageal variceal ligation.     

内镜下套扎治疗晚期血吸虫病食道静脉曲张破裂出血68例

目的 探讨内镜下套扎治疗晚期血吸虫病食道静脉曲张破裂出血的效果。方法 130例晚期血吸虫病食道静脉曲张破裂出血住院患者随机分成2组,治疗组68例接受急诊内镜下套扎治疗,对照组62例给予常规内科治疗。观察各组继续出血率及静脉曲张红色征消失情况等,并进行比较。结果 治疗组继续出血率为10.3%,静脉曲张红色征阳性率为8.8%,均优于对照组,差异有统计学意义（P均＜0.01）。结论 内镜下套扎治疗是晚期血吸虫病食道静脉曲张破裂出血的一种有效止血方法。     

Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers(NSBBs) or endoscopic variceal ligation(EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, com-bined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt(TIPS) with polytetrafluoroethylene(PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred op-tion in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhe-sives, endoloops, endoscopic clipping and argon plasmacoagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompa-nying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclu-sion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.