超声内镜在门脉高压所致食管胃底静脉曲张中的应用价值

食管胃底静脉曲张（EGV）破裂出血严重威胁患者的生命安全,早期诊断并及时采取相应的治疗对改善患者的预后具有重大意义。超声内镜（EUS）将内镜和超声技术进行有机结合,为消化道疾病的诊治开辟了新的途径。EUS可显示胃食管黏膜下解剖结构、门静脉及其属支、食管周围侧支静脉和穿通静脉,协助EGV诊断、复发及再出血风险的评估,从而指导EGV临床诊治策略的制定;同时,还可通过钳道送入多种内镜附件,进行EUS引导硬化、组织胶栓塞及弹簧圈置入等多种介入治疗,可作为常规胃镜治疗失败及具有高异位栓塞风险患者的补充治疗手段。     

内镜下硬化治疗在食管胃静脉曲张中的应用及进展

内镜下硬化剂注射术（endoscopic injection sclerotherapy, EIS）是治疗食管胃静脉曲张出血的重要方法之一。近年来众多学者在注射方法的改良方面进行了大量探索研究,获得了大量有意义的结果。本文结合作者自己的体会就EIS在食管胃静脉曲张的应用及进展做一述评。     

食管胃底静脉曲张的内镜治疗

食管胃底静脉曲张破裂出血是门脉高压最严重的并发症之一，其病情凶险，首次出血的死亡率达40％～70％，再出血的发生率为60％～80％。内镜检查不仅可明确食管和(或)胃底静脉曲张破裂出血的诊断，而且还可在内镜直视下行止血治疗。现已证实内镜下注射硬化剂、组织粘合剂或皮圈套扎是治疗静脉曲张破裂出血的有效方法。     

超声内镜在门脉高压所致食管胃底静脉曲张中的应用价值北大核心CSCD

食管胃底静脉曲张(EGV)破裂出血严重威胁患者的生命安全,早期诊断并及时采取相应的治疗对改善患者的预后具有重大意义。超声内镜(EUS)将内镜和超声技术进行有机结合,为消化道疾病的诊治开辟了新的途径。EUS可显示胃食管黏膜下解剖结构、门静脉及其属支、食管周围侧支静脉和穿通静脉,协助EGV诊断、复发及再出血风险的评估,从而指导EGV临床诊治策略的制定;同时,还可通过钳道送入多种内镜附件,进行EUS引导硬化、组织胶栓塞及弹簧圈置入等多种介入治疗,可作为常规胃镜治疗失败及具有高异位栓塞风险患者的补充治疗手段。     

内镜下治疗食管胃底静脉曲张八例

内镜下治疗食管胃底静脉曲张八例文黎明赵世泉刘红专近来内镜下治疗食管静脉曲张（ＥＶ）报道较多，但同时进行胃底静脉曲张（ＶＦＳ）治疗尚少见报道，作者对８例食管胃底静脉曲张进行了联合治疗，现报告如下。１．对象和方法：本组男６例，女２例，年龄３３～６５岁，病...     

超声内镜在胃食管静脉曲张诊治中的价值

超声内镜（EUS）是将超声探头在内镜直视下到达靶器官进行近距离探查，从而避免了体表超声探查时遇空气等干扰的缺陷，此时靶器官的图像与结构更为清晰。EUS自1980年Dimagno和Green首次应用于临床，近20年来，随着器械的进步，目前已成为与CT、MRI同等重要的影像诊断工具。它结合了胃镜与超声技术于一体，使检查区域远远超出了常规胃镜的范围。它不仅可以清楚地显示胃壁的各层结构，更能够看到胃壁周围的病变，同时还能显示血管的走行与分布。本文介绍EUS在食管胃底静脉曲张诊断及治疗中运用价值。     

超声内镜对食管胃底静脉曲张的诊断及治疗疗效判断

急性消化道出血是消化系疾病中常见的临床症状,其中肝硬变失代偿导致的食管或胃底静脉曲张(esophageal varices,EV/gastric varices,GV)破裂出血尤为棘手,严重时常危及生命,因此,准确的诊断和对治疗疗效的判断至关重要.近年来,国内外应用硬化剂、组织粘合剂(如histoacryl)、皮圈套扎等在紧急内镜止血及预防治疗上取得了显著疗效,但对于上述各治疗方法的疗效评价仍缺乏客观的依据及相对量化的标准且有时仅依赖常规内镜下的肉眼判断,尤其是对胃底曲张静脉的诊断还不够准确.我们复习近期文献同时结合作者自己的临床实践体验,对超声内镜(endoscopic ultrasonography,EUS)在食管和胃底曲张静脉诊断及治疗疗效判断中的临床应用作一概述.     

食管胃静脉曲张内镜治疗的最新进展

食管胃静脉曲张(esophagogastricvarices，EGV)出血是肝硬化门静脉高压症最凶险的并发症之一，防治EGV出血对于延长肝硬化患者的生存期至关重要。现简述近年来内镜诊治EGV的新进展如下。     

门静脉高压并食管胃底静脉曲张出血的治疗策略

食管胃底静脉曲张破裂出血是门静脉高压的严重并发症,如何控制食管胃底静脉曲张破裂出血并预防再出血,是救治肝硬化患者生命的关键。简述了门静脉高压食管胃底静脉曲张出血的治疗和预防的4个阶段,指出应根据患者不同的临床时期、不同的肝静脉压力梯度、不同的肝功能分级,选择不同的治疗策略。     

食管静脉曲张的内镜下治疗现状

目的了解国外食管静脉曲张的内镜下治疗现状,比较各种方法的疗效及优缺点.方法复习了国外1985/1999公开发表的关于内镜下治疗食管静脉曲张的文献,就各种疗法在控制急性出血率、曲张静脉出血复发率、根除率及死亡率等方面作一比较.结果在控制急性食管静脉出血方面,食管套扎与硬化治疗疗效相似但略优,在控制静脉渗血方面,二者疗效相似,控制静脉喷血,套扎疗法优于硬化治疗,死亡率及并发症则显著降低.联合治疗分为同步联合疗法(synchronousEVL+EIS)及序贯联合疗法(sequentialEVL+EIS),同步联合疗法并不比单独套扎疗法优越且并发症较多,而序贯联合疗法在静脉曲张根除率方面,比单独硬化治疗要高,并发症及再出血复发率显著要低.结论食管静脉套扎或食管静脉套扎加硬化疗法联合治疗食管静脉曲张是目前较为理想的治疗方法.     

内镜下治疗食管-胃连通型静脉曲张的研究进展

食管胃静脉曲张破裂出血是肝硬化常见且危重的并发症之一,再出血率及病死率高,食管-胃连通型静脉曲张属于特殊类型静脉曲张,内镜下治疗方法主要包括内镜下静脉曲张硬化术、内镜下组织胶注射及联合序贯治疗等,但在具体方法的选择上还存在一些争议。现就近年来国内外食管-胃连通型静脉曲张内镜下治疗的进展予以综述。     

Evaluation of solitary and scattered esophageal varices according to infrared endoscopy and endoscopic ultrasonography

BACKGROUND AND AIM: The aim of this study was to clarify the etiology and clinical significance of solitary and scattered esophageal varices by evaluating their hemodynamics and other characteristics using infrared endoscopy and endoscopic ultrasonography. METHODS: The study group comprised 44 lesions of these two related types detected in 28 patients by visible-light endoscopy. Infrared endoscopy was used to characterize blue-black coloration before and after rapid intravenous injection of indocyanine green (2 mg/kg). During endoscopic ultrasonography, depth within the esophagus and echo patterns of these varices were characterized. RESULTS: Diameters of these varices were significantly smaller in lesions more strongly staining by infrared endoscopy. Lesion diameter was significantly smaller in varices showing homogeneous low echogenicity than in those showing mixed echogenicity. Lesions showing homogeneous high echogenicity stained most weakly followed in turn by lesions with mixed echogenicity and finally those showing homogeneous low echogenicity. CONCLUSION: Indocyanine green injection was useful for infrared observation of the hemodynamics of solitary and scattered esophageal varices, as was endoscopic ultrasonography in defining the location and morphology of these lesions. Varices with larger diameters stained more persistently when hemodynamics were evaluated by infrared endoscopy, and often showed a mixture of low and high echogenicity by endoscopic ultrasonography. These observations suggest that blood flow in the varices is slowed, and that the risk of hemorrhage increases with increased diameter especially with uniform enhancement and uniform echogenicity.     

Evaluation of the hemodynamics of rectal varices by endoscopic ultrasonography

Background The usefulness of endoscopic color Doppler ultrasonography (ECDUS) for evaluating hemodynamics is examined in 12 cases of rectal varices. We also evaluate the safety of endoscopic therapies in rectal variceal patients. Methods ECDUS was performed for 12 rectal variceal patients with a 7.5-MHz convex-type Pentax FG-32UA system. A Hitachi EUB 525 was used for the display. ECDUS provides a color display of blood flow, and calculates the velocity using a fast-Fourier transform analysis. We monitored the color flow images and measured blood flow velocity in rectal varices. Then, we evaluated the velocity of 350 F2-type esophageal varices via ECDUS, and compared the velocities between rectal varices and esophageal varices. Results Color flow images of rectal varices and of inflow vessels to rectal varices were obtained in all 12 patients with ECDUS. The mean velocity of F2-type rectal varices was 5.5 ± 1.3 cm/s (n = 12), while the mean velocity of F2 esophageal varices was 8.4 ± 3.1 cm/s (range, 4.5–12.5 cm/s) (n = 350) via ECDUS. The velocities in rectal varices were lower than those in esophageal varices. Endoscopic injection sclerotherapy (EIS) was successfully performed in five red-color-sign-positive rectal variceal patients having a mean velocity 5.4 ± 1.1 cm/s. Conclusions The velocities of rectal varices were lower than those of esophageal varices. Evaluation of the hemodynamics of rectal varices is important for determining the appropriate therapeutic option. EIS is an effective therapy in cases of slow variceal flow. ECDUS is a necessary tool for effective and safe EIS for rectal varices.     

Value of endoscopic color doppler ultrasonography in endoscopic injection sclerotherapy‐resistant esophageal varices

A 72‐year‐old man with type C cirrhosis was admitted to our hospital for refractory esophageal varices. Prophylactic endoscopic injection sclerotherapy (EIS) was performed twice in August 2000 for high‐risk esophageal varices at an outside hospital. However, a therapeutic effect was not attained. Endoscopic ?nding revealed F1, Cb, RC (–) at the gastroesophageal junction to approximately a 5‐cm oral site, and F3, Cb, RC (+) varices at the upper site from the 5‐cm oral site of the gastroesophageal junction. Color ?ow images were obtained of the posterior branch of the left gastric vein and revealed an in?ow‐type perforating vein about a site 5 cm oral from the gastroesophageal junction. Color ?ow images of esophageal varices were detected with endoscopic color Doppler ultrasonography. Color ?ow images of out‐?owing‐type perforating veins were discerned in the middle esophagus. The vessel images of intramural esophageal varices were clearly delineated via an ultrasonic microprobe and showed a perforating vein with a diameter of 4 mm. We performed EIS with an attached balloon to occlude the out‐?owing‐type perforating veins with 5% ethanolamine oleate with iopamidol. Seven days after the ?rst EIS, thromboses were observed in the intramural esophageal varices and in the in?ow type‐perforating veins via ultrasonic microprobe. We exchanged the hemodynamics of this esophageal variceal case with blockade of the in?ow‐type perforating vein. Next, we successfully performed EIS, and achieved the blockade of passageways, including the palisade veins. Forty days after EIS, endoscopic ?ndings revealed disappearance of the esophageal varices.     

Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices.

Aim: Because the procedure of balloon-occluded retrograde transvenous obliteration (B-RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long-term outcome of B-RTO, including changes in esophageal varices. Methods: B-RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices (n = 7), F(1) varices (n = 11), and F(2) varices (n = 4). The outcome measures included the development/worsening of esophageal varices after B-RTO and survival rates. Results: The cumulative bleeding-free probability for all 22 patients at 3 years after B-RTO was 100%. The overall 3-year survival was 94.4%. Seven patients who had no esophageal varices prior to B-RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F(1) esophageal varices prior to B-RTO showed no changes in the varices after B-RTO, while two patients progressed to F(2) varices and two developed F(3) varices. The cumulative treatment-free probability of the esophageal varices at 24 months after B-RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre-existing F(1) varices, and 75% for those with pre-existing F(2) varices. Conclusion: Although the B-RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.     

Visualization of palisade veins in esophageal varices by endoscopic color Doppler ultrasonography

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. Levovist is a microbubble echo‐enhancing agent that improves Doppler ultrasound examination. This study is designed to evaluate the usefulness of ECDUS using Levovist in diagnosing palisade veins of esophageal varices. Methods: The study involved 67 patients with esophageal varices using ECDUS. All 67 patients received Levovist intravenously at a concentration of 300 mg/mL. A 7.5‐mL dose of the contrast agent was injected at a slow infusion rate of 1 mL/min. We compared vessel images detected with precontrast with those detected by enhanced ECDUS. Results: Color flow images of palisade veins were obtained in 16 (23.9%) of the 67 patients with precontrast ECDUS. Vessel images of palisade veins were detected in 15 of 61 F2 type varices (24.6%) and in one of six F3 varices (16.7%). The color flows of these vessels showed a continuous wave on fast‐Fourier transform analysis. Sixteen palisade veins had velocities in the 3.3 cm/s?11.6 cm/s range. Color flow images of palisade veins were obtained in 27 (40.3%) of the 67 cases by enhanced ECDUS using Levovist. Palisade veins could be delineated after Levovist contrast in 11 patients who could not be detected on precontrast ECDUS. After Levovist contrast, color flow images detected with precontrast ECDUS were enhanced in all patients. Conclusion: Endoscopic color Doppler ultrasonography with Levovist contrast can improve the diagnostic quality of the palisade veins in esophageal varices.     

Hemodynamics of esophageal varices on three‐dimensional endoscopic ultrasonography and indication of endoscopic variceal ligation

Background: Esophageal varices are treated by endoscopic variceal ligation or sclerotherapy, but the indications for each procedure are not standardized. The present study was designed to determine the indication of endoscopic variceal ligation based on vascular pattern classified by 3‐dimensional endoscopic ultrasonography (3‐D‐EUS). Methods: The pattern of variceal blood flow detected on 3‐D images was classified into type 1 (cardial‐inflow without paraesophageal veins), type 2 (cardial‐inflow with paraesophageal veins), type 3 (azygos‐perforating pattern) and type 4 (complex pattern). 3‐D‐EUS was performed in 89 patients with esophageal varices. Subsequently, ligation was performed in 44 patients, while sclerotherapy with 5% ethanolamine oleate was applied in 45 patients in a prospective randomized trial. Clinical outcome was assessed. Results: Based on the 3‐D‐EUS data, 41 patients (46.1%) were classified as type 1, 12 (13.5%) as type 2, seven (7.9%) as type 3 and 29 patients (32.6%) as type 4. The cumulative recurrence‐free probability at 24 months after treatment was 28.9% for ligation versus 71.1% for sclerotherapy (P < 0.05) in type 1, while the respective probabilities were 72.9% versus 50.0% (NS) for type 2 varices, 100% versus 100% (NS) for type 3 varices and 61.9% versus 64.8% (NS) for type 4 varices. Conclusions: Classification of the vascular pattern of esophageal varices by 3‐D‐EUS enabled us to clarify the criteria for selection of endoscopic procedure. Ligation is indicated for patients who have collaterals, such as paraesophageal veins running parallel to the varices, as the blood flow can be diverted to these blood vessels and controlled by localized ligation.     

Hemodynamic evaluation of rectal varices by endoscopic color Doppler ultrasonography

Background: Rectal varices are an infrequent but potentially serious cause of hematochezia. In this paper, the hemodynamics of rectal varices using endoscopic color Doppler ultrasonography (ECDUS) are evaluated. Method: This study consisted of six rectal variceal patients who had F2 type of the rectum, and four of the six had a positive red color sign. We monitored the color flow images of rectal varices. Results: Color flow images of rectal varices were obtained in all six patients. Color flow images of inflow and outflow vessels of rectal varices were obtained in all six patients. We performed endoscopic injection sclerotherapy (EIS) on three of the six patients. After EIS, ECDUS revealed the disappearance of the variceal blood flow in one case, and the decrease of blood flow in two cases. Conclusion: The technique of ECDUS is a useful modality for detecting rectal varices on color flow images and for evaluating the therapeutic effects of EIS.     

Experience with electronic radial endoscopic color Doppler ultrasonography in esophageal variceal patients

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a method for detecting color flow images in blood vessels. In the present study, electronic radial ECDUS in cases of esophageal varices is described. Methods: Thirteen patients with esophageal varices were studied. The technique of ECDUS was performed using a Pentax EG3630‐UR (forward‐view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz) and B mode/color Doppler/power Doppler capability. A Hitachi EUB 6500 was used for the display, providing a 270° image. We monitored the color flow images of esophageal varices, paraesophageal veins and perforating veins using this technique. Results: Color flow images of esophageal varices and paraesophageal veins were obtained in 13 of the 13 patients, whereas color flow images of perforating veins were obtained in four of the 13 patients (30.8%). The 13 esophageal varices exhibited velocities ranging between 3.0 and 11.7 cm/s (mean = 6.3 cm/ s). The forward‐viewing optics facilitated insertion, but the stiffness of the distal tip limited the flexibility of the scope, especially when attempting J‐ or U‐turn views. Conclusion: Electronic radial ECDUS provides color flow images similar in quality to those of convex‐type ECDUS with the additional advantages of forward‐view optics and extended 270° views.