3种方法治疗肝硬化伴食管静脉曲张破裂出血的比较分析

肝硬化患者晚期多发食管静脉曲张,由多种诱因引起的食管静脉曲张破裂出血往往能够导致患者死亡［1,2］,从而使得食管静脉曲张破裂出血成为肝硬化最严重的并发症［3］。由于单纯的内科保守治疗出血复发率较高,需要进行预防治疗,目前临床上有3种主要治疗方法［4,5］：内镜下食管静脉曲张套扎术、内镜下食管静脉曲张硬化剂注射术以及内镜下食管静脉曲张套扎联合硬化剂治疗。统计显示,近年来食管静脉曲张的预防治疗能够明显延长患者的生存期,取得了明显的效果［6,7］。本文通过对3组采用不同方法治疗的患者术后恢复情况进行统计学分析,探讨何种方式治疗能够起到最佳效果。     

内镜套扎联合硬化剂夹心法治疗食管静脉曲张破裂出血的远期疗效观察

[目的]探讨内镜下静脉曲张套扎同时应用硬化剂夹心法(套扎-硬化-套扎即EVL-EVS-EVL)治疗食管静脉曲张破裂出血的疗效。[方法]对23例肝硬化食管静脉曲张破裂出血的患者采用夹心法治疗,每条曲张静脉结扎皮圈不超过3个,并在2个结扎点之间的曲张静脉内注射l~3ml硬化剂。其中10例在首次内镜治疗时接受食管静脉造影检查。于治疗后2周、1个月、3个月、6个月、12个月胃镜随访,了解静脉曲张变化情况,记录患者不良反应及并发症。[结果]10例行静脉造影检查中7例硬化剂在曲张静脉内滞留时间超过40min。夹心法控制活动性食管静脉曲张出血的止血成功率为100%,静脉曲张消除率为86.9%(20/23),再出血发生率为8.6%(2/23),随访期内静脉曲张复发率为13.0%(3/23)。[结论]夹心法能使硬化剂在曲张静脉内滞留较长时间,在一次治疗后能有效提高静脉曲张消除率,降低再出血率及静脉曲张复发率,是内镜下治疗食管静脉曲张破裂出血的较理想选择。     

内镜下套扎、硬化剂单用及联用治疗食管静脉曲张的对比分析

目的探讨内镜下套扎、硬化剂及二者序贯联合应用治疗食管静脉曲张的临床效果。方法选取玉溪市人民医院收治的194例因肝硬化致食管静脉曲张患者,随机分为套扎组(单独应用套扎)64例、硬化剂组(单独应用硬化剂)65例、联合组(套扎+硬化剂序贯联合应用)65例,对比3组患者的临床治疗效果。结果联合组治疗显效率(72.31%)显著高于套扎组(56.25%)和硬化剂组(52.31%),差异有统计学意义(P0.05),但3组患者的总有效率差异无统计学意义(P0.05)。治疗后3组患者的血流速度、血流量较治疗前均显著提高(P0.05);联合组患者的平均套扎疗程、平均每人套扎环数均显著低于套扎组(P0.05);联合组的平均硬化剂疗程、平均硬化剂每人用量、平均硬化剂用量均显著小于硬化剂组(P0.05);硬化剂组患者的术后发热率显著高于联合组和套扎组(P0.05);套扎组患者的进食异物感发生率显著高于联合组和硬化剂组(P0.05)。结论内镜下套扎、硬化剂序贯联合应用治疗食管静脉曲张的效果显著,术后并发症发生率更低。     

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.     

介入治疗食管胃底静脉曲张破裂出血的体会

在中国,肝硬化是常见病,食管胃底静脉曲张破裂出血是失代偿期肝硬化患者的严重并发症,死亡率在20％～50％。近年来随着内镜技术的普及,更多的消化科医师可以较熟练采用内镜下套扎和硬化剂注射技术治疗和预防食管胃底静脉曲张破裂出血,这显著降低了出血复发率,改善了患者的预后。因此,国内外在制定食管胃底静脉曲张破裂出血治疗指南时均将内镜下治疗作为一线治疗方案。     

内镜套扎术联合药物预防食管静脉曲张破裂出血的观察

目的 探讨内镜套扎术联合药物预防食管静脉曲张破裂出血的有效性.方法 将64例肝硬化伴食管静脉曲张破裂出血患者随机分为治疗组33例(内镜套扎术+普萘洛尔+单硝酸异山梨醇酯)和对照组31例(普萘洛尔+单硝酸异山梨醇酯)分别进行治疗,对比两组治疗前后内镜下食管静脉曲张变化、血液动力学监测结果和再出血率等情况.结果 治疗后两组Dpv、Dsv、Qpv、Qsv与治疗前比较均显著下降(P<0.05),Vpv、Vsv治疗前后比较,差异无统计学意义,两组血液动力学监测对比,差异无统计学意义(P>0.05);6个月时治疗组有3例(9%)、对照组有6例(19.4%)再次发生出血,两组再出血率差异有统计学极显著意义(P<0.01),12个月时治疗组共有4例(12.1%)对照组共有11例(35.5%)再次发生上消化道出血,两组再出血率差异仍有统计学极显著意义(P<0.01);64例进行胃镜复查,治疗组6个月时食管静脉曲张轻度或消失为51.5%(17/33),12个月时为48.5%(16/33),对照组6个月和12个月均为3.2%(1/31),由中度变为轻度.结论 内镜套扎术联合药物预防食管静脉曲张破裂出血效果优于单纯药物治疗,且安全、效果明显,病人易接受,可作为预防食管静脉曲张破裂出血的首选方法.     

硬化剂和套扎治疗食管胃底静脉曲张破裂出血34例临床观察

目的对比分析硬化剂注射术和套扎术治疗食管胃底静脉曲张破裂出血的临床疗效。方法收集在西京医院进修学习期间2014年8月至2015年2月期间经硬化剂注射术治疗的34例食管胃底静脉曲张破裂出血患者设为观察组,另选同期的34例经套扎术治疗的食管胃底静脉曲张破裂出血患者设为对照组,观察两组患者的止血成功率、并发症发生率及病死率。结果观察组和对照组在止血成功率和病死率方面比较差异无统计学意义(P0.05),而观察组并发症发生率明显低于对照组(P0.05)。结论硬化剂注射术和套扎术治疗食管胃底静脉曲张破裂出血均具有良好的临床疗效,而采用硬化剂注射术更能减少并发症发生。     

内镜下套扎联合组织胶注射治疗食管静脉曲张破裂出血的临床疗效

目的:探讨内镜下套扎联合组织胶注射治疗食管静脉曲张破裂出血的临床疗效.方法:选取2007-01/2013-03来武汉市第三医院进行治疗的肝硬化食管胃底静脉曲张出血患者229例,根据治疗情况将患者分为三组:硬化剂联合组织胶治疗组65例、保守治疗组76例及组织胶注射联合套扎术治疗组88例,观察以上三组的临床疗效;按是否行无痛胃镜将组织胶注射联合套扎术治疗组分为无痛组46例、普通组42例,分析手术前后心率(heart rate,HR)、血压(blood pressure,BP)及血氧饱和度(SpO2)指标.结果:不同治疗组间一般疗效指标的比较:组织胶注射联合套扎术治疗组的近期出血6例(6.8%),远期出血8例(9.0%),并发症发生2例(2.3%),死亡3例(3.4%),除并发症发生率(保守治疗组无并发症发生),组织胶注射联合套扎术治疗组的疗效指标数值均小于保守治疗组及硬化剂联合组织胶组.组织胶注射联合套扎术治疗组与硬化剂联合组织胶组相比,远期出血率、并发症发生率及死亡率的差异有统计学意义(P0.05).组织胶注射联合套扎术治疗组与保守治疗组相比,近期出血率、远期出血率及死亡率的差异有统计学意义(P0.05).不同治疗组间内镜下疗效指标的比较:组织胶注射联合套扎术治疗组显效57例(64.8%),有效21例(23.8%),无效10例(11.3%),总效率88.6%.与其他两组相比,显效率和总效率明显提高且差异有统计学意义(P0.05).无痛组和普通组手术前后心率和血氧饱和度无明显统计学差异,无痛组手术后血压低于普通组(P0.05).结论:内镜下组织胶注射联合套扎术的治疗效果较好,而且并发症和死亡率均较低,总有效率较高,是食管胃底静脉曲张破裂出血的首选止血方式.     

内镜下硬化剂注射加食管球囊压迫治疗食管静脉曲张出血的临床研究

目的探讨内镜下硬化剂注射加食管球囊压迫治疗食管静脉曲张出血的疗效及安全性。方法收集我院消化科2009年至2013年收治的101例食管静脉曲张破裂出血进行内镜下硬化剂注射加食管球囊压迫止血及食管静脉曲张内镜下套扎止血的患者,观察其止血成功率,静脉曲张消失率,近再出血率及并发症发生率,进行回顾性对比分析。结果硬化剂加食管球囊压迫组,止血成功率92.9%,近期再出血率为7.14%,静脉曲张消失率和基本消失率为85.7%,总并发症发生率9.5%。套扎组,止血成功率为89.8%。近期再出血率11.9%。静脉曲张消失率和基本消失率为81.4%。总并发症发生率为11.9%。两组在止血成功率,静脉曲张消失率,近再出血率及总并发症发生率比较(P0.05),无显著性差异。结论内镜下硬化剂注射加食管球囊压迫治疗食管静脉曲张破裂出血有效、安全、可靠。但其内镜操作是较为繁琐,有待于进一步改进。     

多环与单环橡皮圈套扎在肝硬化食管静脉曲张出血急诊内镜治疗中的疗效比较

目的:观察多环与单环套扎在肝硬化食管静脉曲张(EV)出血急诊内镜治疗后临床疗效的异同。方法:75例急诊内镜诊断为EV或合并胃底静脉曲张上消化道出血患者随机采用多环或单环橡皮圈套扎治疗,分为多环套扎治疗组和单环套扎治疗组。多环套扎治疗组40例,根据EV程度给予单位点2环、3环或4环套扎治疗;单环套扎治疗组35例。合并胃底静脉曲张须先给予硬化剂聚桂醇+组织胶+硬化剂方法注射治疗。单环套扎治疗再出血患者改用多环套扎治疗。结果:多环套扎治疗组治疗后胃镜复查EV完全消失8例,基本消失26例,EV消失率85%;单环套扎治疗组治疗后胃镜复查EV完全消失5例,基本消失15例,EV消失率57%;2组比较存在显著性差异(P<0.05)。1年再出血率多环套扎治疗组为5%,明显低于单环套扎治疗组的23%(P<0.05)。改用多环套扎治疗的再出血患者曲张静脉明显消失。结论:多环套扎治疗EV效果优于单环套扎治疗。     

内镜套扎术在治疗食管静脉曲张破裂出血中的临床应用价值

目的探讨内镜下食管静脉曲张套扎术（EVL）治疗和预防肝硬化患者食管静脉曲张破裂出血的临床应用价值。方法回顾性分析2008-01～2012-01该院142例肝硬化食管静脉曲张破裂出血患者,其中行EVL治疗74例（治疗组）,内科保守治疗68例（对照组）,并对其临床疗效进行随访观察。结果所有患者随访6个月以上,治疗组的早期再出血率、迟发出血率、曲张静脉好转率、复发率、手术率及病死率均低于对照组（P〈0.05或〈0.01）。结论 EVL能有效地降低肝硬化门脉高压患者食管静脉曲张的程度,降低再出血率、复发率、手术率和病死率,是一种有效的内镜治疗手段。     

Endoscopic therapy for bleeding esophageal varices improves the outcome of Child C cirrhotic patients

BACKGROUND AND AIM: Bleeding from esophageal varices is one of the frequent severe complications arising in patients with liver cirrhosis. The management of esophageal varices is therefore important for patient survival. The purpose of this study was to clarify the predictive factors for mortality in patients with Child C cirrhosis presenting with variceal bleeding. METHODS: A retrospective analysis of 77 Child C cirrhotic patients with bleeding from esophageal varices was conducted. All patients received endoscopic therapy. Twenty-nine patients received endoscopic variceal ligation, and 48 patients received endoscopic injection sclerotherapy or endoscopic injection sclerotherapy with ligation. Univariate and multivariate analyses of clinical data were performed to identify the prognostic factors for survival for these 77 patients. RESULTS: Fifty-seven of 77 patients received endoscopic therapy within 24 h after variceal bleeding, and bleeding was controlled in 55 (96.5%). The remaining 20 patients received endoscopic therapy more than 24 h after bleeding. Higher bilirubin level and rebleeding were the predictive parameters for 6-week survival in the 77 patients, according to univariate and multivariate analysis. Higher bilirubin level, refractory ascites, and the presence of hepatocellular carcinoma were the predictive parameters for mortality in 77 patients as determined by multivariate analysis. CONCLUSIONS: Endoscopic therapy was effective in controlling acute variceal bleeding of Child C cirrhotic patients. The prognosis of Child C stage patients presenting with variceal bleeding depended on the severity of liver damage and the presence of hepatocellular carcinoma.     

Improved long-term survival following complete eradication of esophageal varices by sclerotherapy

BACKGROUND/AIMS: Conflicting results have been reported concerning the effect of endoscopic injection sclerotherapy upon the long-term survival of cirrhotic patients with esophageal varix. The recurrence and rebleeding of esophageal varices seems to be an important factor influencing long-term survival. We investigated the long-term survival of patients after complete eradication of esophageal varices. METHODOLOGY: Forty patients treated by endoscopic injection sclerotherapy for acute esophageal variceal bleeding were studied. The recurrence rate of varices and the long-term survival of patients in whom complete eradication of esophageal varices was obtained were compared with those of patients in whom the eradication of varices was incomplete. RESULTS: The frequency of the recurrence/deterioration rate of varices and rebleeding in the complete eradication group was significantly lower than that in the incomplete eradication group (10.7% vs. 100%, 0% vs. 58.3%, respectively, p < 0.01). Accumulated 5-year survival rate of the complete eradication group was significantly higher than that of the incomplete eradication group (68.2% vs. 43.2%, p < 0.05). CONCLUSIONS: Complete eradication of esophageal varices by endoscopic injection sclerotherapy is effective both in preventing variceal re-bleeding and in improving the survival of cirrhotic patients with esophageal varices.     

经皮经肝曲张静脉栓塞治疗断流术后食管胃底静脉破裂出血的疗效

目的 研究以组织胶为主要栓塞材料,采用经皮经肝曲张静脉栓塞术(PTVE)治疗和预防门奇静脉断流术后食管胃底静脉曲张破裂出血的临床疗效.方法 2006年11月至2008年9月,对22例曾行断流术再发食管胃底静脉曲张破裂出血的患者行PTVE组织胶栓塞(n=10)或内镜下硬化剂(EIS,n=12)治疗,随访两组患者治疗后再出血率、死亡率、治疗前后静脉曲张和肝功能以及PTVE治疗组患者在曲张侧支静脉栓塞前后门静脉压力的变化.结果 ①在平均12.5个月的随访期内,PTVE治疗组患者再出血率和死亡率分别为1/10和0;EIS治疗组随访13.4个月,患者再出血率和死亡率分别为7/12和3/12,两组问差异有统计学意义(P<0.05).②PTVE和EIS治疗均可显著减轻食管和胃底静脉曲张程度.③对有门静脉血栓患者,PTVE联合门静脉球囊成形术,可以改善肝脏门静脉血供.④PTVE和EIS治疗均未加重肝功能损伤.结论 对门奇静脉断流术后食管胃底静脉破裂出血的患者,采用以组织胶为主要栓塞材料的PTVE治疗的疗效优于EIS治疗.     

Nonsurgical treatment of variceal bleeding

Opinion statement Patients with cirrhosis, especially those who have a platelet count of less than 100,000, who are considered compliant, and have no contraindications to beta-blocker therapy, should have a screening endoscopy to ascertain the presence of esophageal varices. Patients with medium to large esophageal varices who are appropriate candidates should be placed on a nonselective beta-blocker (propranolol hyrdochloride, nadolol, timolol maleate) for the prevention of initial variceal hemorrhage. Patients presenting with acute variceal hemorrhage, as determined endoscopically, should be treated with a combination of vasoactive drugs and endoscopic therapy (sclerotherapy or variceal ligation) for the control of acute variceal bleeding and the prevention of early rebleeding. Transjugular intrahepatic portosystemic shunt (TIPS) should be reserved for failures of initial medical therapy. After successful control of initial variceal bleeding is reached, the rebleeding rate approaches 70% in most studies, with the highest risk period being in the first 6 months after control of the index bleed is obtained [1]. Therefore, all patients should be placed on therapy to prevent recurrent variceal bleeding. Options include pharmacologic therapy, endoscopic therapy, and combinations of endoscopic and pharmacologic therapy. TIPS, surgical shunts, and liver transplantation should be reserved for special circumstances and in general, should only be considered for failures of initial medical therapy.     

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。     

Esophageal variceal ligation for acute variceal bleeding: results of three years' follow-up.

BACKGROUND/AIMS: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation. METHODS: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months. RESULTS: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively. CONCLUSIONS: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.     

Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction

Endoscopic sclerotherapy is an effective treatment for bleeding esophageal varices, but it is associated with significant complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, has been shown to be superior to sclerotherapy in adult patients with cirrhosis. To determine the efficacy and safety of endoscopic sclerotherapy and ligation, the 2 methods were compared in a randomized control trial in 49 children with extrahepatic portal venous obstruction who had proven bleeding from esophageal varices. Twenty-four patients were treated with sclerotherapy and 25 with band ligation. No significant differences were found between the sclerotherapy and ligation groups in arresting active index bleeding (100% each) and achieving variceal eradication (91.7% vs. 96%, P =.61). Band ligation eradicated varices in fewer endoscopic sessions than did sclerotherapy (3.9 +/- 1.1 vs. 6.1 +/- 1.7, respectively, P <.0001). The rebleeding rate was significantly higher in the sclerotherapy group (25% vs. 4%, P =.049), as was the rate of major complications (25% vs. 4%, P =.049). After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy (17.4% vs. 10%, P =.67). In conclusion, variceal band ligation in children is a safe and effective technique that achieves variceal eradication more quickly, with a lower rebleeding rate and fewer complications compared with sclerotherapy.     

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

INTRODUCTION In patients with portal hypertension, collaterals should be established to reduce the high portal pressure, and the hemodynamic indicators of such collaterals have been used for the evaluation of therapeutic effects. According to the location…     

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.