晚期血吸虫病并发食管及胃底静脉破裂出血的急诊处理

食管及胃底静脉曲张破裂出血是晚期血吸虫病(下称晚血)门脉高压主要的并发症，首次出血病死率约为20％～40％，2年内再出血率高达70％。因此，晚血食道及胃底静脉曲张破裂出血是病人死亡的主要原因，如何有效控制出血和预防反复出血是一个重要的临床课题。目前认为，食管和(或)胃曲张静脉内压力升高是静脉破裂出血的重要因素，迅速准确确定出血部位和病因并及时作出正确处理，对预后有重要意义。     

食管胃曲张静脉破裂出血的内镜治疗

肝炎后肝硬化在我国常见,约30％的患者并发食管胃静脉曲张,其中约20％～30％发生曲张静脉破裂出血,首次出血后2年内再出血的发生率约80％,每次出血的死亡率约20％,十二指肠曲张静脉及出血则较为罕见(<5‰)。     

腹水型晚期血吸虫病的诊疗规范

参考国外最新临床指南,结合我们多年的实践经验,制定腹水型晚期血吸虫病的诊疗规范。包括诊断、分型、腹水的药物治疗、总体住院时间以及出院后治疗、护理、随访以及原发性细菌性腹膜炎、肝肾综合征的诊断治疗,从而为腹水型晚期血吸虫病的治疗建立一套标准化流程、路线。     

微创治疗肝硬化食管胃底曲张静脉破裂大出血研究

食管胃底曲张静脉破裂是肝硬化门静脉高压上消化道大出血的主要原因，经皮经肝曲张血管栓塞术（percutaneous transhepatic varices embolization，PTVE）和部分脾动脉栓塞术（partial splenic embolization，PSE）是近年来治疗肝硬化门脉高压症的新技术。本研究旨在探讨PTVE联合PSE对门静脉（PV）压力、PV血流量的影响，及对止血、延长出血间期、降低死亡率的价值。     

鱼骨致食管曲张静脉破裂出血一例

患者男,73岁,因慢性阻塞性肺病急性加重期、慢性肺心病于1周前入住我院。既往曾诊断为门脉性肝硬化失代偿期,慢性粒细胞性白血病。入院查体：体温36．7℃,脉搏102次／min,呼吸22次／min,血压80／55mmHg,神志清,对答切题,贫血貌,皮肤黏膜无黄染,全身浅表淋巴结无肿大,肺气肿征阳性,双肺呼吸音低,剑下可见心尖搏动,心率102次／min,律齐,各瓣膜听诊区未闻及病理性杂音,腹平软,脾脏中度肿大,移动性浊音阳性。     

肝硬化食管胃底曲张静脉破裂出血的药物治疗

食管胃底静脉曲张破裂出血是肝硬化严重的并发症，合理选择药物治疗，不仅可以降低临床病死率，而且有效减少该类患者的再出血率。目前生长抑素、质子泵抑制剂、抗生素的联合应用，已成为救治该病的首选方案。     

肝硬化门脉高压非曲张静脉破裂出血

目的 探讨肝硬化门脉高压(PVH)非曲张静脉破裂出血病因及与年龄、门脉高压程度之间的关系，分析其发病机理。方法选择经内镜证实肝硬化门脉高压非曲张静脉破裂出血97例，纪录内镜检查结果、静脉曲张程度、胃粘膜损害情况，并取病理活检、Hp检查，评定肝功能情况。结果门脉高压性胃病(PHG)占58．76％，溃疡病占39．18％，其中胃溃疡19．50％，十二指肠疡16．5％，复合性溃疡3．09％，不明原因2．06％，Hp感染率37．11％，随年龄增大，门脉高压程度增加，非曲张静脉性出血递增，出血量可以很大，以PHG居多，其产生机理认为主要与胃粘膜淤血、动静脉短路建立与开放、粘膜缺氧及PGE降低等有关，而与Hp感染关系不大。讨论肝硬化门脉高压时主要因PHG或溃疡导致出血，以PHG居多，其产生机现认为主要与门脉高压、胃粘膜淤血、动静脉短路建立与开放、粘膜缺氧、PGE2降低等有关，而与Hp感染关系不大。     

食管胃底曲张静脉破裂出血综合治疗的临床路径

肝硬化门静脉高压症合并食管胃底曲张破裂出血是死亡率很高的危重病。本病在诊断、治疗和护理方面十分复杂，医疗费用也很昂贵。为了提高该病种的医疗护理质量，合理使用有效的卫生资源，有必要制定该病种的临床路径。     

食管胃底静脉曲张出血的防治

肝硬化门脉高压(portal hypertension)引起食管胃底曲张静脉破裂出血是肝硬化患者的重要死亡原因之一。肝硬化患者静脉曲张出血每次出血的死亡率约为30％～60％。除强调适当休息、合理饮食、防止过度劳累和继发感染，避免肝损药物的应用外，采取必要的药物和其他干预措施降低门脉压力是提高患者生存率和改善生活质量的重要措施。     

食管曲张静脉套扎术出血原因分析及防范

食管曲张静脉破裂出血是消化科的急危重症，死亡率可达30％～40％。食管曲张静脉套扎术（EVL）对于防治其破裂出血已被证实是有效的，但套扎过程中或套扎后近期一旦发生出血，则预后凶险，常危及患者生命。笔者自1995年8月至2005年2月间行EVL102例，有5例发生与套扎相关的大出血，现就出血原因及防范措施等报道如下。     

New model predicting gastroesophageal varices and variceal hemorrhage in patients with chronic liver disease

Introduction and objectivesThe predictors for gastroesophageal varices (GOV) and hemorrhage development have not been well studied in different liver diseases or different population. This study aimed to evaluate whether a new algorithm focusing on chronic hepatitis B (CHB) patients is also applicable to other chronic liver diseases (CLDs) in Chinese population.Patients or materials and methodsWe retrospectively analyzed 659 CHB patients and 386 patients with other CLDs. A total of 439 CHB patients were included in training set, the other 220 CHB patients and other patients with CLDs were included in validation set. A new algorithm for diagnosing GOV was established and its sensitivity and specificity for predicting the varices was verified.ResultsMultivariable logistic regression revealed that the rough surface of the liver (p < 0.001), splenic thickness (p < 0.001), and liver stiffness (p = 0.006) were independent predictors of GOV. The new algorithm was considered to be a reliable diagnostic model to evaluate the presence of varices. The AUROC was 0.94 (p < 0.001) in CHB validation set and 0.90 (<0.001) in non-CHB validation set. When the cut-off value was chosen as −1.048, the sensitivity and specificity in diagnosing GOV in CHB population were 89.1% and 82.5%, respectively. Importantly, the new algorithm accurately predicted the variceal hemorrhage not only in CHB patients, but also in patients with other CLDs.ConclusionThe new algorithm is regarded as a reliable model to prognosticate varices and variceal hemorrhage, and stratified not only the high-risk CHB patients, but also in patients with other CLDs for developing GOV and variceal bleeding.     

内镜下套扎术预防晚期血吸虫病食管静脉曲张破裂出血

目的 目的 探讨内镜下套扎术预防晚期血吸虫病 （晚血） 食管静脉曲张再发和破裂出血的作用。方法 方法 治疗组为42 例套扎术后晚血患者, 对照组为同期住院不愿接受套扎治疗的30例晚血患者, 治疗期间3～6个月复查胃镜1次, 了解食管 静脉曲张情况, 并记录有关医疗事件。 结果 结果 套扎治疗后随访2～3年, 平均29个月。治疗组静脉曲张复发8例, 复发率 19.0%, 平均复发时间30个月; 发生食管静脉曲张破裂出血5例, 发生率11.9%, 平均发生时间25个月, 死亡2例。对照组静 脉曲张复发13例, 复发率43.3%, 平均复发时间18个月, 发生出血11例, 发生率36.7%, 平均发生时间18个月, 死亡7例。 治疗组在预防食管静脉曲张破裂出血, 降低病死率方面优于对照组。结论 结论 套扎术可作为预防晚血食管静脉曲张破裂出 血的方法。     

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the presence of large esophageal varices with recent stigmata of bleeding,or fresh blood visible in the stomach with no other source of bleeding identified.Transfusion of blood products,pharmacological treatments and early endoscopic therapy are often effective;however,if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs,transjugular intrahepatic portosystemic shunt(TIPS)is recommended as rescue treatment.The TIPS represents a major advance in the treatment of complications of portal hypertension.Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS,which has a 90%to 100%success rate.However,TIPS is associated with a mortality of 30%to 50%in such a setting.Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure,before the clinical condition worsens.Furthermore,admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively.This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage,particularly as a rescue therapy following failure of endoscopic approaches.     

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

Purpose  

To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era.     

Prophylactic antibiotics for variceal hemorrhage: clostridium difficile infection still can be a risk

Bron et al presented a retrospective study regarding the prophylactic use of antibiotics for variceal hemorrhage. Antibiotics appeared to improve the survival rate of patients without increasing clostridium difficile infection (CDI). We argue against the conclusion of the authors and consider that this result may be simply due to concurrent use of metronidazole, a therapeutic agent against CDI.     

Noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage

Aim To identify noninvasive factors predicting the presence of large varices (LV) in patients hospitalized with gastroesophageal variceal hemorrhage (GEVH). Methods Case records of patients admitted with GEVH between January 1998 and June 2005 were retrospectively analyzed. Relevant clinical parameters assessed included Child-Pugh class, ascites (clinical and/or on ultrasound), portosystemic encephalopathy (PSE), splenomegaly (clinical and/or on ultrasound), and hemodynamic instability. The laboratory parameters assessed were hemoglobin level, platelet count, prothrombin time, serum bilirubin, and albumin. The ultrasonographic characteristics noted were splenic size, presence of splenic varices, and portal vein diameter. Results A total of 420 patients (264 men) presented with GEVH during the study period. The mean age, gender distribution, and presence of cirrhosis were similar in the two groups. Liver cirrhosis with hepatocellular carcinoma (HCC), Child-Pugh class C, presence of clinically detectable ascites, grade 3–4 PSE, detectable splenomegaly, previous history of GEVH, hemodynamic instability and platelet count <91,000 were more common in the LV group. The frequency of radiologically detected ascites, splenomegaly, and portal vein diameter were similar in both groups. On multivariate analysis, the independent predictors for the presence of LV were cirrhosis with HCC, clinically detectable splenomegaly, hemodynamic instability, a previous history of GEVH, platelet count <91,000, and splenic size ≥158 mm. Conclusion Cirrhosis with HCC, clinical splenomegaly, hemodynamic instability, a previous history of GEVH, thrombocytopenia (i.e., platelet count <91,000), and splenic size ≥158 mm are independent noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage.     

Diabetes mellitus is associated with gastroesophageal variceal bleeding in cirrhotic patients

Diabetes mellitus (DM) has been reported to increase the risk of complications of liver cirrhosis of any etiology and subsequent survival. However, the impact of DM on the development of gastroesophageal variceal bleeding (GEVB) remains unclear. We aimed to elucidate whether DM is an independent risk factor for GEVB among cirrhotic patients. A total of 146 consecutive patients with liver cirrhosis (Child-Pugh Class A, n = 75; Class B, n = 40; and Class C, n = 31) were prospectively enrolled. Data on clinical and biochemical characteristics and history of ascites, GEVB, hepatic encephalopathy, and spontaneous bacterial peritonitis were retrospectively reviewed. Of these 146 patients, 37 (25%) had DM. Patients with DM had significantly higher ratio of Child-Pugh Class B/C (p = 0.043), renal insufficiency (p = 0.002), and history of GEVB (p = 0.006) compared with non-DM patients. GEVB was associated with Child-Pugh Class B/C (p = 0.001), ascites (p = 0.002), hepatic encephalopathy (p = 0.023), and low platelet counts (p < 0.001). Based on stepwise multiple logistic regression analysis, Child-Pugh class B/C [odds ratio (OR) = 4.90, p = 0.003] and DM (OR = 2.99, p = 0.022) were identified as independent predictors of GEVB. In the subgroup analysis, DM significantly correlated with GEVB in patients with Child-Pugh Class A (p = 0.042), but not in patients with Child-Pugh Class B/C (p = 0.128). DM is independently associated with GEVB in cirrhotic patients, especially in those with Child-Pugh Class A.