LDRf分型方法在消化道异位静脉曲张中的应用

目的 探讨LDRf分型方法是否能覆盖食管胃静脉曲张以外的消化道异位静脉曲张(EcV)的内镜下分型.方法 参考相关文献,采用LDRf分型方法对消化道EcV患者914例进行内镜下分型,统计病变位置(L)、血管直径(D)、危险因素(Rf).检查门静脉高压(PH)病因,予相应治疗并随访.结果 EcV按部位进行内镜下LDRf分型,包括:十二指肠198例、空肠回肠93例、胆管105例、结肠65例、直肠453例.各部位EcV血管直径为0.3 ～3.5 cm,危险因素表现亦有不同.PH病因:肝硬化伴门静脉高压者630例(68.9％),其中自身免疫性肝病肝硬化及门静脉海绵样变性各3例(0.6％),伴食管胃静脉曲张252例(27.6％),脾切除者4例(0.5％).EcV患者治疗315例,其中组织胶治疗43例、硬化剂治疗76例、套扎治疗74例、介入治疗52例、外科剖腹探查术70例.共19例因EcV出血死亡.内镜检查随访13～36个月,无静脉曲张复发,1年生存率100％.结论 LDRf分型方法适合于全消化道静脉曲张,其对治疗方法与时机的选择具有明显指导作用,且简便、规范、统一,适合临床推广.     

位置、直径、出血风险在食管胃底静脉曲张破裂出血患者分型中应用初探

目的 初步探讨应用静脉曲张位置、直径、出血风险对食管胃底静脉曲张破裂出血患者进行分型(LDRf分型)的可行性.方法 回顾分析381例因食管胃底静脉曲张破裂出血行内镜下急诊治疗患者,对静脉曲张位置、直径和出血危险因素进行分析,并尝试进行LDRf分型.结果 食管胃底静脉出血好发于食管中下段,不同直径的曲张静脉均有出血,曲张静脉多见有红色征.所有患者均可进行LDRf分型,食管静脉曲张破裂出血患者中,Rf1共计 133 例(45.4%),Rf2共计 160 例(54.6%);胃静脉曲张破裂出血患者中,Rf1共计47例(53.4%),Rf2共计41例(46.6%).结论 LDRf可用于食管胃静脉曲张的分类并对诊断治疗有一定指导意义.     

食管胃静脉曲张内镜下一级预防治疗对出血率的影响及其相关因素

目的:探讨内镜下一级预防治疗对食管胃静脉曲张出血率的影响及其相关因素。方法:127例肝硬化伴食管静脉曲张无出血史患者在知情同意情况下分别纳入内镜治疗组及无内镜治疗组,依据LDRf分型明确诊断胃静脉曲张（Lgf）及食管静脉曲张（Le,g）,并遵循该方法建议原则选择相应治疗方案,观察治疗组及未治疗组3个月、6个月、1年及2...     

组织粘合剂注射联合门静脉栓塞治疗食管胃底静脉曲张出血的临床研究

目的评价内镜下注射组织粘合剂联合经皮经肝胃冠状静脉栓塞治疗食管胃底静脉曲张的疗效。方法将57例食管胃静脉曲张患者分为2组，分别进行内镜下组织粘合剂注射（单纯组，38例）和内镜下组织粘合剂注射联合经皮经肝胃冠状静脉栓塞（联合组，19例）治疗。比较2组疗效。结果联合组近期再发出血1例，6个月后再发出血2例，分别占5．3％和10．5％；术后3～6个月行食管钡餐检查，食管静脉曲张消失或基本消失13例（68．4％），明显好转6例。单纯组近期再出血7例，6个月后再发出血12例，分别占18．4％、31．6％；术后3～6个月行食管钡餐检查，食管静脉曲张消失或基本消失16例（42．1％），明显好转22例。结论相对于单纯内镜下组织粘合剂注射治疗，联合经皮经肝胃冠状静脉栓塞术是一种安全有效的治疗食管胃底静脉曲张的方法。     

内镜下十二指肠乳头切除术对十二指肠乳头部腺瘤的治疗价值

目的评价内镜下十二指肠乳头切除术在十二指肠乳头部腺瘤治疗中的应用价值。方法回顾性分析31例因十二指肠乳头部腺瘤行内镜下十二指肠乳头切除术治疗患者的临床资料,总结内镜治疗完成情况、并发症发生情况以及术后随访情况。结果29例（93．5％,29／31）成功完成内镜下十二指肠乳头切除术治疗,术后病理提示腺瘤伴低级别上皮类瘤变25例、腺瘤伴上皮类瘤变4例。术中1例（3．4％,1／29）发生出血,无穿孔;术后无出血和穿孔,17例（58．6％,17／29）并发高淀粉酶血症、3例（10．3％,3／29）并发轻度胰腺炎,均经内科保守治疗痊愈。有2例（6．9％,2／29）伴有上皮类瘤变者分别在术后6个月及2年后复发;其余27例随访期间无复发,随访时间11个月至5年,平均（33．6±8．5）个月。结论内镜下十二指肠乳头切除术治疗十二指肠乳头部腺瘤安全可行,具有较好的临床应用价值,虽然术后复发率较低,但仍应注意密切随访。     

内镜下治疗十二指肠静脉曲张出血二例

病例1男,23岁,因反复大量呕血,黑便12h入院,既往有10年乙型肝炎病史。急诊胃镜检查,见食管重度静脉曲张,表面有红色征,未见明显破口和血痂,胃和十二指肠黏膜色泽正常。即予1％乙氧硬化醇30ml分点行食管静脉硬化治疗后退镜。3h后患者再次呕血,急诊胃镜检查见胃腔内有新鲜血迹,十二指肠降部近乳头处有条直径约0．6cm,长约3cm的纵形曲张静脉,表面黏膜色泽正常,有破口,鲜血渗出,回顾性参照LDRF分型,为Ld2D1Rf2,给予1％乙氧硬化醇5ml曲张静脉内注射后出血停止。1个月后复查曲张静脉变细,随访1年未再出血。     

小探头超声用于胃底静脉曲张诊断及判断组织粘合剂疗效的初步评价

目的 与常规内镜下肉眼判断比较,评价小探头超声检查在诊断胃底静脉曲张及评价内镜下组织粘合剂治疗疗效中的临床价值。方法 １０例临床诊断为肝硬化的患者于内镜治疗前先行胃底腔内小探头超声检查,随后对诊断存在胃底静脉曲张的患者行内镜下组织粘合剂治疗,而后即刻再行小探头超声检查以观察其疗效。结果 常规内镜下肉眼判断与小探头超声检查对胃底静脉曲张的诊断准确率分别为７０％（７／１０）和１００％（１０／１０）;后     

经内镜栓塞术联合套扎术治疗食管胃底静脉曲张出血的疗效观察

目的探讨胃底静脉曲张栓塞术联合内镜下食管静脉曲张套扎术（EVL）治疗肝硬化上消化道出血的疗效。方法经急诊胃镜检查发现活动性胃底静脉曲张出血合并Ⅱ°以上食管静脉曲张且排除其他病因的上消化道出血患者共156例,分为治疗组和对照组,治疗组胃底静脉曲张组织粘合剂栓塞同时食管静脉EVL治疗;对照组胃底静脉曲张组织粘合剂栓塞治疗2个月后行食管静脉EVL。结果两组均未发生与治疗相关的并发症。止血成功率治疗组为96．3％（77／80）,对照组为97．4％（74／76）,（P〉0．05）;近期再出血率治疗组为6．4％（5／78）,对照组为21．3％（16／75）,两组差异有统计学意义（P〈0．05）;两组患者随访6个月,再出血率分别为13．0％（9／69）、25．4％（17／67）,差异有统计学性意义（P〈0．05）。胃底静脉曲张改善总有效率治疗组和对照组分别为61．6％、59．1％,食管曲张静脉改善总有效率为74．0％、67．9％,差异均无统计学意义。结论胃底静脉曲张栓塞联合EVL是治疗肝硬化胃底静脉曲张出血并食管静脉曲张的安全有效方法,同时联合治疗更能降低再出血率。     

不同直径、不同压力离体猪食管曲张静脉套扎度的实验研究

目的依据曲张静脉LDRf分型理论,探讨离体猪食管曲张静脉压力和直径对完全套扎度的影响。方法选取实验用猪静脉血管制成离体猪不同静脉压力血管模型,按预设定压力分成3组（A组25～30cmH20,B组35～40cmH20,C组45～50cmH20,1cmH20=0．098kPa）,再选取猪食管进一步制成离体猪食管静脉曲张模型,根据所测直径分成3组（D1组0．4～1．0cm,D：组〉1．0～1．5cm,D,组〉1．5～2．0cm）,采用单因素和多因素分析方法统计压力和直径对完全套扎度的影响。结果按压力分组时,A组完全套扎18个（56．25％,18／32）,B组完全套扎12个（37．50％,12／32）,C组完全套扎11个（33．33％,11／33）,各组完全套扎率差异无统计学意义（χ2=3．6126,P=0．0573）,但P值接近0．05,预示曲张静脉压力是完全套扎度的干扰因素;按直径分组时,D,组完全套扎35个（94．59％,35／37）,D2组完全套扎6个（16．67％,6／36）,D3组无一个完全套扎,各组完全套扎率差异有统计学意义（χ2=38．0014,P=0．0000）,提示曲张静脉直径对完全套扎度影响较大。多因素非条件Logistic回归分析结果显示,食管曲张静脉压力、曲张静脉直径是完全套扎度的独立危险因素（P=0．000）。结论猪食管静脉曲张血管直径在0．4—1．0cm或血管压力在25—30cmH：0时完全套扎率高,套扎效果确实、完全,使用静脉曲张LDRf分型指导内镜下套扎猪食管静脉曲张是科学和可行的。     

食管胃底静脉曲张内镜下根治联合心得安序贯治疗的远期疗效分析

目的：评价食管胃底静脉曲张内镜下根治性治疗联合心得安治疗肝硬化食管胃底静脉曲张出血的远期疗效。方法：随访观察2007年7月至2010年7月的乙型肝炎肝硬化食管胃底静脉曲张患者208例,根据患者意愿及之后的随访资料将其分为3组： A组：内镜下根治治疗＋心得安序贯治疗组,即根据食管胃底静脉曲张程度行内镜下治疗,直至曲张静脉消失或不能再行内镜下治疗,内镜治疗结束后开始序贯口服心得安行降低门脉压治疗; B组为内镜下根治治疗组,未服用心得安; C组：一次内镜下治疗＋心得安序贯治疗组。所有患者均进行内镜随访,随访时间为3年,分别记录静脉曲张消除例数,近期出血、远期出血例数及发生并发症情况。结果：3种治疗方案中近期再出血率比较差异无显著性意义（2.9％、4.5％、3.6％）,而根治性治疗的静脉曲张消除率A、 B组（89.9％、89.5％）显著高于仅行一次内镜治疗（39.3％）。在远期再出血率方面,内镜下食管胃底曲张根治治疗 A、 B 组（40.6％、53.7％）显著低于一次内镜治疗组（76.8％）,而根治治疗联合序贯心得安治疗（89.9％）与仅行根治治疗（89.5％）比较,静脉曲张消除率无显著差异,但A组远期再出血率最低（40.6％、53.7％、76.8％）。结论：内镜下食管胃底静脉曲张根治性治疗联合序贯心得安疗法在对食管胃底静脉曲张的静脉曲张消除率及远期出血率方面都有一定的优势,可供临床参考。     

30岁以下人群食管胃静脉曲张患者临床特点分析

目的 分析总结30岁以下食管胃静脉曲张(GOV)患者的临床特点。方法 2015年1月～2020年12月解放军总医院第一医学中心消化内科医学部收治的61例30岁以下GOV患者,提取、分析和总结其临床资料。结果 在61例GOV患者中,肝硬化门静脉高压症27例(44.3%),其中隐源性肝硬化占40.7%,乙型肝炎肝硬化占33.3%,和非肝硬化性门静脉高压(NCPH)34例(55.7%),其中以门静脉海绵样变占61.8%;基于内镜下静脉曲张LDRf分型,在位置方面主要以Le/g型多见(77.1%),在直径方面,D1.0占41.0%,在出血风险方面,Rf1分级占77.1%;针对GOV治疗,以二级预防治疗为主(85.7%),多采用组织胶或硬化剂注射或套扎联合治疗(66.1%);NCPH患者GOV再出血比例为11.8%,显著低于肝硬化组的29.6%(P<0.01)。结论 30岁以下人群GOV患者以NCPH居多,其中以各种原因引起的门脉海绵样变最多见。NCPH患者并发GOV经内镜治疗后再出血发生率显著低于肝硬化患者。     

The clinical characteristics, endoscopic treatment, and prognosis for patients presenting with duodenal varices

BACKGROUND/AIMS: This study investigated the clinical characteristics, endoscopic appearances, usefulness of endoscopic treatments, and survival of patients with duodenal varices. METHODOLOGY: Twelve patients were evaluated in whom endoscopy confirmed duodenal varices (13 lesions), and patient data was retrospectively analyzed regarding underlying diseases, hepatic function, endoscopic appearance, previous treatment for other complicated varices, endoscopic treatment for hemorrhage from duodenal varices, and survival. RESULTS: Underlying diseases consisted of liver cirrhosis in 8 patients, and pancreatic cancer-related pylemphraxis in 4 patients. Endoscopic appearances of hemorrhage from duodenal varices revealed negative red color (RC) signs in all 6 lesions, and 5 of 6 lesions were F3 lesions. Three of 5 patients with hemorrhagic duodenal varices had received treatment for esophageal varices. Successful hemostasis and complete eradication by endoscopic treatments was achieved in all 5 patients (6 lesions). The 1, 3, and 5 year cumulative survival rates were 66.7%, 48.6%, and 36.5% in the patients with duodenal varices. CONCLUSIONS: The hemorrhagic factor of duodenal varices is F factor, but not RC sign. Changes of blood flow in the collateral circulatory pathway after treatment for esophageal varices may increase the risk of hemorrhage from duodenal varices. Endoscopic treatment is useful for hemorrhagic duodenal varices.     

Endoscopic classification of gastric varices

Endoscopic observations of gastric varices in 124 patients were classified according to form, location, and color. Form was classified into three types: tortuous (F1), nodular (F2), and tumorous (F3). Location was classified into five types: anterior (La), posterior (Lp), lesser (Ll) and greater curvature (Lg) of the cardia, and fundic area (Lf). Color was white (Cw) or red (Cr). Glossy, thin-walled focal redness on the varix was defined as red color spot (RC spot). Stepwise logistic regression analysis for multivariate adjustments was performed for all of the endoscopic covariates, and four risk factors (La, Lg, F2, RC spot) that affect bleeding from gastric varices were independently identified. This classification should aid in assessing gastric varices observed by fiberoptic endoscopy and help design appropriate treatment.     

Perforating Veins in Recurrent Esophageal Varices after Endoscopic Therapy Visualized by Endoscopic Color Doppler Ultrasonography

This study was designed to evaluate the detection rate and the direction of blood flow of perforating veins using endoscopic color Doppler ultrasonography (EC-DUS) in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. Perforating veins were defined as vessels communicating between esophageal varices and paraesophageal veins. The study involved thirty patients with recurrent esophageal varices who had been followed up for more than one year. Seven of them had high risk intramucosal venous dilatation (IMVD) of the esophagus, and 23 had F₁ (small straight varices) red color (RC) positive varices. Color flow images of perforating veins were obtained in 18 patients (60.0%). The perforating veins were classified into three types according to flow direction. Type 1 had inflow from paraesophageal veins to esophageal varices, Type 2 had outflow type from esophageal varices to paraesophageal veins, and Type 3 was mixed, showing both inflow and outflow. Of the 18 patients in whom color flow images were obtained, 15 (83.3%) cases were Type 1, none were Type 2, and three (16.7%) were Type 3. All the color flow images in the perforating veins were demonstrated as a continuous wave. In conclusion, perforating veins can be detected at a high rate by ECDUS in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. (Dig Endosc 1999; 11: 236–240)     

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.     

Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases

Backgroud/rationale of study. Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/ embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications.Results. Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy-without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis-3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson’s disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occludedretrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred.Conclusions. This work suggests that angiographic-occlusion-with-sclerotherapy/embolotherapy-without-TIPS is relatively effective (-90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.     

Effects of endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study.

The effect of endoscopic injection sclerotherapy (EIS) for esophageal varices on portal hypertensive gastropathy (PHG) was investigated in 137 patients who underwent EIS from July 1987 to March 1990. Two groups, PHG(+) (N = 35) and PHG(-) (N = 102) were distinguished by endoscopic findings obtained before EIS. PHG was classified into four grades by endoscopy scored as 0, 1, 2, or 3. The PHG score significantly worsened after EIS (p < 0.01), and PHG became worse 6 to 9 months after the eradication of varices followed by gradual improvement. Recurrent small veins, which required additional EIS, appeared more frequently in the PHG(+) group (p < 0.05). New gastric varices appeared or gastric varices enlarged after EIS more frequently in the PHG(+) group (7 patients, 20.0%) than in the PHG(-) group (12 patients, 11.8%), but this was not statistically significant. Thus, frequent endoscopy after EIS is needed with special attention directed to development of PHG and gastric varices, especially for patients with PHG prior to treatment.     

Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.