原发性肝癌合并动静脉瘘的介入治疗进展

原发性肝癌患者合并动静脉瘘(AVS)较常见。由于AVS的存在可导致肿瘤细胞播散和转移,并加重肝硬化患者门脉高压,从而引起上消化道大出血、腹水,甚至导致肝功能衰竭。AVS增加了肝癌治疗的难度,严重影响患者的预后。现就目前肝癌患者合并AVS的介入治疗做一综述。     

肝硬化患者生存质量及其影响因素的研究进展

肝硬化是一种常见的以肝功能损害和门静脉高压为主要表现的慢性肝病,晚期常出现消化道出血、肝性脑病、继发感染等严重并发症,并引起患者生存质量严重下降。本文就不同病因导致肝硬化患者的生存质量及其影响因素研究做一综述。     

彩色多普勒血流图对经颈内静脉肝内门体分流术疗效观察

应用彩色多普勒血流图观察６６例肝硬化门脉高压症行经颈内静脉肝内门体分流术（ｔｒａｎ－ｓｊｕｇｕｌａｒｉｎｔｒａｈｅｐａｔｉｃｐｏｒｔｏｓｙｓｔｅｍｉｃｓｔｅｎｔｓｈｕｎｔＴＩＰＳＳ）治疗的患者术后不同时期的门脉系血流动力学变化，检出支撑管栓塞２例，认为ＴＩＰＳＳ术对肝硬化门脉高压症的治疗有一定疗效。     

卡维地洛防治肝硬化门脉高压症临床研究进展

肝硬化是由多种原因引起的肝脏慢性炎症损伤导致的严重疾病,常并发门静脉高压。门静脉高压形成的主要原因包括肝内血管阻力增加和门静脉血流量增加。卡维地洛是一种第三代非选择性β受体阻滞剂（NSBB）,具有α1受体阻滞作用,被认为在降低门静脉压力方面优于传统NSBB。本文综述了卡维地洛在门静脉高压治疗中的作用机制及临床应用,重点探讨其在静脉曲张的一级和二级预防中的效果及其对肝硬化合并顽固性腹水患者的生存影响。认为卡维地洛通过多重机制显著降低HVPG,预防静脉曲张破裂出血,延长患者生存期。然而,其副作用及最优剂量仍需进一步研究以确保临床应用的安全性和有效性。     

肝硬化食管静脉曲张破裂出血患者门静脉血流参数的变化

目的 探讨彩色多普勒超声预测肝硬化门静脉高压症(cirrhotic portal hypertension)患者食管静脉曲张破裂出血的应用价值.方法 肝硬化门静脉高压症患者81例,根据有无出血史分为出血组(36例),非出血组(45例).应用彩色多普勒超声分别检测两组的门静脉(pv)和脾静脉(sv)内径(Dpv、Dsv)、血流动力学参数并进行对比分析.结果 门静脉和脾静脉的内径、血流速度(Vpv、Vsv)及脾静脉的血流量(Qsv)在两组间差异均有统计学意义(P<0.05),但门静脉血流量(Qpv)在两组间差异无统计学意义(P>0.05).结论 彩色多普勒超声检测肝硬化门静脉高压症患者门静脉和脾静脉内径及血流动力学参数,对预测肝硬化门静脉高压时食管静脉曲张破裂出血是有价值的.     

血清腹水白蛋白梯度诊断非门脉高压性腹水价值

目的:探讨血清腹水白蛋白梯度(SAAG)诊断非门脉高压性腹水的价值。方法:选择腹水患者60例,其中肝硬化21例、原发性肝癌10例为门脉高压性腹水组。癌性腹水18例、结核性腹膜炎5例、细菌性腹膜炎4例、胰性腹水1例、肾源性腹水1例为非门脉高压性腹水组。分别测定其血清白蛋白及腹水白蛋白值进行比较。结果:非门脉高压组SAAG为(6.94±2.01)g/L,门脉高压组SAAG为(18.67±7.25)g/L,2组比较差异有显著性(P<0.05)。结论:SAAG对鉴别非门脉高压性腹水有重要意义,在临床工作中有较好的指导作用。     

Traitement des complications de l’hypertension portale par TIPS en 2016

Portal hypertension (PHT) is defined by an increase of the pressure gradient between the sus-hepatic vena and the portal vein. PHT is most often due to liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created low-resistance channel between the portal and the hepatic veins. The goal of TIPS is to reduce portal pressure by shunting blood from the portal to the systemic circulation, bypassing the liver. TIPS could permit to treat severe portal hypertension-related complication such as esophageal or gastric varices bleeding. TIPS is currently indicated as the salvage therapy in patients with bleeding esophageal varices who failed to respond to standard treatment. More recently, applying TIPS early has been shown to be an effective treatment to control bleeding and decrease mortality in patients with severe cirrhosis. TIPS is also recommended as the second-line treatment for secondary prophylaxis. TIPS is a promising treatment for refractory ascites or hepatic hydrothorax. TIPS should be considered in the treatment of Budd-Chiari syndrome. However, the role of TIPS in the treatment of hepatorenal syndrome is not well defined.     

The duodenum in liver cirrhosis: endoscopic, morphological and clinical findings

Endoscopic studies were performed to determine whether changes occurred in the duodenum related to portal hypertension in patients with liver cirrhosis. The total of 271 patients studied were subdivided into three groups: 83 patients with liver cirrhosis and portal hypertension, 53 with liver cirrhosis but no portal hypertension, and 135 controls. In the duodenum of cirrhotic patients with portal hypertension several changes were observed on endoscopy that were also present in the other two groups. Atrophy and vascular malformations, however, were present only in the duodenum of cirrhotic patients with portal hypertension, although in only a few patients and with statistical significance only for vascular malformations (p less than 0.01, phi = 0.21). Eleven percent of the patients had more than one endoscopic finding, but the associations of findings were without statistical significance. No statistically significant correlation was observed between the clinical severity of cirrhosis or the severity of esophageal varices and the endoscopic findings. Finally, there was no statistically significant difference between the histological findings of duodenitis in the three groups of patients.     

脉动色素浓度测定法检测吲哚氰绿清除试验在肝储备功能评估中的应用

目的:探讨脉动色素浓度测定法(pulse dye densito graphanalyzer,PDDG)检测吲哚氰绿(ICG)清除试验在肝炎后肝硬化患者术前肝储备功能评估中的作用。方法:用PDDG法进行ICG清除试验,分析其在104例肝炎后肝硬化患者在术后恢复方面与Child-Pugh评分的相关性。结果:吲哚氰绿15min潴留率(ICGR15)在术后腹水、白蛋白用量、利尿剂用量、黄疸等方面与Child-Pugh评分有较好的一致性;同时ICGR15较Child-Pugh评分在术后并发症及治疗方面相关系数更高,相关性更强。结论:PDDG试验是行ICG清除试验检测肝储备功能实用可行的理想方法,能很好地反映肝炎后肝硬化、门脉高压症患者的肝储备功能,对手术后恢复情况有良好的预计性。     

肝硬化伴发上消化道出血47例临床观察

目的探讨肝硬化伴发上消化道出血常见病因及临床治疗效果。方法回顾分析2009年8月至2011年4月诊治的肝硬化伴发上消化道出血47例患者临床资料。结果经胃镜检查出血原因以食管静脉曲张破裂为主,占53.19%(25/47)。其次为门脉高压性胃病、消化性溃疡,分别占19.15%(9/47)、12.77%(6/47)。47例患者总止血有效率89.36%(42/47)。结论肝硬化患者上消化道出血原因主要有食管静脉曲张破裂、门脉高压性胃病、消化性溃疡等,及时给予综合治疗可有效控制出血、降低病死率。     

Hepatogenic ulcer (various aspects of its pathogenesis)

Functional and morphological state of the stomach and duodenum was studied in 98 patients with liver cirrhosis. Hepatogenous ulcer was revealed in 21.7 per cent of the patients with alcoholic and in 25 per cent of those with viral liver cirrhosis. A specific feature of the condition was the development of ulcer in reduced gastric acid production and its asymptomatic course. The incidence of gastric and duodenal affections in liver cirrhosis was significantly higher in pronounced portal hypertension. Study of the portal blood flow with Doppler ultrasonography can reveal the risk group (patients with pronounced portal hypertension) which has high probability of the development of erosion-ulcerous lesions. These patients require obligatory medical checkups with gastric and duodenal endoscopy 2-3 times a year.     

Portal hypertension and varices in patients with liver cirrhosis

Portal hypertension is a complication seen in patients with liver cirrhosis and is characterised by high pressure in the portal vein. As portal hypertension worsens, varices can form, leading to increased morbidity and mortality if these rupture. Bleeding can be prevented with pharmacological agents and endoscopic therapy; however, some patients will experience variceal haemorrhage. Medical and nursing management of acute variceal haemorrhage is key to a successful outcome, and after initial resuscitation, endoscopic therapy should be undertaken. Long-term management to prevent re-bleeding may involve surgery to implant shunts, which aim to reduce portal venous pressure. However, patients often require referral to specialist centres for transplant assessment.     

超声检查附脐静脉开放腹壁静脉曲张在门静脉高压临床分型的意义

目的应用彩色多普勒超声对门静脉高压附脐静脉开放和腹壁静脉曲张门腔之间侧支循环进行研究,确定门脉高压分型。方法超声检查86例肝硬化门静脉高压、13例布加综合征及6例门静脉主干、脾静脉血栓3组门静脉高压患者的腹壁静脉曲张门腔之间侧支循环吻合情况及血流方向。结果肝硬化门静脉高压组腹壁静脉曲张在脐以上血流流向头端,而脐以下血流流向腹端。布加综合征合并下腔静脉阻塞组,血流均流向上胸端。门静脉主干、脾静脉血栓未见脐静脉开放及腹壁静脉曲张。结论应用彩色多普勒超声判断附脐静脉开放和腹壁静脉曲张门腔之间侧支循环的情况,可明确血管阻塞部位、程度、范围,为肝前、肝内及肝后门静脉高压分型的诊断提供有效依据,对临床制定合理治疗方案具有指导意义。     

肝硬化门静脉高压门脉血流动力学检测及其临床意义

目的：探讨肝硬化门脉高压患者门脉血流动力学状态并分析其与Child-Pugh肝功能分级的关系。方法：利用多普勒超声技术检测了100例肝硬化门脉高压患者及24例正常人门脉血流动力学状态,并将100例肝硬化门脉高压患者按Child-Pugh肝功能分级分析两者之间的关系。结果：肝硬化门脉高压门脉血流动力学检查与正常对照组比较、门脉高压组门静脉（PV）内径明显增宽、血流速明显减慢、血流量参数明显增加,差异有显著性意义（P＜0．01）;脾静脉（SV）肠系膜上静脉（SMV）内径（D）、血流速度（V）、血流量参数（Q）也有类似改变。A、B、C三级肝硬化的PV内径,按A、B、C顺序显示门静脉宽度逐渐增宽,C级的Dpv较A、B级均有显著性增宽（P＜0．05）,A、B级间差异无显著性意义（P＞0．05）,但B级较A级也有增宽趋势,按A、B、C顺序显示 门静脉血流速度逐渐降低,且各级间比较差异有显著性意义（P＜0．05）。A、B、C级的Qpv相互比较无统计学差异（P＞0．05）。结论多普勒超声检测门脉血流动力学有助于评价肝硬化患者的肝储备功能、门静脉高压程度及预后。     

Hepatic sarcoidosis with portal hypertension. A report of seven cases with a review of the literature

We have reviewed the clinical, histological and hemodynamic features of sarcoidosis complicated by portal hypertension in seven patients and in 40 previously reported cases. Young black patients of either sex and white females over 40 years were selectively affected. In 12 of these 47 patients, portal hypertension appeared to be a consequence of cirrhosis due to longstanding intrahepatic cholestasis; in white patients, this condition was clinically, histologically, and serologically indistinguishable from primary biliary cirrhosis. In most of the other patients, portal hypertension was the predominant and often the presenting symptom of hepatic sarcoidosis; in these patients portal hypertension was due to a presinusoidal block probably determined by portal granulomas, with or without superimposed sinusoidal block determined by fibrosis. Corticosteroids did not prevent the development of portal hypertension.     

彩色多普勒超声对门脉高压食管静脉曲张出血的诊断价值

目的评价门脉血流动力学参数在预测肝硬化食管静脉曲张高危患者中的作用。方法对85例肝硬化患者行胃镜和彩色多普勒超声检查,使用单因素分析和多元分析对门脉血流动力学指标与确认的食管静脉曲张的存在和规模间的关系进行评估。结果食管静脉曲张组的肝动脉阻力指数、脾动脉阻力指数、充血指数、门脉高压指数较无食管静脉曲张组大,肝血管指数较无食管静脉曲张组小,食管静脉曲张重度组的肝动脉阻力指数、脾动脉阻力指数、脾脏长径、充血指数、门脉高压指数较轻-中度组大,肝血管指数较轻-中度组小,差异均有统计学意义（P〈0．05）。结论彩色多普勒超声对门脉高压食管静脉曲张出血有较高的诊断价值。     

A case of non-cirrhotic portal hypertension associated with anti-retroviral therapy in a Japanese patient with human immunodeficiency virus infection

The diagnosis of non-cirrhotic portal hypertension (NCPH), a rare but potentially life-threatening complication in human immunodeficiency virus (HIV)-positive individuals, often occurs only after the emergence of fatal manifestations such as bleeding of esophageal varices. We herein report a female Japanese HIV patient who developed NCPH approximately 4 years after discontinuation of 65 months of didanosine (ddI) administration. The patient presented with severe ascites, bloody bowel discharge, extreme abdominal swelling, and symptoms of portal hypertension but no sign of liver cirrhosis. Examination revealed esophageal varices, oozing-like bleeding from a wide part of the colon, significant atrophy of the right lobe of the liver, and arterio-portal shunting and recanalization from the left medial segment branch of the portal vein to a paraumbilical vein, but no visible obstruction of the main trunk of the portal vein. Treatment for esophageal varices consisted of coagulation therapy with argon plasma after enforcement by endoscopic sclerotherapy and oral administration of β-blockers for elevated portal blood pressure. The patient has not experienced gastrointestinal bleeding in the approximately 5 years since the diagnosis of NCPH. Reviewing this case suggests the importance of suspecting NCPH in HIV patients with liver dysfunction of unknown etiology with a history of ddI and other purine analogs use, as well as the importance of controlling portal hypertension and esophageal varices in the treatment of NCPH.     

术前内镜下胆道内外引流的临床意义

目的：探讨术前内镜下胆道内外引流（ENBD）和／或ERBD）对梗阻性黄疸患者进行治疗和术前准备的临床意义。方法：根据病因将胆道梗阻病例33例分为良性组（21例）,恶性组（12例）。33例患者实施急诊或择期引流的同时行胆道造影以明确诊断。结果;所有患者胆道均得到充分引流,急性胆管炎者胆道感染得以迅速控制,免于急诊手术;恶性组除2例晚期胰头癌患者仅行ERBD姑息治疗外,其余经ERBD或ENBD引流后,TB均降至40μmol/L以下,为手术创造了条件。全部行根治性手术,除1例出现肝残而胆瘘外,余无并发症发生,无手术死亡率。结论：术前ENBD和ERBD确有进一步的影像学诊断价值和微创及良好的胆道引流减压减黄效果,急诊床旁ENBD尤其对急性重症胆管炎及老年急性胆管炎的治疗具有特别重要的意义。     

Study of central and porto-hepatic hemodynamics before the surgical treatment of patients with liver cirrhosis and portal hypertension

Basing on the results of hemodynamic findings related to the heart and liver in 41 patients with hepatic cirrhosis and portal hypertension (33 of them were operated on for portal hypertension), it is suggested that when deciding on the type of surgery in such patients, initial status of central and portal hemodynamics as well as expected changes in these parameters due to surgery should be taken into consideration. Pathogenetic grounds for some routine interventions in hepatic cirrhosis and portal hypertension are thought open to question.     

Our judgements on the potential for surgical treatment of patients with liver cirrhosis and portal hypertension

The results of surgery of 267 patients with liver cirrhosis and portal hypertension were analyzed. Operation was indicated in actual danger of bleeding from varicose dilated esophageal and gastric veins; surgical intervention should be limited to selective portocaval anastomoses or to direct operation on esophageal and gastric veins. Indications for splenectomy in such patients should be limited. Analysis of the results of treatment of 80 patients with decompensated liver cirrhosis was indicative of some progress in therapy of patients with ascites resistant to drug therapy.