两次食管静脉曲张硬化治疗后均发生化脓性胆囊炎1例报告

<正>1病历资料男性,患者,41岁,2007年因乙型肝炎肝硬化、食管胃底静脉曲张破裂出血于外院行内镜下食管静脉曲张硬化治疗术,术后患者出现化脓性胆囊炎,经保守治疗后病情缓解。该患者2013年8月因再次"呕血、黑便1 d"入住威海市立医院,本次住院前曾行B超检查:肝硬化,门静脉高压,脾静脉、肠系膜上静脉、下腔静脉肝后段栓塞,胆囊多发结石,胆囊壁厚。住院后随即行相关化验检查,血常规:白细胞(WBC)4.7×109/L,中性粒     

Balloon-occluded retrograde transvenous obliteration for gastric varices via the intercostal vein

Gastric varices are usually associated with a gastrorenal(G-R) shunt.However,the gastric varices described in this case report were not associated with a G-R shunt.The inflow vessel was the posterior gastric vein and the outflow vessels were the narrow inferior phrenic vein and the dilated cardio-phrenic vein.First,percutaneous transhepatic obliteration of the posterior gastric vein was performed,but the gastric varices remained patent.Then,micro-balloon catheterization of the subphrenic vein was carried out via the jugular vein,pericardial vein and cardio-phrenic vein,however,micro-balloon-occluded inferior phrenic venography followed by micro-coil embolization of the cardio-phrenic vein revealed no delineation of gastric varices resulting in no further treatment.Thereafter,as a gastrosubphrenic-intercostal vein shunt developed,a microballoon catheter was advanced to the gastric varices via the intercostal vein and balloon-occluded retrograde transvenous obliteration(BRTO) was performed resulting in the eradication of gastric varices.BRTO for gastric varices via the intercostal vein has not previously been documented.     

肝硬化食管胃静脉曲张破裂出血与再出血危险性预测的研究进展

肝硬化食管静脉曲张破裂出血与再出血危险性预测有门静脉高压、食管胃静脉曲张出血史、瞬时弹性成像术、多层螺旋CT成像、肝硬化脾肝体积比、内镜下食管静脉曲张套扎术后、内镜治疗后随访的顺应性、血清腹水白蛋白梯度、血小板计数进行性下降、出血的控制时间、细菌感染和病毒复制。本文就这些方面作一综述。     

血清腹水清蛋白梯度与门静脉高压症食管胃底曲张静脉破裂出血的相关性研究

目的探讨血清腹水清蛋白梯度（SAAG）与门静脉高压症食管胃底静脉破裂出血的关系。方法对2009∽2011年冀中能源峰峰集团总医院门静脉高压症并发食管胃底静脉曲张破裂患者36例行选择性断流手术（观察组）,另选取同期40例食管胃底静脉曲张未出血患者作为对照组,2组患者的年龄、门静脉宽度、总胆红素、SAAG、部分凝血活酶时间（APTT）值进行比较,同时对出血手术患者SAAG和门静脉压力梯度（PPG）变化值行直线相关性分析。通过受试者工作特征（ROC）曲线确定血清SAAG对门静脉高压症食管胃底静脉破裂出血的预测值。结果观察组患者SAAG为（24.2±7.1）g/L,对照组患者SAAG为（15.2±6.0）g/L,2组比较差异有统计学意义（P〈0.05）。观察组患者SAAG与PPG变化值两者之间存在正相关（r=0.84,P〈0.01）,利用ROC曲线确定SAAG并预测门静脉高压症食管胃底静脉破裂出血的最佳诊断切点为18.3g/L,敏感度和特异度分别为95.1%和66.1%。结论血清SAAG是预测门静脉高压症食管胃底静脉破裂出血的良好指标。     

肝静脉压力梯度预测内镜下食管静脉曲张套扎术后早期再出血的临床应用

目的 探讨肝静脉压力梯度(HVPG)预测内镜下食管静脉曲张套扎术(EVL)后早期再出血的应用价值.方法 研究有肝硬化食管静脉曲张出血史、EVL前行HVPG测定患者105例.收集其住院期间HVPG值、内镜下表现及EVL术后2周内是否出血及其他严重并发症等.应用x2检验、秩和检验、logiStic回归模型的假设检验及受试者工作特征曲线(ROC)分析进行统计学处理. 结果 经统计学分析,只有HVPG是EVL术后早期再出血的独立危险因素.对HVPG关于EVL术后早期再出血行ROC分析,得出曲线下面积(AUC)为0.866,当HVPG≥16 mmHg时,AUC为0.838,有一定准确性,其敏感性为90.9％,特异性为76.6％.结论 HVPG是影响EVL术后早期再出血的独立危险因素.HVPG≥16 mmHg作为预测EVL术后早期再出血的阈值,具有一定准确性、敏感性及特异性.     

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。     

Esophagogastric varices as a prognostic factor for the determination of clinical stage in patients with primary biliary cirrhosis

Background Primary biliary cirrhosis (PBC) is usually classified as either asymptomatic PBC (a-PBC) or symptomatic PBC (s-PBC). Although the proportion of a-PBC versus s-PBC patients has been consistently increasing, it is not clear whether the present criteria for the staging of PBC are optimal or not. We investigated the clinical stage of PBC patients from the standpoint of esophagogastric varices (EGV).Methods One hundred and nine PBC patients were enrolled in this retrospective study. We investigated the clinical features of PBC based on laboratory data, histological stage, symptoms, and existence of EGV. In addition, the clinical course and prognosis in patients who were periodically followed up were also studied.Results (1) EGV was detected in a-PBC patients, and there was no difference in the grade of EGV between a-PBC and s-PBC patients. (2) a-PBC patients with EGV had more liver damage than those without EGV, and a-PBC patients with EGV had a poorer prognosis than those without EGV. (3) Three of 11 patients who progressed from a-PBC to s-PBC within 3 years had EGV. (4) One of 3 a-PBC patients with EGV had progressed to s-PBC at 3-year follow-up.Conclusions These results indicate that EGV is one of the most important factors for evaluating PBC. Therefore, we would like to propose that a-PBC patients with EGV should either be included in the presently defined s-PBC class, or that new prognostic classes of PBC be created that include EGV as a prognostic factor.     

Isolated varices over hepatic flexure colon indicating superior mesenteric venous thrombosis caused by uncinate pancreatic head cancer--a case report

Very rare cases of varices involving right side colon were reported. Most of them were due to cirrhotic portal hypertension or other primary causes. No report case contributed to pancreatic cancer. Here, we reported a case of uncinate pancreatic cancer with the initial finding of isolated hepatic flexure colon varices. Following studies confirmed isolated varices involving hepatic flexure colon due to pancreatic cancer with occlusion of superior mesenteric vein. From this report, superior mesenteric vein occlusion caused by uncinate pancreatic head cancer should be considered as a differential diagnosis of colon varices.     

Long-Term prognosis of non-shunt operation for idiopathic portal hypertension

This report presents 46 Japanese patients with idiopathic portal hypertension (IPH) in whom non-shunt operation was performed for the management of esophageal varices. Non-shunt operation included transthoracic esophageal transection (Sugiura's procedure) in 37 patients, transabdominal esophageal transection (TAET) in 3 patients, and Hassab's procedure in 6 patients. Rates of postoperative variceal eradication were: 78.4% by Sugiura's procedure; 100% by TAET; and 50% by Hassab's procedure. The cumulative rates for recurrent varices and recurrent bleeding were 3.9%, and 5.1%, respectively, at 5 years, and 8.9% and 9.8% at both 10 and 15 years. Only 3 patients required additional endoscopic injection sclerotherapy to treat recurrent varices. Although 3 patients developed upper gastrointestinal bleeding, the source of hemorrhage was esophageal varices in 1, and portal hypertensive gastropathy in 2; none of the patients died from bleeding. Actuarial survival for all patients was 87.5% at 5 years, 77.9% at 10 years, and 58.8% at 15 years. There were no deaths within the first 30 days after surgery. These results show that non-shunt operation is useful in preventing bleeding from esophageal varices in patients with IPH. (Received Feb. 4, 1997; accepted Aug. 22, 1997)     

Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion

Aim: This study provides a retrospective evaluation of cases with gastric varices secondary to splenic vein occlusion. Methods: Our study group consisted of 14 patients. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively. Results: Eleven patients had co‐existing pancreatic diseases: seven with chronic pancreatitis, three with cancer of the pancreatic body or tail and one with severe acute pancreatitis. Among the three remaining patients, one had advanced left renal cancer, one had myeloproliferative disease and the third had splenic vein occlusion due to an obscure cause. A diagnosis of gastric varices was made following endoscope gastroduodenoscopy or endoscopic color Doppler ultrasonography (ECDUS), and splenic vein occlusions were diagnosed from enhanced computed tomography in all cases. Specific findings of gastric varices secondary to splenic vein occlusion were based on ECDUS color flow images of gastric variceal flow that clearly depicted round cardiac and fundal regions at the center, with varices expanding to the curvatura ventriculi major of the gastric body. For three cases with gastric variceal bleeding, endoscopic injection sclerotherapy using a mixture of histoacryl and lipiodol (70% histoacryl solution) was performed, after which no further bleeding from gastric varices was detected. Due to a high risk of gastric variceal rupture, splenectomy was performed in two cases and splenic arterial embolization in another two cases. Conclusion: ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion. Treatment should take into account the diseases underlying these conditions.