食管静脉及食管、胃粘膜变化预测门脉高压食管静脉曲张出血的价值

为探讨门脉高压症患者内镜下食管静脉(EV)、食管粘膜及胃粘膜变化预测出血的价值,将60例肝硬化门脉高压患者分为出血组(36例)和非出血组(24例),分别观察其EV曲张形态、范围及颜色,炎性表现,胃粘膜改变及有无胃食管返流病(GERD)等.结果出血组EV曲张范围多超过食管中段,呈灰蓝、樱红色,静脉扭曲呈结节状,外径平均6.0±1.6mm;非出血组EV多局限于食管下段,呈灰白或灰蓝色,外径平均4.2±1.2mm;出血组食管炎20例(55.5%),非出血组5例(20.8%).出血组有胃粘膜损害者20例,非出血组为6例(P＜0.01).认为食管静脉曲张超过中段、外径≥6.0mm、有樱红样征;伴有食管炎、GERD及门脉高压性胃病者的出血率明显增加;上述指标预测门脉高压出血具有实用价值.     

Endoprosthetics for malignant esophageal disease

Currently used stents for malignant esophageal strictures include self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), and biodegradable stents. For the palliative treatment of malignant dysphagia, both SEMS and SEPS effectively provide rapid relief of dysphagia. SEMS are preferred over SEPS as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, stent migration, and both tumoral and nontumoral tissue overgrowths are common. Complication rates are probably also affected by stent “behavior” in the esophagus, with radial and axial forces being important determinants. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer has not convincingly been proven. Concurrent treatment with chemotherapy and radiotherapy seems to be safe and effective, although biodegradable stents have shown disappointing results. It can be expected that removable stents will increasingly be used as bridge to surgery to maintain luminal patency during neoadjuvant treatment.     

Comparison of esophageal capsule endoscopy and esophagogastroduodenoscopy for diagnosis of esophageal varices

AIM： To investigate the utility of esophageal capsule endoscopy in the diagnosis and grading of esophageal varices.
METHODS： Cirrhotic patients who were undergoing esophagogastroduodenoscopy （EGD） for variceal screening or surveillance underwent capsule endoscopy. Two separate blinded investigators read each capsule endoscopy for the following results： variceal grade, need for treatment with variceal banding or prophylaxis with beta-blocker therapy, degree of portal hypertensive gastropathy, and gastric varices.
RESULTS： Fifty patients underwent both capsule and EGD. Forty-eight patients had both procedures on the same day, and 2 patients had capsule endoscopy within 72 h of EGD. The accuracy of capsule endoscopy to decide on the need for prophylaxis was 74%, with sensitivity of 63% and specificity of 82%. Interrater agreement was moderate （kappa = 0.56）. Agreement between EGD and capsule endoscopy on grade of varices was 0.53 （moderate）. Inter-rater reliability was good （kappa = 0.77）. In diagnosis of portal hypertensive gastropathy, accuracy was 57%, with sensitivity of 96% and specificity of 17%. Two patients had gastric varices seen on EGD, one of which was seen on capsule endoscopy. There were no complications from capsule endoscopy.
CONCLUSION： We conclude that capsule endoscopy has a limited role in deciding which patients would benefit from EGD with banding or beta-blocker therapy. More data is needed to assess accuracy for staging esophageal varices, PHG, and the detection of gastric varices.     

Endoscopic management of esophageal varices

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis     

Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life threatening situation with mortality rates of at least 20%. Prophylactic treatment with non-selective beta blockers(NSBBs) is recommended for patients with small varices that have not bled but with increased risk for bleeding. The recommended treatment strategies on primary prevention of variceal bleeding in patients with medium and largesized varices are NSBBs or endoscopic band ligation. Nitrates, shunt surgery and sclerotherapy are not recommended in this setting. In this review, the most recent data on prevention of esophageal variceal bleeding are presented. Available data derived from randomized-controlled trials suggest both treatment strategies, and according to Baveno V consensus in portal hypertension "the choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects and contra-indications".     

北京地区门脉高压食管胃静脉曲张出血调查分析

目的；研究不同因素对门脉高压食管胃静脉曲张了血转归的影响。方法：对北京地区16家医院826例门脉高压管胃静脉曲张出血住院患者病例资料进行了分析，包括：年龄，性别，肝硬化病因，肝硬化病程，出血病程，出血次数，出血程度，肝Child分级，降门脉压药物使用，三腔两囊管，内镜下食管静脉套扎术（EVL),内镜下食管静脉硬化术（EVS），外科治疗等因素对门脉高压食管胃静脉曲张出血转归的影响进行分析；对影响转归的各种因素进行多因素逐步Logistic回归分析；并对各种止血方法疗效进行比较。结果：本组资料门脉高压食管胃静脉曲张破裂出血转归与患者年龄，出血病程，出血程度，肝功能分级，胆红素，白蛋白，凝血酶原时间，奥曲肽，凝血酶，巴曲酶，三腔两囊管，EVL及EVS等多因素相关；目前门脉高压食管胃静脉曲张出血以内科治疗为主，总止血成功率为90．90％；死亡97例，死亡率为11．74％。EVS能改善门脉高压食管胃静脉曲张出血转归，止血成功率达98．88％，为门脉高压食管胃静脉破裂中重度出血治疗首选方法。     

经皮肝穿食管曲张静脉栓塞术和脾栓塞的临床应用

目的 联合应用经皮肝穿食管曲张静脉栓塞术（ＰＴＯ）和部分性脾栓塞术（ＰＳＥ）、探讨其对预防和治疗胃底和食管曲张静脉破裂出血合并脾功能亢进的治疗效果。方法 对１３例肝硬化门脉高压口才行ＰＴＯ治疗,然后进行ＰＳＥ《结果 全部病例术后造影及胃镜复查食管静脉曲张明显缓解或消失,未见再出血者。超声复查,脾脏栓塞面积达５０￣６０％,１￣３个月后患者周围血象不同程度回升。结论 ＰＴＯ加ＰＳＥ是治疗食管静脉曲张破     

肝硬化门静脉高压合并食管静脉曲张出血的风险评估

食管静脉曲张破裂出血是肝硬化门静脉高压常见及最严重的并发症之一,常危及患者的生命。据报道,每年约7%的肝硬化患者发生食管静脉曲张破裂出血。因此,评估食管静脉曲张出血风险对于临床防治具有重要意义。目前,内镜、一些血清标志物、影像学检查及肝静脉压力梯度(HVPG)等对曲张静脉出血风险的预测具有一定价值。本文将对预测肝硬化门静脉高压所致食管静脉曲张出血风险研究进展作一概述。     

Per rectal portal scintigraphy as a useful tool for predicting esophageal variceal bleeding in cirrhotic patients

AIM： To investigate potential roles of per rectal portal scintigraphy in diagnosis of esophageal varices and predicting the risk of bleeding. METHODS： Fifteen normal subjects and fifty cirrhotic patients with endoscopically confirmed esophageal varices were included. Patients were categorized into bleeder and non-bleeder groups according to history of variceal bleeding. All had completed per rectal portal scintigraphy using ^99mTechnetium pertechnetate. The shunt index was calculated from the ratio of ^99mTechnetium pertechnetate in the heart and the liver. Data were analyzed using Student＇s t-test and receiver operating characteristics. RESULTS： Cirrhotic patients showed a higher shunt index than normal subjects （63.80 ± 25.21 vs 13.54 ± 6.46, P 〈 0.01）. Patients with variceal bleeding showed a higher shunt index than those without bleeding （78.45 ± 9.40 vs 49.35 ± 27.72, P 〈 0.01）. A shunt index of over 20% indicated the presence of varices and that of over 60% indicated the risk of variceal bleeding. CONCLUSION： In cirrhotic patients, per rectal portal scintigraphy is a clinically useful test for identifying esophageal varices and risk of variceal bleeding.     

部分脾栓塞缓解门脉高压脾亢及胃底食管静脉曲张

目的 探讨部分脾动脉栓塞对缓解门脉高压并脾亢及胃底食管静脉曲张的临床疗效。方法 采用Seldinger技术经股动脉穿刺插管，超选择性脾动脉栓塞治疗肝硬化门脉高压并脾亢及胃底食管静脉曲张46例。观察治疗前后门脉压力，血液白细胞、血小板计数，肝功能及胃底食管静脉曲张的变化情况，判断其治疗效果。结果 栓塞范围为40％～90％，术后患者门脉压力明显降低，肝功能GPT下降，外周血象明显改善，血液白细胞和血小板计数升高，胃底食管静脉曲张得到缓解，上消化道再出血间期延长。无严重的并发症发生。结论 部分脾栓塞治疗肝硬化门脉高压并脾功能亢进是一种安全、有效的方法。既可以降低门脉压力，又可以减轻脾功能亢进，缓解胃底食管静脉曲张。     

Role of serotonin in development of esophageal and gastric fundal varices

AIM:To determine the effect of free serotonin concentrations in plasma on development of esophageal and gastric fundal varices. METHODS:This prospective study included 33 patients with liver cirrhosis and 24 healthy controls. Ultrasonography and measurement of serotonin concentration in plasma were carried out in both groups of subjects. The upper fiber panendoscopy was performed only in patients with liver cirrhosis. RESULTS:The mean plasma free serotonin levels were much higher in liver cirrhosis patients than in healthy controls (219.0 ± 24.2 nmol/L vs 65.4 ± 18.7 nmol/L,P < 0.0001). There was no significant correlation be-tween serotonin concentration in plasma and the size of the esophageal varices according to Spearman coefficient of correlation (rs =-0.217,P > 0.05). However,the correlation of plasma serotonin concentration and gastric fundal varices was highly significant (rs =-0.601,P < 0.01). CONCLUSION:Free serotonin is significant in pathogenesis of portal hypertension especially in development of fundal varices,indicating the clinical value of serotonergic receptor blockers in these patients.     

Surgical management of bleeding stomal varices

A retrospective chart review of nine patients with stomal varices and portal hypertension who required surgical management of bleeding varices from 1978 to 1986 was performed. The patient's mean age at stoma formation was 46 years (range, 36 to 70 years). Three were female, six were male, and all were Caucasian. Three patients had colostomies and six had ileostomies. Indications for creation of the ostomies included inflammatory bowel disease in six patients and carcinoma in three patients. The time from creation of the stoma to the first bleed was 11 to 196 months (mean, 82 months). The average time between this bleed and surgical treatment was six months. The operative procedures performed included nine mucocutaneous disconnections (MCD) in seven patients (one for recurrent bleeding) and two stoma relocations (one for recurrence). MCD is simple, quick, and associated with a lower morbidity and intraoperative blood loss than stomal relocation. Post-operative follow-up has ranged from 4 months to 4.6 years (mean, 2.5 years). During this period there were two episodes of recurrent varices that required surgery. In the select group of patients that cannot be managed conservatively, MCD is favored and relocation considered only if MCD is technically impossible. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987. The opinions expressed are those of the authors and do not reflect the opinions of the United States Air Force or the Department of Defense.     

肝硬化高危食管曲张静脉出血无创性预测指标的临床研究

目的分析血小板计数、脾脏直径、血小板计数/脾脏直径比值与肝硬化高危食管曲张静脉的关系及其临床价值。方法连续收集近3年肝硬化合并食管静脉曲张住院患者272例。出血组113例,其中行胃镜检查并明确静脉曲张分级的共94例,非出血组159例,其中101例既往无出血史。以胃镜检查发现重度食管曲张静脉和/或红色征作为高危食管曲张静脉标准,将非出血组分为高危组77例,非高危组24例。分析出血组与非出血组、高危组与非高危组之间血小板计数、脾脏直径和血小板计数/脾脏直径比值,并通过绘制受试者工作特征(ROC)曲线计算脾脏直径,预测肝硬化合并高危食管曲张静脉的敏感度、特异度、阳性预测值和阴性预测值。结果出血组与非出血组之间血小板计数、脾脏直径、血小板计数/脾脏直径比较差异均无统计学意义(P>0.05)。高危组脾脏直径大于非高危组(161.96±33.64 vs 139.15±24.29,P=0.024);经ROC曲线分析,脾脏直径预测肝硬化患者合并高危食管曲张静脉的灵敏度为87.9%,特异度为53.8%,阳性预测值为85.9%,阴性预测值为58.1%,ROC曲线下面积为0.71。结论脾脏直径可以作为预测肝硬化高危食管曲张静脉的指标,其灵敏度较好,诊断效率较高,但特异度欠佳。     

Egyptian revalidation of non-invasive parameters for predicting esophageal varices in cirrhotic patients: A retrospective study

Background and study aimsIn resource-limited countries, non-invasive tests for assessing liver fibrosis are a potential alternative to costly endoscopic screening for esophageal varices. We aimed to validate several non-invasive parameters for predicting the presence of varices.Patients and methodsBetween September 2006 and August 2017, a total of 46,014 patients who underwent upper gastrointestinal endoscopy as one of the perquisites for receiving hepatitis C virus (HCV) therapy were enrolled and divided into group I (without varices) and group II (with varices). Non-invasive parameters of fibrosis, namely Lok index, Bonacini score, liver stiffness, FIB-4, Baveno, and extended Baveno criteria, were validated.ResultsLok index, Bonacini score, liver stiffness, and FIB-4 had areas under the receiver operating characteristic curve (AUCs) of >0.6 (all P < 0.01 for the null hypothesis that the AUC was 0.5) for determination of the presence/absence of varices, with cutoff values of 0.80, 6.5, 21.9 kPa, and 2.94, and sensitivities of 74%, 74%, 66%, and 83%, respectively. The expanded Baveno VI criteria performed better than the Baveno VI criteria (spared endoscopy rate 81% versus 63%).ConclusionThe use of non-invasive methods is of limited value in predicting esophageal varices. The limited accuracy of ≤60% may delay the use of appropriate primary prophylaxis against variceal bleeding in a large proportion of cirrhotic patients.     

肝硬化食管胃静脉曲张破裂出血的相关危险因素分析

目的探讨可以评估肝硬化患者食管胃静脉曲张破裂出血风险的临床指标。方法回顾性分析572例合并食管胃静脉曲张破裂出血的肝硬化患者(观察组)及704例未发生出血的肝硬化患者(对照组)的临床资料,对两组间存在差异性的指标运用单因素和多因素Logistic回归模型进行分析。结果两组在肝功能分级状况(P0.05)、血清白蛋白(t=5.05,P=0.000)、凝血酶原时间(t=-2.80,P=0.005)、门静脉内径(t=-2.28,P=0.006)、脾脏厚度(t=-2.73,P=0.006)方面比较,差异有统计学意义。单因素非条件Logistic回归分析显示白蛋白(OR=0.944,P=0.000)、凝血酶原时间(OR=1.067,P=0.007)、门静脉内径(OR=3.423,P=0.007)、脾脏厚度(OR=1.276,P=0.007)与出血存在相关性,进一步多因素非条件Logistic回归分析提示白蛋白(OR=0.936,P=0.000)、门静脉内径(OR=4.098,P=0.013)、脾脏厚度(OR=1.275,P=0.007)是出血的独立危险因素。结论白蛋白、门静脉内径、脾脏厚度是肝硬化并发食管胃静脉曲张破裂出血的独立危险因素,对预测食管胃静脉曲张破裂出血的发生有重要的临床价值,改善白蛋白可在一定程度上减少肝硬化并发食管胃静脉曲张破裂出血的风险。     

经颈静脉肝内门体分流术治疗食道静脉曲张破裂出血

采用经颈静脉肝内门体分流术(TIPSS)治疗5例肝硬化门静脉高压症(CPH)食管静脉反复破裂出血病人,平均门静脉压力由术前3.6±0.7kPa,降至术后1.73±0.35kPa,术后24小时全部病例出血均停止,门静脉血流阻力系数降低,曲张静脉消失或减轻。TIPSS 治疗门脉高压食管静脉反复性出血具有损伤小、合并症少,近期疗效确切等特点,是治疗门脉高压食道静脉破裂出血的首选方法。     

硬化剂在肝硬化食管静脉曲张破裂出血防治中的优化应用

约50%的肝硬化患者初诊时即存在食管胃静脉曲张,尤以食管静脉曲张(EV)常见,且EV的发生率随肝脏疾病严重程度增加而增高(Child-Pugh A 43%、Child-Pugh B 71%、Child-Pugh C 76%)[1]。<5 mm的EV以每年10%的速度进展为大的EV,小EV的年出血率为5%,而大EV可达15%,EV出血后6周内死亡率高达20%[2-4]。急性EV破裂出血停止后再次出血率和死亡率较高,未进行二级预防的EV患者1~2年内再次出血率高达60%,死亡率高达33%[5]。因此EV破裂出血的防治非常重要,内镜干预在EV破裂出血的防治中起重要作用,包括内镜下静脉曲张套扎术(EVL)、内镜下硬化剂注射治疗(EIS)、自膨式金属支架等[5-6]。本文就EIS在EV破裂出血的防治作用做一述评。     

New index to predict esophageal variceal bleeding in cirrhotic patients

AIM:To develop a safe,simple,noninvasive and affordable system to predict esophageal variceal bleeding(EVB)in decompensated cirrhosis patients.METHODS:Four hundred and eighty-six patients with decompensated cirrhosis(238 males and 248 females),with a mean age of 63.1±11.2 years,were admitted to Changshu Affiliated Hospital of Suzhou University between May 2008 and March 2011.Patients enrolled in this study underwent ultrasound-Doppler(US-Doppler)to assess left gastric vein(LGV)blood flow velocity(LGVV)and blood flow direction(LGVBFD),and were evaluated by the Model For End-Stage Liver Disease(MELD)scoring system.All patients received followup evaluations every three months.The resulting data were entered into a database after each time point collection.RESULTS:Four hundred and sixteen patients com-pleted follow-up evaluations for an average of 31.6mo(range:12 to 47 mo).Fifty-one(12.3%)patients experienced EVB.The change in the MELD score over three months(ΔMELD),LGVV and LGVBFD were independently associated with EVB occurrence.MELDUS-Doppler Index(MUI),a new index,was developed and calculated using the following logistic regression equation:MUI=Logit(P)=1.667(ΔMELD)+2.096(LGVV)-3.245(LGVBFD)-1.697.The area under the receiver operating characteristic curve for prediction of EVB occurrence was significantly higher for the MUI[0.858(95%CI:0.774-0.920)]than forΔMELD[0.734(95%CI:0.636-0.817);P<0.05],LGVV[0.679(95%CI:0.578-0.769);P<0.05]or LGVBFD[0.726(95%CI:0.627-0.810);P<0.05]alone.When the MUI was set at 46,the index had high diagnostic accuracy(85.8%),with high specificity(80%)and sensitivity(87.27%).CONCLUSION:The MUI,a noninvasive and affordable index,can predict EVB occurrence in decompensated cirrhotic patients and serve as an alternative when conventional endoscopic screening is declined.     

Primary and secondary prophylaxis of esophageal variceal bleeding

Cirrhosis is a chronic condition with high-mortality. Portal hypertension (PH) is the initial and main consequence of cirrhosis and is responsible for most of its complications, including esophageal varices. A portal pressure, as determined by the hepatic venous pressure gradient (HVPG) >5 mm Hg defines PH. When the HVPG reaches 10 mm Hg or greater, the patient with compensated cirrhosis has developed clinically significant PH and is at a higher risk of developing varices and clinical decompensation. Patients with varices that have not bled are still in the compensated stage but are at a higher risk of decompensation than those without varices. Variceal hemorrhage constitutes a decompensating event, but its mortality differs whether it presents as an isolated complication of cirrhosis (20% 5-year mortality) or whether it presents in association with other complications (more than 80% 5-year mortality). While in the past, emphasis had been placed on managing the direct complications of PH, varices and variceal hemorrhage, it is now clear that these complications cannot be considered in an isolated manner. Rather, they should be considered in the context of advances in the staging of cirrhosis and other complications of cirrhosis that might occur concomitant or subsequent to the development of varices and variceal hemorrhage.     

Endoprosthetics for the treatment of esophageal leaks and fistula

Esophageal leaks, perforations, and fistula represent life-threatening complications, with a reported mortality of 12%-50% in the surgical literature. Endoscopic treatment by stenting has been reported in a large number of patients with good outcomes. The principles of this method might be described with the acronym DCWR (drain, close, water-tightness, and remove). Briefly, after the drainage of associated collections, the insertion of a self-expandable esophageal stent across the leakage region enables diversion of the esophageal contents from the wound cavity. When the stent allows water-tightness, the leak closes by second intention. Some weeks later, the stent is removed. The global sealing rate and clinical success reaches 79% and 76%, respectively, in pooled data analysis of available published cohorts. Reported mortality is approximately 11%. We reviewed the details of published cohorts emphasizing on the factors associated with endoscopic treatment success, the stent choice in respect to relative advantages and complications, the removal protocols, and development perspectives.