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.     

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     

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。     

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。     

The epidemiology and pathogenesis of gastrointestinal varices

Gastrointestinal varices are a consequence of portal hypertension that can occur in the setting of cirrhosis or extrahepatic portal vein obstruction. Increased intrahepatic vascular resistance, a hyperdynamic circulation, and increased flow through the portal and collateral venous system lead to persistently elevated portal pressures that result in angiogenesis and formation of collaterals between the portal and systemic circulation. Despite this physiological attempt at decompression, portal hypertension persists as collateral vessels have higher resistance than the normal liver. Variceal wall tension is the main factor that determines vessel rupture and bleeding occurs when tension in the wall exceeds the limit of elasticity of the vessel. Progressive distension leads to increasing resistance to flow and hemorrhage ensues when the limits of resistance to further dilation are surpassed. Gastroesophageal varices are present in 50% of patients with cirrhosis and progress in size at a rate of 8%-10% per year. Hemorrhage occurs at a rate of approximately 12% per year and large esophageal varices carry a higher risk of rupture. Gastric varices occur in 20% of patients with portal hypertension and bleed less frequently, but more severely. Cardiofundal varices have a complex vascular anatomy that is important to consider as it pertains to the effectiveness of strategies used for management. Ectopic varices make up 2%-5% of all variceal bleeding, occur more frequently in patients with extrahepatic portal hypertension, and their identification should prompt assessment of the intra-abdominal vasculature. Varices in the setting of splenic vein thrombosis should be considered a distinct entity owing to their disparate etiologic basis and treatment approach.     

门脉高压患者内镜下胃静脉曲张分类及其发病分析

目的 对肝硬化患者内镜下胃静脉曲张进行分类，并分析其出血的好发因素。方法 确诊肝硬化门静脉高压患者139例，采用Soehendra和Sarin标准进行食管-胃静脉曲张分类，分析各类型的发生率、出血率、静脉曲张间的关系及出血与肝功能的关系。结果胃静脉曲张的发生率为35％，以GOV1发生率最高，多见于重度食管静脉曲张患者；胃静脉曲张出血率为12％，见于肝功能B级以上患者及GOV2和IOV1，显著低于食管静脉曲张出血率，食管静脉曲张出血见于中度以上静脉曲张、肝功能B级以上患者。结论胃静脉曲张在中国人群中有较高的发病率，出血多发生于胃底部位的曲张静脉，与肝功能差有关；食管静脉曲张出血发生率高于胃静脉曲张，与曲张静脉和肝功不良严重程度有关。     

胃静脉曲张:临床及内镜特征初探

目的 初步观察胃静脉曲张的临床及内镜特征。方法 回顾分析10年来我院资料完整的胃静脉曲张（GV）85例,并与同期仅有食管静脉曲张（EV）196例对照。结果 GV的检出率占同期静脉曲张的30．2％,其中胃食管静脉曲张I型（GOV－1）占74．1％,GOV－Ⅱ型占22．4％,单纯胃静脉曲张I型（IGV－I）占2．4％,IGV－Ⅱ型占1．2％。GOV型GV的病因以肝硬化门脉高压最多见,IGV型GV主要见于非肝硬化节段性门脉高压;GV的各型的检出率与肝功能Child分级无关,GV合并门脉高压性胃病（PHC）发生率高于EV（P＜0．01）。GOV－Ⅱ较GOV－I合并PHG的检出率高、程度重,GOV－Ⅱ较GOV－I合并EV的程度重;而GV的出血率显著低于EV（P＜0．01）。结论 Sarin分类法简单、实用,适合国内推广应用。GV并非少见,检出率占全部静脉曲张的30．2％,其中,GOV－I最多见,GOV－Ⅱ次之,IGV较少,而GV出血较EV少见。     

Portal-hypertensive gastropathy develops less in patients with cirrhosis and fundal varices

Background/Aims: The aim of this prospective study was to examine the association of portal-hypertensive gastropathy and fundal varices in patients with cirrhosis.Methods: We carried out an endoscopic observation in 476 patients with cirrhosis (study 1), including 62 patients undergoing endoscopic obliteration of esophageal varices (study 2). In study 1, patients were classified into five subgroups: no esophagofundal varices (n=119), small esophagofundal varices (n=127), dominant esophageal varices (n=177), dominant fundal varices (n=27), and large esophagofundal varices (n=26). The severity of liver dysfunction was assessed by Pugh-Child classification: class A (n=222), class B (n=200), and class C (n=54). In study 2, two groups, poorly developed fundal varices (n=50) and well developed fundal (n=12), were distinguished and the follow-up endoscopic examinations were performed on the basis of 3-month intervals for 2 years. In each study, the severity of portal-hypertensive gastropathy was scored: 0 (absent), 1 (mild), 2 (severe), and 3 (bleeding).Results: Study 1: One-way ANOVA showed that both variceal pattern and Pugh-Child class significantly influenced portal-hypertensive gastropathy score. However, two-way ANOVA indicated that variceal pattern was the only significant variable. Portal-hypertensive gastropathy score was significantly higher in patients with dominant esophageal varices than in either patients with no esophagofundal varices or patients with small esophagofundal varices. In contrast, portal-hypertensive gastropathy score in patients with dominant fundal varices was similar to that in patients with no esophagofundal varices and was significantly lower compared with that in patients with dominant esophageal varices. Furthermore, portal-hypertensive gastropathy score was significantly lower in patients with large esophagofundal varices than in patients with dominant esophageal varices. Study 2: After the obliteration of esophageal varices, portal-hypertensive gastropathy score in patients with poorly developed fundal varices became significantly higher at 3-, 6-, 9-months while it was not modified in patients with well developed fundal varices during the follow-up period. Furthermore, the integrated incremental change in portal-hypertensive gastropathy score during the first 1-year follow-up period was significantly lower in patients with well developed fundal varices than in patients with poorly developed fundal varices.Conclusions: These results indicate that both spontaneous and obliteration-induced portal-hypertensive gastropathy lesions develop less in patients with cirrhosis and fundal varices.     

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。     

Update on management of gastric varices

Gastric varices(GV) have different physiology and clinical characteristics compared to oesophageal varices(OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies' recommendations are based are scrutinised in this review and areas of research are identified.     

Update on the management of gastrointestinal varices

Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.     

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。     

Sonographic gallbladder wall thickness measurement and the prediction of esophageal varices among cirrhotics

Acute variceal bleeding in patients with liver cirrhosis and portal hypertension (PHT) is the most serious emergency complication among those patients and could have catastrophic ‎outcomes if not timely managed. ‎Early screening by esophago-gastro-duodenoscopy (EGD) for the presence of esophageal varices (EVs) is ‎‎currently recommended by the practice guidelines for all cirrhotic patients. Meanwhile, EGD is not readily accepted or preferred by many patients. The literature is rich in ‎studies to investigate and validate ‎ non-invasive markers of EVs prediction aiming at reducing the unneeded endoscopic procedures. Gallbladder (GB) wall thickness (GBWT) ‎measurement has been found promising in many published research ‎articles. We aim to highlight the validity of sonographic GBWT measurement in the ‎prediction of EVs based on the available evidence.‎ We searched databases including Cochrane library, PubMed, Web of Science and many others for relevant articles. GBWT is associated with the presence of EVs in cirrhotic patients with PHT of different etiologies. The cut-off of GBWT that can predict the presence of EVs varied in the literature and ranges from 3.1 mm to 4.35 mm with variable sensitivities of 46%-90.9% and lower cut-offs in viral cirrhosis compared to non-viral, however GBWT > 4 mm in many studies is associated with acceptable sensitivity up to 90%. Furthermore, a relation was also noticed with the degree of varices and portal hypertensive gastropathy. Among cirrhotics, GBWT > 3.5 mm predicts the presence of advanced (grade III-IV) EVs with a sensitivity of 45%, the sensitivity increased to 92% when a cut-off ≥ 3.95 mm was used in another cohort. Analysis of these results should carefully be revised in the context of ascites, hypoalbuminemia and other intrinsic GB diseases among cirrhotic patients. The sensitivity for prediction of EVs improved upon combining GBWT measurement with other non-invasive predictors, e.g., platelets/GBWT.     

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.     

食管静脉曲张内镜气囊测压的临床价值

目的初步探讨食管静脉曲张内镜气囊测压的临床价值。方法采用Ｔｒｅｉｅｒ公司生产的食管曲张静脉测压仪（ＥＶＭ），由２名操作者分别对２６名肝硬化食管静脉曲张患者进行食管曲张静脉测压，同时测定相应的肝功能指标。结果２６名患者中２３名测压成功，无副反应；测量值变异系数为７．１８％±２．６４％；两操作者之间测压值呈显著相关性（ｒ＝０．８３５Ｐ＜０．００１）；有红色征和（或）有曲张静脉出血史者测压值明显升高（Ｐ＜０．０１）；曲张静脉压力与曲张静脉直径、Ｃｈｉｌｄ－Ｐｕｇｈ分级之间无明显相关性。结论内镜气囊测压技术无创伤，安全，无副反应，简便易行，重复性较好，对预测曲张静脉出血风险及药物降压疗效的评估有一定的临床价值。     

Endoprosthetics for bleeding esophageal varices

Refractory esophageal hemorrhage and early rebleeding following endoscopic therapy remain challenging conditions to treat and are associated with a high mortality. Techniques such as balloon tamponade (BT) and transjugular intrahepatic portosystemic shunt (TIPS) are highly effective at controlling refractory bleeding, but they can be associated with a high rate of complications and, in the case of TIPS, may not be immediately available outside specialist centers. Recently, removable self-expanding metal stents (SEMSs) have been introduced in clinical practice for the management of esophageal variceal bleeding. SEMSs control bleeding by tamponade of varices in the distal esophagus and can remain in situ for a number of days, thus preventing early rebleeding. The use of SEMSs does not require the transfer of the patient to a specialist center, and unlike TIPS, it is not associated with deterioration in liver function. The use of SEMSs has been described in small series of patients with refractory bleeding. These series report high rates of hemostasis with low complication rates, suggesting that SEMSs may have an important role in the management of refractory bleeding either as an alternative to BT or where TIPS is contraindicated. SEMSs may also have a role in treating complications of therapy for bleeding esophageal varices, such as postbanding ulceration and BT-induced esophageal tears. The aim of this review is to summarize the published data on the efficacy of SEMSs and suggest future studies that may clarify its role in the management of esophageal variceal hemorrhage.     

应用正丁基-2-氰丙烯酸盐经门静脉硬化治疗胃底静脉曲张

目的 探讨应用正丁基-2-氰丙烯酸盐(NBCA)经门静脉硬化治疗胃底静脉曲张(GFV)的临床疗效及安全性. 方法经胃镜确诊为GFV的21例门静脉高压症患者接受了经门静脉硬化治疗,所有患者采取经皮经肝或经脾穿刺门静脉造影及供血静脉造影,然后用微导管插管到曲张静脉内,注入硬化剂NBCA和碘化油混合乳剂(NBCA LP).对8例伴有高流量胃肾分流者,治疗前经股静脉、左肾静脉放置阻塞球囊导管于分流道,治疗时扩张球囊阻塞分流道.随访评价包括血清肝功能指标变化、内镜复查及再出血情况. 结果 20例GFV成功进行硬化治疗(95.2%);未成功的1例,为高流量胃肾分流者,术中因未有阻塞球囊导管,未能进行治疗.5例少量NBCA-LP进入到肺动脉,2例出现一过性刺激性咳嗽,2例发生门静脉分支栓塞.术后6个月,血清ALT、白蛋白、凝血酶原时间明显改善,血清总胆红素变化不明显.15例患者3个月胃镜复查,GFV消失10例,好转4例,有效率93.3%(14/15),3例食管静脉曲张较术前加重(20.0%).平均随访(16.7±8.8)个月,再出血4例,1年累积再出血率为9.52%.结论 应用NBCA经门静脉硬化治疗是控制GFV破裂出血的安全有效方法,微导管技术、球囊逆行阻塞胃肾分流道技术是提高疗效、防止肺栓塞的关键.     

内镜下组织黏合剂预防食管胃底静脉曲张出血的影响因素及疗效分析

目的 调查内镜下组织黏合剂治疗肝硬化食管胃底静脉曲张(GOV)患者的预后情况,评价各种因素对治疗后出血的影响.方法 回顾性分析157例内镜下组织黏合剂治疗或组织黏合剂联合套扎治疗的肝硬化GOV出血或中重度GOV患者.调查入选时患者的基本情况、肝功能状况及血液生物化学指标等.采用Kaplan-Meier法分析治疗后再出血情况,运用Log rank检验进行生存曲线的比较,采用Logistic逐步回归模型的方法进行多因素分析,运用受试者工作特征曲线及曲线下面积(AUC)评判预后预测指标.结果 157例患者中,26例发生再出血,中位再出血时间为3.4个月.单因素分析显示,FIB4评分(Z=-1.282,P=0.100)及门静脉右支内径(Z=-1.812,P=0.035)在出血组和未出血组间差异有统计学意义.多因素分析显示,门静脉右支内径是再出血的独立影响因素(OR=1.733,95％CI:1.045～2.874,P=0.033),且8.5mm为最佳诊断阈值(AUC=0.724,95％CI:0.537～0.910),敏感度为77.8％,特异度为66.6％.结论 门静脉右支内径是影响组织黏合剂预防出血和预后的重要因素之一,FIB4评分对预测治疗后复发或出血有一定的参考价值.