内镜套扎术和硬化疗法治疗食管静脉曲张破裂出血的比较研究

目的比较内镜套扎术(EVL)和硬化疗法(EIS)治疗食管静脉曲张破裂出血的疗效和安全性.方法84例肝硬化伴食管静脉曲张破裂出血患者随机分为2组,EVL组40例,EIS组44例.EVL组患者应用Stiegmann-Goff结扎设备,每次结扎间隔2周;EIS组患者在同样时间间隔内静脉内注射乙氧硬化醇.结果EVL组患者曲张静脉消除率为75.0%(30/40),EIS组为63.6%(28/44)(P＞0.05);EVL组患者曲张静脉消除期限为11.5周±6.0周,EIS组为18.0周±14.0周(P=0.036);EVL组患者出血复发率为30%(12/40),EIS组为50%(22/44)(P=0.03);EVL组5例和EIS组13例患者发生各种并发症(P＜0.005);EVL组患者食管静脉曲张复发率为52.5%(21/40),EIS组为27.3%(12/44)(P＜0.05);EVL组2例患者发生门静脉高压性胃病;EVL组7例和EIS组9例患者死亡,EVL组5例和EIS组10例患者治疗失败.结论EVL组患者食管静脉曲张消除较EIS组快,并发症发生率低,出血复发率较低但静脉曲张复发率较高,治疗后易发生门静脉高压性胃病;两组患者的死亡率和治疗失败率无显著差异,但倾向于EVL的治疗失败率较低;当选择预防静脉出血复发的内镜治疗时,EVL应为首选.     

Sequelae after Esophageal Variceal Ligation and Sclerotherapy: A Prospective Randomized Study

Objectives: Esophageal variceal ligation is a new approach to the treatment of esophageal varices that does not result in transmural tissue injury and inflammation, and therefore might produce fewer sequelae and symptoms than sclerotherapy. We conducted a prospective, randomized comparison of sclerotherapy with ligation to study the relative short-term risks of these two procedures with respect to bacteremia, pulmonary and coagulation function, esophageal motility, and gas-troesophageal reflux. Methods: Patients with previously documented high grade esophageal varices were randomized to receive sclerotherapy or ligation. Blood was drawn for culture and coagulation profiles, and patients underwent pulmonary function tests, esophageal ma-nometry, and intraesophageal pH monitoring before and after treatment. Results: Six patients with Childs class B cirrhosis and one patient with presinusoidal portal hypertension underwent 20 courses of therapy. Neither sclerotherapy nor ligation produced significant clinical changes in pulmonary or coagulation parameters, or bacteremia requiring treatment. The majority of ligation treatments were without worsening of motility or reflux scores, and none were associated with symptoms. Sclerotherapy was followed by significantly greater esophageal dysmotility and worsening reflux patterns. Conclusions: Patient acceptance of ligation was much greater than that for sclerotherapy. Our data define the advantages of ligation over sclerotherapy.     

Efficacy of Prophylactic Endoscopic Variceal Sclerotherapy in Patients with Hepatocellular Carcinoma

Abstract: A setrospective study to determine the influence of prophylactic endoscopic sclerotherapy on the survival rate of patients with hepatocellular carcinoma complicated by esophageal varices was conducted. The subjects included 132 patients without esophageal varices at the time of diagnosis (NV group), 37 patients with hepatocellular carcinoma for whom prophylactic sclerotherapy had been performed for risky esophageal varices (PS group) and 26 patients with hepatocellular carcinoma and risky varices for whom prophylaxis was not performed (NPS group). Multiple regression analysis was used to identify factors affecting the survival rate of the 132 patients without esophageal varices. A tumor embolus in the primary branch or main trunk of the portal vein adversely affected long-term survival in these patients. The patients were further divided into 2 subgroups, namely those with (Vp3) and without (Vp0-Vp2) tumor emboli in the main trunk and primary branch of the portal vein. In the Vp0– Vp2 emboli subgroup, the patients who received prophylactic sclerotherapy and the patients without varices had similar survival rates. Patients without prophylactic sclerotherapy had a significantly shorter survival rate than the group without varices and the prophylactic sclesotherapy group (p<0.01 and p<0.05). A significant bleeding rate was observed in the group without prophylaxis and not in the group with prophylaxis. However, in the Vp3 subgroup, the survival rate in each group was identical. Thus prophylactic variceal sclerotherapy is indicated for patients with hepatocellular carcinoma who do not have tumor emboli in the main trunk or primary branch of portal vein.     

Complications of Endoscopic Injection Sclerotherapy: A Review

As endoscopic injection sclerotherapy becomes more widely applied to the treatment of bleeding esophageal varices, an increasing number of complications are being reported. Dysphagia, chest pain, and fever are usually transient and incosequential but may herald more serious life-threatening sequelae. Mortality commonly results from the major complications of recurrent bleeding, perforation, sepsis, and respiratory disorders. We carried out a review of sclerotherapy complications to understand their basis and to determine what measures can be taken to prevent or manage them.     

经内镜结扎和硬化剂治疗食管静脉曲张和门脉高压性胃病的疗效及预后

目的：观察经内镜结扎和硬化剂治疗食管静脉曲张的疗效及对门脉高压性胃病（PHG）的影响。方法;对92例患者随机分为套扎组（n=43)和硬化剂（n=49),分别在治疗后1－3月和1－3年内复查。观察静脉曲张及PHG的转归情况。结果：1－3月内复查套扎组完成26例,其中食管静脉曲张根除12例,曲张减轻12例,无效2例,PHG加重17例。硬化剂组完成29例,其中静脉曲张根除4例,曲张减轻22例,无效3例,PHG加重11例。1－3年内复查套扎组和硬化剂组的再曲张率及再出血率分别为61．5％、46．7％和44．4％．33．3％。结论：近期套扎治疗在根治静脉曲张方面优于硬化剂注射,但更易诱发和加重PHG。而套扎组和硬化剂组远期均可出现再曲张和再出血。两组比较无差异。     

内镜治疗食管静脉曲张对门脉高压性胃病的影响

探讨内镜下硬化剂(EST)和套扎(EVL)治疗食管静脉曲张术后对门脉高压性胃病(PHG)和胃底静脉曲张(GV)的影响,对21例注射硬化剂治疗和27例套扎治疗的共48例患者进行了1年的内镜随访,观察PHG和GV的程度。结果在接受治疗3个月和1年后,PHG发生率较治疗前(35％,17/48)明显增加,分别为75％(36/48)和87％(42/48);GV较治疗前(17％,8/48)增多,分别为33％(16/48)和43％(21/48)。结论:食管静脉曲张的内镜下硬化剂和套扎治疗将加重PHG和GV且有可能增加PHG和GV的出血机会。     

Endoscopic Intravariceal Injection Sclerotherapy with 5% Ethanolamine in 187 Acute Oesophageal Variceal Bleeding Patients

One hundred and eighty seven patients (161 males and 26 females) with endoscopically proven active variceal bleeding underwent endoscopic sclerotherapy by the intravariceal method (EST). All of the patients were cirrhotic and 37.4 percent (70/187) had associated underlying diseases. The patients' status before EST, according to Child-Turcotte's classification, were class A % 6.4%, class B = 49. 7%, and class C = 43% respectively. An intravariceal injection with 4 ml of ethanolamine oleate per varix through an Olympus fiberoptic scope was performed. Then sclerotherapy sessions required for each patients was different. Seventy four percent (138/187) required only one session. Neither a compression balloon nor sliding tube after injection were used. Bleeding was arrested in all cases after this method. The results revealed that recurrent bleeding developed in 17.6 percent of the patients (33/187) and occurred between one day (one case) to two years afer EST. Hemorrhagic gastritis (22/187) was the major cause of post sclerotherapy bleeding. Complications related with EST in this report occurred in two patients (1.06 percent). The first case had a low grade fever after treatment which spontaneously subsided on day three after EST without any specific medication. The other one had oesophageal perforation and died with severe post operative sepsis.     

Prediction of Variceal Hemorrhage: A Prospective Study

Prophylactic therapy to prevent the first variceal hemorrhage ceased being recommended for any cirrhotic because risks outweighed benefits. In this study, we identified cirrhotics that have never bled who are most prone to hemorrhage from varices. We developed a numerical grading system which combined size with other endoscopic characteristics, so varices would get an aggregate grade of 1 to 10. Varices were classified as either high grade (scored greater than or equal to 8) or low grade (scored less than or equal to 7). The grading system had a predictive value for bleeding when studied prospectively for a mean duration of 26 months in 52 patients subjected to placebo (15 patients) or various treatments (37 patients) in a randomized trial. High grade varices had a significantly higher association with bleeding than did low grade varices; 73% versus 7% (p less than 0.001) analyzing all 52 patients (of which 21% bled), and 83% versus 11% (p less than 0.05) analyzing the 15 placebo-treated patients (of which 40% bled). An esophagram positive for varices proved to be a sensitive screen for high grade varices, picking up 91% of them. However, it was a poor predictor of bleeding (one-third bled), since only 45% of radiologically evident varices were high grade. Since almost all cirrhotics with high grade varices can be expected to bleed within 2 yr, this group should be the focus of controlled trials to determine whether low risk prophylactic therapies reduce the incidence of first variceal hemorrhage.     

Sclerosants for Variceal Sclerotherapy: A Critical Appraisal

Endoscopic sclerotherapy is a well-accepted technique for the treatment of variceal bleeding. It is carried out by injecting a sclerosant into or around a varix. Sclerosants are oily or aqueous chemicals which produce sclerosis, depending on their necroinflammatory and thrombotic properties. The safety and efficacy of various sclerosants has been evaluated in experimental and human studies. However, due to the presence of a large number of variables, conflicting results have been reported. Based primarily on anecdotal experiences, sodium tetradecyl sulfate, ethanolamine oleate, polidocanol, and alcohol appear to be potent and safe sclerosants. There is great need to perform double-blind trials to identify ideal sclerosant(s) with optimum thrombogenic and minimum necroinflammatory properties.     

Sequential Esophageal Motility Studies after Endoscopic Injection Sclerotherapy: A Prospective Investigation

To assess prospectively the effects of endoscopic intravariceal sclerosis (EIS) on esophageal function, we performed esophageal manometry on 13 cirrhotic patients before EIS, 24 h after the second session and 4 wk after the fourth session. EIS had no impact on lower esophageal sphincter pressure. However, a significant decrease in the amplitude of peristaltic waves was observed immediately post-EIS in the lower two-thirds of the esophagus. There was no modification of duration or velocity of progression of peristaltic waves. A four-fold increase in simultaneous contractions was observed early after EIS. These changes were reversible, as assessed by late esophageal testing after EIS. No correlations were demonstrated between esophageal motor parameters and doses of sclerosant. We conclude that sclerosant injection into the esophageal wall acutely impairs esophageal motility, but motor function is partially restored 4 wk after completion of EIS, suggesting that dysmotility is reversible.     

Development of Squamous Cell Carcinoma of the Esophagus after Endoscopic Variceal Sclerotherapy

We describe the case of a 45-yr-old white male with portal hypertension and presumed Laennec's cirrhosis who developed squamous cell carcinoma of the esophagus 8 months after completion of a course of endoscopic variceal sclerotherapy. The epidemiology and natural history of esophageal cancer and their relationship to our patient are analyzed. This report emphasizes that squamous cell carcinoma of the esophagus should be considered in the differential diagnosis of postsclerotherapy dysphagia. Further studies will be required to determine whether or not esophageal variceal sclerotherapy is associated coincidently or causally with the development of squamous cell carcinoma of the esophagus in patients at increased risk for this condition.     

Complete Esophageal Obstruction Secondary to Dissecting Intramural Hematoma after Endoscopic Variceal Sclerotherapy

Endoscopic variceal sclerotherapy (EVS) is an accepted alternative to surgery in many patients with bleeding esophageal varices. Esophageal ulceration is a common sequelae of EVS with chest pain, stricture, and perforation occurring less frequently. We present a patient with Laennec's cirrhosis and coagulopathy who developed an obstructing esophageal hematoma caused by submucosal dissection after two EVS treatments.     

奥曲肽预防食管静脉曲张硬化治疗后早期再出血的临床研究

背景：食管静脉曲张破裂出血患者经食管静脉曲张硬化治疗（EVS）后再出血发生率仍较高．是导致肝硬化门静脉高压患者死亡的重要原因之一，尤其是早期再出血。奥曲肽能降低门静脉压力。与EVS联合应用可能降低早期再出血发生率。目的：了解EVS加用奥曲肽后降低早期再出血发生率的情况，探讨影响早期再出血发生的因素。方法：80例食管胃静脉曲张患者被随机分为试验组和对照组，每组40例。两组患者均予择期或急诊EVS．根据食管静脉曲张消失情况行3～5次EVS，每隔7d治疗1次，静脉曲张消失或基本消失为一疗程结束。试验组于第1、2、3次EVS术后第4～6d加用奥曲肽治疗。结果：试验组EVS后有1例发生早期再出血，发生率为2．5％．对照组有7例发生早期再出血，发生率为17．5％，试验组早期再出血发生率显著低于对照组（P=0．028）。Logistic逐步回归分析显示奥曲肽对早期再出血发生率有显著影响（P=0．049）。结论：EVS联合奥曲肽治疗可降低EVS后早期再出血发生率。     

The Effects of Endoscopic Sclerotherapy Combined with Transhepatic Variceal Obliteration on Portal Hemodynamics

We studied the effects of endoscopic sclerotherapy with transhepatic variceal obliteration on portal hemodynamics in 20 patients with cirrhosis (six with a spontaneous splenorenal shunt and 14 without it). Portal venous flow 1 month after combined therapy (measured by pulsed Doppler flowmeter) was significantly increased compared with that before therapy (n = 20, 843 +/- 339 vs. 669 +/- 253 ml/min, p less than 0.001). Portal vein catheterization and portal venous flow measurement were repeated 18 months after therapy in eight patients without a splenorenal shunt before therapy and in two patients with a splenorenal shunt before therapy. Two of the former developed a splenorenal shunt. In these 10 patients, portal venous flow before, one month, and 18 months after therapy was 617 +/- 219, 784 +/- 227, and 720 +/- 224 ml/min, respectively, and in 8 of 10 patients the portal venous flow at 18 months remained similar to the values at one month. Portal vein pressures were not significantly elevated 18 months after therapy (35.4 +/- 6.4 vs. 33.6 +/- 5.1 cm H2O) and the mean portal vein pressure change was 2.75 cm H2O (range -6 to +7.5 cm H2O). To summarize, portal venous flow was significantly increased one month after combined sclerotherapy in cirrhotics, the portal venous flow at 18 months remained similar to the values at 1 month in most patients, and the change in portal vein pressure after therapy was small.     

Efficacy of Octreotide and Sclerotherapy in the Treatment of Acute Variceal Bleeding in Cirrhotic Patients: A Prospective,Multicentric, and Randomized Clinical Trial

Background: Sclerotherapy is the most widely used method for treatment of acute variceal bleeding. Previous reports have suggested that octreotide infusion is as effective as sclerotherapy. Our aim was to investigate the efficacy and safety of octreotide in comparison with sclerotherapy in controlling variceal bleeding. Methods: Seventy-six cirrhotic patients were randomized to receive either sclerotherapy (n = 37) or octreotide (n     

Combination Endoscopic Band Ligation and Sclerotherapy Compared with Endoscopic Band Ligation Alone for the Secondary Prophylaxis of Esophageal Variceal Hemorrhage: A Meta-Analysis

Endoscopic band ligation (EBL) is the community-accepted standard therapy for the secondary prophylaxis of esophageal variceal hemorrhage. Recent data indicate that combination EBL and sclerotherapy may be a more effective therapy than EBL alone. Yet existing data are conflicting. We therefore performed a meta-analysis to compare the efficacy and safety of EBL and sclerotherapy versus EBL alone for the secondary prophylaxis of esophageal variceal hemorrhage. We performed a systematic review of two computerized databases (MEDLINE and EMBASE) along with manual-searching of published abstracts to identify relevant citations without language restrictions from 1990 to 2002. Eight studies met explicit inclusion criteria. We performed meta-analysis of these studies to pool the relative risk for the following outcomes: esophageal variceal rebleeding, death, number of endoscopic sessions to achieve variceal obliteration, and therapeutic complications. There were no significant differences between EBL and sclerotherapy versus EBL alone in the risk of esophageal variceal rebleeding (RR = 1.05; 95% CI = 0.67–1.64; P = 0.83), death (RR = 0.99; 95% CI = 0.68–1.44; P = 0.96), or number of endoscopic sessions to variceal obliteration (RR = 0.23; 95% CI = 0.055–0.51; P = 0.11). However, the incidence of esophageal stricture formation was significantly higher in the EBL group than in the sclerotherapy group. There is no evidence that the addition of sclerotherapy to endoscopic band ligation changes clinically relevant outcomes (variceal rebleeding, death, time to variceal obliteration) in the secondary prophylaxis of esophageal variceal hemorrhage. Moreover, combination EBL and sclerotherapy had more esophageal stricture formation than EBL alone.     

The Rebleeding Course and Long-Term Outcome of Esophageal Variceal Hemorrhage after Ligation: Comparison with Sclerotherapy

Background: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation and compare it with that after sclerotherapy. Methods: One hundred and eighty-five liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were randomized to undergo endoscopic variceal sclerotherapy or ligation. These patients received regular follow-up and detailed clinical assessment. Results: Two patients developed hepatoma within 6 months of entry in each group and were excluded. Another six patients in the sclerotherapy group and seven patients in the ligation group were excluded because of poor compliance or lost to follow-up. Therefore, 84 patients in each group were analyzed. In this long-term follow-up (55.3 - 12.5 months) the rebleeding rate for ligation was lower than that for sclerotherapy, regardless of whether the rebleeding was analyzed by patient number or Kaplan-Meier analysis. With regard to the rebleeding risk of various periods, the sclerotherapy risk was higher than that of ligation within 4 weeks of the initial endoscopic treatment or before variceal eradication. Multifactorial analysis showed hematemesis, poor hepatic function, and sclerotherapy were the risk factors determining rebleeding. The annual hepatocellular carcinoma incidence was 4.9%. There was no difference in survival between sclerotherapy and ligation. Multifactorial analysis showed that poor hepatic function was the only factor determining survival. Conclusions: The rebleeding risk was higher in sclerotherapy than in ligation before variceal eradication, especially within 4 weeks of the initial endoscopic treatment. Long-term survival was dependent on hepatic reserve regardless of the treatment method.