食管静脉曲张治疗后复发出血的临床分析

探讨食管静脉曲张硬化治疗后复发出血的规律及有关因素。对２６０例肝硬化食管静脉曲张硬化治疗后患者，追随观察６到７２个月，对反复出血的５５例患者进行临床分析。本组复发出血率为２１．２％，一年内复发出血占６９％，５２例再次接受硬化治疗，急诊止血率为９６．１％。追随期中，死亡８例，其中３例死于出血。存活４７例，生存期１～６年。结论：１．复发出血与肝功能、门静脉主干宽度无明显关系，而与静脉曲张消失和基本消失率低以及其他门体静脉侧支未建立有关。２．复发出血者小中量占多数。３；对复发出血的规律及如何预防复发出血作了简要讨论。     

SUCCESSFUL ENDOSCOPIC HEMOSTASIS FOR RUPTURED DUODENAL VARICES AFTER BALLOON‐OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION

A 75‐year‐old man with general malaise and appetite loss was transferred to our hospital for assessment and treatment of liver failure. Laboratory findings on admission showed anemia, and gastroduodenoscopy (GDS) revealed linear esophageal varices and tensive duodenal varices (DV) in the second portion of the duodenum. Systemic examinations did not reveal any significant lesion capable of explaining his anemia, except for DV. Balloon‐occluded retrograde transvenous obliteration was carried out to prevent DV bleeding. Good pooling of sclerosant was observed using two balloon catheters. However, contrast‐enhanced computed tomography after the procedure revealed no thrombosis in DV, and the patient complained of tarry stools before additional therapy. Emergent GDS revealed ruptured DV with fresh blood and erosions on the surface. Emergent endoscopic obliteration using the tissue adhesive N‐butyl‐2‐cyanoacrylate was carried out and complete hemostasis was achieved. Although no rebleeding episodes were observed after emergent obliteration, the patient died of sepsis following spontaneous bacterial peritonitis 53 days after admission. Autopsy revealed that DV dropped out, and the deep vein was replaced by granulation tissue. No signs of thrombi were detected, except varices. This autopsy case revealed the difficulty in DV management.     

230例食管胃静脉曲张出血患者急诊硬化治疗

总结２３０例食管胃静脉曲张出血患者２８３次急诊硬化治疗（ＥＩＳ）的经验。２３０例出血患者于出血后２４小时内行２８３次ＥＩＳ，采用５％鱼肝油酸钠或１％乙氧硬化醇，食管胃静脉内注射法。２８３例次中活动性出血２５３例次，３０例次出血已停止，首次ＥＩＳ能明确出血部位共１４２例次，为６３％（１２８／２５３）。急诊止血率为９６．４％，并发症２０例，发生率８．６％，ＥＩＳ并发症引起的死亡４例，死亡率为１．７％。ＥＩＳ是食管胃静脉曲张出血的一种有效治疗方法，适应证宽，方法简便、安全。     

CLINICAL CHARACTERISTICS AND TREATMENT FOR PATIENTS PRESENTING WITH BLEEDING DUODENAL VARICES

Background and Aim: Bleeding from ectopic varices, including duodenal varices, is uncommon, but it can be difficult to manage. The clinical data of patients diagnosed and treated for duodenal varices were reviewed to investigate the strategy for treatment. Methods: The present study reviewed the clinical data of 10 patients with duodenal varices (mean age, 58.2 ± 15.6 years) at our associated institutes during the period between January 1996 and December 2008. Results: Nine patients had duodenal varices located in the second portion, whereas in one case they were located in the duodenal bulbus. The underlying diseases included liver cirrhosis in eight patients, and extrahepatic portal vein obstruction in two patients. The lesions were identified with bleeding from varices in eight of 10 patients. Initial hemostasis was achieved in all eight patients. However, among four patients treated endoscopically only, two patients died from rebleeding from varices and two died from hepatic failure resulting from variceal bleeding. Additional interventional radiology (IVR) was used in three patients and additional surgery was carried out in one case. One patient who was treated with balloon‐occluded retrograde transvenous obliteration rebled during IVR and died from bleeding. Two patients who underwent double balloon‐occluded embolotherapy and one case who had surgery achieved good clinical outcomes. Conclusions: Although endoscopic treatment is useful for initial hemostasis of hemorrhagic duodenal varices, the patients who underwent additional IVR after endoscopic treatment achieved good outcomes.     

食管静脉曲张硬化疗法的长期疗效观察

对５４２例肝硬化并发食管静脉曲张患者行硬化剂治疗，随访１～７年，平均为３．９年。按所用硬化剂不同分四组：（１）５％鱼肝油酸钠８１例；（２）纯酒精６７例；（３）混合剂（鱼肝油酸钠加纯酒精）２０９例；（４）混合剂加服汉防己甲素１８５例。结果：急性出血止血率９５．５％，曲张静脉消失率１２１例（２２．３％），完全消失仅２２例。止血效果四组间无差异。静脉曲张消失以３、４组为高（Ｐ＜０．０５）。失访２３例，改外科治疗７０例。累计再出血率为１４．７％，死亡９５例，占随访４４９例２１．１％。直接死于再发出血３４例。随访期生存例数３５４例（７８．８％）。本文提示硬化剂治疗食管静脉曲张急性出血止血率高，但曲张静脉消失率仍低，若加服汉防己甲素并结合外科治疗能提高病人生存率。     

ENDOSCOPIC ULTRASONOGRAPHY FINDINGS AND CLINICAL BACKGROUNDS IN CASES WITH EARLY RECURRENCE OF ESOPHAGEAL VARICES AFTER ENDOSCOPIC INJECTION SCLEROTHERAPY

Aims: To investigate the factors affecting early recurrence of esophageal varices after endoscopic injection sclerotherapy (EIS). Subjects and Methods: Forty‐four cases with esophageal varices were examined by esophagogastroscopy and endoscopic ultrasonography (EUS) 2 months after EIS. Cases with and without red color (RC) signs evaluated within 1 year after EIS were classified as Early Recurrent Group (ERG) and Non‐Early Recurrent Group (N‐ERG), respectively, and compared with EUS images and clinical backgrounds. Results: Compared with ERG (17 cases), N‐ERG (27 cases) had significantly higher detection rates of cardiac intramural veins (CV) and esophageal intramural veins (EV), larger maximum diameters of CV and EV, and higher numbers of CV (P < 0.05). The detection rates of gastric perforating veins (GPV)—but not esophageal perforating veins (EPV), paragastric veins (PGV), or paraesophageal veins (PEV)—correlated with recurrence of varices (P < 0.05). ERG differed in age, gender, γ‐glutamyltranspeptidase (GTP), and detection rates of portosystemic (PS) shunts from N‐ERG (P < 0.05). Age, serum alanine aminotransferase (ALT) and γ‐GTP level, detection rates of PS shunt, maximum diameters of CV and EV, numbers of CV, and GPV‐positive case differed (P < 0.10) by univariate analysis, and maximum diameters (hazard ratio (HR)), 7.16: 95% CI [1.45–35.33]; P = 0.016) and numbers (HR, 1.96: 95% CI, [1.02–3.75]; P = 0.043) of CV differed significantly between the two groups by multivariate analysis. Conclusions: EUS is useful in predicting recurrence of esophageal varices after EIS, and the degree of the development of CV is the most important critical factor for early recurrences.     

善得定治疗食道静脉曲张破裂出血的疗效评价

经胃镜诊断４４例食道静脉曲张破裂出血患者，随机分成善得定治疗组（２２例）和垂体后叶素对照组（２２例）结果止血率／２４ｈｒ，治疗组为９０．９％，对照组为６６．７％，两组差异显著（Ｐ〈０．０１），副作用方面如头痛，胸痛，腹痛，治疗组仅１例（８．２％），对照组１Ｃ组（４５．５％），两组差异有显著性意义（Ｐ〈０．０１）。     

ENDOSCOPIC LIGATION BY DETACHABLE SNARE FOR THE HEMOSTASIS OF COLONIC BLEEDING FOLLOWED BY SUCCESSFUL LIVER TRANSPLANTATION

A 40‐year‐old male patient with liver cirrhosis developed hematochezia resulting in hepatic encephalopathy. Colonoscopic examination revealed a large, approximately 4.0 cm‐sized villous adenoma in the sigmoid colon which showed diffuse blood oozing. We succeeded in the control of bleeding from the lesion only with a detachable snare. The patient recovered from hepatic encephalopathy and may have an opportunity for liver transplantation. Fortunately, the patient regained normal liver function after a successful liver transplantation.     

奥曲肽降低食管曲张静脉压力及减少硬化剂注射针孔出血的临床研究

１０例肝硬化食管静脉曲张患者内镜直视下硬化剂注射针穿刺入曲张静脉内直接测压，继而外周静脉内推注奥曲肽（Ｏｃｔｒｅｏｔｉｄｅ）０．ｌｍｇ，测定其后１０分钟曲张静脉内压力变化。２０例患者静脉注射奥曲肽０．１ｍｇ，约１０分钟后行食管曲张静脉内硬化剂注射治疗，观察注射针孔出血情况并与２６例单纯硬化剂注射组作比较。结果表明奥曲肽静脉注射后１分钟内，所有用者均有效地降低曲张静脉内压力，１０分钟内平均降低５１％（１８．６５ｍｍＨｇ）。注射奥曲肽组曲张静脉硬化剂注射针孔出血较对照组明显减少（Ｐ＜０．０１）。本研究结果表明，奥曲肽能迅速有效地降低曲张静脉内压力，有利于控制食管静脉曲张急性出血；奥曲肽减少曲张静脉穿刺针孔出血可提高硬化剂注射治疗安全性。     

CURATIVE TREATMENT OF BLEEDING ESOPHAGEAL VARICES SECONDARY TO A SPLENIC ARTERIO-VENOUS FISTULA

A 59 year old female, who presented with abdominal pain, diarrhea, and ascites, developed major bleeding from esophageal varices. Celiac angiography demonstrated a splenic arterio-venous fistula with early filling of an enlarged splenic vein and esophageal varices (pre-sinusoidal extra hepatic portal hypertension). The patient underwent splenectomy and resection of the fistula with resultant disappearance of the varices and presenting symptoms.     

SCLEROTHERAPY AS TREATMENT OF RECURRENT BLEEDING FROM UPPER GASTROINTESTINAL TELANGIECTASIA IN CREST SYNDROME

A case of CREST syndrome is reported with recurrent bleedingfrom oesophageal telangiectasia which required repeated bloodtransfusions. No other cause for the haemorrhage was found.This complication was effectively treated by sclerotherapy withno recurrence of bleeding over a 12-month period of follow up. KEY WORDS: CREST syndrome, Systemic sclerosis, Telangiectasia, Sclerotherapy, Oesophagus     

CLINICAL APPLICATION OF AN INDWELLING NEEDLE FOR ESOPHAGEAL VARICES IN ENDOSCOPIC INJECTION SCLEROTHERAPY WITH SIMULTANEOUS LIGATION

Endoscopic injection sclerotherapy (EIS), in which a sclerosing agent is infused into esophageal varices, is advantageous in obstructing a blood‐supplying route; however, accurate intravascular infusion is technically difficult. To achieve accurate continuous intravascular infusion that does not depend on respiration or vomiting reflex, we developed an indwelling needle for esophageal varices. This indwelling needle facilitated intravascular puncture, as demonstrated for conventional puncture needles, and stabilized infusion of a sclerosing agent. Furthermore, EIS with ligation (EISL) prevented hemorrhage after the needle was removed. EISL with an indwelling needle may improve the treatment results.     

双气囊压迫硬化剂治疗食管静脉曲张急性出血

介绍双气囊压迫硬化剂注射治疗食管静脉曲张急性出血的方法，其优点主要在于通过双气囊的压迫使曲张的食管静脉血流暂时阻断，使其出血减慢或暂时停止。并在静脉内注入多量的硬化剂，不随血流稀释流失，以便在短期内发生血凝块栓塞，达到即时止血的目的。作者采用此法治疗３８例，其控制急性出血率达９７．４％。经１～４年随访，曲张静脉的消失率与硬化治疗的次数有关。本组经６次治疗后其消失率为６８．７％，无严重并发症，值得推广应用。     

十二指肠球部溃疡并出血患者外周血T淋巴细胞亚群的测定

目的：观察消化性溃疡与免疫功能之间的关系。方法：采用ＡＰＡＡＰ方法，测定了４１例十二指肠球部溃疡并出血患者及２３例正常对照者外周血Ｔ淋巴细胞亚群水平，并研究了球部溃疡患者Ｔ淋巴细胞亚群水平与溃疡面积大上、贫血程度、病史长短之间的相关性。结果：溃疡组ＣＤ３、ＣＤ４及ＣＤ４／ＣＤ８水平（分别为４７４４±７８７，３０２２±７４４，１１２±０３１）显著低于对照组（分别为５５７２±８２６，４４５２±６６７，１８５±０１７８）（Ｐ＜０．００１）。溃疡组ＣＤ８的水平（２８２２±７６５）显著高于对照组（２３８５±５５１）（Ｐ＜０００１）。Ｔ淋巴细胞亚群的水平与溃疡面积大小、贫血程度、病史长短之间无明显相关。结论：十二指肠球部溃疡并出血患者存在明显的免疫抑制；免疫功能异常在溃疡病的发病中可能起重要作用