高位食管静脉曲张破裂出血患者内镜诊治经验:10年单中心回顾性分析

doi:10.3969/j.issn.1672-5069.2022.04.019

摘要/Abstract

摘要： 目的探索高位食管静脉曲张破裂出血(SEVB)患者内镜诊治特点及预后。方法 2010年1月～2020年1月哈尔滨医科大学附属第二医院内镜中心行内镜诊治的食管胃静脉曲张(GEV)患者25539例,其中SEVB者12例(0.4‰),其中采用急诊内镜下止血5例,非急诊内镜下止血7例。结果 12例SEVB患者中,乙型肝炎肝硬化5例,丙型肝炎肝硬化4例,酒精性肝炎肝硬化2例,不明原因性肝硬化1例;11例有明显的呕血、黑便、便血或周围循环障碍临床表现;5例急诊内镜下即时止血均成功,7例非急诊内镜下即时止血成功6例,无统计学差异(P>0.05);9例单用食管静脉曲张套扎术(EVL)治疗,其他采取硬化剂注射、EVL联合组织胶注射、EVL联合硬化剂和组织胶注射各1例;术后发生不良反应7例;随访8例患者(31.0±28.5)个月,近期再出血1例,远期再出血5例。在7例全程随访患者中,择期行脾切除术者1例,脾切除术联合贲门周围血管离断术2例,全因病死率为42.9%。结论对于SEVB患者多采用EVL治疗,即时止血效果好,但远期预后仍差。术后需联合其他方法治疗以长期控制门脉高压症,降低远期再出血和死亡风险。

关键词: 肝硬化, 高位食管静脉曲张破裂出血, 内镜下食管静脉曲张套扎术, 治疗

Abstract: Objective The aim of this study was to summarize the experience about endoscopic management of cirrhotics with superior esophageal variceal bleeding(SEVB). Methods 25539 patients with gastroesophageal varices (GEV) were encountered in our hospital between January 2010 and January 2020, out of them, 12 patients(0.4‰)had SEVB and all underwent endoscopic management (urgent in 5 cases and non-urgent in 7 cases). Results The etiology of the 12 patients with SEVB included hepatitis B cirrhosis in 5 cases, hepatitis C cirrhosis in 4 cases, alcoholic liver cirrhosis in 2 cases and unknown cause cirrhosis in 1 case; 11 patients had obvious clinical manifestations, such as hematemesis, melena, hematochezia or peripheral circulation disorder; 5 cases had successful hemostasis immediately with urgent endoscopic management, and 6 of 7 had with non-urgent management(P>0.05); the endoscopic variceal ligation(EVL) therapy was done in 9 cases, sclerotherapy in 1 case, EVL combined with tissue glue injection in 1 case and EVL combined with sclerotherapy and tissue glue injection in 1 case; the adverse reactions occurred after endoscopic management in 7 cases; 8 patients were followed-up for (31.0±28.5)m, and 1 patient had recent rebleeding and 5 patients had long-term rebleeding; out of 7 patients followed-up after treatment, 1 patient had splenectomy and 2 patients had splenectomy and pericardial devascularization; the all-cause mortality in our series was 42.9%. Conclusion The EVL is the first choice for patients with SEVB with high immediate hemostasis, but a poor long-term prognosis. It is necessary to reduce portal hypertension in combination with other treatments to decrease the risk of long-term rebleeding and death.

Key words: Liver cirrhosis, Superior esophageal variceal bleeding, Endoscopic variceal ligation, Therapy

季雪纯, 金世柱, Nepal Narayan, 李宁, 杨宁宁, 张思佳, 林秋池, 陈浩源. 高位食管静脉曲张破裂出血患者内镜诊治经验:10年单中心回顾性分析[J]. 实用肝脏病杂志, 2022, 25(4): 530-533.

Ji Xuechun, Jin Shizhu, Nipal Narayan, et al. Endoscopic management of superior esophageal variceal bleeding: a 10-year single center retrospective experience[J]. Journal of Practical Hepatology, 2022, 25(4): 530-533.

参考文献

[1] Kovacs T, Jensen DM. Varices: esophageal, gastric, and rectal. Clin Liver Dis, 2019,23(4):625-642.
[2] 江秋维, 黄理, 姚朝光. 乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者临床特征及其危险因素分析. 实用肝脏病杂志, 2021,24(4):532-535.
[3] Esmati E, Maddah Safaei A, Ghalehtaki R, et al. Outcomes of definitive chemoradiotherapy for cervical and upper thoracic esophageal cancers: a single-institution experience of a rare cancer. J Gastrointest Cancer, 2019,50(3):380-385.
[4] Rhoades DP, Forde KA, Tabibian JH. Proximal esophageal varices: a rare yet treatable cause of hemorrhage. Clin Gastroenterol Hepatol, 2016,14(9):e105-106.
[5] Park CH, Park SW, Jung JH, et al. Clinical outcomes of sedation during emergency endoscopic band ligation for variceal bleeding: multicenter cohort study. Dig Endosc, 2020,32(6):894-903.
[6] Sharma M, Singh S, Desai V, et al. Comparison of therapies for primary prevention of esophageal variceal bleeding: a systematic review and network meta-analysis. Hepatology, 2019,69(4): 1657-1675.
[7] Salman AA, Shaaban HE, Atallah M, et al. Long-term outcome after endoscopic ligation of acute esophageal variceal bleeding in patients with liver cirrhosis. Acta Gastroenterol Belg, 2020,83(3):373-380.
[8] Kaplan DE, Dai F, Aytaman A, et al. Development and performance of an algorithm to estimate the Child-Turcotte-Pugh score from a national electronic healthcare database. Clin Gastroenterol Hepatol, 2015,13(13):2333-2341.e6.
[9] Yip TC, Chan HL, Tse YK, et al. On-treatment improvement of MELD score reduces death and hepatic events in patients with hepatitis B-related cirrhosis. Am J Gastroenterol, 2018,113(11):1629-1638.
[10] 中华医学会消化内镜学分会食管胃静脉曲张学组. 消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年). 中华消化内镜杂志, 2010,27(1):1-4.
[11] 李志群, 令狐恩强, 刘迎娣, 等. LDRf分型在食管联合胃底静脉曲张初次内镜治疗中的应用价值. 中华消化内镜杂志, 2015,32(6):388-390.
[12] Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol, 2019,13(12):1161-1167.
[13] Oakland K, Kahan BC, Guizzetti L, et al. Development, validation, and comparative assessment of an international scoring system to determine risk of upper gastrointestinal bleeding. Clin Gastroenterol Hepatol, 2019,17(6):1121-1129.e2.
[14] Laursen SB, Oakland K, Laine L, et al. ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study. Gut, 2021,70(4):707-716.
[15] Horibe M, Iwasaki E, Bazerbachi F, et al. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc, 2020,92(3):578-588.e4.
[16] Robertson M, Ng J, Abu Shawish W, et al. Risk stratification in acute variceal bleeding: comparison of the AIMS65 score to established upper gastrointestinal bleeding and liver disease severity risk stratification scoring systems in predicting mortality and rebleeding. Dig Endosc, 2020, 32(5):761-768.
[17] Bai DS, Zhou BH, Qian JJ, et al. Effects of laparoscopic splenectomy and azygoportal disconnection on liver synthesis function and cirrhosis: a 2-year prospective study. Surg Endosc, 2020, 34(11):5074-5082.
[18] Lu S, Hu G, Chen S, et al. Risk factors of portal vein thrombosis after devascularization treatment in patients with liver cirrhosis: a nested case-control study. Biomed Res Int, 2020,2020(9):1-11.
[19] Ding H, Zhang Y, Zhao L, et al. What intervention regimen is most effective prevention for portal venous system thrombosis after splenectomy in cirrhotics patients with portal hypertension? Systematic review and network meta-analysis. Pharmacol Res, 2020,157:104825.
[20] Song Z, Feng H, Yang C, et al. Prediction of the factors influencing the Shengjing classification of portal vein thrombosis after splenectomy for portal hypertension in cirrhosis: a single-center retrospective case-control study. Biomed Res Int, 2020,2020:2396710.