肝硬化食管胃静脉曲张出血后肝静脉压力梯度测定指导二级预防的临床应用

路筝; 金波; 张文辉; 张军华; 迟春生; 吴立兵; 闫丽萍; 刘博; 韩晶晶; 马雪梅; 王艳玲; 韩军; 于晓莉; 吴勤; 段学章; 李捍卫

doi:10.3969/j.issn.1001-5256.2020.01.024

肝硬化食管胃静脉曲张出血后肝静脉压力梯度测定指导二级预防的临床应用

DOI: 10.3969/j.issn.1001-5256.2020.01.024

1. 解放军总医院第五医学中心肝硬化诊疗一中心
2. 解放军总医院第五医学中心肿瘤放射治疗中心

基金项目:

北京市自然科学基金资助项目(7192201)；

详细信息

中图分类号: R575.2
计量
- 文章访问数: 1395
- HTML全文浏览量: 82
- PDF下载量: 248
- 被引次数: 0
出版历程
- 收稿日期: 2019-06-30
- 出版日期: 2020-01-20

Clinical application of hepatic venous pressure gradient measurement after esophagogastric variceal bleeding in guiding secondary prevention for patients with liver cirrhosis

First Liver Cirrhosis Diagnosis and Treatment Center,The Fifth Medical Center of Chinese PLA General Hospital

Research funding:

摘要

摘要: 目的探讨食管胃静脉曲张出血后行内镜二级预防或TIPS二级预防的选择依据,评估肝静脉压力梯度（HVPG）协助临床决策的价值。方法回顾性分析了2016年1月-2018年2月解放军总医院第五医学中心食管胃静脉曲张出血后测得HVPG在12mm Hg以上并接受内镜或TIPS二级预防的患者148例,依据指南意见,HVPG> 18 mm Hg是食管胃静脉曲张再出血的高危因素,将148例患者分为中压力组（HVPG 12～18 mm Hg） 78例和高压力组（HVPG> 18 mm Hg） 70例,归纳两组的临床特点和内镜表现。再细化为12～16 mm Hg、>16～18 mm Hg、>18～20 mm Hg和>20 mm Hg 4组,对比各组行不同二级预防方式的安全性和有效性,重点关注再出血及预后情况。计量资料2组间比较采用独立样本t检验,计数资料2组间比较采用χ2检验,等级资料多组间比较采用Kruskal-Wallis H检验。结果二级预防前中压力组和高压力组的血红蛋白、血小板、白蛋白、胆红素、肌酐、血氨和凝血酶原时间、Child-Pugh评分和MELD评分比较,差异均...
- 肝硬化 /
- 食管和胃静脉曲张 /
- 出血 /
- 肝静脉压力梯度 /
- 二级预防
Abstract: Objective To investigate the basis for the selection of secondary prevention with endoscopy or transjugular intrahepatic portosystemic shunt(TIPS) after esophagogastric variceal bleeding and the value of hepatic venous pressure gradient(HVPG) in clinical decision-making. Methods A retrospective analysis was performed for 148 patients who had an HVPG of above 12 mm Hg after esophagogastric variceal bleeding and received secondary prevention with endoscopy or TIPS in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to February 2018. According to related guidelines,HVPG > 18 mm Hg was a high-risk factor for esophagogastric variceal rebleeding,and the patients were divided into medium pressure group(HVPG 12-18 mm Hg) with 78 patients and high pressure group(HVPG > 18 mm Hg) with 70 patients. Clinical features and endoscopic findings were summarized for both groups. The patients were further divided into four groups with an HVPG of 12-16 mm Hg, > 16-18 mm Hg, > 18-20 mm Hg,and > 20 mm Hg,respectively,and the four groups were compared in terms of the safety and efficacy of secondary prevention,with focuses on rebleeding and prognosis. The two-independent-samples t test was used for comparison of continuous data between groups,the chi-square test was used for comparison of categorical data between groups,the Kruskal-Wallis H test was used for comparison of ranked data between groups. Results Before secondary prevention,there were no significant differences between the medium pressure group and the high pressure group in hemoglobin,platelet,albumin,bilirubin,creatinine,blood ammonia,prothrombin time,Child-Pugh score,and Model for End-Stage Liver Diseasescore,and the medium pressure group had a significantly higher proportion of patients with opening of collateral circulation than the high pressure group(67. 95% vs 50. 00%,χ2= 11. 250,P = 0. 004). There was no significant difference in the LDRf type of esophageal and gastric varices between the two groups. The high pressure group had a significantly higher proportion of patients who selected TIPS than the medium pressure group(28. 57% vs 10. 26%,χ2= 8. 067,P = 0. 005). After secondary prevention,the mean follow-up time was 28. 66 ±11. 20 months,and no serious complications were observed. No patients experienced the progression of liver cirrhosis,and there was an improvement in ascites. Rebleeding rate within 1 year after secondary prevention with endoscopy tended to increase with the increase in HVPG,and 41. 03% of the patients with HVPG > 20 mm Hg underwent the preventive treatment for the second time within 1 year. Secondary prevention with endoscopy had a good clinical effect in the patients with an HVPG of 12-16 mm Hg,with a rebleeding rate of 14. 63% within1 year. The patients with an HVPG of > 20 mm Hg who underwent secondary prevention with TIPS had a significantly lower rebleeding rate within 1 year than those who underwent secondary prevention with endoscopy(10% vs 34. 48%). Conclusion It is recommended to select secondary prevention for variceal bleeding based on HVPG,develop a follow-up plan for patients with different HVPG values after secondary prevention,and give individualized treatment.
- liver cirrhosis /
- esophageal and gastric varices /
- hemorrhage /
- hepatic venous pressure gradient /
- secondary prevention

HTML全文

参考文献(11)

[1] GARRCIA-PAGAN JC,REVERTER E,ABRALDERS JG,et al. Acute variceal bleeding[J]. Semin Respir Crit Care Med,2012,33(1):46-54.

[2] Chinese Society of Hepatology,Chinese Medical Association;Chinese Society of Gastroenteroloty,Chinese Medical Association; Chinese Society of Endoscopy,Chinese Medical Association. Guidelines for the diagnosis and treatment of esophageal and gastric variceal bleeding in cirrhotic portal hypertension[J]. J Clin Hepatol,2016,32(2):203-219.(in Chinese)中华医学会肝病学分会，中华医学会消化病学分会，中华医学会内镜学分会．肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J]．临床肝胆病杂志，2016,32(2):203-219.

[3] CHENG LF,LI CZ. A multi-center survey of esophagogastic variceal bleeding in China[J]. J Clin Hepatol,2012,28(6):462-464.(in Chinese)程留芳，李长政．全国多中心食管胃静脉曲张出血调查[J]．临床肝胆病杂志，2012,28(6):462-464.

[4] WU M,SUN M. Method and research progress of non-invasive assessment of portal vein pressure[J]. Chin J Dig Surg,2018,17(10):1055-1058.(in Chinese)吴敏，孙敏．门静脉压力无创测定的方法和研究进展[J]．中华消化外科杂志，2018,17(10):1055-1058.

[5] Interventional Group,Chinese Society of Radiology,Chinese Medical Association. Expert consensus on transjugular intrahepatic portosystemic shunt[J]. J Clin Hepatol,2017,33(7):1218-1228.(in Chinese)中华医学会放射学分会介入学组．经颈静脉肝内门体分流术专家共识[J]．临床肝胆病杂志，2017,33(7):1218-1228.

[6] DENG H,QI XS,GUO XZ. UK guidelines on the management of variceal haemorrhage in cirrhotic patients(2015):An excerpt of recommendations[J]. J Clin Hepatol,2015,31(6):852-854.(in Chinese)邓晗，祁兴顺，郭晓钟．《2015年英国肝硬化静脉曲张出血防治指南》摘译[J]．临床肝胆病杂志，2015,31(6):852-854.

[7] TRIPATHI D,STANLEY AJ,HAYES PC,et al. U. K. guidelines on the management of variceal haemorrhage in cirrhotic patients[J]. Gut,2015,64(11):1680-1704.

[8] de FRANCHIS R,Baveno VI Faculty. Expanding consensus in portal hypertension:Report of the Baveno VI Consensus Workshop:Stratifying risk and individualizing care for portal hypertension[J]. J Hepatol,2015,63(3):743-752.

[9] SEO YS,PARK SY,KIM MY,et al. Lack of difference among terlipressin,somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage[J]. Hepatology,2014,60(3):954-963.

[10] Portal Hypertension Group,Chinese Society of Surgery,Chinese Medical Association. Expert consensus on the diagnosis and treatment of esophagogastric variceal bleeding in cirrhotic portal hypertension[J]. Chin J Pract Surg,2015,35(10):1086-1090.(in Chinese)中华医学会外科学分会门静脉高压症学组．肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2015)[J]．中国实用外科杂志，2015,35(10):1086-1090.

[11] NORONHA FERREIRA C,SEIJO S,PLESSIER A,et al. Natural history and management of esophagogastric varices in chronic noncirrhotic,nontumoral portal vein thrombosis[J]. Hepatology,2016,63(5):1640-1650.

施引文献

资源附件(0)

访问统计