肝硬化上消化道出血的微创治疗进展

徐敏; 倪宇; 张瑞; 王小兵; 黄缘

doi:10.3969/j.issn.1001-5256.2023.02.028

肝硬化上消化道出血的微创治疗进展

DOI: 10.3969/j.issn.1001-5256.2023.02.028

徐敏¹,
倪宇¹,
张瑞¹,
王小兵¹,
黄缘^2, , ,

1.
哈尔滨医科大学附属第一医院消化内科，哈尔滨 150001
2.
清华大学附属北京清华长庚医院肝胆内科，北京 102218

基金项目:

黑龙江省博士后科研启动金 (LBH-Q20033)

利益冲突声明：所有作者均声明不存在利益冲突。

作者贡献声明：徐敏负责搜索相关文献，撰写论文；王小兵负责对初稿进行修改：倪宇、张瑞负责进一步完善稿件; 黄缘指导撰写。

详细信息

通信作者:
黄缘，huangy9815@163.com(ORCID：0000-0003-1392-4619)

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- 被引次数: 0
出版历程
- 收稿日期: 2022-07-13
- 录用日期: 2022-08-18
- 出版日期: 2023-02-20

Advances in minimally invasive treatment of upper gastrointestinal bleeding in liver cirrhosis

Min XU¹,
Yu NI¹,
Rui ZHANG¹,
Xiaobing WANG¹,
Yuan HUANG^{2
, ,
,}

1.
Department of Gastroenterology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
2.
Department of Hepatobiliary Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China

Research funding:

Heilongjiang Postdoctoral Scientific Research Developmental Fund (LBH-Q20033)

More Information

Corresponding author: HUANG Yuan, huangy9815@163.com(ORCID: 0000-0003-1392-4619)

摘要

摘要: 肝硬化是临床上常见的一种慢性肝病，主要病因包括病毒、酒精、免疫等方面。在肝硬化晚期，患者会出现多种并发症，常见的并发症有上消化道出血、肝性脑病、肝肾综合征以及肝癌等，而上消化道出血则是导致患者死亡的主要原因，所以对于控制及预防肝硬化引起的上消化道出血是降低患者死亡率，延长生存期的关键所在。本综述主要归纳了目前临床上常用的治疗肝硬化上消化道出血的微创手段，通过分析不同治疗方式的适应证及相关的最新进展，为临床医师选择最适合患者实际情况的治疗方案提供了参考，从而提高患者的生存率。
- 肝硬化 /
- 出血 /
- 最小侵入性外科手术
Abstract: Liver cirrhosis is a common chronic liver disease in clinical practice, and the main causes of this disease include virus, alcohol, and immunity. Patients may experience a variety of complications in the late stage of liver cirrhosis, including upper gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome, and liver cancer, among which upper gastrointestinal bleeding is the main cause of death, and therefore, the control and prevention of upper gastrointestinal bleeding caused by liver cirrhosis is the key to reducing mortality rate and prolonging survival time. This article summarizes the commonly used minimally invasive methods for the treatment of upper gastrointestinal bleeding in liver cirrhosis and analyzes the indications for different treatment methods and related advances, so as to provide a reference for clinicians to choose the most suitable treatment regimen for the patient, thereby improving the survival rate of patients.
- Liver Cirrhosis /
- Hemorrhage /
- Minimally Invasive Surgical Procedures

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参考文献(45)

[1]	ALQAHTANI SA, JANG S. Pathophysiology and management of variceal bleeding[J]. Drugs, 2021, 81(6): 647-667. DOI: 10.1007/s40265-021-01493-2.
[2]	Chinese Society of Hepatology, Chinese Medical Association, Chinese Society of Gastroenterology, 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. DOI: 10.3969/j.issn.1001-5256.2016.02.002. 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. DOI: 10.3969/j.issn.1001-5256.2016.02.002.
[3]	The Emergency Physicians Branch of the Chinese Medical Association, the Emergency Medicine Branch of the Chinese Medical Association, the Military Emergency Medical Professional Committee, et al. Expert consensus on emergency diagnosis and treatment process of acute upper gastrointestinal bleeding[J]. Chin J Crit Care Med, 2021, 41 (1): 1-10. DOI: 10.3969/j.issn.1002-1949.2021.01.001. 中国医师协会急诊医师分会, 中华医学会急诊医学分会, 全军急救医学专业委员会, 等. 急性上消化道出血急诊诊治流程专家共识[J]. 中国急救医学, 2021, 41(1): 1-10. DOI: 10.3969/j.issn.1002-1949.2021.01.001.
[4]	Chinese Society of Hepatology, Chinese Medical Association. Chinese guidelines on the management of liver cirrhosis[J]. J Clin Hepatol, 2019, 35(11): 2408-2425. DOI: 10.3969/j.issn.1001-5256.2019.11.006. 中华医学会肝病学分会. 肝硬化诊治指南[J]. 临床肝胆病杂志, 2019, 35(11): 2408-2425. DOI: 10.3969/j.issn.1001-5256.2019.11.006.
[5]	JUNG DH, HUH CW, KIM NJ, et al. Optimal endoscopy timing in patients with acute variceal bleeding: A systematic review and meta-analysis[J]. Sci Rep, 2020, 10(1): 4046. DOI: 10.1038/s41598-020-60866-x.
[6]	HUH CW, KIM JS, JUNG DH, et al. Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding[J]. Dig Liver Dis, 2019, 51(7): 993-998. DOI: 10.1016/j.dld.2019.01.013.
[7]	PLAZ TORRES MC, BEST LM, FREEMAN SC, et al. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis[J]. Cochrane Database Syst Rev, 2021, 3(3): CD013122. DOI: 10.1002/14651858.CD013122.pub2.
[8]	European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis[J]. J Hepatol, 2018, 69(2): 406-460. DOI: 10.1016/j.jhep.2018.03.024.
[9]	DENG SM, ZHANG JX, QI Y, et al. Application of endoscopic ligation in esophageal varices and its risk factors for postoperative rebleeding[J]. Clin J Med Offic, 2021, 49(6): 718-720. DOI: 10.16680/j.1671-3826.2021.06.43. 邓水苗, 张嘉星, 齐晔, 等. 内镜下套扎术在食管静脉曲张中应用及其术后再出血高危因素研究[J]. 临床军医杂志, 2021, 49(6): 718-720. DOI: 10.16680/j.1671-3826.2021.06.43.
[10]	HAYASHI T, WATANABE T, SHIBATA M, et al. Endoscopic injection sclerotherapy improves liver function compared with endoscopic variceal ligation[J]. Sci Rep, 2021, 11(1): 20479. DOI: 10.1038/s41598-021-99855-z.
[11]	ZHANG GL, NING CM. Application experience of transparent cap assisted gastroscopic sclerotherapy for esophageal varices[J]. Chin J Med, 2017, 52(1): 96-99. DOI: 10.3969/j.issn.1008-1070.2017.01.031. 张国玲, 宁纯民. 透明帽辅助胃镜下食管静脉曲张硬化治疗的应用体会[J]. 中国医刊, 2017, 52(1): 96-99. DOI: 10.3969/j.issn.1008-1070.2017.01.031.
[12]	WANG AJ, ZHENG XL, HONG JB, et al. Cap-assisted endoscopic sclerotherapy vs ligation in the long-term management of medium esophageal varices: A randomized trial[J]. Clin Transl Gastroenterol, 2020, 11(12): e00285. DOI: 10.14309/ctg.0000000000000285.
[13]	WANG J, ZHANG X, ZHAO S. Transparent cap-assisted endoscopic injection sclerotherapy for the treatment of patients with esophageal varices[J]. Medicine (Baltimore), 2020, 99(24): e20721. DOI: 10.1097/MD.0000000000020721.
[14]	LINGHU EQ, FENG J. Application of tissue adhesive in endoscopic treatment of esophagogastric varices[J]. Chin J Dig Endosc, 2008, 25(2): 59-60. DOI: 10.3760/cma.j.issn.1007-5232.2008.02.002. 令狐恩强, 冯佳. 组织粘合剂在食管胃静脉曲张内镜治疗中的应用[J]. 中华消化内镜杂志, 2008, 25(2): 59-60. DOI: 10.3760/cma.j.issn.1007-5232.2008.02.002.
[15]	LI P, LIU BR. Endoscopic treatment of esophageal gastric variceal bleeding[J]. Chin J Gastroenterol Hepatol, 2018, 27(1): 105-110. DOI: 10.3969/j.issn.1006-5709.2018.01.024. 李萍, 刘冰熔. 食管胃底静脉曲张出血的内镜下治疗[J]. 胃肠病学和肝病学杂志, 2018, 27(1): 105-110. DOI: 10.3969/j.issn.1006-5709.2018.01.024.
[16]	WANG AJ, LI BM, ZHENG XL, et al. Utility of endoscopic ultrasound in the diagnosis and management of esophagogastric varices[J]. Endosc Ultrasound, 2016, 5(4): 218-224. DOI: 10.4103/2303-9027.187840.
[17]	LIN MS, LIAO SC, PENG YC, et al. Application of endoscopic US-guided tissue adhesive injection as a rescue therapy for post-tissue adhesive variceal obturation-related gastric wall bleeding[J]. Gastrointest Endosc, 2014, 79(3): 514-515. DOI: 10.1016/j.gie.2013.10.018.
[18]	BUSCAGLIA JM, DRAY X, SHIN EJ, et al. A new alternative for a transjugular intrahepatic portosystemic shunt: EUS-guided creation of an intrahepatic portosystemic shunt (with video)[J]. Gastrointest Endosc, 2009, 69(4): 941-947. DOI: 10.1016/j.gie.2008.09.051.
[19]	MCCARTY TR, NJEI B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: A systematic review and meta-analysis[J]. Dig Endosc, 2016, 28(5): 539-547. DOI: 10.1111/den.12626.
[20]	RODRIGUES SG, CÁRDENAS A, ESCORSELL À, et al. Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: A systematic review and meta-analysis[J]. Semin Liver Dis, 2019, 39(2): 178-194. DOI: 10.1055/s-0039-1678726.
[21]	GUNDLING F, TILLER M, SCHEPP W. Comment on "esophageal balloon tamponade vs. esophageal stent in controlling acute refractory variceal bleeding: A multicenter RCT"[J]. Hepatology, 2017, 65(6): 2120-2121. DOI: 10.1002/hep.29046.
[22]	PFISTERER N, RIEDL F, PACHOFSZKY T, et al. Outcomes after placement of a SX-ELLA oesophageal stent for refractory variceal bleeding-A national multicentre study[J]. Liver Int, 2019, 39(2): 290-298. DOI: 10.1111/liv.13971.
[23]	LINGHU EQ. Preliminary study on a new endoscopic classification method for varicose veins[J]. Dig Dis Endosc, 2008, 2(9): 23-26. https://www.cnki.com.cn/Article/CJFDTOTAL-XHNJ2008Z1008.htm 令狐恩强. 新的内镜下静脉曲张分型的方法初步探讨[J]. 中国消化内镜, 2008, 2(9): 23-26. https://www.cnki.com.cn/Article/CJFDTOTAL-XHNJ2008Z1008.htm
[24]	LI X, JIANG T, GAO J. Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis[J]. Eur J Gastroenterol Hepatol, 2017, 29(6): 621-628. DOI: 10.1097/MEG.0000000000000861.
[25]	DEGUCHI H, KATO J, MAEDA Y, et al. Argon plasma coagulation is effective for prevention of recurrent esophageal varices after endoscopic injection sclerotherapy: Single-center case-control study[J]. Dig Endosc, 2016, 28(1): 42-49. DOI: 10.1111/den.12538.
[26]	SONG Y, FENG Y, SUN LH, et al. Role of argon plasma coagulation in treatment of esophageal varices[J]. World J Clin Cases, 2021, 9(3): 521-527. DOI: 10.12998/wjcc.v9.i3.521.
[27]	HOLSTER IL, POLEY JW, KUIPERS EJ, et al. Controlling gastric variceal bleeding with endoscopically applied hemostatic powder (Hemospray^TM)[J]. J Hepatol, 2012, 57(6): 1397-1398. DOI: 10.1016/j.jhep.2012.07.024.
[28]	IBRAHIM M, EL-MIKKAWY A, ABDEL HAMID M, et al. Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial[J]. Gut, 2019, 68(5): 844-853. DOI: 10.1136/gutjnl-2017-314653.
[29]	BAI M, QI X, YANG M, et al. Combined therapies versus monotherapies for the first variceal bleeding in patients with high-risk varices: a meta-analysis of randomized controlled trials[J]. J Gastroenterol Hepatol, 2014, 29(3): 442-452. DOI: 10.1111/jgh.12396.
[30]	CHENG R, XU XY. Clinical progress of gastrointestinal bleeding in liver cirrhosis[J]. Clin Intern Med, 2019, 36(12): 793-795. DOI: 10.3969/j.issn.1001-9057.2019.12.001. 程然, 徐小元. 肝硬化消化道出血的临床进展[J]. 临床内科杂志, 2019, 36(12): 793-795. DOI: 10.3969/j.issn.1001-9057.2019.12.001.
[31]	RAJESH S, GEORGE T, PHILIPS CA, et al. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update[J]. World J Gastroenterol, 2020, 26(37): 5561-5596. DOI: 10.3748/wjg.v26.i37.5561.
[32]	KHAN F, TRIPATHI D. Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions[J]. World J Gastroenterol, 2021, 27(44): 7612-7624. DOI: 10.3748/wjg.v27.i44.7612.
[33]	de FRANCHIS R, BOSCH J, GARCIA-TSAO G, et al. Baveno VⅡ - Renewing consensus in portal hypertension[J]. J Hepatol, 2022, 76(4): 959-974. DOI: 10.1016/j.jhep.2021.12.022.
[34]	TRIPATHI D, STANLEY AJ, HAYES PC, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension[J]. Gut, 2020, 69(7): 1173-1192. DOI: 10.1136/gutjnl-2019-320221.
[35]	LV Y, YANG Z, LIU L, et al. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2019, 4(8): 587-598. DOI: 10.1016/S2468-1253(19)30090-1.
[36]	HOLSTER IL, TJWA ET, MOELKER A, et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β-blocker for prevention of variceal rebleeding[J]. Hepatology, 2016, 63(2): 581-589. DOI: 10.1002/hep.28318.
[37]	LV Y, ZUO L, ZHU X, et al. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study[J]. Gut, 2019, 68(7): 1297-1310. DOI: 10.1136/gutjnl-2018-317057.
[38]	MIRAGLIA R, MARUZZELLI L, LUCA A. Transjugular intrahepatic portosystemic shunt: A Single-Centre Mid-term Experience Using the Viatorr Controlled-Expansion Stent[J]. Dig Dis Sci, 2021, 66(12): 4565-4567. DOI: 10.1007/s10620-021-06867-w.
[39]	PALETI S, NUTALAPATI V, FATHALLAH J, et al. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for treatment of gastric varices because of portal hypertension: A Systematic Review and Meta-Analysis[J]. J Clin Gastroenterol, 2020, 54(7): 655-660. DOI: 10.1097/MCG.0000000000001275.
[40]	LEE EW, SHAHROUKI P, ALANIS L, et al. Management options for gastric variceal hemorrhage[J]. JAMA Surg, 2019, 154(6): 540-548. DOI: 10.1001/jamasurg.2019.0407.
[41]	WANG ZW, LIU JC, ZHAO F, et al. Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: A Meta-Analysis[J]. Can J Gastroenterol Hepatol, 2020, 2020: 5143013. DOI: 10.1155/2020/5143013.
[42]	KOBAYAKAWA M, OHNISHI S, SUZUKI H. Recent development of balloon-occluded retrograde transvenous obliteration[J]. J Gastroenterol Hepatol, 2019, 34(3): 495-500. DOI: 10.1111/jgh.14463.
[43]	LIN XQ, WU W, JIN RF, et al. Transjugular intrahepatic portosystem shunt plus gastric coronary vein embolization for cirrhotics portal hypertension complicating upper gastrointestinal bleeding[J]. Chin J General Surg, 2019, 34(3): 217-221. DOI: 10.3760/cma.j.issn.1007-631X.2019.03.007. 林秀清, 吴伟, 金瑞放, 等. 经颈静脉肝内门体静脉分流术联合胃冠状静脉栓塞术治疗肝硬化门静脉高压症上消化道出血的疗效分析[J]. 中华普通外科杂志, 2019, 34(3): 217-221. DOI: 10.3760/cma.j.issn.1007-631X.2019.03.007.
[44]	WANG JY, XUE H, LI WZ, et al. Ultrasound-guided portal vein puncture for TIPS combined with percutaneous transhepatic variceal embolization in treatment of upper gastrointestinal hemorrhage in patients with liver cirrhosis[J]. Chin J Interv Imaging Ther, 2018, 15(7): 392-396. DOI: 10.13929/j.1672-8475.201708030. 汪靖园, 薛挥, 李伟之, 等. 超声引导下门静脉穿刺导引TIPS联合曲张静脉栓塞治疗肝硬化上消化道出血[J]. 中国介入影像与治疗学, 2018, 15(7): 392-396. DOI: 10.13929/j.1672-8475.201708030.
[45]	LIN GY, MA MY, CAI ZY. Clinical effect of ultrasound-guided portal vein puncture guided tran- sjugular intrahepatic portosystemic shunt combined with varicose vein embolization in the treatment of esophageal gastric fundus varices rupture and bleeding[J]. China Modern Med, 2020, 27(7): 113-116. DOI: 10.3969/j.issn.1674-4721.2020.07.034. 林纲毅, 马洺远, 蔡宗洋. 超声引导下门静脉穿刺导引经颈静脉肝内门体分流术联合曲张静脉栓塞治疗食管胃底静脉曲张破裂出血的临床效果[J]. 中国当代医药, 2020, 27(7): 113-116. DOI: 10.3969/j.issn.1674-4721.2020.07.034.