【作者】 周玮；

【导师】 卢雪峰；

【作者基本信息】 山东大学 ， 内科学， 2007， 硕士

【摘要】 目的:内镜下治疗是防治门静脉高压食管胃底静脉曲张破裂出血的有效而又简便的方法。本研究的目的是探讨密集结扎疗法与组织粘合剂栓塞联合治疗对门静脉高压食管静脉曲张合并胃底静脉曲张患者的治疗效果;在此基础上,进行硬化加固治疗,以观察其对于食管静脉曲张复发的防治作用。并进一步探讨内镜治疗前后门静脉与其属支血流动力学变化。方法:1.首先对胃底静脉曲张用组织粘合剂进行栓塞治疗。注射针预充10%碘化油(Lipiodol)1ml,于内镜下选择好曲张的靶静脉,刺入静脉内,依“三明治”法先注入碘化油1ml,随后注射组织胶1～2ml,再注入碘油1ml,然后退出针头,再注10%葡萄糖液5ml,冲洗注射针,以防止注射针堵塞,依上述步骤进行其他靶静脉的注射。2.对食管静脉曲张进行密集结扎疗法。于贲门齿状线上方开始,自下而上环绕食管壁对曲张静脉进行密集、多位点结扎,直至可见的曲张静脉全部被结扎,两次治疗间隔4周。观察其对食管静脉曲张破裂出血患者止血成功率、静脉消失率的影响,以及并发症的发生情况。3.对食管静脉曲张套扎治疗后食管曲张静脉消失或基本消失的患者进行硬化剂加固治疗,从齿状线开始依次往上在残存小曲张静脉内或血管旁粘膜下层注射5%鱼肝油酸钠,每点注射1-2ml,每次共注射10～16ml。如有必要,每2～4周加固一次。观察其对静脉曲张消失后复发的预防作用。4.内镜治疗前后门静脉系统血流动力学改变。应用彩色多普勒超声测定每例患者内镜治疗前后门静脉、脾静脉、胃左静脉、脐静脉、肠系膜静脉等的内径、平均血流速度与血流量。结果:组织粘合剂注射48例患者共注射56例次,每次注射1～4点,平均每点注胶1.36ml,一次总量2～6ml,平均每例注射量为2.80ml。急诊治疗胃底贲门区静脉出血9例,均立刻止血。无活动性出血39例,注胶后见静脉增粗、发白、变硬。注射后1wk见注射点轻度糜烂,胃底曲张静脉呈白色。1mo见固化组织粘合剂排出,3～6mo组织粘合剂完全排出,静脉消除。食管静脉曲张首次结扎12～22点,平均18.8点。每例患者平均结扎1.8次,止血成功率97.9%,静脉曲张消失率94.6%,再出血发生率3.5%,静脉曲张复发6.5%。联合治疗的并发症:治疗后常感胸骨后不适,一般不需特殊处理,不影响进食,12小时后可自动缓解。所有患者在注胶后均有不同程度的上腹部疼痛,疼痛明显者肌注强痛定50～100mg。2例患者高热。由套圈脱落或排胶引起近期再发出血2例(4.2%)。均未发生与治疗直接有关的食管狭窄、穿孔、异位栓塞、严重感染等并发症。经内镜治疗食管胃底静脉曲张消除或基本消除后,行粘膜层加固治疗。加固治疗组23例共行硬化治疗48次,平均2.1次,最多治疗4次。随访1～3年,平均19个月,未发现食管静脉曲张再出现,原有细小静脉明显减轻或消失,超声内镜检查食管旁静脉检出率明显低于单纯结扎组,且大食管旁静脉发生率低于单纯结扎组。而未经加固治疗者25例中有4例(16%)食管中下段出现孤立性静脉瘤或条段状静脉曲张,伴有片状红色征,2例(8%)发生再出血。加固治疗组食管旁静脉发现率明显低于非加固治疗组(21.9%vs 46.5%,P<0.01)。而且,大食管旁静脉发现率明显低于非加固治疗组。加固治疗组治疗后均有胸骨后轻度疼痛或恶心,一般不需特殊处理,多于治疗后2～4小时自行缓解。食管腔轻度狭窄1例,不影响进食。还有2例治疗后发热37.5～38℃,未经特殊处理次日退烧。总并发症为5.6%。经门静脉系统血流动力学测定,48例患者于治疗前后均探测到门静脉与脾静脉(100%),45例探测到胃左静脉(93.8%),40例探测到脐静脉(83.3%),41例探测到肠系膜静脉(85.4%),内镜治疗前后门静脉血管内径无显著变化,平均血流速度(24.5±4.35 cm/s vs 27.4±6.54 cm/s,p<0.05)与血流量均显著增加(19.38±3.37ml/m vs 24.35±4.77ml/m,p<0.05);脾静脉血管内径无显著变化,平均血流速度(28.6±5.65 cm/s vs31.47±7.21 cm/s,p<0.05)与血流量增加(15.87±3.51 ml/m vs 19.12±4.67 ml/m,p<0.05);胃左静脉血管内径、平均血流速度、血流量均无统计学差异。但血流方向发生显著变化。治疗前胃左静脉的血流方向为离肝性者占91.1%(41/45),双向血流者占6.7%(3/45),正向血流者占2.2%(1/45)。而治疗后向肝血流者占68.9%(31/45),离肝血流者明显减少,占20%(9/45),双向血流者占11.1%(5/45),差异非常显著(P<0.01)。脐静脉、肠系膜静脉血管内径、平均血流速度与血流量均无显著变化。结论:密集套扎与粘合剂血管栓塞联合治疗食管静脉曲张合并胃底静脉曲张对防治曲张静脉破裂出血有确实可靠的疗效。操作成功率、止血成功率、曲张静脉消失率较高,再出血发生率、并发症以及术后复发率较低。经EVL治疗后食管静脉曲张消失或基本消失的患者再进行小剂量硬化剂血管内与粘膜下注射加固治疗,可显著减少食管旁静脉的发生、防止闭塞消失的静脉再通、延缓静脉曲张的复发,有助于提高结扎术的长期疗效,预防再出血的发生。门静脉高压合并食管与胃底静脉曲张患者采用套扎与胃底静脉曲张栓塞联合治疗对门静脉系统血流动力学的影响主要是门静脉主干的血流速度与血流量增加、脾静脉血流速度和血流量增加,以及胃左静脉血流方向的改变,而胃左静脉由离肝血流转而改为向肝血流可能是门静脉与脾静脉血流动力学改变的主要原因。以上血流动力学的改变可能有助于改善回肝血流和促进肝功能的恢复。更多还原

【Abstract】 AIMs;Endoscopic variceal ligation is recommended as the endoscopic treatment of choice for patients with esophageal variceal bleeding.Lower rates of recurrent bleeding,mortality,complications and the need for fewer sessions for variceal eradication are the main arguments in favor of variceal ligation.The purposes of the present study are to evaluate the efficacy of dense ligation plus adhesive injection for the treatment of esophageal and gastric varices;to evaluate the efficacy of sclerotherapy as a reinforcing method for preventing recurrence of varix after variceal eradication was achived by variceal ligation therapy;to evaluate the haemodynamical changes of portal vein and its branch veins before and after the treatment.METHODs;1.The patients with esophageal varices and gastric varices were treated by endoscopic adhesive injection first.Target varix was choiced under endoscope and punctured.Sandwiched method was employed for injection into stomach fundal varices(1ml of Lipiodol,then 1～2ml of histoacryl,then 1ml of Lipiodol again).2.In succession,dense ligation was used to treat the esophageal varices.The ligating device was attached to the tip of the endoscope and trip line was passed through the biopsy channel.Varices were ligated with an elastic O ring at or near the gastric-esophageal junction and continued up the esophagus.Each varix was ligated as many as necessary to make it no loner visible.Endoscopic variceal ligations were performed regularly,every 4 weeks,until the varices at the distal esophagus were eradicated.3.For the patients whose varices were eradicated or nearly eradicated,endoscopic sclerotherapy was performed.5%ethanolamine oleate was injected into and aroud small residual varices at a level just above the gastro-esophageal junction.1-2ml of 5%ethanolamine oleate was injected per point,and total volume was 10 to 16ml per session.Additional injection was done every 10 to 14 days if necessary.4.Color Doppler sonography was employed to measure the dynamical changes of portal vein and its branch veins before and after endoscopic variceal ligation and histoacryl injection.Including the inside diameter,blood flow velocity and blood flow rate of portal vein,spleen vein,left gastric vein,umbilical vein and mesenteric vein.RESULTs;1.The fourty-six patients received 56 sessions of injection.1～4 points were injected.1.6ml of histoacryl was injected for every point.The total volum for each patient was 2～6 ml(mean 2.8ml).Hemorrhage in 9 patients with gastric variceal bleeding was stopped.The successful hemostasis of histoacryl injection was 100%.The gastric varices terned hard.The complete eradication rate was 81.2%for the first injection.2.The mean number of ligation was 1.8.The number of rubber bands placed per session was 16-22(mean 18.8)initially and 4-6 ligations were placed at subsequent sessions.The successful hemostasis rate of variceal ligation was 97.9%.The eradicated rate was 94.6%.The rebleeding rate was 3.5%,varices recurred in 7 patients(6.3%).The efficacy of dense variceal ligation in the prevention of initial episodes of variceal bleeding in patients at high risk of variceal bleeding was superior to conventional ligation.Frequency of mild complications such as slight abdominal pain and retrosternal pain and pyrexia were found.No severe complications such as lung,brain and heart embolism occured.The hepatic and renal function was not affected.3.Twenty-eight patients in sclerotherapy-enforcing group underwent 58 sessions of injections(mean 2.1 for each patients),proximally four session for one patient.During one to three years(mean 19 months)following up period,no recurrent varix was observed.And the risidual varices diminished or completely eradicated.However,4 patients(16%)receiving variceal ligation only developed solitary varices or stripe varices accomplished with red sign,of which two patients rebled(8%).The residual varices in three patients(12%)in this group enlarged including one bleeding.Less paraesophageal varices was detected by endoscopic ultrosonography with subsequent endoscopic seclerotherapy than in patients receiving endoscopic varices ligation alone(21.9%vs 46.5%,P＜0.01). Moreover,large paraesophageal varices occurred more often in variceal ligation alone than in variceal ligation plus later endoscopic seclerotherapy group.4.Portal vein and spleen vein in 48 patients were detected befor and after endoscopic treatmen(100%),The inside diameter of portal vein and spleen vein had no significant changes,but their blood flow velocity(spleen vein;24.5±4.35 cm/s vs 27.4±6.54 cm/s,P＜0.05;spleen vein;28.6±5.65 cm/s vs 31.47±7.21 cm/s,P＜0.05,respectively)and blood flow rate increased significantly(spleen vein;15.87±3.51 ml/m vs 19.12±4.67 ml/m,P＜0.05,spleen vein;19.38±3.37ml/m vs 24.35±4.77ml/m,P＜0.05).left gastic vein was discovered in 45 patients(93.8%).The inside diameter,blood flow velocity and blood flow rate of left gastric vein had no significant changes.But the blood flow direction had significant change after the endoscopic therapy.41 patients(91.1%)showed hepatofugal flow,3 patients(6.7%) bi-directional flow,and one patient(2.2%)hepatopetal flow before the treatment,while 31 patients(68.9%)showed hepatopetal flow,9(20%)patients showed hepatofugal flow,and 5 patients(11.1%)bi-directional flow after treatment(P＜0.01).Umbilical vein in 40 patients(83.3%)and mesenteric vein in 41 patients (85.4%)were detected,respectively.The inside diameter,blood flow velocity and blood flow rate of umbilical vein and mesenteric vein had no significant changes.CONCLUSIONs;Endoscopic band ligation plus adhesive injection for esophageal varices and gastric fundus varices is a safe and effective therapy.It has higher successful rate,hemostatic rate and variceal obliteration,and has lower rebleeding rate,complications and variceal recurrence rate.Later sclerosant injection into the residual varices,perivarices and submucosa in patients who had undergone variceal ligation and obtained complete variceal obliteration or incomplete obliteration was able to decrease the frequency of paraesophageal varices appearance,reduced variceal recurrence and improve the long-term efficacy of variceal ligation.It could be concluded that the combination of variceal obligation with subsequent endoscopic sclerotherapy may significantly decrease the rate of complications associated with endoscopic sclerotherapy alone.In terms of variceal recurrence,it seems that this combination is better than variceal ligation alone.The dynamical measurement indicates that endoscopic combined treatment could increase the blood flow velocity and blood flow rate and thereby improve the blood suply.The direction of left gastric vein may be the main cause.更多还原