门静脉高压症的无创检查
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摘要
门静脉高压症作为一种常见的临床综合征,其引发严重的并发症如慢性肝病患者的食管胃静脉曲张、腹水和肝性脑病等,会间接影响肝硬化患者的预后情况。目前,肝静脉压力梯度(HVPG)为评估门静脉高压症的金标准,但因有创、价格昂贵等特点限制了其在临床上的推广使用。因此,无创且精确的技术研发在疾病诊断、风险分层、疗效监测、预后预测等方面都至关重要。阐述了临床实践中门静脉高压症无创性检测方法的最新进展,强调注重无创技术研发,HVPG检测标准化与疾病精准分层管理的重要性。
As a common clinical syndrome,portal hypertension can cause severe complications including gastroesophageal varices,ascites,and hepatic encephalopathy in patients with chronic liver diseases,which indirectly affects the prognosis of cirrhotic patients. At present,hepatic venous pressure gradient( HVPG) is the gold standard for the evaluation of portal hypertension,but its clinical application is limited by invasiveness and high cost. Therefore,the development of noninvasive and accurate measurements for portal pressure is crucial in the diagnosis,risk stratification,outcome monitoring,and prognosis prediction. This article reviews the latest advances in noninvasive examinations of portal hypertension in clinical practice and emphasizes the research and development of noninvasive techniques,HVPG standardization,and precise risk stratification management.
As a common clinical syndrome,portal hypertension can cause severe complications including gastroesophageal varices,ascites,and hepatic encephalopathy in patients with chronic liver diseases,which indirectly affects the prognosis of cirrhotic patients. At present,hepatic venous pressure gradient( HVPG) is the gold standard for the evaluation of portal hypertension,but its clinical application is limited by invasiveness and high cost. Therefore,the development of noninvasive and accurate measurements for portal pressure is crucial in the diagnosis,risk stratification,outcome monitoring,and prognosis prediction. This article reviews the latest advances in noninvasive examinations of portal hypertension in clinical practice and emphasizes the research and development of noninvasive techniques,HVPG standardization,and precise risk stratification management.
引文
[1]GARCIA-TSAO G,ABRALDES JG,BERZIGOTTI A,et al.Portal hypertensive bleeding in cirrhosis:Risk stratification,diagnosis,and management:2016 practice guidance by the A-merican Association for the study of liver diseases[J].Hepatology,2017,65(1):310-335.
[2]ASRANI SK,DEVARBHAVI H,EATON J,et al.Burden of liver diseases in the world[J].J Hepatol,2018.[Epub ahead of print]
[3]WANG X,LIN SX,TAO J,et al.Study of liver cirrhosis over ten consecutive years in Southern China[J].World J Gastroenterol,2014,20(37):13546-13555.
[4]SINGH S,VENKATESH SK,LOOMBA R,et al.Magnetic resonance elastography for staging liver fibrosis in non-alcoholic fatty liver disease:A diagnostic accuracy systematic review and individual participant data pooled analysis[J].Eur Radiol,2016,26(5):1431-1440.
[5]ASRANI SK,TALWALKAR JA,KAMATH PS,et al.Role of magnetic resonance elastography in compensated and decompensated liver disease[J].J Hepatol,2014,60(5):934-939.
[6]HAMETNER S,FERLITSCH A,FERLITSCH M,et al.The VITROscore(von willebrand factor antigen/thrombocyte ratio)as a new marker for clinically significant portal hypertension in comparison to other non-invasive parameters of fibrosis including ELF test[J].Plos One,2016,11(2):e0149230.
[7]SANDAHL TD,MCGRAIL R,MOLLER HJ,et al.The macrophage activation marker sCD163 combined with markers of the Enhanced Liver Fibrosis(ELF)score predicts clinically significant portal hypertension in patients with cirrhosis[J].Aliment Pharmacol Ther,2016,43(11):1222-1231.
[8]PIND ML,BENDTSEN F,KALLEMOSE T,et al.Indocyanine green retention test(ICG-r15)as a noninvasive predictor of portal hypertension in patients with different severity of cirrhosis[J].Eur J Gastroenterol Hepatol,2016,28(8):948-954.
[9]LEEMING DJ,VEIDAL SS,KARSDAL MA,et al.Pro-C5,a marker of true type V collagen formation and fibrillation,correlates with portal hypertension in patients with alcoholic cirrhosis[J].Scand J Gastroenterol,2015,50(5):584-592.
[10]BUCK M,GARCIA-TSAO G,GROSZMANN RJ,et al.Novel inflammatory biomarkers of portal pressure in compensated cirrhosis patients[J].Hepatology,2014,59(3):1052-1059.
[11]WANG L,FENG Y,MA X,et al.Diagnostic efficacy of noninvasive liver fibrosis indexes in predicting portal hypertension in patients with cirrhosis[J].PLo S One,2017,12(8):e0182969.
[12]BRUHA R,JACHYMOVA M,PETRTYL J,et al.Osteopontin:A non-invasive parameter of portal hypertension and prognostic marker of cirrhosis[J].World J Gastroenterol,2016,22(12):3441-3450.
[13]KIM M,BAIK S,PARK D,et al.Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis:A prospective nonrandomized study[J].Liver Int,2007,27(8):1103-1110.
[14]BOLOGNESI M,SACERDOTI D,MERKEL C,et al.Noninvasive grading of the severity of portal hypertension in cirrhotic patients by echo-color-Doppler[J].Ultrasound Med Biol,2001,27(7):901-907.
[15]MARUYAMA H,YOKOSUKA O.Ultrasonography for noninvasive assessment of portal hypertension[J].Gut Liver,2017,11(4):464-473.
[16]BERZIGOTTI A,PISCAGLIA F,AMAT-ROLDAN I,et al.Non-invasive measurement of HVPG using graph analysis of dynamic contrast-enhanced ultrasound:The CLEVER study[J].J Hepatol,2018,68:s76-s77.
[17]BERZIGOTTI A,SEIJO S,ARENA U,et al.Elastography,spleen size,and platelet count identify portal hypertension in patients with compensated cirrhosis[J].Gastroenterology,2013,144(1):102-111.
[18]SHI KQ,FAN YC,PAN ZZ,et al.Transient elastography:Ameta-analysis of diagnostic accuracy in evaluation of portal hypertension in chronic liver disease[J].Liver Int,2013,33(1):4-6.
[19]YOU MW,KIM KW,PYO J,et al.A Meta-analysis for the diagnostic performance of transient elastography for clinically significant portal hypertension[J].Ultrasound Med Bio,2016,43(1):59-68.
[20]BERZIGOTTI A.Non-invasive evaluation of portal hypertension using ultrasound elastography[J].J Hepatol,2017,67(2):399-411.
[21]ATTIA D,SCHOENEMEIER B,RODT T,et al.Evaluation of liver and spleen stiffness with acoustic radiation force impulse quantification elastography for diagnosing clinically significant portal hypertension[J].Ultraschall Med,2015,36(6):603-610.
[22]DENG H,QI X,ZHANG T,et al.Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases:A meta-analysis[J].Expert Rev Gastroenterol Hepatol,2017,12(1):91-98.
[23]SONG J,HUANG J,HUANG H,et al.Performance of spleen stiffness measurement in prediction of clinical significant portal hypertension:A meta-analysis[J].Clin Res Hepatol Gastroenterol,2017.[Epub ahead of print].
[24]TAKUMA Y,NOUSO K,MORIMOTO Y,et al.Portal hypertension in patients with liver cirrhosis:Diagnostic accuracy of spleen stiffness[J].Radiology,2016,279(2):609-619.
[25]JANSEN C,BOGS C,VERLINDEN W,et al.Shear-wave elastography of the liver and spleen identifies clinically significant portal hypertension:A prospective multicentre study[J].Liver Int,2017,37(3):396-405.
[26]GOUYA H,GRABAR S,VIGNAUX O,et al.Portal hypertension in patients with cirrhosis:Indirect assessment of hepatic venous pressure gradient by measuring azygos flow with 2D-cine phase-contrast magnetic resonance imaging[J].Eur Radiol,2016,26(7):1981-1990.
[27]PALANIYAPPAN N,COX E,BRADLEY C,et al.Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging[J].J Hepatol,2016,65(6):1131-1139.
[28]CHOUHAN MD,MOOKERJEE RP,BAINBRIDGE A,et al.Caval subtraction 2D phase-contrast MRI to measure total liver and hepatic arterial blood flow:Proof-of-principle,correlation with portal hypertension severity and validation in patients with chronic liver disease[J].Invest Radiol,2017,52(3):170-176.
[29]GHARIB AM,HAN M,MEISSNER EG,et al.Magnetic resonance elastography shear wave velocity correlates with liver fibrosis and hepatic venous pressure gradient in adults with advanced liver disease[J].Biomed Res Int,2017,2017:2067479.
[30]ABRALDES JG,BUREAU C,STEFANESCU H,et al.Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis:The"Anticipate"study[J].Hepatology,2016,64(6):2173-2184.
[31]LIU F,NING Z,LIU Y,et al.Development and validation of a radiomics signature for clinically significant portal hypertension in cirrhosis(CHESS1701):A prospective multicenter study[J].EBio Medicine,2018,36:151-158.
[32]QI XL.Cirrhotic portal hypertension in the non-invasive era:What we grasp[J].Chin J Hepatol,2018,26(4):241-244.(in Chinese)祁小龙.肝硬化门静脉高压无创时代:我们如何把握[J].中华肝脏病杂志,2018,26(4):241-244.
[2]ASRANI SK,DEVARBHAVI H,EATON J,et al.Burden of liver diseases in the world[J].J Hepatol,2018.[Epub ahead of print]
[3]WANG X,LIN SX,TAO J,et al.Study of liver cirrhosis over ten consecutive years in Southern China[J].World J Gastroenterol,2014,20(37):13546-13555.
[4]SINGH S,VENKATESH SK,LOOMBA R,et al.Magnetic resonance elastography for staging liver fibrosis in non-alcoholic fatty liver disease:A diagnostic accuracy systematic review and individual participant data pooled analysis[J].Eur Radiol,2016,26(5):1431-1440.
[5]ASRANI SK,TALWALKAR JA,KAMATH PS,et al.Role of magnetic resonance elastography in compensated and decompensated liver disease[J].J Hepatol,2014,60(5):934-939.
[6]HAMETNER S,FERLITSCH A,FERLITSCH M,et al.The VITROscore(von willebrand factor antigen/thrombocyte ratio)as a new marker for clinically significant portal hypertension in comparison to other non-invasive parameters of fibrosis including ELF test[J].Plos One,2016,11(2):e0149230.
[7]SANDAHL TD,MCGRAIL R,MOLLER HJ,et al.The macrophage activation marker sCD163 combined with markers of the Enhanced Liver Fibrosis(ELF)score predicts clinically significant portal hypertension in patients with cirrhosis[J].Aliment Pharmacol Ther,2016,43(11):1222-1231.
[8]PIND ML,BENDTSEN F,KALLEMOSE T,et al.Indocyanine green retention test(ICG-r15)as a noninvasive predictor of portal hypertension in patients with different severity of cirrhosis[J].Eur J Gastroenterol Hepatol,2016,28(8):948-954.
[9]LEEMING DJ,VEIDAL SS,KARSDAL MA,et al.Pro-C5,a marker of true type V collagen formation and fibrillation,correlates with portal hypertension in patients with alcoholic cirrhosis[J].Scand J Gastroenterol,2015,50(5):584-592.
[10]BUCK M,GARCIA-TSAO G,GROSZMANN RJ,et al.Novel inflammatory biomarkers of portal pressure in compensated cirrhosis patients[J].Hepatology,2014,59(3):1052-1059.
[11]WANG L,FENG Y,MA X,et al.Diagnostic efficacy of noninvasive liver fibrosis indexes in predicting portal hypertension in patients with cirrhosis[J].PLo S One,2017,12(8):e0182969.
[12]BRUHA R,JACHYMOVA M,PETRTYL J,et al.Osteopontin:A non-invasive parameter of portal hypertension and prognostic marker of cirrhosis[J].World J Gastroenterol,2016,22(12):3441-3450.
[13]KIM M,BAIK S,PARK D,et al.Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis:A prospective nonrandomized study[J].Liver Int,2007,27(8):1103-1110.
[14]BOLOGNESI M,SACERDOTI D,MERKEL C,et al.Noninvasive grading of the severity of portal hypertension in cirrhotic patients by echo-color-Doppler[J].Ultrasound Med Biol,2001,27(7):901-907.
[15]MARUYAMA H,YOKOSUKA O.Ultrasonography for noninvasive assessment of portal hypertension[J].Gut Liver,2017,11(4):464-473.
[16]BERZIGOTTI A,PISCAGLIA F,AMAT-ROLDAN I,et al.Non-invasive measurement of HVPG using graph analysis of dynamic contrast-enhanced ultrasound:The CLEVER study[J].J Hepatol,2018,68:s76-s77.
[17]BERZIGOTTI A,SEIJO S,ARENA U,et al.Elastography,spleen size,and platelet count identify portal hypertension in patients with compensated cirrhosis[J].Gastroenterology,2013,144(1):102-111.
[18]SHI KQ,FAN YC,PAN ZZ,et al.Transient elastography:Ameta-analysis of diagnostic accuracy in evaluation of portal hypertension in chronic liver disease[J].Liver Int,2013,33(1):4-6.
[19]YOU MW,KIM KW,PYO J,et al.A Meta-analysis for the diagnostic performance of transient elastography for clinically significant portal hypertension[J].Ultrasound Med Bio,2016,43(1):59-68.
[20]BERZIGOTTI A.Non-invasive evaluation of portal hypertension using ultrasound elastography[J].J Hepatol,2017,67(2):399-411.
[21]ATTIA D,SCHOENEMEIER B,RODT T,et al.Evaluation of liver and spleen stiffness with acoustic radiation force impulse quantification elastography for diagnosing clinically significant portal hypertension[J].Ultraschall Med,2015,36(6):603-610.
[22]DENG H,QI X,ZHANG T,et al.Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases:A meta-analysis[J].Expert Rev Gastroenterol Hepatol,2017,12(1):91-98.
[23]SONG J,HUANG J,HUANG H,et al.Performance of spleen stiffness measurement in prediction of clinical significant portal hypertension:A meta-analysis[J].Clin Res Hepatol Gastroenterol,2017.[Epub ahead of print].
[24]TAKUMA Y,NOUSO K,MORIMOTO Y,et al.Portal hypertension in patients with liver cirrhosis:Diagnostic accuracy of spleen stiffness[J].Radiology,2016,279(2):609-619.
[25]JANSEN C,BOGS C,VERLINDEN W,et al.Shear-wave elastography of the liver and spleen identifies clinically significant portal hypertension:A prospective multicentre study[J].Liver Int,2017,37(3):396-405.
[26]GOUYA H,GRABAR S,VIGNAUX O,et al.Portal hypertension in patients with cirrhosis:Indirect assessment of hepatic venous pressure gradient by measuring azygos flow with 2D-cine phase-contrast magnetic resonance imaging[J].Eur Radiol,2016,26(7):1981-1990.
[27]PALANIYAPPAN N,COX E,BRADLEY C,et al.Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging[J].J Hepatol,2016,65(6):1131-1139.
[28]CHOUHAN MD,MOOKERJEE RP,BAINBRIDGE A,et al.Caval subtraction 2D phase-contrast MRI to measure total liver and hepatic arterial blood flow:Proof-of-principle,correlation with portal hypertension severity and validation in patients with chronic liver disease[J].Invest Radiol,2017,52(3):170-176.
[29]GHARIB AM,HAN M,MEISSNER EG,et al.Magnetic resonance elastography shear wave velocity correlates with liver fibrosis and hepatic venous pressure gradient in adults with advanced liver disease[J].Biomed Res Int,2017,2017:2067479.
[30]ABRALDES JG,BUREAU C,STEFANESCU H,et al.Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis:The"Anticipate"study[J].Hepatology,2016,64(6):2173-2184.
[31]LIU F,NING Z,LIU Y,et al.Development and validation of a radiomics signature for clinically significant portal hypertension in cirrhosis(CHESS1701):A prospective multicenter study[J].EBio Medicine,2018,36:151-158.
[32]QI XL.Cirrhotic portal hypertension in the non-invasive era:What we grasp[J].Chin J Hepatol,2018,26(4):241-244.(in Chinese)祁小龙.肝硬化门静脉高压无创时代:我们如何把握[J].中华肝脏病杂志,2018,26(4):241-244.