计算机视觉食管曲张静脉气囊测压技术的建立与临床应用研究
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摘要
研究背景
食管曲张静脉压力增高是直接导致血管破裂出血的关键因素,测量食管曲张静脉压力,对于评价出血风险及其防治效果具有重要意义。现有的食管曲张静脉气囊测压方法,是依据血管被刚刚压陷时(通过透明气囊观察),血管腔内外压力平衡的原理。操作者按照自己的经验判断曲张静脉被压陷时刻,决定曲张血管压力。测压结果依赖观察经验,因此存在主观性,也没有得到广泛认同与应用。如能建立一种基于计算机视觉的食管曲张静脉气囊测压技术,利用计算机视觉替代传统气囊测压方法人眼视觉,则能确定测压过程中曲张静脉被刚刚压陷的瞬间时刻,提高食管曲张静脉气囊测压技术的精确性。
目的
1.建立计算机视觉食管曲张静脉气囊测压技术;
2.通过体外模拟食管曲张静脉的仿真测压,验证该项检测技术指标的可靠性和精确性;
3.通过门脉高压症患者体内测压验证,与肝静脉压力梯度及预测出血风险其他因素对照,评估体内测压的可行性;
4.前瞻性评估计算机视觉食管曲张静脉气囊测压技术对预测曲张静脉首次出血的价值,并探讨影响食管曲张静脉破裂出血的危险因素。
材料与方法
1.建立计算机视觉食管曲张静脉气囊测压技术(Computerized endoscopic balloon manometry , CEBM):由电子测压计与计算机共同组成,能同步记录曲张静脉压力与内镜测压图像改变。
2.体外验证CEBM测压的可行性:将装有透明测压气囊的胃镜放置在食管模型中,对其中的模型曲张静脉内压力进行测量。曲张静脉模型有3种不同直径(3 mm, 6 mm, 9 mm),分别模拟轻、中、重度食管曲张静脉,模拟曲张血管充满水并与水柱测压计相连,通过调节水柱的高度而改变曲张静脉模型内压力。内镜医师只负责测压操作,不知道曲张血管模型内压力, 3种不同直径血管模型的压力范围均在8-36 mmHg之间。
3.测试CEBM体内应用的可靠性与可行性:在23例肝硬化食管静脉曲张患者中,将测压结果与肝静脉压力梯度(Hepatic venous pressure gradient, HVPG)对照,以验证CEBM测压的临床可靠性。
4.前瞻性评估计算机视觉食管曲张静脉气囊测压技术对预测曲张静脉首次出血的价值:纳入未发生过食管曲张静脉出血的57例肝硬化患者,CEBM测压并随访12个月,分析年龄、性别、肝硬化病因、食管曲张静脉内镜下表现(血管大小、红色征)、曲张静脉压力、肝功能严重程度Child-Pugh分级及腹水指标对食管曲张静脉破裂出血的影响,评价CEBM对预测曲张静脉首次出血的价值,并探讨影响食管曲张静脉破裂出血的危险因素。
结果
1.计算机视觉食管曲张静脉气囊测压技术运行稳定,在体内外实验中均完成压力检测;
2. CEBM体外实验发现,不同直径模拟曲张静脉测压值与血管内实际压力值具有良好相关性(r≥0.993, P <0.001),测压值偏差小(95%C.I.: -0.13 cmH2O-0.33 cmH2O之间),模拟曲张静脉的直径大小不影响测压结果;
3. CEBM体内验证发现,检测23例肝硬化食管曲张静脉压力,全部病例均测压成功,没有胸骨后疼痛、食管曲张静脉出血、难以控制的咳嗽及呼吸困难等严重副作用。平均每名患者5次测压所需的总时间为12±3 min (mean±SD)。测压可重复性好,变异系数小(r≥0.998)。平均食管曲张静脉压(25.6±4.8 mmHg)高于HVPG(18.1±3.7 mmHg),回归分析表明,食管曲张静脉压力与HVPG间具有良好的相关性(r=0.885, P<0.001),仅2例测压不满意,压力偏差稍大。曾有出血史病例的食管曲张静脉压力明显高于无出血史患者(28.6±3.1 mmHg vs 21.3±3.0 mmHg, P<0.001),粗大曲张静脉压力较细小血管高(26.6±4.7 mmHg vs 22.6±3.8 mmHg, P=0.05),有红色征患者食管曲张静脉压力较无红色征患者高(27.3±4.2 mmHg vs 22.5±4.1 mmHg, P=0.015)。Child-Pugh分级与食管曲张静脉压力无相关性,Child A级(n=11)患者平均压力为25.09±3.94 mmHg,Child B+C级(n=12)患者平均压力为25.71±5.52 mmHg (t=0.31, P=0.76);
4.对57例肝硬化食管曲张静脉患者首次出血风险评估发现,1年内34例患者(34/57, 59.6 %)发生曲张静脉破裂出血。单因素分析表明,食管曲张静脉压力(bleeder 28.87±2.61 mmHg; nonbleeder 20.43±2.98 mmHg; P < 0.001)、曲张静脉直径(bleeder 8.91±2.04 mm; nonbleeder 7.09±2.75 mm; P = 0.006)、内镜下红色征(bleeding rate, bleeder 81% vs nonbleeder 47.2%, P = 0.012)预示较高的出血风险。多因素非条件Logistic回归分析发现,食管曲张静脉压力是预测首次出血的最主要危险因子(OR = 2.817, P = 0.003,95.0% C.I. 1.437-5.521)。食管曲张静脉首次出血时间的多因素Cox比例风险模型分析,最终进入方程变量只有曲张静脉压力。预测首次出血曲张静脉压力值的ROC曲线下面积为0.98 (95% C.I.: 0.95-1.00)。根据ROC曲线,计算曲张静脉压力阈值为25.3 mmHg,其预测出血的灵敏度与特异度均为91%。在25.3 mmHg的曲张静脉压力阈值以下患者,1年出血率明显低于25.3 mmHg以上的患者(P < 0.001)。影响曲张静脉压力的因素主要是血管直径与红色征表现。粗大的曲张静脉压力比细小血管内压力高(GradeⅢ26.56±4.46 mmHg vs GradeⅡ21.74±4.49 mmHg, P=0.02)。出血组34例病人,内镜下红色征者的食管曲张静脉压力比无红色征者增高(28.40±2.41 mmHg vs 23.25±3.69 mmHg, P < 0.001);非出血组23例病人,具有红色征者的食管曲张静脉压力同样比无红色征者升高(26.74±4.95 mmHg vs 19.97±2.18 mmHg, P < 0.001)。
结论
我们的研究提示,计算机视觉食管曲张静脉气囊测压技术有较高的准确性与可行性,据此测定的食管曲张静脉压力是预测食管曲张静脉破裂出血的主要危险因素,具有进一步开发应用的潜在价值。
Background and aims
Variceal pressure has been identified as the key factor leading to variceal rupture. Measuring variceal pressure is important in predicting esophageal variceal bleeding. Noninvasive balloon techniques assume that varices behave as an elastic structure because of their thin walls and lack of external tissue support; thus, the pressure needed to compress a varix (which can be sensed under direct vision using clear balloons) equals the pressure inside the varix. Manometry uses an endoscopic balloon to measure variceal pressure. Up until now, this method relied on the visual appearance of the varices and, therefore, was subjected to observer bias. Endoscopic balloon methods of measuring variceal pressure have not gained wide popularity. We have recently developed a computerized endoscopic balloon manometry (CEBM), with computer visualization to determine the moment of variceal wall collapse during balloon manometry instead of the visual evaluation of variceal compression used in the traditional balloon method. In this paper, we report the preliminary results of in-vitro and in-vivo testing of CEBM.
The aims of the present study were: (1) to develop a new computerized endoscopic balloon manometry; (2) to validate this technique of CEBM in-vitro; (3) to test the clinical reliability and feasibility of this manometry by compared with the HVPG; and to correlate measured pressure values to endoscopic bleeding risk parameters as previously described; (4) to assess the applicability of this method for predict a first variceal hemorrhage in cirrhotic patients during the prospective study, and to detect clinical factors in the evaluation of the risk of bleeding.
Patients and methods
The CEBM system, comprising an esophageal variceal manometer and a computer, records variceal pressure and manometry images simultaneously. (1) In the in-vitro study, variceal models were fixed inside an artificial esophagus, into which an endoscope with transparent balloon was inserted for intraluminal pressure measurement. The artificial varix was filled with water and connected to a water column to modulate the intraluminal pressure. This CEBM system was tested blindly in three variceal models (the artificial variceal models, which were 3, 6, and 8mm in diameter) with different intraluminal pressures, ranging from 8 to 36 cmH2O. (2) CEBM was also used to measure variceal pressure in 23 patients with liver cirrhosis and esophageal varices, and the results were compared with the hepatic venous pressure gradient (HVPG), to assess the accuracy of this method. (3) Fifty-seven patients with liver cirrhosis and esophageal varices who had never experienced variceal bleeding were followed for 12 months. The patients underwent variceal pressure measurement by CEBM technique. The endpoint of the study was the presence or absence of a variceal hemorrhage. The relation between variceal hemorrhage with age, sex, etiology of cirrhosis, endoscopic findings of varices (size of varices, red color signs), variceal pressure, Child-Pugh’s class, and ascites were studied.
Results
(1) The experiments proved that the measured pressure by CEBM has high stability. Variceal pressure measurements were technically satisfactory in-vitro and in clinical study. (2) In-vitro study, the measured intraluminal pressure correlated significantly with the actual intraluminal pressure for different diameters (r≥0.993, P <0.001). No obvious measurement bias was found for any of the varices (95%C.I were -0.13 cmH2O to 0.33 cmH2O). The diameter of artificial varices did not affect the measurement of variceal pressure. (3) Variceal pressure measurements with CEBM were technically successful in 23 patients. The endoscope with the deflated balloon could be introduced into the stomach without difficulty. No adverse effect related to the measuring procedure and sedation was observed, except for slight retching during intubation. We noticed that in particular there was no retrosternal pain, variceal bleeding, or uncontrolled coughing during slow inflation of the balloon. The time required to make five measurements of variceal pressure in each patient was 12±3 minutes (mean±SD). There was a close agreement between the two individuals regarding the point of flattening of the balloon variceal markers (correlation coefficients: r≥0.998). Overall, the value for mean variceal pressure (25.6±4.8 mmHg) was higher than that for mean HVPG (18.1±3.7 mmHg, P<0.001). Variceal pressure values (28.9±2.9 mmHg) were higher in patients with bleeding compared with nonbleeding patients (21.3±3.0 mmHg, P<0.001). Regression analysis showed a good correlation between variceal pressure measured with CEBM and the HVPG (r= 0.858, P <0.001). However, determination of the variceal pressure was not very satisfactory in two patients. The presence of previous bleeding episodes was strongly associated with higher variceal pressure (28.6±3.1 mmHg vs 21.3±3.0 mmHg, P<0.001). Variceal pressure correlated positively to variceal sizes (large varix, 26.6±4.7 mmHg vs small varix, 22.6±3.8 mmHg, P=0.05). We also found a significant relationship between variceal pressure and the presence of red color signs (27.3±4.2 mmHg vs 22.5±4.1 mmHg, P=0.015). Child–Pugh class parameter did not correlate with variceal pressure. The average of variceal pressure in Child–Pugh class A (n=11) was 25.09±3.94 mmHg, the average of variceal pressure in Child–Pugh class B plus C (n=12) were 25.71±5.52 mmHg (t=0.31, P=0.76). (4) In all 57 cirrhotic patients, thirty-four patients (34/57, 59.6 %) developed a variceal hemorrhage. In univariate analysis, the level of variceal pressure (bleeder 28.87±2.61 mmHg; nonbleeder 20.43±2.98 mmHg; P < 0.001), the diameter of varices (bleeder 8.91±2.04 mm; nonbleeder 7.09±2.75 mm; P = 0.006), and the endoscopic red color sign on the variceal wall (bleeding rate, bleeder 81% vs nonbleeder 47.2%, P = 0.012) predicted a higher risk of variceal hemorrhage. With the results obtained from univariate analysis, a multiple logistic regression model was created which revealed that variceal pressure was major predictor of the risk for a first variceal bleeding (OR = 2.817, P = 0.003, 95.0% C.I. were 1.437 to 5.521). The area under the receiver operating characteristic (ROC) of variceal pressure for predicting variceal bleeding was 0.98 and at variceal pressure cutoff value of 25.3 mmHg, specificity and sensitivity were 91%. Higher variceal pressures have been documented in patients with large varices(gradeⅢ26.56±4.46 mmHg vs gradeⅡ21.74±4.49 mmHg, P=0.02), and in those with red color signs ( bleeder, 28.40±2.41 mmHg vs 23.25±3.69 mmHg, P < 0.001; nonbleeder, 26.74±4.95 mmHg vs 19.97±2.18 mmHg, P < 0.001), which are those more prone to bleed.
Conclusions
Our preliminary results indicate that CEBM of esophageal varices is feasible and accurate. This technique may become a more reliable method for noninvasive measurement of variceal pressure and warrants further investigation. The level of variceal pressure is a major predictor for variceal bleeding in cirrhotic patients.
食管曲张静脉压力增高是直接导致血管破裂出血的关键因素,测量食管曲张静脉压力,对于评价出血风险及其防治效果具有重要意义。现有的食管曲张静脉气囊测压方法,是依据血管被刚刚压陷时(通过透明气囊观察),血管腔内外压力平衡的原理。操作者按照自己的经验判断曲张静脉被压陷时刻,决定曲张血管压力。测压结果依赖观察经验,因此存在主观性,也没有得到广泛认同与应用。如能建立一种基于计算机视觉的食管曲张静脉气囊测压技术,利用计算机视觉替代传统气囊测压方法人眼视觉,则能确定测压过程中曲张静脉被刚刚压陷的瞬间时刻,提高食管曲张静脉气囊测压技术的精确性。
目的
1.建立计算机视觉食管曲张静脉气囊测压技术;
2.通过体外模拟食管曲张静脉的仿真测压,验证该项检测技术指标的可靠性和精确性;
3.通过门脉高压症患者体内测压验证,与肝静脉压力梯度及预测出血风险其他因素对照,评估体内测压的可行性;
4.前瞻性评估计算机视觉食管曲张静脉气囊测压技术对预测曲张静脉首次出血的价值,并探讨影响食管曲张静脉破裂出血的危险因素。
材料与方法
1.建立计算机视觉食管曲张静脉气囊测压技术(Computerized endoscopic balloon manometry , CEBM):由电子测压计与计算机共同组成,能同步记录曲张静脉压力与内镜测压图像改变。
2.体外验证CEBM测压的可行性:将装有透明测压气囊的胃镜放置在食管模型中,对其中的模型曲张静脉内压力进行测量。曲张静脉模型有3种不同直径(3 mm, 6 mm, 9 mm),分别模拟轻、中、重度食管曲张静脉,模拟曲张血管充满水并与水柱测压计相连,通过调节水柱的高度而改变曲张静脉模型内压力。内镜医师只负责测压操作,不知道曲张血管模型内压力, 3种不同直径血管模型的压力范围均在8-36 mmHg之间。
3.测试CEBM体内应用的可靠性与可行性:在23例肝硬化食管静脉曲张患者中,将测压结果与肝静脉压力梯度(Hepatic venous pressure gradient, HVPG)对照,以验证CEBM测压的临床可靠性。
4.前瞻性评估计算机视觉食管曲张静脉气囊测压技术对预测曲张静脉首次出血的价值:纳入未发生过食管曲张静脉出血的57例肝硬化患者,CEBM测压并随访12个月,分析年龄、性别、肝硬化病因、食管曲张静脉内镜下表现(血管大小、红色征)、曲张静脉压力、肝功能严重程度Child-Pugh分级及腹水指标对食管曲张静脉破裂出血的影响,评价CEBM对预测曲张静脉首次出血的价值,并探讨影响食管曲张静脉破裂出血的危险因素。
结果
1.计算机视觉食管曲张静脉气囊测压技术运行稳定,在体内外实验中均完成压力检测;
2. CEBM体外实验发现,不同直径模拟曲张静脉测压值与血管内实际压力值具有良好相关性(r≥0.993, P <0.001),测压值偏差小(95%C.I.: -0.13 cmH2O-0.33 cmH2O之间),模拟曲张静脉的直径大小不影响测压结果;
3. CEBM体内验证发现,检测23例肝硬化食管曲张静脉压力,全部病例均测压成功,没有胸骨后疼痛、食管曲张静脉出血、难以控制的咳嗽及呼吸困难等严重副作用。平均每名患者5次测压所需的总时间为12±3 min (mean±SD)。测压可重复性好,变异系数小(r≥0.998)。平均食管曲张静脉压(25.6±4.8 mmHg)高于HVPG(18.1±3.7 mmHg),回归分析表明,食管曲张静脉压力与HVPG间具有良好的相关性(r=0.885, P<0.001),仅2例测压不满意,压力偏差稍大。曾有出血史病例的食管曲张静脉压力明显高于无出血史患者(28.6±3.1 mmHg vs 21.3±3.0 mmHg, P<0.001),粗大曲张静脉压力较细小血管高(26.6±4.7 mmHg vs 22.6±3.8 mmHg, P=0.05),有红色征患者食管曲张静脉压力较无红色征患者高(27.3±4.2 mmHg vs 22.5±4.1 mmHg, P=0.015)。Child-Pugh分级与食管曲张静脉压力无相关性,Child A级(n=11)患者平均压力为25.09±3.94 mmHg,Child B+C级(n=12)患者平均压力为25.71±5.52 mmHg (t=0.31, P=0.76);
4.对57例肝硬化食管曲张静脉患者首次出血风险评估发现,1年内34例患者(34/57, 59.6 %)发生曲张静脉破裂出血。单因素分析表明,食管曲张静脉压力(bleeder 28.87±2.61 mmHg; nonbleeder 20.43±2.98 mmHg; P < 0.001)、曲张静脉直径(bleeder 8.91±2.04 mm; nonbleeder 7.09±2.75 mm; P = 0.006)、内镜下红色征(bleeding rate, bleeder 81% vs nonbleeder 47.2%, P = 0.012)预示较高的出血风险。多因素非条件Logistic回归分析发现,食管曲张静脉压力是预测首次出血的最主要危险因子(OR = 2.817, P = 0.003,95.0% C.I. 1.437-5.521)。食管曲张静脉首次出血时间的多因素Cox比例风险模型分析,最终进入方程变量只有曲张静脉压力。预测首次出血曲张静脉压力值的ROC曲线下面积为0.98 (95% C.I.: 0.95-1.00)。根据ROC曲线,计算曲张静脉压力阈值为25.3 mmHg,其预测出血的灵敏度与特异度均为91%。在25.3 mmHg的曲张静脉压力阈值以下患者,1年出血率明显低于25.3 mmHg以上的患者(P < 0.001)。影响曲张静脉压力的因素主要是血管直径与红色征表现。粗大的曲张静脉压力比细小血管内压力高(GradeⅢ26.56±4.46 mmHg vs GradeⅡ21.74±4.49 mmHg, P=0.02)。出血组34例病人,内镜下红色征者的食管曲张静脉压力比无红色征者增高(28.40±2.41 mmHg vs 23.25±3.69 mmHg, P < 0.001);非出血组23例病人,具有红色征者的食管曲张静脉压力同样比无红色征者升高(26.74±4.95 mmHg vs 19.97±2.18 mmHg, P < 0.001)。
结论
我们的研究提示,计算机视觉食管曲张静脉气囊测压技术有较高的准确性与可行性,据此测定的食管曲张静脉压力是预测食管曲张静脉破裂出血的主要危险因素,具有进一步开发应用的潜在价值。
Background and aims
Variceal pressure has been identified as the key factor leading to variceal rupture. Measuring variceal pressure is important in predicting esophageal variceal bleeding. Noninvasive balloon techniques assume that varices behave as an elastic structure because of their thin walls and lack of external tissue support; thus, the pressure needed to compress a varix (which can be sensed under direct vision using clear balloons) equals the pressure inside the varix. Manometry uses an endoscopic balloon to measure variceal pressure. Up until now, this method relied on the visual appearance of the varices and, therefore, was subjected to observer bias. Endoscopic balloon methods of measuring variceal pressure have not gained wide popularity. We have recently developed a computerized endoscopic balloon manometry (CEBM), with computer visualization to determine the moment of variceal wall collapse during balloon manometry instead of the visual evaluation of variceal compression used in the traditional balloon method. In this paper, we report the preliminary results of in-vitro and in-vivo testing of CEBM.
The aims of the present study were: (1) to develop a new computerized endoscopic balloon manometry; (2) to validate this technique of CEBM in-vitro; (3) to test the clinical reliability and feasibility of this manometry by compared with the HVPG; and to correlate measured pressure values to endoscopic bleeding risk parameters as previously described; (4) to assess the applicability of this method for predict a first variceal hemorrhage in cirrhotic patients during the prospective study, and to detect clinical factors in the evaluation of the risk of bleeding.
Patients and methods
The CEBM system, comprising an esophageal variceal manometer and a computer, records variceal pressure and manometry images simultaneously. (1) In the in-vitro study, variceal models were fixed inside an artificial esophagus, into which an endoscope with transparent balloon was inserted for intraluminal pressure measurement. The artificial varix was filled with water and connected to a water column to modulate the intraluminal pressure. This CEBM system was tested blindly in three variceal models (the artificial variceal models, which were 3, 6, and 8mm in diameter) with different intraluminal pressures, ranging from 8 to 36 cmH2O. (2) CEBM was also used to measure variceal pressure in 23 patients with liver cirrhosis and esophageal varices, and the results were compared with the hepatic venous pressure gradient (HVPG), to assess the accuracy of this method. (3) Fifty-seven patients with liver cirrhosis and esophageal varices who had never experienced variceal bleeding were followed for 12 months. The patients underwent variceal pressure measurement by CEBM technique. The endpoint of the study was the presence or absence of a variceal hemorrhage. The relation between variceal hemorrhage with age, sex, etiology of cirrhosis, endoscopic findings of varices (size of varices, red color signs), variceal pressure, Child-Pugh’s class, and ascites were studied.
Results
(1) The experiments proved that the measured pressure by CEBM has high stability. Variceal pressure measurements were technically satisfactory in-vitro and in clinical study. (2) In-vitro study, the measured intraluminal pressure correlated significantly with the actual intraluminal pressure for different diameters (r≥0.993, P <0.001). No obvious measurement bias was found for any of the varices (95%C.I were -0.13 cmH2O to 0.33 cmH2O). The diameter of artificial varices did not affect the measurement of variceal pressure. (3) Variceal pressure measurements with CEBM were technically successful in 23 patients. The endoscope with the deflated balloon could be introduced into the stomach without difficulty. No adverse effect related to the measuring procedure and sedation was observed, except for slight retching during intubation. We noticed that in particular there was no retrosternal pain, variceal bleeding, or uncontrolled coughing during slow inflation of the balloon. The time required to make five measurements of variceal pressure in each patient was 12±3 minutes (mean±SD). There was a close agreement between the two individuals regarding the point of flattening of the balloon variceal markers (correlation coefficients: r≥0.998). Overall, the value for mean variceal pressure (25.6±4.8 mmHg) was higher than that for mean HVPG (18.1±3.7 mmHg, P<0.001). Variceal pressure values (28.9±2.9 mmHg) were higher in patients with bleeding compared with nonbleeding patients (21.3±3.0 mmHg, P<0.001). Regression analysis showed a good correlation between variceal pressure measured with CEBM and the HVPG (r= 0.858, P <0.001). However, determination of the variceal pressure was not very satisfactory in two patients. The presence of previous bleeding episodes was strongly associated with higher variceal pressure (28.6±3.1 mmHg vs 21.3±3.0 mmHg, P<0.001). Variceal pressure correlated positively to variceal sizes (large varix, 26.6±4.7 mmHg vs small varix, 22.6±3.8 mmHg, P=0.05). We also found a significant relationship between variceal pressure and the presence of red color signs (27.3±4.2 mmHg vs 22.5±4.1 mmHg, P=0.015). Child–Pugh class parameter did not correlate with variceal pressure. The average of variceal pressure in Child–Pugh class A (n=11) was 25.09±3.94 mmHg, the average of variceal pressure in Child–Pugh class B plus C (n=12) were 25.71±5.52 mmHg (t=0.31, P=0.76). (4) In all 57 cirrhotic patients, thirty-four patients (34/57, 59.6 %) developed a variceal hemorrhage. In univariate analysis, the level of variceal pressure (bleeder 28.87±2.61 mmHg; nonbleeder 20.43±2.98 mmHg; P < 0.001), the diameter of varices (bleeder 8.91±2.04 mm; nonbleeder 7.09±2.75 mm; P = 0.006), and the endoscopic red color sign on the variceal wall (bleeding rate, bleeder 81% vs nonbleeder 47.2%, P = 0.012) predicted a higher risk of variceal hemorrhage. With the results obtained from univariate analysis, a multiple logistic regression model was created which revealed that variceal pressure was major predictor of the risk for a first variceal bleeding (OR = 2.817, P = 0.003, 95.0% C.I. were 1.437 to 5.521). The area under the receiver operating characteristic (ROC) of variceal pressure for predicting variceal bleeding was 0.98 and at variceal pressure cutoff value of 25.3 mmHg, specificity and sensitivity were 91%. Higher variceal pressures have been documented in patients with large varices(gradeⅢ26.56±4.46 mmHg vs gradeⅡ21.74±4.49 mmHg, P=0.02), and in those with red color signs ( bleeder, 28.40±2.41 mmHg vs 23.25±3.69 mmHg, P < 0.001; nonbleeder, 26.74±4.95 mmHg vs 19.97±2.18 mmHg, P < 0.001), which are those more prone to bleed.
Conclusions
Our preliminary results indicate that CEBM of esophageal varices is feasible and accurate. This technique may become a more reliable method for noninvasive measurement of variceal pressure and warrants further investigation. The level of variceal pressure is a major predictor for variceal bleeding in cirrhotic patients.
引文
1. Sharara AI, Rockey DC. Gartroesophageal variceal hemorrhage. N Engl J Med, 2001; 345(9): 669-681.
2. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med, 1988; 319(15): 983-989.
3. Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol, 2000; 95(10): 2915-2920.
4. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient:anything worth doing should be done right. Hepatology, 2004; 39(2):280-282.
5. Dittrich S, de Mattos AA, Becker M, Gon?aves DM, Cheinquer H. Role of hepatic hemodynamic study in the evaluation of patients with cirrhosis. Hepatogastroenterology, 2003; 50(54): 2052-2056.
6. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology, 2006; 131(5): 1611-1624.
7. Lebrec D, Vinel JP, Dupas JL. Complications of portal hypertension in adults: a French consensus. Eur J Gastroenterol Hepatol, 2005; 17(4):403-410.
8. Polio J, Hanson J, Sikuler E, Vogel G, Gusberg R, Fisher R, Groszmann RJ. Critical evaluation of a pressure-sensitive capsule for measurement of esophageal varix pressure. Studies in vitro and in canine mesenteric vessels. Gastroenterology, 1987; 92(5 pt 1): 1109-1115.
9. Rigau J, Bosch J, Bordas JM, Navasa M, Mastai R, Kravetz D, Bruix J, Feu F, Rodés J. Endoscopic measurement of variceal pressure in cirrhosis: Correlation with portal pressure and variceal hemorrhage. Gastroenterology, 1989; 96(3):873-880.
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17. Escorsell A, Bordas JM, Casta?eda B, Llach J, García-Pagán JC, Rodés J, Bosch J. Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension. Hepatology. 2000, 31(5):1061–1067.
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20. Mosimann R. Nonaggresive assessment of portal hypertension using endoscopic measurement of variceal pressure. Am J Surg, 1982; 143(2): 212-214
21. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut, 1987; 28(9): 1162-1165.
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23. Pontes JM, Leit?o MC, Portela F, Nunes A, Freitas D. Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility. Endoscopy, 2002; 34(12): 966–972.
24. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy, 1998; 30(4):326-332.
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27.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002;19(4): 74-76.
28.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004;21(1): 36-38.
29. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol, 1998; 29(1):94-102.
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8. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
9. Nevens F, Sprengers D, Feu F, Bosch J, Fevery J. Measurement of variceal pressure with an endoscopic pressure sensitive gauge: validation and effect of propranolol therapy in chronic conditions. J Hepatol. 1996, 24(1):66-73.
10. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy. 1998, 30(4):326-332.
11. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol. 1998, 29(1):94-102.
12. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-19.
13.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004, 21(1): 36-38.
1. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
2.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
3.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志, 2004, 21(1): 36-38.
4. Gertsch PH, Fischer G, Kleber G, Wheatley AM, Geigenberger G, Sauerbruch T. Manometry of esophageal varices: comparison of an endoscopic balloon technique with needle puncture. Gastroenterology. 1993, 105(4): 1159-1166.
5. Kong DR, Xu JM,Zhang L, Zhang C, Fu ZQ, He BB, Sun B, Xie Y. A computerized endoscopic balloon manometry to detect esophageal variceal pressure. Endoscopy. 2009,46(5): 415-420.
6.中华医学会消化内镜分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年).中华消化内镜杂志. 2004, 21(3): 149-151.
7. Kleber G, Sauerbruch T, Fischer G, Paumgartner G. Pressure of intraesophageal varices assessed by fine needle puncture: its relation to endoscopic signs and severity of liver disease in patients with cirrhosis. Gut. 1989, 30(2): 228-232.
8. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-9.
9. Escorsell A, Bordas JM, Casta?eda B, Llach J, García-Pagán JC, Rodés J, Bosch J. Predictive value of the variceal pressure response to continued pharmacologicaltherapy in patients with cirrhosis and portal hypertension. Hepatology. 2000, 31(5): 1061-1067.
10. Atti El, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal haemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut. 1999, 45(4): 618-621
11. Gertsch PH, Wheatley AM, Maibach R, Maddern GJ, Vauthey JN. Experimental evaluation of an endoscopic balloon for manometry of esophageal varices. Gastroenterology. 1991,101(6): 1692-1700.
12. Pontes JM, Leit?o MC, Portela F, Nunes A, Freitas D. Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility. Endoscopy. 2002, 34(12): 966-972.
13.孔德润,许建明,付忠谦,何兵兵,孙斌,张磊,谢岳.基于计算机视觉的无创性食管曲张静脉测压仪.生物医学工程学杂志,2007, 24(3): 519-521.
14. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol. 1998, 29(1): 94-102.
15. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988, 319(15): 983-989.
16.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
17. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy. 1998, 30(4): 326-332.
18. Kleber G, Sauerbruch T, Ansari H, Paumgartner G. Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology. 1991,100 (5 Pt 1): 1332-1337.
19. Burroughs AK, D’Heygere F, McIntyre N. Pitfalls in studies of prophylactic therapy for variceal bleeding in cirrhotics. Hepatology. 1986, 6(6): 1407-1413.
20.吴云林,王玲玲,徐志红,陆和平,杨根妹,施华秀,冯莉.经内镜食管曲张静脉测压及生长抑素和奥曲肽的降压作用研究.中华消化内镜杂志,2000, 17(4): 208-209
21. Ming-Chih Hou, Han-Chieh Lin, Benjamin Ing-Tieu Kuo, Tung-Min Liao, Fa-Yauh Lee, Full-Young Chang and Shou-Dong Lee. Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding. J Hepatology. 1998, 29(5): 772-778.
22. Wadhawan M, Dubey S, Sharma BC, Sarin SK. Hepatic venous pressure gradient in cirrhosis: correlation with the size of varices, bleeding, ascites, and Child’s Status. Dig Dis Sci. 2006, 51(12): 2264-2269.
23. Bellis L, Castellacci R, Montagnese F, Festuccia F, Corvisieri P, Puoti C. Hepatic venous pressure gradient determination in patients with hepatitis C virus-related and alcoholic cirrhosis. Eur J Gastroenterol Hepatol. 2003, 15(10): 1085-1089.
1. Sharara AI, Rockey DC. Gartroesophageal variceal hemorrhage. N Engl J Med2001, 345(9): 669-681.
2. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988, 319(15): 983-989.
3. Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the NorthItalian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000, 95(10): 2915-2920.
4. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology. 2004, 39(2):280-282.
5. Dittrich S, de Mattos AA, Becker M, Gon?aves DM, Cheinquer H. Role of hepatic hemodynamic study in the evaluation of patients with cirrhosis. Hepatogastroenterology. 2003, 50(54): 2052-2066.
6. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology. 2006, 131(5): 1611-1624.
7. Lebrec D, Vinel JP, Dupas JL. Complications of portal hypertension in adults: a French consensus. Eur J Gastroenterol Hepatol. 2005, 17(4): 403-410.
8. Polio J, Hanson J, Sikuler E, Vogel G, Gusberg R, Fisher R, Groszmann RJ. Critical evaluation of a pressure-sensitive capsule for measurement of esophageal varix pressure. Studies in vitro and in canine mesenteric vessels. Gastroenterology. 1987, 92(5 pt 1): 1109-1115.
9. Kong DR, Xu JM, Zhang L, Zhang C, Fu ZQ, He BB, Sun B, Xie Y. A computerized endoscopic balloon manometry to detect esophageal variceal pressure. Endoscopy. 2009,46(5):415-420.
10.孔德润,许建明,付忠谦,何兵兵,孙斌,张磊,谢岳.基于计算机视觉的无创性食管曲张静脉测压仪.生物医学工程学杂志,2007, 24(3): 519-521.
11. Rigau J, Bosch J, Bordas JM, Navasa M, Mastai R, Kravetz D, Bruix J, Feu F, Rodés J. Endoscopic measurement of variceal pressure in cirrhosis: Correlation with portal pressure and variceal hemorrhage. Gastroenterology. 1989, 96(3):873-880.
12. Spahr L, Giostra E, Morard I, Mentha G, Hadengue A. Perendoscopic variceal pressure measurement, a reliable estimation of portal pressure in patients withcirrhosis? Gastroenterol Clin Biol. 2006, 30(8-9): 1012-1018.
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15.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
16.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004, 21(1): 36-38.
17. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-19.
18. Atti El, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal haemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut. 1999,45(4): 618–621.
19. Ming-Chih Hou, Han-Chieh Lin, Benjamin Ing-Tieu Kuo, Tung-Min Liao, Fa-Yauh Lee, Full-Young Chang and Shou-Dong Lee. Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding. J Hepatol. 1998, 29(5): 772–778.
20.吴云林,王玲玲,徐志红,陆和平,杨根妹,施华秀,冯莉.经内镜食管曲张静脉测压及生长抑素和奥曲肽的降压作用研究.中华消化内镜杂志,2000, 17(4): 208-209.
21. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
22. Mosimann R. Nonaggresive assessment of portal hypertension using endoscopic measurement of variceal pressure. Am J Surg. 1982, 143(2): 212-214.
23.刘浔阳,朱晒红,黄飞舟,聂晚频,刘波,任树平.食管曲张静脉微创测压研究.中华消化杂志, 2001, 21(7): 411-413.
24. Polio J, Groszmann R. Hemodynamic factors involved in the development and rupture of esophageal varices: a pharmacologic approach to treatment. Semin Liver Dis. 1986, 6(4): 318-331.
25. Beppu K, Inokuchi K, Koyanagi N, Sakata H, Kitano S, Kobayashi M. Prediction of a variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc. 1981, 27:213-218.
26. Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings of esophageal varices. Jpn J Surg. 1980, 10(1): 84-87.
27. Kleber G, Sauerbruch T, Ansari H, Paumgartner G. Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology. 1991, 100 (5 Pt 1): 1332-1337.
28. Escorsell A, Ginès A, Llach J, García-Pagán JC, Bordas JM, Bosch J, Rodés J. Increasing intra-abdominal pressure increases pressure, volume and wall tension in esophageal varices. Hepatology. 2002, 36(4 Pt 1): 936-940.
29. Kravetz D, Bildozola M, Argonz J, Romero G, Korula J, Mu?oz A, Suarez A, Terg R. Patients with ascites have higher variceal pressure and wall tension than patients without ascites. Am J Gastroenterol. 2000, 95(7): 1770-1775.
30. Lo GH, Liang HL, Lai KH, Chang CF, Hwu JH, Chen SM, Lin CK, Chiang HT. The impact of endoscopic variceal ligation on the pressure of the portal venous system. J Hepatol. 1996, 24(1): 74-80.
31. Pereira-Lima JC, Zanette M, Lopes CV, Lopes CV, de Mattos AA. The influence of endoscopic variceal ligation on the portal pressure gradient in cirrhotics. Hepatogastroenterology, 2003, 50(49): 102-106.
32. Zoli M, Merkel C, Magalotti D, Marchesini G, Gatta A, Pisi E. Evaluation of a new endoscipic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis. Hepatology. 1996, 24(5): 1047-1052.
1 Sharara AI, Rockey DC. Gartroesophageal variceal hemorrhage. N Engl J Med. 2001, 345(9): 669-681.
2 The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988, 319(15): 983-989.
3 Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000, 95(10): 2915-2920.
4 Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology. 2004, 39(2):280-282.
5 Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-19.
6 Polio J, Hanson J, Sikuler E, Vogel G, Gusberg R, Fisher R, Groszmann RJ. Critical evaluation of a pressure-sensitive capsule for measurement of esophageal varix pressure. Studies in vitro and in canine mesenteric vessels. Gastroenterology. 1987, 92(5 pt 1): 1109-1115.
7 Rigau J, Bosch J, Bordas JM, Navasa M, Mastai R, Kravetz D, Bruix J, Feu F, Rodés J. Endoscopic measurement of variceal pressure in cirrhosis: Correlation with portal pressure and variceal hemorrhage. Gastroenterology. 1989, 96(3):873-880.
8 Groszmann RJ. Reassessing portal venous pressure measurements. Gastroenterology. 1984, 86(6):1611–1614.
9 Sarin, S.K. Saraya, A. Effects of in travenous nitroglycerin and metoclopramide on intravariceal pressure: a double blind ranodomized study. Am J Gastroenterology. 1995, 90(1):48-53.
10 Polio J, Groszmann RJ. Hemodynamic factors involved in the development and rupture of esophageal varices: a pathophysiologic approach to treatment. Semin Liver Dis. 1986, 6(4):318–331.
11 Mosimann R. Nonaggresive assessment of portal hypertension using endoscopic measurement of variceal pressure. Am J Surg. 1982, 143(2): 212-214.
12 Bosch J, Bordas JM, Rigau J. Noninvasive measurement of the pressure of esophageal varices using an endoscopic gauge: comparison with measurements by variceal puncture in patients undergoing endoscopic sclerotherapy. Hepatology. 1986, 6(4): 667-672.
13 Polio J, Leonard R, Groszmann RJ, et al. An improved pressure-sensitive capsule for endoscopic measurement of esophageal variceal pressure. Dig Dis Sci. 1988, 33(6):737–740.
14 Feu F, Bordas JM, García-Pagán JC, Bosch J, Rodés J. Double-blind investigation of the effects of propranolol and placebo on the pressure of esophageal varices in patients with portal hypertension. Hepatology. 1991, 13(5): 917-922.
15 Ueno K, Hashizume M, Ohta M, Tomikawa M, Kitano S, Sugimachi K. Noninvasive variceal pressure measurement may be useful for predicting effect of sclerotherapy for esophageal varices. Dig Dis Sci. 1996, 41(1): 191-196.
16 Nevens F, Van-Steenbergen W, Yap SH, Fevery J. Assessment of variceal pressure by continuous non-invasive endoscopic registration: a placebo controlled evaluation of the effect of terlipressin and octreotide. Gut. 1996, 38(1): 129-134.
17 Escorsell A, Bordas JM, Feu F, García-Pagán JC, Ginès A, Bosch J, Rodés J. Endoscopic assessment of variceal volume and wall tension in cirrhotic patients: effects of pharmacological therapy. Gastroenterology. 1997, 113(5): 1640-1646.
18 Escorsell A, Bordas JM, Casta?eda B, Llach J, García-Pagán JC, Rodés J, Bosch J. Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension. Hepatology. 2000, 31(5):1061–1067.
19 Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
20 Gertsch PH, Wheatley AM, Maibach R, Maddern GJ, Vauthey JN. Experimental evaluation of an endoscopic balloon for manometry of esophageal varices. Gastroenterology. 1991,101(6):1692-1700.
21 Gertsch PH, Fischer G, Kleber G, Wheatley AM, Geigenberger G, Sauerbruch T. Manometry of esophageal varices: comparison of an endoscopic balloon technique with needle puncture. Gastroenterology. 1993, 105(4): 1159-1166.
22 Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy. 1998, 30(4):326-332.
23 Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol. 1998, 29(1):94-102.
24 Miller ES, Kim JK, Gandehok J, Hara M, Dai Q, Malik A, Miller A, Miller L. A new device for measuring esophageal variceal pressure. Gastrointest Endosc. 2002, 56(2): 284-291.
25 Miller LS, Dai Q, Thomas A, Chung CY, Park J, Irizarry S, Nguyen T, ThangadaV, Miller ES, Kim JK. A new ultrasound-guided esophageal variceal pressure measuring device. Am J Gastroenterol. 2004, 99(7):1267-1273.
26 Puckett JL, Liu J, Bhalla V, Kravetz D, Krinsky ML, Hassanein T, Mittal RK. Ultrasound system to measure esophageal varix pressure: an in vitro validation study. Am J Physiol Gastrointest Liver Physiol. 2005, 288(5): G914–G919.
27 Vegesna AK, Chung CY, Bajaj A, Tiwana MI, Rishikesh R, Hamid I, Kalra A, Korimilli A, Patel S, Mamoon R, Riaz J, Miller LS. Minimally invasive measurement of esophageal variceal pressure and wall tension (with video). Gastrointest Endosc. 2009, 70(3):407-413.
2. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med, 1988; 319(15): 983-989.
3. Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol, 2000; 95(10): 2915-2920.
4. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient:anything worth doing should be done right. Hepatology, 2004; 39(2):280-282.
5. Dittrich S, de Mattos AA, Becker M, Gon?aves DM, Cheinquer H. Role of hepatic hemodynamic study in the evaluation of patients with cirrhosis. Hepatogastroenterology, 2003; 50(54): 2052-2056.
6. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology, 2006; 131(5): 1611-1624.
7. Lebrec D, Vinel JP, Dupas JL. Complications of portal hypertension in adults: a French consensus. Eur J Gastroenterol Hepatol, 2005; 17(4):403-410.
8. Polio J, Hanson J, Sikuler E, Vogel G, Gusberg R, Fisher R, Groszmann RJ. Critical evaluation of a pressure-sensitive capsule for measurement of esophageal varix pressure. Studies in vitro and in canine mesenteric vessels. Gastroenterology, 1987; 92(5 pt 1): 1109-1115.
9. Rigau J, Bosch J, Bordas JM, Navasa M, Mastai R, Kravetz D, Bruix J, Feu F, Rodés J. Endoscopic measurement of variceal pressure in cirrhosis: Correlation with portal pressure and variceal hemorrhage. Gastroenterology, 1989; 96(3):873-880.
10. Feu F, Bordas JM, Luca A, García-Pagán JC, Escorsell A, Bosch J, Rodés J. Reduction of variceal pressure by propranolol: comparison of the effects on portal pressure and azygos blood flow in patients with cirrhosis. Hepatology, 1993; 18(5): 1082–1089.
11. Nevens F, Sprengers D, Feu F, Bosch J, Fevery J. Measurement of variceal pressure with an endoscopic pressure sensitive gauge: validation and effect of propranolol therapy in chronic conditions. J Hepatol , 1996; 24(1):66–73.
12. Bosch J, Bordas JM, Rigau J, Viola C, Mastai R, Kravetz D, Navasa M, Rodés J. Noninvasive measurement of the pressure of esophageal varices using an endoscopic gauge: comparison with measurements by variceal puncture in patients undergoing endoscopic sclerotherapy. Hepatology, 1986; 6(4):667–672.
13. Ueno K, Hashizume M, Ohta M, Tomikawa M, Kitano S, Sugimachi K. Noninvasive variceal pressure measurement may be useful for predicting effectsof sclerotherapy for esophageal varices. Dig Dis Sci, 1996; 41(1):191–196.
14. Ruiz del Arbol L, Martin de Argila C, Vázquez M. Endoscopic measurement of variceal pressure during hemorrhage from esophageal varices. Hepatology, 1992; 16(2):147.
15. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology, 1998; 27(1): 15-19.
16. El Atti EA, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal hemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut, 1999; 45(4):618–621.
17. Escorsell A, Bordas JM, Casta?eda B, Llach J, García-Pagán JC, Rodés J, Bosch J. Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension. Hepatology. 2000, 31(5):1061–1067.
18. Sarin, S.K. Saraya, A. Effects of in travenous nitroglycerin and metoclopramide on intravariceal pressure: a double blind ranodomized study. Am J Gastroenterology. 1995, 90(1):48-53.
19. Polio J, Groszmann RJ. Hemodynamic factors involved in the development and rupture of esophageal varices: a pathophysiologic approach to treatment. Semin Liver Dis, 1986, 6(4):318–331.
20. Mosimann R. Nonaggresive assessment of portal hypertension using endoscopic measurement of variceal pressure. Am J Surg, 1982; 143(2): 212-214
21. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut, 1987; 28(9): 1162-1165.
22. Miller ES, Kim JK, Gandehok J, Hara M, Dai Q, Malik A, Miller A, Miller L. A new device for measuring esophageal variceal pressure. Gastrointest Endosc, 2002; 56(2): 284-291.
23. Pontes JM, Leit?o MC, Portela F, Nunes A, Freitas D. Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility. Endoscopy, 2002; 34(12): 966–972.
24. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy, 1998; 30(4):326-332.
25. Miller LS, Dai Q, Thomas A, Chung CY, Park J, Irizarry S, Nguyen T, Thangada V, Miller ES, Kim JK. A new ultrasound-guided esophageal variceal pressure measuring device. Am J Gastroenterol, 2004; 99(7):1267-1273.
26. Vegesna AK, Chung CY, Bajaj A, Tiwana MI, Rishikesh R, Hamid I, Kalra A, Korimilli A, Patel S, Mamoon R, Riaz J, Miller LS. Minimally invasive measurement of esophageal variceal pressure and wall tension (with video). Gastrointest Endosc, 2009; 70(3):407-413.
27.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002;19(4): 74-76.
28.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004;21(1): 36-38.
29. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol, 1998; 29(1):94-102.
1. Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding--unresolved issues. Summary of an American Association for the study of liver diseases and European Association for the study of the liver single-topic conference. Hepatology. 2008, 47(5): 1764-1772.
2.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(2): 74-76.
3.许建明,付忠谦,孔德润,谢岳,孙斌,何兵兵,张磊.计算机视觉食管曲张静脉压力测定仪,国家发明专利;专利号,ZL 2004 1 0065936.94. 4.
4.郭兴明,姚晓帅,吴继辉.基于模糊逻辑理论的红细胞图像边缘检测.北京生物医学工程,2003, 22(4): 263-265.
5.张莉,吴剑锋,林强. B超心脏序列图像左室短轴轮廓曲线的动态跟踪。福州大学学报,2000, 28(6): 22-25.
6.吴继辉,郭兴民.数字图像处理[M].北京大学出版社,2002.
7.孔德润,许建明,付忠谦,何兵兵,孙斌,张磊,谢岳.基于计算机视觉的无创性食管曲张静脉测压仪.生物医学工程学杂志,2007, 24(3): 519-521.
8. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
9. Nevens F, Sprengers D, Feu F, Bosch J, Fevery J. Measurement of variceal pressure with an endoscopic pressure sensitive gauge: validation and effect of propranolol therapy in chronic conditions. J Hepatol. 1996, 24(1):66-73.
10. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy. 1998, 30(4):326-332.
11. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol. 1998, 29(1):94-102.
12. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-19.
13.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004, 21(1): 36-38.
1. Gertsch PH, Meister JJ. Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method. Gut. 1987, 28(9): 1162-1165.
2.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
3.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志, 2004, 21(1): 36-38.
4. Gertsch PH, Fischer G, Kleber G, Wheatley AM, Geigenberger G, Sauerbruch T. Manometry of esophageal varices: comparison of an endoscopic balloon technique with needle puncture. Gastroenterology. 1993, 105(4): 1159-1166.
5. Kong DR, Xu JM,Zhang L, Zhang C, Fu ZQ, He BB, Sun B, Xie Y. A computerized endoscopic balloon manometry to detect esophageal variceal pressure. Endoscopy. 2009,46(5): 415-420.
6.中华医学会消化内镜分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年).中华消化内镜杂志. 2004, 21(3): 149-151.
7. Kleber G, Sauerbruch T, Fischer G, Paumgartner G. Pressure of intraesophageal varices assessed by fine needle puncture: its relation to endoscopic signs and severity of liver disease in patients with cirrhosis. Gut. 1989, 30(2): 228-232.
8. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-9.
9. Escorsell A, Bordas JM, Casta?eda B, Llach J, García-Pagán JC, Rodés J, Bosch J. Predictive value of the variceal pressure response to continued pharmacologicaltherapy in patients with cirrhosis and portal hypertension. Hepatology. 2000, 31(5): 1061-1067.
10. Atti El, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal haemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut. 1999, 45(4): 618-621
11. Gertsch PH, Wheatley AM, Maibach R, Maddern GJ, Vauthey JN. Experimental evaluation of an endoscopic balloon for manometry of esophageal varices. Gastroenterology. 1991,101(6): 1692-1700.
12. Pontes JM, Leit?o MC, Portela F, Nunes A, Freitas D. Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility. Endoscopy. 2002, 34(12): 966-972.
13.孔德润,许建明,付忠谦,何兵兵,孙斌,张磊,谢岳.基于计算机视觉的无创性食管曲张静脉测压仪.生物医学工程学杂志,2007, 24(3): 519-521.
14. Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, G?rich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of an endoscopic balloon technique compared with direct portal pressure measurement. J Hepatol. 1998, 29(1): 94-102.
15. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988, 319(15): 983-989.
16.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
17. Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy. 1998, 30(4): 326-332.
18. Kleber G, Sauerbruch T, Ansari H, Paumgartner G. Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology. 1991,100 (5 Pt 1): 1332-1337.
19. Burroughs AK, D’Heygere F, McIntyre N. Pitfalls in studies of prophylactic therapy for variceal bleeding in cirrhotics. Hepatology. 1986, 6(6): 1407-1413.
20.吴云林,王玲玲,徐志红,陆和平,杨根妹,施华秀,冯莉.经内镜食管曲张静脉测压及生长抑素和奥曲肽的降压作用研究.中华消化内镜杂志,2000, 17(4): 208-209
21. Ming-Chih Hou, Han-Chieh Lin, Benjamin Ing-Tieu Kuo, Tung-Min Liao, Fa-Yauh Lee, Full-Young Chang and Shou-Dong Lee. Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding. J Hepatology. 1998, 29(5): 772-778.
22. Wadhawan M, Dubey S, Sharma BC, Sarin SK. Hepatic venous pressure gradient in cirrhosis: correlation with the size of varices, bleeding, ascites, and Child’s Status. Dig Dis Sci. 2006, 51(12): 2264-2269.
23. Bellis L, Castellacci R, Montagnese F, Festuccia F, Corvisieri P, Puoti C. Hepatic venous pressure gradient determination in patients with hepatitis C virus-related and alcoholic cirrhosis. Eur J Gastroenterol Hepatol. 2003, 15(10): 1085-1089.
1. Sharara AI, Rockey DC. Gartroesophageal variceal hemorrhage. N Engl J Med2001, 345(9): 669-681.
2. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988, 319(15): 983-989.
3. Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the NorthItalian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000, 95(10): 2915-2920.
4. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology. 2004, 39(2):280-282.
5. Dittrich S, de Mattos AA, Becker M, Gon?aves DM, Cheinquer H. Role of hepatic hemodynamic study in the evaluation of patients with cirrhosis. Hepatogastroenterology. 2003, 50(54): 2052-2066.
6. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology. 2006, 131(5): 1611-1624.
7. Lebrec D, Vinel JP, Dupas JL. Complications of portal hypertension in adults: a French consensus. Eur J Gastroenterol Hepatol. 2005, 17(4): 403-410.
8. Polio J, Hanson J, Sikuler E, Vogel G, Gusberg R, Fisher R, Groszmann RJ. Critical evaluation of a pressure-sensitive capsule for measurement of esophageal varix pressure. Studies in vitro and in canine mesenteric vessels. Gastroenterology. 1987, 92(5 pt 1): 1109-1115.
9. Kong DR, Xu JM, Zhang L, Zhang C, Fu ZQ, He BB, Sun B, Xie Y. A computerized endoscopic balloon manometry to detect esophageal variceal pressure. Endoscopy. 2009,46(5):415-420.
10.孔德润,许建明,付忠谦,何兵兵,孙斌,张磊,谢岳.基于计算机视觉的无创性食管曲张静脉测压仪.生物医学工程学杂志,2007, 24(3): 519-521.
11. Rigau J, Bosch J, Bordas JM, Navasa M, Mastai R, Kravetz D, Bruix J, Feu F, Rodés J. Endoscopic measurement of variceal pressure in cirrhosis: Correlation with portal pressure and variceal hemorrhage. Gastroenterology. 1989, 96(3):873-880.
12. Spahr L, Giostra E, Morard I, Mentha G, Hadengue A. Perendoscopic variceal pressure measurement, a reliable estimation of portal pressure in patients withcirrhosis? Gastroenterol Clin Biol. 2006, 30(8-9): 1012-1018.
13. Lacerda CM, Freire W, Vieira de Melo PS, Lacerda HR, Carvalho G. Splenectomy and ligation of the left gastric vein in schistosomiasis mansoni: the effect on esophageal variceal pressure measured by a non-invasive technique. Keio Journal of Medicine. 2002, 51(2): 89-92.
14. Ma ZM, Kwok LS, Guan YC. Development of a non-invasive measurement system for the pressure of esophageal varices. 1st Annual International IEEE-EMBS Special Topic Conference on Microtechnologies in Medicine & Biology. 2000, 127-129.
15.许建明,张磊.食管静脉曲张内镜气囊测压的临床价值.中华消化内镜杂志,2002, 19(4): 74-76.
16.张磊,许建明,孔德润,王玲,谢惠君,胡乃中.食管静脉曲张内镜气囊测压法的应用研究.中华消化内镜杂志,2004, 21(1): 36-38.
17. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. 1998, 27(1): 15-19.
18. Atti El, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal haemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut. 1999,45(4): 618–621.
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