内镜下套扎治疗食道静脉曲张的疗效及对门脉血流动力学影响的观察
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摘要
目的:探讨内镜下套扎治疗食道静脉曲张的治疗效果及其对门脉血流动力学的影响。
方法:选取临床诊断的26例肝炎后肝硬化失代偿期的住院患者,其中食道静脉曲张中度4例,重度22例。急性出血期套扎16例。观察:(1)食道静脉曲张套扎治疗的止血成功率、再出血率及食道静脉曲张减轻或消失情况。(2)用彩色多普勒超声测定每例患者套扎前后门静脉主干、脾静脉、胃左静脉内径及平均血流速度,并测定胃左静脉的血流方向。(3)采用放射免疫分析法测定每例患者套扎前后空腹血浆胰高血糖素水平。
结果:(1)疗效观察:16例急性出血患者经套扎治疗后,12小时内经临床判断有15例出血停止,即刻止血率93.75%;26例套扎患者14-20天复查胃镜,其中食管静脉曲张减轻19例,食管曲张静脉基本消退4例,其余3例无变化,有效率88.46%。追踪观察6个月,有3例先后再次出血,出血复发率11.54%。(2)门脉血流动力学测定: 26例患者于治疗前后均探测到门静脉与脾静脉(100%),24例探测到胃左静脉(88.5%)。套扎治疗前后门静脉血管内径无显著变化(13.33±1.74mm vs 13.41±1.50mm.P>0.05),套扎治疗后门静脉平均血流速度较治疗前增加,有显著差异(24.5±4.35 cm/s vs 27.4±6.54 cm/s.P<0.05)。套扎前后脾静脉血管内径无显著变化(10.57±2.97 vs 10.64±2.85.P>0.05),套扎治疗后脾静脉平均血流速度较治疗前增加,有显著差异(28.6±5.65 cm/s vs 31.47±7.21 cm/s,P<0.05)。胃左静脉血管内径、平均血流速度均无统计学差异,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87.0%(20/23),双向血流者占8.7%(2/23),向肝血流者占4.3%(1/23);而治疗后,向肝血流者占65.2%(15/23),离肝血流者明显减少,占21.7%(5/23),双向血流者占13.0%(3/23),差异非常显著(P<0.01)。(3)胰高血糖素水平测定:26例患者套扎治疗后血浆胰高血糖素水平与治疗前相比较无显著差别(195.71±50.9ng/L vs 218.7±79.6ng/L,P>0.05)。
结论:
(1)食道静脉套扎治疗是预防及治疗食道静脉曲张破裂出血的有效手段。
(2)食道静脉曲张套扎治疗对门静脉系统血流动力学有一定影响,表现为门静脉主干及脾静脉的血流速度增加,胃左静脉血流方向改变。
(3)食道静脉曲张套扎前后血浆胰高血糖素水平无明显变化。
Objective:To evaluate the efficacy of endoscopic variceal ligation(EVL) for the treatment of esophageal varices and to observe the haemodynamical changes of portal system before and after the treatment.
Methods:26 patients with liver cirrhosis and esophageal varices were treated by endoscopic variceal ligation.(1)To observe the efficiency of EVL including the rate of immediate hemostasis,the rate of bleeding recrudescence and the changes of esophageal variceal.(2)To measure the dynamical changes of portal vein and its branch veins before and after EVL including the inside diameter and blood flow velocity of portal vein,spleen vein,and left gastric vein.(3)To measure the plasma level of glucagon by the method of radioimmunoassay before and after EVL.
Results:(1) The successful immediate hemostasis rate of variceal ligation was 93.75%.14-20 days latter,the eradicated and diminished rate of esophageal varices was 88.46%.During 6 months there are 3 ptients bleeding again,and the rebleeding rate was 11.54%.(2) Portal vein and spleen vein in 26 patients were detected befor and after endoscopic treatmen(100%),The inside diameter of portal vein and spleen vein had no significant changes(portal vein:13.33±1.74mm vs 13.41±1.50mm.P>0.05;spleen vein:10.57±2.97 vs 10.64±2.85 , P>0.05) , but their blood flow velocity increased significantly (potal vein:24.5±4.35 cm/s vs 27.44±6.54cm/s,P<0.05;spleen vein:28.6±5.65cm/s vs 31.47±7.21cm/s,P<0.05).Left gastic vein was discovered in 24 patients(88.5%).The inside diameter and blood flow velocity of left gastric vein had no significant changes.But the blood flow direction had significant change after EVL.20 patients(87%) showed hepatofugal flow,2 patients(8.7%)bi-directional flow,and 1 patient(4.3%)hepatopetal flow before the treatment,while 15 patients(65.2%)showed hepatopetal flow,5 patients(20%) showed hepatofugal flow,and 3 patients(13.0%) bi-directional flow after treatment(P<0.01).(3) The plasma level of glucagon had no significant change before and after EVL(195.71±50.9ng/L vs 218.7±79.6ng/L, P<0.05).
Conclusions:
(1)Endoscopic variceal ligation is an effective method to prevent and treat esophageal variceal bleeding.
(2)The dynamical measurement indicates that endoscopic variceal ligation could increase the blood flow velocity of portal vein,spleen vein and change the direction of left gastric vein.
(3) The plasma level of glucagon has no obscure change before and after endoscopic variceal ligation.
方法:选取临床诊断的26例肝炎后肝硬化失代偿期的住院患者,其中食道静脉曲张中度4例,重度22例。急性出血期套扎16例。观察:(1)食道静脉曲张套扎治疗的止血成功率、再出血率及食道静脉曲张减轻或消失情况。(2)用彩色多普勒超声测定每例患者套扎前后门静脉主干、脾静脉、胃左静脉内径及平均血流速度,并测定胃左静脉的血流方向。(3)采用放射免疫分析法测定每例患者套扎前后空腹血浆胰高血糖素水平。
结果:(1)疗效观察:16例急性出血患者经套扎治疗后,12小时内经临床判断有15例出血停止,即刻止血率93.75%;26例套扎患者14-20天复查胃镜,其中食管静脉曲张减轻19例,食管曲张静脉基本消退4例,其余3例无变化,有效率88.46%。追踪观察6个月,有3例先后再次出血,出血复发率11.54%。(2)门脉血流动力学测定: 26例患者于治疗前后均探测到门静脉与脾静脉(100%),24例探测到胃左静脉(88.5%)。套扎治疗前后门静脉血管内径无显著变化(13.33±1.74mm vs 13.41±1.50mm.P>0.05),套扎治疗后门静脉平均血流速度较治疗前增加,有显著差异(24.5±4.35 cm/s vs 27.4±6.54 cm/s.P<0.05)。套扎前后脾静脉血管内径无显著变化(10.57±2.97 vs 10.64±2.85.P>0.05),套扎治疗后脾静脉平均血流速度较治疗前增加,有显著差异(28.6±5.65 cm/s vs 31.47±7.21 cm/s,P<0.05)。胃左静脉血管内径、平均血流速度均无统计学差异,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87.0%(20/23),双向血流者占8.7%(2/23),向肝血流者占4.3%(1/23);而治疗后,向肝血流者占65.2%(15/23),离肝血流者明显减少,占21.7%(5/23),双向血流者占13.0%(3/23),差异非常显著(P<0.01)。(3)胰高血糖素水平测定:26例患者套扎治疗后血浆胰高血糖素水平与治疗前相比较无显著差别(195.71±50.9ng/L vs 218.7±79.6ng/L,P>0.05)。
结论:
(1)食道静脉套扎治疗是预防及治疗食道静脉曲张破裂出血的有效手段。
(2)食道静脉曲张套扎治疗对门静脉系统血流动力学有一定影响,表现为门静脉主干及脾静脉的血流速度增加,胃左静脉血流方向改变。
(3)食道静脉曲张套扎前后血浆胰高血糖素水平无明显变化。
Objective:To evaluate the efficacy of endoscopic variceal ligation(EVL) for the treatment of esophageal varices and to observe the haemodynamical changes of portal system before and after the treatment.
Methods:26 patients with liver cirrhosis and esophageal varices were treated by endoscopic variceal ligation.(1)To observe the efficiency of EVL including the rate of immediate hemostasis,the rate of bleeding recrudescence and the changes of esophageal variceal.(2)To measure the dynamical changes of portal vein and its branch veins before and after EVL including the inside diameter and blood flow velocity of portal vein,spleen vein,and left gastric vein.(3)To measure the plasma level of glucagon by the method of radioimmunoassay before and after EVL.
Results:(1) The successful immediate hemostasis rate of variceal ligation was 93.75%.14-20 days latter,the eradicated and diminished rate of esophageal varices was 88.46%.During 6 months there are 3 ptients bleeding again,and the rebleeding rate was 11.54%.(2) Portal vein and spleen vein in 26 patients were detected befor and after endoscopic treatmen(100%),The inside diameter of portal vein and spleen vein had no significant changes(portal vein:13.33±1.74mm vs 13.41±1.50mm.P>0.05;spleen vein:10.57±2.97 vs 10.64±2.85 , P>0.05) , but their blood flow velocity increased significantly (potal vein:24.5±4.35 cm/s vs 27.44±6.54cm/s,P<0.05;spleen vein:28.6±5.65cm/s vs 31.47±7.21cm/s,P<0.05).Left gastic vein was discovered in 24 patients(88.5%).The inside diameter and blood flow velocity of left gastric vein had no significant changes.But the blood flow direction had significant change after EVL.20 patients(87%) showed hepatofugal flow,2 patients(8.7%)bi-directional flow,and 1 patient(4.3%)hepatopetal flow before the treatment,while 15 patients(65.2%)showed hepatopetal flow,5 patients(20%) showed hepatofugal flow,and 3 patients(13.0%) bi-directional flow after treatment(P<0.01).(3) The plasma level of glucagon had no significant change before and after EVL(195.71±50.9ng/L vs 218.7±79.6ng/L, P<0.05).
Conclusions:
(1)Endoscopic variceal ligation is an effective method to prevent and treat esophageal variceal bleeding.
(2)The dynamical measurement indicates that endoscopic variceal ligation could increase the blood flow velocity of portal vein,spleen vein and change the direction of left gastric vein.
(3) The plasma level of glucagon has no obscure change before and after endoscopic variceal ligation.
引文
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2.Terblanche J, Krige JE, Bornman PC. Endoscopic sclerotherapy. Surg Clin North Am ,1990,70: 341-359
3.Stiegmann GV,Camber T,Sun JH. A new endoscopic elastic band ligating device.Gastmintest Endosc,1986,32:230
4.Noophun P,Kongkam P,Gonlachanvit S,et a1.Bleeding gastric varices:results of endoscopic injection with cyanoacrylate at King Chulalongkom Memorial Hospital . W J Gastroenterol,2005,11:7531-7535
5.Bryant ML,Stephen H,Caldwell,et a1.Endoscopic Treatment of Gastric Varices:Use of Band Ligation,Cyanoacrylate Glue and Novel.Ther Tech Gastrointest Endosc,2005,7:26-30
6.Ohmoto K,Yoshioka N,Tomiyama Y,et a1.Improved prognosis of cirrhosis patients with esophageal varices and thrombocytopenia treated by endoscopic variceal ligation plus partial splenic embolization.Digest Dis Sci,2006,51(2):352-358
7.Goff J S. Three years experience with endoscopic variceal ligation for treatment of bleeding varices. Endoscopy,1992,24:401
8.李楠,顾凯华,池春,等.食管静脉曲张套扎术对门脉高压性胃病再出血的影响机制.世界华人消化杂志,2000,8:128-129
9.陆伟,邱秀霞,王波.内镜套扎术预防性治疗食管静脉曲张临床应用研究.世界华人消化杂志,2000,特刊8:49b
10.Nakayama M, wao T,Oho K,et a1.Role of estravariceal collateral channels in the development of portal hypentensire gastropathy before and after sclerotherapy.J Gastroenterol,1998 ,33(2):142.
11.中华医学会病毒性肝炎防治方案.中华传染病杂志,2006,19(1):56-62
12.中华医学会消化内镜分会.食管胃底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
13.刘浔阳.食管胃底静脉曲张内镜治疗.北京人民卫生出版社,2000:164-166
14.王风月,赵梦华.食管静脉曲张内镜结扎预防再出血的价值.新消化病学杂志,1996, 4(Supple 5) :57
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