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Article(id=1200023160893571720, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1200023152219746543, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2124.2023.0303, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1665590400000, receivedDateStr=2022-10-13, revisedDate=null, revisedDateStr=null, acceptedDate=1669478400000, acceptedDateStr=2022-11-27, onlineDate=1764037416908, onlineDateStr=2025-11-25, pubDate=1698422400000, pubDateStr=2023-10-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764037416908, onlineIssueDateStr=2025-11-25, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764037416908, creator=13701087609, updateTime=1764037416908, updator=13701087609, issue=Issue{id=1200023152219746543, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='10', pageStart='1115', pageEnd='1236', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764037414841, creator=13701087609, updateTime=1764038706792, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1200028571126301693, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1200023152219746543, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1200028571126301694, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1200023152219746543, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1115, endPage=1121, ext={EN=ArticleExt(id=1200023163552760523, articleId=1200023160893571720, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Treatment strategies of variceal bleeding in cirrhosis, columnId=1190669170040783872, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Expert Review, runingTitle=null, highlight=null, articleAbstract=

Esophagogastric variceal bleeding in cirrhotic patients is associated with high mortality if not adequately managed. Standardized treatment of esophagogastric variceal bleeding includes adequate resuscitation maneuvers, restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy, and endoscopic therapy. After this initial treatment, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. Placing a preemptive transjugular intrahepatic portosystemic shunt in high-risk patients, as soon as possible after admission, to achieve early control of bleeding has proved to improve survival. The present review will focus on the initial management of patients with acute esophagogastric variceal bleeding, including general management and assessment, pharmacotherapy, as well as the available endoscopic, interventional and salvage treatments, trying to provide reference for standardizing the treatment process of such patients, in order to improve their survival rate.

, correspAuthors=Xue-Feng Luo, authorNote=null, correspAuthorsNote=
E-mail:
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肝硬化患者出现食管胃静脉曲张出血时，如果处理不当，容易导致病死率升高。急性食管胃静脉曲张出血的标准化治疗包括充分的复苏治疗、限制性输血策略、预防性抗生素使用、药物治疗及内镜治疗。在初始治疗后，必须根据风险分层策略制定预防早期及晚期再出血的最佳治疗方法。对于肝硬化食管胃静脉曲张出血的高危患者，在入院后应尽早行经颈静脉肝内门体分流术以早期有效控制出血，此法已被证实可以提高患者的生存率。本文就急性食管胃静脉曲张破裂出血患者的初始治疗，包括一般治疗、药物治疗、可行的内镜治疗、介入治疗及挽救性治疗等进行系统论述，为规范食管胃静脉曲张破裂出血的救治流程提供参考，以期提高此类患者的生存率。

, correspAuthors=罗薛峰, authorNote=null, correspAuthorsNote=
罗薛峰，E-mail：
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向童，硕士研究生，主要从事肝硬化门脉高压症等方面的研究

罗薛峰，医学博士，副教授，硕士研究生导师。巴塞罗那Hospital Clinic访问学者，Baveno Ⅶ共识(门静脉高压治疗全球权威指南)专家组成员，中华医学会放射学会介入/青年委员，中国抗癌协会肿瘤微创治疗委员会门脉高压专委会常委。在Hepatology，Radiology，Journal of Hepatology等SCI收录期刊发表论文40余篇，主持国家自然科学基金及省级科研项目5项。

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向童，硕士研究生，主要从事肝硬化门脉高压症等方面的研究

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向童，硕士研究生，主要从事肝硬化门脉高压症等方面的研究

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罗薛峰，医学博士，副教授，硕士研究生导师。巴塞罗那Hospital Clinic访问学者，Baveno Ⅶ共识(门静脉高压治疗全球权威指南)专家组成员，中华医学会放射学会介入/青年委员，中国抗癌协会肿瘤微创治疗委员会门脉高压专委会常委。在Hepatology，Radiology，Journal of Hepatology等SCI收录期刊发表论文40余篇，主持国家自然科学基金及省级科研项目5项。

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罗薛峰，医学博士，副教授，硕士研究生导师。巴塞罗那Hospital Clinic访问学者，Baveno Ⅶ共识(门静脉高压治疗全球权威指南)专家组成员，中华医学会放射学会介入/青年委员，中国抗癌协会肿瘤微创治疗委员会门脉高压专委会常委。在Hepatology，Radiology，Journal of Hepatology等SCI收录期刊发表论文40余篇，主持国家自然科学基金及省级科研项目5项。

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A.增强CT动脉期见门静脉显像清晰，考虑肝动脉-门静脉瘘(黄色箭头)；B.增强CT门脉期见门静脉主干部分充盈缺损，考虑门静脉主干血栓(黄色箭头)；C.增强CT三维血管成像显示脾静脉截断，代之以迂曲的曲张静脉(黄色箭头)，考虑左侧区域性门静脉高压；D.增强CT三维血管成像显示粗大的胃肾分流道(黄色箭头)

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肝硬化食管胃静脉曲张出血的治疗策略
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向童 , 罗薛峰 * , 杨丽
解放军医学杂志 | 专家述评 2023,48(10): 1115-1121
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解放军医学杂志 | 专家述评 2023, 48(10): 1115-1121
肝硬化食管胃静脉曲张出血的治疗策略
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向童, 罗薛峰* , 杨丽
作者信息
  • 四川大学-牛津大学华西消化道肿瘤联合研究中心/四川大学华西医院消化内科，四川成都 610041

    • 向童，硕士研究生，主要从事肝硬化门脉高压症等方面的研究

    罗薛峰，医学博士，副教授，硕士研究生导师。巴塞罗那Hospital Clinic访问学者，Baveno Ⅶ共识(门静脉高压治疗全球权威指南)专家组成员，中华医学会放射学会介入/青年委员，中国抗癌协会肿瘤微创治疗委员会门脉高压专委会常委。在Hepatology，Radiology，Journal of Hepatology等SCI收录期刊发表论文40余篇，主持国家自然科学基金及省级科研项目5项。

通讯作者:

罗薛峰，E-mail：
Treatment strategies of variceal bleeding in cirrhosis
Tong Xiang, Xue-Feng Luo* , Li Yang
Affiliations
  • Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University/Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Chengdu, Sichuan 610041, China
出版时间: 2023-10-28 doi: 10.11855/j.issn.0577-7402.2124.2023.0303
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摘要
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肝硬化患者出现食管胃静脉曲张出血时，如果处理不当，容易导致病死率升高。急性食管胃静脉曲张出血的标准化治疗包括充分的复苏治疗、限制性输血策略、预防性抗生素使用、药物治疗及内镜治疗。在初始治疗后，必须根据风险分层策略制定预防早期及晚期再出血的最佳治疗方法。对于肝硬化食管胃静脉曲张出血的高危患者，在入院后应尽早行经颈静脉肝内门体分流术以早期有效控制出血，此法已被证实可以提高患者的生存率。本文就急性食管胃静脉曲张破裂出血患者的初始治疗，包括一般治疗、药物治疗、可行的内镜治疗、介入治疗及挽救性治疗等进行系统论述，为规范食管胃静脉曲张破裂出血的救治流程提供参考，以期提高此类患者的生存率。

肝硬化  /  胃肠出血  /  食管胃静脉曲张  /  治疗

Esophagogastric variceal bleeding in cirrhotic patients is associated with high mortality if not adequately managed. Standardized treatment of esophagogastric variceal bleeding includes adequate resuscitation maneuvers, restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy, and endoscopic therapy. After this initial treatment, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. Placing a preemptive transjugular intrahepatic portosystemic shunt in high-risk patients, as soon as possible after admission, to achieve early control of bleeding has proved to improve survival. The present review will focus on the initial management of patients with acute esophagogastric variceal bleeding, including general management and assessment, pharmacotherapy, as well as the available endoscopic, interventional and salvage treatments, trying to provide reference for standardizing the treatment process of such patients, in order to improve their survival rate.

liver cirrhosis  /  gastrointestinal hemorrhage  /  esophageal and gastric varices  /  treatment
向童, 罗薛峰, 杨丽. 肝硬化食管胃静脉曲张出血的治疗策略. 解放军医学杂志, 2023 , 48 (10) : 1115 -1121 . DOI: 10.11855/j.issn.0577-7402.2124.2023.0303
Tong Xiang, Xue-Feng Luo, Li Yang. Treatment strategies of variceal bleeding in cirrhosis[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (10) : 1115 -1121 . DOI: 10.11855/j.issn.0577-7402.2124.2023.0303
正文
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肝硬化食管胃静脉曲张出血(esophagogastric variceal bleeding，EGVB)是门脉高压的严重并发症，也是肝硬化患者死亡的主要原因[1]。肝硬化EGVB发病率约为4%，中-重度EGVB发病率以每年15%的速度增长[2]。近10年来，肝硬化EGVB的临床救治水平已有较大进步，尤其是内科治疗理念的更新、内镜及介入治疗技术的优化与普及[3]，但EGVB的6周病死率仍高达15%~20%[4]。华西医院消化内科是国内较早开展肝硬化EGVB内镜及介入治疗的中心，且已建立了完善的急性上消化道大出血救治绿色通道。本文结合华西医院临床实践经验及笔者参与Baveno第七版共识意见修订的体会，探讨肝硬化EGVB救治的现状及展望。
1 一般治疗及评估
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1.1 容量复苏及凝血评估
肝硬化患者出现消化道出血时需加强监护，评估其呼吸及循环状况，对于急性上消化道大出血或显性肝性脑病患者，应考虑气管插管，避免误吸[5-6]。一旦出现血流动力学不稳定的情况，应尽快进行扩容以恢复血容量，但注意应采用限制性输血输液的策略，避免因门静脉压力升高导致止血失败。多项随机对照试验(randomized controlled trial，RCT)及荟萃分析的数据均显示，限制性输血策略可降低再出血率及病死率[7-9]。笔者建议对EGVB患者采用限制性输血策略，即血红蛋白低于60 g/L时可以输血，对于合并心血管疾病、高龄、急性失血、持续出血等难以代偿的患者，可适当提高输血阈值。
肝硬化急性出血患者可表现为血小板减少、凝血时间延长及低纤维蛋白原等，是否需要积极纠正凝血异常尚存在争议[10]。慢性肝病相关凝血研究提示，现有常规凝血检查并不能全面反映患者出凝血平衡的变化情况，多数患者处于动态再平衡状态而非出血倾向[11]。包含2项RCT研究的荟萃分析显示，输注重组Ⅶ因子可以纠正延长的凝血酶原时间，对于控制5 d治疗失败具有一定益处，但对于降低6周再出血率及病死率未见明显效果，且增加了血栓栓塞风险[12]。纠正肝硬化EGVB患者“凝血异常”往往需要大量输注血液制品，但同时也增加了门脉高压出血的风险，基于现有证据不推荐常规纠正。
1.2 影像学评估
影像检查能够比较直观地显示静脉曲张的部位及严重程度，明确肝硬化、肝癌诊断及是否合并门静脉栓塞等，但其在肝硬化EGVB领域的临床应用尚不广泛。一项回顾性研究纳入577例行急诊胃镜治疗的消化道出血患者，结果显示增强CT血管成像对静脉曲张的诊断准确率显著高于普通CT(96.4% vs. 0.0%)[13]。对于胃底静脉曲张，增强CT血管成像能够准确显示曲张静脉的位置及直径，并可显示曲张静脉的流入道及流出道，对于指导内镜及介入治疗方式的选择非常重要[14]。
图1中4例患者均为EGVB，但因基础疾病存在差异，治疗也需要结合增强CT影像评估而做出相应的调整。1例肝硬化患者合并晚期肝癌及肝动脉-门静脉瘘，除一般EGVB治疗外，还需要考虑介入封堵瘘口以降低静脉曲张压力(图1A)。1例患者门静脉系统广泛血栓，倾向于选择经颈静脉肝内门体分流术(transjungular intrahepatic portosystemic shunt，TIPS)，在一定程度上有助于门静脉再通(图1B)。1例患者系脾静脉回流受限导致左侧区域性门静脉高压，此类患者往往表现为孤立性胃静脉曲张破裂出血，需开通脾静脉或择期行脾脏切除术(图1C)。1例患者存在粗大的胃肾分流，治疗选择上倾向于球囊阻断逆行曲张静脉闭塞术(balloon-occluded retrograde transvenous obliteration，BRTO)或TIPS(图1D)。因为影像检查在EGVB评估中的巨大价值，Baveno Ⅶ首次提出所有EGVB患者均应接受增强CT或磁共振显像检查，评估内脏静脉血栓、肝细胞癌及门体侧支循环等情况，以指导下一步治疗方案的选择[5]。
2 药物治疗
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2.1 血管活性药物
临床常用的血管活性药物为生长抑素、奥曲肽及特利加压素，可减少内脏血流以降低门静脉压力，提高止血成功率，降低病死率并且减少输血需求[15]。一般认为这3种药物的疗效、止血成功率及病死率均相当，但使用特利加压素时需关注低钠血症的风险[16]。一旦确诊为EGVB，应持续使用血管活性药物2~5 d[5,17]。
2.2 预防性应用抗生素
预防性应用抗生素是肝硬化EGVB治疗的重要组成部分，但临床实践中很多医师未给予足够重视。研究发现，细菌感染与EGVB患者控制出血失败、早期再出血及死亡均相关[18]。对于失代偿期肝硬化患者，院内喹诺酮类抗生素耐药比例高或既往已经使用过喹诺酮类抗生素预防感染的患者，预防性使用抗生素推荐首选头孢曲松钠；其他患者则推荐口服喹诺酮类药物。在临床实践中需结合当地的抗菌药物敏感性及患者自身情况(既往抗生素使用、感染史、细菌定植等)选择适合的抗生素[5]。Child-Pugh A级肝硬化患者感染风险相对较低，是否可以从预防性抗感染治疗策略中获益尚需研究。
有研究显示，接受预防性抗感染治疗的静脉曲张出血患者仍有超过20%发生细菌感染，肺部感染是最常见的感染类型，其次为自发性细菌性腹膜炎(spontanous bacterial peritonitis，SBP)。多因素分析发现，肝功能Child-Pugh C级，肝性脑病(Ⅲ~Ⅳ级)，使用鼻胃管、气管插管及食管气囊填塞等均与患者肺部感染的发生独立相关[19]。
2.3 质子泵抑制剂
尽管缺乏质子泵抑制剂(proton pump inhibitors，PPIs)治疗肝硬化EGVB的有效证据，但其临床应用仍非常广泛[20]。2005年，一项RCT纳入44例内镜下曲张静脉套扎(endoscopic variceal ligation，EVL)术后患者，随机分组接受泮托拉唑或安慰剂治疗，结果发现，泮托拉唑组套扎后溃疡面积小于安慰剂组(37 mm2 vs. 82 mm2，P<0.01)，其他临床预后指标差异无统计学意义[21]。2013年，Lo等[22]也发现，EGVB患者EVL术后使用PPIs组较未使用PPIs组2周后溃疡发生率低(64% vs. 86%)，溃疡面积小，但2组的5 d内止血率、6周再出血率差异并无统计学意义，且肝硬化EGVB患者使用PPIs存在较大的风险。Dultz等[23]开展的一项前瞻性研究显示，PPIs可使患者的死亡风险增加(HR=2.330)。Dam等[24]研究发现，长时间使用PPIs会增加SBP(HR=1.72)及肝性脑病(HR=1.88)的风险。鉴于此，笔者认为尚需更多临床研究评估PPIs在EGVB中的疗效。考虑到急诊上消化道出血患者很难鉴别是曲张静脉出血还是其他出血，入院时使用PPIs是合理的，但在明确EGVB出血后应考虑停用。
3 内镜治疗
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内镜治疗是控制EGVB急性期出血及预防早期再出血的有效措施，主要包括内镜下硬化剂注射治疗(endoscopic injection sclerotherapy，EIS)、EVL及内镜下组织胶注射治疗(endoscopic cyanoacrylate injection，ECI)。
3.1 内镜检查/治疗的时机
国内外多数指南均推荐在血流动力学稳定的情况下12 h内完成内镜检查及治疗。2009年，Cheung等[25]分析了210例血流动力学稳定的EGVB患者，比较不同时间窗行内镜治疗对患者6周病死率的影响，结果发现血流动力学稳定的患者绝大部分可实现内镜下成功止血，内镜治疗时间并不影响患者的病死率。同年，Hsu等[26]选取311例肝硬化EGVB患者，分析与患者院内死亡相关的危险因素，发现延迟(>15 h)内镜检查是肝硬化EGVB患者院内死亡的独立危险因素。一项关于急性上消化道出血的大样本研究显示，与急性非曲张静脉出血比较，内镜检查的时间对EGVB的影响较小，不影响患者的30 d全因死亡率，但晚期(24~48 h)内镜治疗者30 d重复内镜治疗率及ICU住院率更高[27]。值得注意的是，关于EGVB患者内镜检查时间的研究大多为观察性研究，仍需要更多高质量的临床研究来明确最佳的内镜干预时机。不过基于现有证据，笔者建议应充分评估患者容量及气道保护情况，充分发挥无创性影像学评估的作用，不刻意追求12 h内的紧急内镜干预，但一般也不宜超过24 h。
3.2 常规内镜治疗
意识障碍及活动性出血的患者应考虑在气管插管下进行内镜检查或治疗，以免胃内容物误吸导致窒息等情况发生。一旦内镜检查完成，也应尽早拔管，以免增加感染风险。
内镜治疗的选择仍然以EVL及ECI为主，与传统治疗策略差异不大。EVL主要用于食管静脉曲张，ECI主要应用于胃静脉或异位静脉曲张。一项RCT纳入77例食管静脉曲张出血患者，随机行EVL或EIS，EVL组较EIS组再出血率低，曲张静脉根除所需内镜治疗的次数少，并且食管狭窄、食管溃疡等并发症发生率亦低[28]。与欧美国家相比，EIS在我国应用较多，但需要高质量临床研究证据的支持。
与食管静脉曲张比较，胃静脉曲张出血风险较低，但出血量大，导致救治相对困难。根据胃静脉曲张与食管静脉曲张的关系，可分为食管胃静脉曲张(gastroesophageal varices，GOV)及孤立性胃静脉曲张(isolated gastric varices，IGV)，前者又分为GOV1型及GOV2型，后者分为IGV1型及IGV2型，即最常用的Sarin分型[29]。GOV1型类似于食管静脉曲张，可采用EVL或ECI进行治疗。对于胃底静脉曲张出血，主要是GOV2及IGV1型，建议行ECI治疗，其风险主要是异位栓塞(肺栓塞、脑栓塞等)，发生率约0.7%[30]。有学者提议在超声内镜引导下行ECI，以提高胃底静脉曲张出血止血的精确性及安全性[31]。除此之外，超声内镜引导下弹簧圈置入、弹簧圈联合组织胶或明胶海绵注射、凝血酶注射等均是胃底静脉曲张出血的有效治疗方式[32]。然而，超声内镜引导下的胃静脉曲张治疗相对内镜治疗而言更耗费时间，且操作难度高，另需配备经过专业培训的超声内镜医师，在一定程度上影响该治疗方法的临床推广。
3.3 止血粉的应用
将止血粉通过精细的内镜传输系统释放至出血部位，与血液、组织等结合后形成机械屏障，黏附并覆盖在出血部位，可实现快速止血。该技术不需要很高的内镜操作经验，有助于避免因缺乏内镜专家所致的治疗延误。Ibrahim等[33]开展的一项RCT发现，在给予标准药物及内镜治疗同时，早期(入院后2 h内)使用止血粉可能有助于提高EGVB止血成功率及6周生存率。目前关于止血粉治疗EGVB的疗效研究尚少，还需要更多临床研究验证。
4 经颈静脉肝内门体分流术
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血管活性药物、预防性使用抗生素及内镜治疗是肝硬化EGVB的标准治疗方案。对于评估治疗失败或出血相关死亡风险较高的EGVB患者，应在入院72 h内(最好在24 h内)行TIPS治疗，即早期/优先TIPS。优先TIPS并非否定内镜治疗，而是在内镜治疗标准化的基础上，增加TIPS干预，以更高效地抢救高危患者。
Moitinho等[34]的研究显示，肝静脉压力梯度(hepatic venous pressure gradient，HVPG)大是EGVB患者控制出血失败及早期再出血的独立危险因素，通过ROC曲线得出最佳HVPG界值为20 mmHg(1 mmHg=0.133 kPa)。随后，一些研究将HVPG是否大于20 mmHg作为患者风险分层的依据[35-36]。Monescillo等[35]研究发现，早期TIPS可降低高危患者(HVPG≥20 mmHg)治疗失败率、院内病死率及1年病死率。但采取HVPG对EGVB患者进行风险分层在实际运用中存在一定困难，在急性出血期检测HVPG的可行性不高，只有少数中心可以开展这一项目。
2010年，巴塞罗那García-Pagán等[37]在《新英格兰医学杂志》撰文，首次提出Child-Pugh C级10~13分、Child-Pugh B级伴有内镜下活动性出血可作为高危EGVB患者的标准，其研究显示，优先TIPS组患者止血成功率及生存率均高于标准治疗组。优先TIPS的理念对肝硬化EGVB患者现有治疗策略是极大的挑战，也引发了国内外肝病学者广泛的研究兴趣。后续研究大多证实了优先TIPS在EGVB高危患者中的价值，但对如何界定“高危”也提出了新的思考，并进行了深入探索，尤其是对于Child-Pugh B级患者是否能够获益于优先TIPS的争议较大。一项基于单个病例数据的荟萃分析表明，与标准治疗相比，优先TIPS能够提高Child-Pugh C级<14分或者Child-Pugh B级>7分伴内镜下活动性出血患者的1年生存率，降低控制出血失败率、再出血率，以及腹水加重、肝性脑病等风险[38]。慢加急性肝衰竭、肝性脑病及高胆红素血症是传统TIPS术前评估的相对禁忌证，但符合“高危”标准的EGVB患者，仍然可获益于优先TIPS，此类相对禁忌不应该阻碍TIPS的实施[39]。尽管众多研究显示优先TIPS对于EGVB有着非常明显的疗效，但其在真实世界中的应用率仍然较低[40]，这可能由于临床医师对此技术能切实改善肝硬化EGVB患者预后缺乏信心，且能够开展此技术的临床研究中心亦较少。
5 球囊阻断逆行曲张静脉闭塞术
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BRTO是指将球囊导管经外周血管入路插入胃肾或胃腔分流道的流出道，随后充盈球囊使其阻断血流，向分流道内注射硬化剂，使胃曲张静脉闭塞的一种微创介入治疗方法[41]，可用于伴有分流道，且分流道类型及直径适合的胃静脉曲张及异位静脉曲张出血患者。因自发分流道的存在，此类患者行ECI治疗时的异位栓塞风险将增高[42]。来自韩国的一项研究显示，在控制胃静脉曲张急性出血及改善预后方面，BRTO优于ECI[43]。Paleti等[44]的一篇荟萃分析纳入7项比较TIPS与BRTO治疗胃静脉曲张出血的对照研究，结果显示，二者在控制急性出血成功率、手术成功率及相关并发症发生率等方面差异无统计学意义，但BRTO术后再出血率、肝性脑病发生率均低于TIPS。尽管目前BRTO并非控制急性胃曲张静脉出血的首选方法，但笔者认为BRTO已经是一项成熟的、疗效确切的技术，对于伴有分流道的胃静脉曲张患者，可作为内镜治疗或TIPS的有效替代方法用于控制急性出血。
6 挽救性治疗
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球囊填塞(balloon tamponade，BT)可短暂用于难以控制的消化道出血，作为确切性治疗(内镜治疗或介入治疗等)前的过渡手段。气囊放气后，50%的患者可能再出现消化道出血，且使用BT可能出现误吸、窒息或食管溃疡等不良反应，病死率高达20%~40%，通常使用时间不宜超过24 h[45]。
自膨式金属支架(self-expandable metallic stents，SEMS)与BT类似，主要用于难治性食管静脉曲张出血，但其安全性及有效性更高，保留时间更长。2019年的一篇系统评价纳入570例行BT及188例行SEMS的难以控制出血的EGVB患者，结果显示，BT的短期治疗失败率为35.5%，SEMS的短期、长期治疗失败率分别为12.7%、21.5%，二者的中期(6周或30 d)病死率相近[46]。综上所述，SEMS相比BT是更安全的EGVB挽救性治疗措施，但目前国内应用较少，未来还需要更多研究探讨SEMS的成本效益。
对于药物及内镜治疗均难以控制出血的EGVB患者，可考虑将TIPS作为挽救措施。研究显示TIPS控制EGVB出血的成功率大于90%[47]。但并非所有难治性EGVB患者都适合行挽救性TIPS。Maimone等[48]分析了144例因EGVB难以控制出血行挽救性TIPS的患者发现，对于Child-Pugh评分14~15分的患者，无一例存活超过30 d，这在一定程度上说明此类患者行挽救性TIPS可能无效。Walter等[49]开展的多中心回顾性研究显示，动脉血乳酸浓度>12 mmol/L以及MELD评分>30分的患者6周病死率高达90%，此类患者可能不适合行挽救性TIPS。
7 总结与展望
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肝硬化EGVB的治疗手段越来越多，超声内镜有望成为改善胃静脉曲张出血治疗现状的新技术，未来也需要开展更多的临床研究，以比较超声内镜引导下胃静脉曲张治疗与内镜下组织胶注射的疗效及安全性，同时探讨其成本效益。优先TIPS这一理念的应用，有助于早期对高危患者采取更积极的治疗，但其最佳适用人群及干预时机仍需不断优化，国内的研究数据相对缺乏，亟需开展更多高质量的临床研究进行探讨。肝硬化EGVB临床救治的成功，有赖于急诊、消化和重症等多学科的协作，以及内镜、介入、外科技术平台的支持，更重要的是运行通畅的急诊救治绿色通道的建立。同时，也要注意不同地区医疗中心的技术水平不同，肝硬化EGVB救治还需要结合各地区临床工作实际及医疗资源进行相应调整。我国是肝病大国，肝炎及肝硬化疾病负荷较重，但同时也具有宝贵的临床研究资源，区域医疗中心应注重高质量临床研究的开展，切实改善EGVB的临床预后。
基金
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  • 四川省科技厅国际合作项目(2020YFH0089)
  • 四川大学华西医院学科卓越发展1-3-5工程临床研究孵化项目(2019HXFH055)
文献
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2023年第48卷第10期
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doi: 10.11855/j.issn.0577-7402.2124.2023.0303
  • 接收时间：2022-10-13
  • 首发时间：2025-11-25
  • 出版时间：2023-10-28
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  • 收稿日期：2022-10-13
  • 录用日期：2022-11-27
基金
International Cooperation Project of Science and Technology Department of Sichuan Province(2020YFH0089)
四川省科技厅国际合作项目(2020YFH0089)
1-3-5 Project for Disciplines of Excellence-Clinical Research Incubation Project, West China Hospital, Sichuan University(2019HXFH055)
四川大学华西医院学科卓越发展1-3-5工程临床研究孵化项目(2019HXFH055)
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    四川大学-牛津大学华西消化道肿瘤联合研究中心/四川大学华西医院消化内科，四川成都 610041

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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