切换至 "中华医学电子期刊资源库"
高级检索
中华消化病与影像杂志(电子版)

中华消化病与影像杂志(电子版) ›› 2019, Vol. 09 ›› Issue (06) : 256 -262. doi: 10.3877/cma.j.issn.2095-2015.2019.06.005

所属专题： 文献；

临床研究

肝静脉压力梯度指导下食管静脉曲张再出血预防方法选择
王思宁1, 王广川1, 张明艳1, 黄广军1, 陈世耀2, 张春清1,†()   
  1. 1. 250021　济南，山东大学附属省立医院消化内科
    2. 200032　上海，复旦大学附属中山医院消化科
  • 收稿日期:2019-10-03 出版日期:2019-12-01
  • 通信作者: 张春清
  • 基金资助:
    国家自然科学基金(81770606)

Prevention for rebleeding of esophageal varices under the guidance of hepatic venous pressure gradient

Sining Wang1, Guangchuan Wang1, Mingyan Zhang1, Guangjun Huang1, Shiyao Chen2, Chunqing Zhang1,†()   

  1. 1. Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
    2. Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
  • Received:2019-10-03 Published:2019-12-01
  • Corresponding author: Chunqing Zhang
  • About author:
    Corresponding author: Zhang Chunqing, Email:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

王思宁, 王广川, 张明艳, 黄广军, 陈世耀, 张春清. 肝静脉压力梯度指导下食管静脉曲张再出血预防方法选择[J/OL]. 中华消化病与影像杂志(电子版), 2019, 09(06): 256-262.

Sining Wang, Guangchuan Wang, Mingyan Zhang, Guangjun Huang, Shiyao Chen, Chunqing Zhang. Prevention for rebleeding of esophageal varices under the guidance of hepatic venous pressure gradient[J/OL]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2019, 09(06): 256-262.

目的

肝静脉压力梯度(HVPG)是肝硬化病情评估、判断预后的重要指标，本研究探索依据患者不同HVPG值采取不同术式降低肝硬化食管静脉曲张患者再出血率的价值。

方法

收集2010年4月至2019年10月既往有消化道出血病史、行HVPG测定的270例肝硬化食管静脉曲张患者为观察对象。其中130例患者(HVPG指导组)根据HVPG值选择不同术式进行个体化治疗：10 mmHg≤HVPG≤16 mmHg的患者采用内镜下食管静脉曲张套扎术(EVL)联合非选择性β受体阻断剂(NSBB)治疗；16 mmHg<HVPG≤20 mmHg的患者采用经皮经肝胃食管静脉曲张栓塞术(PTVE)治疗；HVPG>20 mmHg的患者则使用经颈静脉肝内门体分流术(TIPS)治疗。另外140例患者(非HVPG指导组)均采用EVL联合NSBB治疗。观察主要终点为门脉高压相关再出血，次要终点为死亡。

结果

中位随访时间为26个月。HVPG指导组再出血率低于非HVPG指导组(12.31%比30.00%，P＝0.000 88)，但两组生存率无明显差异(93.08%比91.43%，P＝0.71)。进一步亚组分析显示，对于16 mmHg<HVPG≤20 mmHg患者，PTVE治疗的再出血率低于EVL＋NSBB治疗(5.00%比31.82%，P＝0.02)，但两组生存率无明显差异；对于HVPG>20 mmHg的患者，TIPS治疗的再出血率低于EVL＋NSBB治疗(6.12%比36.36%，P＝0.000 88)，两组生存率仍无明显差异。

结论

基于HVPG的个体化治疗具有重要理论和临床意义，根据HVPG的风险分层，个体化选择食管静脉曲张出血二级预防治疗方案(EVL＋NSBB、PTVE或TIPS)可降低静脉再出血率，为肝硬化患者的个体化治疗提供新的研究思路。

关键词: 肝硬化, 个体化治疗, 肝静脉压力梯度, 经皮经肝胃食管静脉曲张栓塞术, 经颈静脉肝内门体分流术
Objective

Hepatic venous pressure gradient(HVPG)is an important indicator for the evaluation and prognosis of liver cirrhosis.This study explores the value of different procedures according to HVPG for reducing the rate of rebleeding in cirrhotic patients with esophageal varices.

Methods

A total of 270 cirrhotic patients with esophageal varices who had a history of variceal bleeding and HVPG performance from April 2010 to October 2019 were enrolled.Among them, 130 patients(HVPG guided group)underwent individualized treatment according to HVPG value: patients with 10 mmHg≤HVPG≤16 mmHg accepted endoscopic esophageal variceal ligation(EVL)combined with non-selectiveβreceptor blocker(NSBB)treatment; patients with 16 mmHg<HVPG≤20 mmHg underwent percutaneous transhepatic variceal embolization (PTVE); for patients with HVPG>20 mmHg, transjugular intrahepatic portosystemic shunt(TIPS)was used.Another 140 patients(non-HVPG guided group)were treated with EVL plus NSBB.The primary end point was rebleeding associated with portal hypertension, and the secondary end point was death.

Results

The median follow-up time was 26 months.The rate of rebleeding in the HVPG guided group was lower than that in the non-HVPG guided group(12.31% vs.30.00%, P=0.000 88), but there was no significant difference in survival between the two groups(93.08% vs.91.43%, P=0.71). Further subgroup analysis showed that for patients with 16 mmHg<HVPG≤20 mmHg, the rebleeding rate of patients with PTVE treatment was lower than that of patients with EVL+ NSBB(5.00% vs.31.82%, P=0.02), but there was no significant difference in survival between the two groups.In patients with HVPG>20 mmHg, the rebleeding rate of patients with TIPS was lower than that of patients with EVL+ NSBB(6.12% vs.36.36%, P=0.000 88), but there was no significant difference in survival between the two groups.

Conclusion

Individualized therapy based on HVPG has important theoretical and clinical significance.According to the risk stratification of HVPG, individualized choice of secondary prevention of esophageal variceal bleeding(EVL+ NSBB, PTVE or TIPS)can reduce the risk of rebleeding, which is worthy of further clinical research for individualized therapy of cirrhotic patients.

Key words: Liver cirrhosis, Individualized treatment, Hepatic vein pressure gradient, Percutaneous transhepatic variceal embolization, Transjugular intrahepatic portosystemic shunt
图1 试验设计流程图
图2 患者，男性，47岁，肝硬化食管静脉曲张，经皮经肝胃食管静脉曲张栓塞术(PTVE)治疗
图3 患者，男性，50岁，肝硬化食管静脉曲张，经颈静脉肝内门体分流术(TIPS)治疗
表1 非HVPG指导组与HVPG指导组患者的基本资料
项目及类别 非HVPG指导组(n＝140) HVPG指导组(n＝130) 检验统计量 P值
年龄(岁) 52.8±11.9 52.0±11.6 0.583 0.56
性别[例(%)] ? ? ? ?
? 女 48 (34.29) 42 (32.31) 0.119 0.73
? 男 92 (65.71) 88 (67.69) ? ?
脾切除或脾栓塞[例(%)] ? ? ? ?
? 否 118 (84.29) 108 (83.08) 0.072 0.788
? 是 22 (15.71) 22 (16.92) ? ?
腹水[例(%)] ? ? ? ?
? 无 68 (48.57) 50 (38.46) 2.8 0.094
? 有 72 (51.43) 80 (61.54) ? ?
Child分级[例(%)] ? ? ? ?
? A级 70 (50) 65 (50) 8 815 0.615
? B级 68 (48.57) 55 (42.31) ? ?
? C级 2 (1.43) 10 (7.69) ? ?
病因[例(%)] ? ? ? ?
? 病毒性 90 (64.29) 71 (54.62) 2.671 0.274
? 酒精性 18 (12.86) 20 (15.38) ? ?
? 其他 32 (22.86) 39 (30.00) ? ?
肝性脑病[例(%)] ? ? ? ?
? 无 139 (99.29) 127 (97.69) － 0.355
? 有 1 (0.71) 3 (2.31) ? ?
食管静脉曲张程度[例(%)] ? ? ? ?
? 轻度 0 5 (3.85) 9 075 0.958
? 中度 34 (24.29) 25 (19.23) ? ?
? 重度 106 (75.71) 100 (76.92) ? ?
白蛋白(g/L) 33.4 (30.3～36.6) 33.2 (29.3～37.7) 9 304.5 0.75
ALT(u/L) 23.1 (18.0～33.0) 22.0 (16.2～32.8) 9 733.5 0.323
AST(u/L) 33.0 (25.8～44.0) 32.0 (24.0～44.0) 9 411 0.627
血红蛋白(g/L) 85.5 (71.8～99.0) 79.0 (67.2～96.0) 10 328 0.055
肝静脉压力梯度(mmHg) 17.0 (13.0～20.0) 18.0 (13.0～22.9) 7 986 0.082
血小板计数(×109) 68.5 (51.0～105.5) 80.5 (52.2～118.5) 8 531 0.375
凝血酶原时间(s) 14.8 (13.6～16.1) 14.9 (13.6～16.2) 8 962 0.83
总胆红素(μmol/L) 20.6 (14.5～25.3) 19.8 (14.7～27.9) 8 792 0.631
肌酐(μmol/L) 63.5 (54.6～76.6) 63.3 (53.4～73.2) 9 311 0.742
图4 2组患者食管静脉曲张再出血及生存比较
图5 16 mmHg<肝静脉压力梯度(HVPG)≤20 mmHg的患者行经皮经肝胃食管静脉曲张栓塞术(PTVE)治疗和内镜下食管静脉曲张套扎术(EVL)＋非选择性β受体阻断剂(NSBB)治疗的再出血和生存比较
图6 肝静脉压力梯度(HVPG)>20 mmHg的患者行经颈静脉肝内门体分流术(TIPS)治疗和行内镜下食管静脉曲张套扎术(EVL)＋非选择性β受体阻断剂(NSBB)治疗的再出血和生存比较
1
De Franchis R．Expanding consensus in portal hypertension：Report of the Baveno VI Consensus Workshop：Stratifying risk and individualizing care for portal hypertension [J]．J Hepatol，2015，63(3):743-752.
2
Bosch J, Garcia-Pagan J C．Prevention of variceal rebleeding [J]．Lancet，2003，361(9361):952-954.
3
Qi XS, Fan DM.Hepatic venous pressure gradient measurement before TIPS for acute variceal bleeding [J]．World J Gastroenterol，2014，20(23):7523-7524.
4
Tage-Jensen U, Henriksen JH, Christensen E，et al.Plasma catecholamine level and portal venous pressure as guides to prognosis in patients with cirrhosis [J]．J Hepatol，1988，6(3):350-358.
5
Merkel C, Bolognesi M, Sacerdoti D，et al.The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis [J]．Hepatology，2000，32(5):930-934.
6
Stanley AJ, Robinson I, Forrest EH，et al.Haemodynamic parameters predicting variceal haemorrhage and survival in alcoholic cirrhosis [J]．QJM，1998，91(1):19-25.
7
Moitinho E, Escorsell A, Bandi JC，et al.Prognostic value of early measurements of portal pressure in acute variceal bleeding [J]．Gastroenterology，1999，117(3):626-631.
8
Bosch J, Abraldes JG, Berzigotti A，et al.The clinical use of HVPG measurements in chronic liver disease [J]．Nat Rev Gastroenterol Hepatol，2009，6(10):573-582.
9
Gonzalez A, Augustin S, Perez M，et al.Hemodynamic response-guided therapy for prevention of variceal rebleeding：an uncontrolled pilot study [J]．Hepatology，2006，44(4):806-812.
10
Zhang CQ, Liu FL, Liang B，et al.A modified percutaneous transhepatic varices embolization with 2-octyl cyanoacrylate in the treatment of bleeding esophageal varices [J]．J Clinical Gastroenterol，2009，43(5):463-469.
11
Abraldes JG, Gilabert R, Turnes J，et al.Utility of color Doppler ultrasonography predicting tips dysfunction [J]．Am J Gastroenterol，2005，100(12):2696-2701.
12
Groszmann RJ, Wongcharatrawee S．The hepatic venous pressure gradient：anything worth doing should be done right [J]．Hepatology，2004，39(2):280-282.
13
Monescillo A, Martinez-Lagares F, Ruiz-Del-Arbol L，et al.Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding [J]．Hepatology，2004，40(4):793-801.
14
刘丙菊，吴利春，王广川，等肝静脉压力梯度预测内镜下食管静脉曲张套扎术后早期再出血的临床应用[J]．中华肝脏病杂志，2015，23(1):50-54.
15
Tian X, Shi Y, Hu J，et al.Percutaneous transhepatic variceal embolization with cyanoacrylate vs.transjugular intrahepatic portal systematic shunt for esophageal variceal bleeding [J]．Hepatol Int，2013，7(2):636-644.
16
Polio J, Groszmann RJ.Hemodynamic factors involved in the development and rupture of esophageal varices：a pathophysiologic approach to treatment [J]．Semin Lver Dis，1986，6(4):318-331.
17
Rigau J, Bosch J, Bordas JM，et al.Endoscopic measurement of variceal pressure in cirrhosis：correlation with portal pressure and variceal hemorrhage [J]．Gastroenterology，1989，96(3):873-880.
[1] 叶美妮, 刘思嘉, 臧玉玮, 刘云建. 肝硬化门静脉血栓形成的研究进展[J/OL]. 中华普通外科学文献(电子版), 2024, 18(05): 379-384.
[2] 王浩元, 王舒, 王娟, 杨建军. 基于类器官模型探索肠道与肠道菌群间相互关系的研究进展[J/OL]. 中华普通外科学文献(电子版), 2024, 18(03): 220-224.
[3] 贺健, 张骊, 王洪海, 蒋文涛. 肝移植术后脾功能亢进转归及治疗研究进展[J/OL]. 中华移植杂志(电子版), 2024, 18(05): 310-314.
[4] 王浩源, 汪海洋, 孙建明, 陈以宽, 祁小桐, 唐博. 腹腔镜与开放修补对肝硬化腹外疝患者肝功能及凝血的影响[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 654-659.
[5] 吴俊嶺, 孟科, 刘江涛, 孙刚. 基于HVPG分层的门脉高压内镜治疗中远期疗效研究[J/OL]. 中华腔镜外科杂志(电子版), 2024, 17(02): 100-105.
[6] 蔡艺丹, 方坚, 张志强, 陈莉, 张世安, 夏磊, 阮梅, 李东良. 经颈静脉肝内门体分流术对肝硬化门脉高压患者肠道菌群及肝功能的影响[J/OL]. 中华细胞与干细胞杂志(电子版), 2024, 14(05): 285-293.
[7] 邓万玉, 陈富, 许磊波. 肝硬化与非肝硬化乙肝相关性肝癌患者术后无复发生存比较及其影响因素分析[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 670-674.
[8] 刘起帆, 蒋安. 肝硬化门静脉高压症门静脉压力无创测量进展[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(03): 270-275.
[9] 张宇, 余灵祥, 赵亮, 张宁, 赵德希, 刁广浩, 杨木易, 刘佳, 李鹏, 任辉. 利伐沙班在脾切除联合贲门周围血管离断术后门静脉血栓预防中的疗效[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(02): 195-199.
[10] 刘悦, 潘纯. 急性呼吸窘迫综合征患者肌松剂滴定的必要性与可行性[J/OL]. 中华重症医学电子杂志, 2024, 10(02): 108-112.
[11] 崔健, 夏青, 林云, 李光玲, 李心娜, 王位. 血小板与淋巴细胞比值、免疫球蛋白、心肌酶谱及心电图对中老年肝硬化患者病情及预后的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(05): 400-406.
[12] 秦相清, 朱陈, 张海银. 构建诺模图模型预测肝硬化食管胃底静脉曲张出血的风险[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(04): 330-335.
[13] 刘燚隆, 党荣广, 艾蓉, 张凯. 肝硬化合并静脉曲张出血患者内镜治疗后再出血风险的模型建立与验证[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(04): 336-342.
[14] 戚泽雪, 赵连晖, 王广川, 张春清. 从国内专家共识推荐意见更新探讨经颈静脉肝内门体分流术的临床应用进展[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(03): 193-196.
[15] 王秀, 王义国. 益生菌联合恩替卡韦治疗乙型肝炎肝硬化临床疗效的meta分析[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(02): 164-171.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号