食管静脉曲张——从血管解剖基础到内镜下治疗

doi:10.3877/cma.j.issn.2095-2015.2024.01.001

食管的静脉系统结构非常复杂，包括食管内静脉和食管外静脉。在食管的下段，根据食管静脉的结构特征，食管可以分为胃区、栅栏区、穿支区和干区4个区。在血液引流方面，颈部、胸部和腹部食管分别流入不同的静脉血管。门静脉高压时，由于门脉血管内静脉压增高，胃左静脉、胃后静脉和胃短静脉成为输入血管，食管各层的血管出现扩张，特别是深静脉明显扩张，形成内镜下可见的3～4条迂曲的曲张静脉。曲张静脉的血液来自胃区血管和穿通支血管，存在单纯胃区供血、单纯穿通支供血和二者同时供血三种情况。食管静脉曲张的内镜下治疗包括套扎和硬化治疗，两种治疗方法各有利弊。理解食管静脉的正常解剖结构和血液引流对于理解食管静脉曲张的发病机制、异位栓塞的途径、制定合理的、个体化的内镜治疗方案具有重要意义。

关键词: 食管静脉曲张, 食管静脉曲张内镜硬化剂注射术, 食管静脉曲张内镜套扎术, 食管血管解剖

The normal anatomy of esophageal venous system is very complex, consisting of intrinsic veins and extrinsic veins. In the lower part of esophagus, according to the structural characteristics of esophageal veins, four distinct zones can be found: gastric zone, palisade zone, perforating zone and truncal zone. In terms of venous drainage, venous blood from the neck, chest, and abdominal esophagus drains into different veins. In portal hypertension, because of hepatofugal blood flow from veins such as left gastric vein, posterior gastric vein and short gastric vein, venous dilation in all layers occurs, especially deep intrinsic veins, leading to 3-4 endoscopically observed tortuous veins. Blood in varices can come from veins in gastric zone only, perforating vein only or from both. Endoscopic treatment of esophageal varices includes ligation and sclerotherapy, both of which have their own advantages and disadvantages. Familiarity with normal esophageal venous anatomy and drainage has important implications for understanding of varices formation, ectopic embolisation and personalized options of endoscopic treatment modality.

Key words: Esophageal varices, Endoscopic sclerotherapy for esophageal varices, Endoscopic ligation of esophageal varices, Esophageal vascular anatomy

图1 食管内静脉和食管外静脉示意图^[2]

图2 食管静脉曲张输出血管示意图^[17]注：LBCV左头臂静脉，LGV胃左静脉，AV奇静脉。

图3 栅栏区血管示意图^[9]

图4 食管静脉曲张分型示意图^[28]注：Azygos vein奇静脉，Paraesophageal vein食管旁静脉，Posterior branch胃左静脉后支，Anterior branch胃左静脉前支，Cardiac-inflow type without collaterall vesells胃底供血型（无壁外血管扩张），Cardiac-inflow type with collaterall vesells胃底供血型（有壁外血管扩张），Azygos-perforating type奇静脉穿通支型，Complicated type混合型。

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Esophageal varices: from vascular anatomic basis to endoscopic treatment

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Esophageal varices: from vascular anatomic basis to endoscopic treatment