失代偿期门静脉高压并发食管胃静脉曲张出血的防治：内镜 vs 经颈静脉肝内门体分流术

刘梦莹; 李伟之; 李培杰; 马富权; 陈羽玲; 孙焕焕; 高恬恬; 薛挥

doi:10.3969/j.issn.1001-5256.2023.07.003

失代偿期门静脉高压并发食管胃静脉曲张出血的防治：内镜 vs 经颈静脉肝内门体分流术

DOI: 10.3969/j.issn.1001-5256.2023.07.003

刘梦莹¹,
李伟之¹,
李培杰¹,
马富权¹,
陈羽玲²,
孙焕焕¹,
高恬恬¹,
薛挥^{1, 2, , ,}

1.
西安交通大学第一附属医院消化内科，西安 710061
2.
西安交通大学医学部，西安 710061

基金项目:

陕西省重点研发计划一般项目 (2020SF-073);

陕西省重点研发计划一般项目 (2021SF-126);

陕西省重点研发计划一般项目 (2018SF-051);

陕西省重点研发计划一般项目 (2019SF-195)

利益冲突说明：本文不存在任何利益冲突。

作者贡献声明：刘梦莹参与收集分析文献，撰写文章及修改；李伟之参与文章修改；李培杰、马富权、陈羽玲、孙焕焕、高恬恬参与收集文献；薛挥负责撰写文章，指导文章修改及最后定稿。

详细信息

通信作者:
薛挥，zj2@mail.xjtu.edu.cn (ORICD: 0000-0003-3837-5361)

计量
- 文章访问数: 457
- HTML全文浏览量: 75
- PDF下载量: 114
- 被引次数: 0
出版历程
- 收稿日期: 2023-05-09
- 录用日期: 2023-06-10
- 出版日期: 2023-07-20

Comparison of endoscopic therapy and TIPS in prophylaxis and treatment of variceal bleeding in decompensated portal hypertension

1.
Department of Gastroenterology, The Frist Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
2.
Xi'an Jiaotong University Health Science Center, Xi'an 710061, China

Research funding:

Key Research and Development Program of Shaanxi Provincial in China (2020SF-073);

Key Research and Development Program of Shaanxi Provincial in China (2021SF-126);

Key Research and Development Program of Shaanxi Provincial in China (2018SF-051);

Key Research and Development Program of Shaanxi Provincial in China (2019SF-195)

More Information

Corresponding author: XUE Hui, zj2@mail.xjtu.edu.cn (ORICD: 0000-0003-3837-5361)

摘要

摘要: 食管胃静脉曲张出血(EGVB)是失代偿期门静脉高压症的主要并发症之一，尤其是肝硬化患者，病死率很高。EGVB以药物联合内镜标准防治为主；经颈静脉肝内门体分流术(TIPS)联合曲张静脉栓塞术在某些高危患者中也可优先选择，以肝静脉压力梯度为参考采取个体化诊治门静脉高压应当成为最新共识和主要策略。本文主要对失代偿期门静脉高压EGVB患者的内镜下防治及TIPS防治的相关适应证选择、并发症发生率及优劣予以综述。
- 门静脉高压 /
- 肝硬化 /
- 食管和胃静脉曲张 /
- 出血 /
- 门体分流术, 经颈静脉肝内
Abstract: Esophagogastric variceal bleeding (EGVB) is one of the main complications of decompensated portal hypertension, especially in patients with liver cirrhosis, and it often has a high mortality rate. Medication combined with endoscopy is the main prevention and treatment method for EGVB, while transjugular intrahepatic portosystemic shunt (TIPS) combined with variceal embolization can also be selected for some high-risk patients, and individualized diagnosis and treatment of portal hypertension based on hepatic venous pressure gradient should become the latest consensus and the main strategy. This article mainly reviews endoscopic therapy and TIPS for the prevention and treatment of EGVB patients with decompensated portal hypertension in terms of selection of indications, incidence rate of complications, and respective advantages and disadvantages.
- Portal Hypertension /
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Portasystemic Shunt, Transjugular Intrahepatic

HTML全文

参考文献(34)

[1]	de FRANCHIS R, Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension[J]. J Hepatol, 2010, 53(4): 762-768. DOI: 10.1016/j.jhep.2010.06.004.
[2]	GARCIA-TSAO G, ABRALDES JG, BERZIGOTTI A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases[J]. Hepatology, 2017, 65(1): 310-335. DOI: 10.1002/hep.28906.
[3]	de FRANCHIS R, Baveno VI Faculty. 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. DOI: 10.1016/j.jhep.2015.05.022.
[4]	BOSCH J, GARCÍA-PAGÁN JC. Prevention of variceal rebleeding[J]. Lancet, 2003, 361(9361): 952-954. DOI: 10.1016/S0140-6736(03)12778-X.
[5]	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. DOI: 10.1016/s0016-5085(99)70455-5.
[6]	KOVALAK M, LAKE J, MATTEK N, et al. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database[J]. Gastrointest Endosc, 2007, 65(1): 82-88. DOI: 10.1016/j.gie.2006.08.023.
[7]	MERLI M, NICOLINI G, ANGELONI S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients[J]. J Hepatol, 2003, 38(3): 266-272. DOI: 10.1016/s0168-8278(02)00420-8.
[8]	AMITRANO L, GUARDASCIONE MA, MANGUSO F, et al. The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients: refining short-term prognosis and risk factors[J]. Am J Gastroenterol, 2012, 107(12): 1872-1878. DOI: 10.1038/ajg.2012.313.
[9]	YOSHIJI H, NAGOSHI S, AKAHANE T, et al. Evidence-based clinical practice guidelines for liver cirrhosis 2020[J]. Hepatol Res, 2021, 51(7): 725-749. DOI: 10.1111/hepr.13678.
[10]	de FRANCHIS R, BOSCH J, GARCIA-TSAO G, et al. Baveno VⅡ - Renewing consensus in portal hypertension[J]. J Hepatol, 2022, 76(4): 959-974. DOI: 10.1016/j.jhep.2021.12.022.
[11]	DONG H, CHEN W, CHEN H, et al. New progress in endoscopic hemostasis treatment of esophageal and gastric variceal bleeding with portal hypertension in liver cirrhosis[J]. China Prac Med, 2011, 6(19): 82-83. DOI: 10.3969/j.issn.1673-7555.2011.19.053. 董辉, 陈武, 陈贺, 等. 肝硬化门脉高压食管胃底静脉曲张出血内镜下止血治疗新进展[J]. 中国实用医药, 2011, 6(19): 82-83. DOI: 10.3969/j.issn.1673-7555.2011.19.053.
[12]	TANG YY, LE MX, LIU DL. Optimited application of sclerosing against in the prevention and treatment of esophageal variceal bleeding in cirrhosis[J/CD]. Chin J Gastrointestial Endoscopy (Electronic Editon), 2020, 7(1): 39-42. DOI: 10.3877/cma.j.issn.2095-7157.2020.01.010. 谭玉勇, 乐梅先, 刘德良. 硬化剂在肝硬化食管静脉曲张破裂出血防治中的优化应用[J/CD]. 中华胃肠内镜电子杂志, 2020, 7(1): 39-42. DOI: 10.3877/cma.j.issn.2095-7157.2020.01.010.
[13]	LI X, JIANG T, GAO J. Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis[J]. Eur J Gastroenterol Hepatol, 2017, 29(6): 621-628. DOI: 10.1097/MEG.0000000000000861.
[14]	HENRY Z, PATEL K, PATTON H, et al. AGA clinical practice update on management of bleeding gastric varices: expert review[J]. Clin Gastroenterol Hepatol, 2021, 19(6): 1098-1107. e1. DOI: 10.1016/j.cgh.2021.01.027.
[15]	GREENWALD BD, CALDWELL SH, HESPENHEIDE EE, et al. N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study and cost analysis[J]. Am J Gastroenterol, 2003, 98(9): 1982-1988. DOI: 10.1111/j.1572-0241.2003.07637.x.
[16]	GUO YW, MIAO HB, WEN ZF, et al. Procedure-related complications in gastric variceal obturation with tissue glue[J]. World J Gastroenterol, 2017, 23(43): 7746-7755. DOI: 10.3748/wjg.v23.i43.7746.
[17]	WANG FH, LONG D, ZHU JC, et al. Clinical observation on the treatment of gastric varices with modified sandwich sandwich tissue gel injection under endoscopy[J]. J Med Theor & Pract, 2019, 32(19): 3099-3100. DOI: 10.19381/j.issn.1001-7585.2019.19.028. 王富华, 龙丹, 朱建臣, 等. 内镜下改良三明治夹心法组织胶注射治疗胃静脉曲张的临床观察[J]. 医学理论与实践, 2019, 32(19): 3099-3100. DOI: 10.19381/j.issn.1001-7585.2019.19.028.
[18]	ROMERO-CASTRO R, ELLRICHMANN M, ORTIZ-MOYANO C, et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos)[J]. Gastrointest Endosc, 2013, 78(5): 711-721. DOI: 10.1016/j.gie.2013.05.009.
[19]	MONESCILLO A, MARTÍNEZ-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. DOI: 10.1002/hep.20386.
[20]	GARCÍA-PAGÁN JC, CACA K, BUREAU C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding[J]. N Engl J Med, 2010, 362(25): 2370-2379. DOI: 10.1056/NEJMoa0910102.
[21]	HERNÁNDEZ-GEA V, PROCOPET B, GIRÁLDEZ Á, et al. Preemptive-TIPS improves outcome in high-risk variceal bleeding: an observational study[J]. Hepatology, 2019, 69(1): 282-293. DOI: 10.1002/hep.30182.
[22]	NICOARǍ-FARCǍU O, HAN G, RUDLER M, et al. Effects of early placement of transjugular portosystemic shunts in patients with high-risk acute variceal bleeding: a meta-analysis of individual patient data[J]. Gastroenterology, 2021, 160(1): 193-205. e10. DOI: 10.1053/j.gastro.2020.09.026.
[23]	HALABI SA, SAWAS T, SADAT B, et al. Early TIPS versus endoscopic therapy for secondary prophylaxis after management of acute esophageal variceal bleeding in cirrhotic patients: a meta-analysis of randomized controlled trials[J]. J Gastroenterol Hepatol, 2016, 31(9): 1519-1526. DOI: 10.1111/jgh.13303.
[24]	NJEI B, MCCARTY TR, LAINE L. Early transjugular intrahepatic portosystemic shunt in US patients hospitalized with acute esophageal variceal bleeding[J]. J Gastroenterol Hepatol, 2017, 32(4): 852-858. DOI: 10.1111/jgh.13593.
[25]	BUREAU C, THABUT D, OBERTI F, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites[J]. Gastroenterology, 2017, 152(1): 157-163. DOI: 10.1053/j.gastro.2016.09.016.
[26]	ZHANG M, WANG G, ZHAO L, et al. Second prophylaxis of variceal bleeding in cirrhotic patients with a high HVPG[J]. Scand J Gastroenterol, 2016, 51(12): 1502-1506. DOI: 10.1080/00365521.2016.1193218.
[27]	LV Y, QI X, HE C, et al. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial[J]. Gut, 2018, 67(12): 2156-2168. DOI: 10.1136/gutjnl-2017-314634.
[28]	TRIPATHI D, THERAPONDOS G, JACKSON E, et al. The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations[J]. Gut, 2002, 51(2): 270-274. DOI: 10.1136/gut.51.2.270.
[29]	SAAD WE, WAGNER CC, LIPPERT A, et al. Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO)[J]. Am J Gastroenterol, 2013, 108(10): 1612-1619. DOI: 10.1038/ajg.2013.232.
[30]	Minimally Invasive Intervention Group, Chinese Society of Gastroenterology. Expert consensus on transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension[J]. Chin J Hepatol, 2022, 30(12): 1349-1364. DOI: 10.3760/cma.j.cn501113-20221109-00553. 中华医学会消化病学分会微创介入协作组. 经颈静脉肝内门体静脉分流术治疗门静脉高压专家共识(2022年版)[J]. 中华肝脏病杂志, 2022, 30(12): 1349-1364. DOI: 10.3760/cma.j.cn501113-20221109-00553.
[31]	LI PJ, XU J, YAN LJ, et al. Comparison of five-year survival status of patients with liver cirrhosis and esophagogastric varices bleeding treated by transjugular intrahepatic portosystemic shunt and drug combined with endoscopic treatment[J]. Chin J Dig, 2021, 41(5): 323-329. DOI: 10.3760/cma.j.cn311367-20200828-00518. 李培杰, 徐菁, 闫丽晶, 等. 经颈静脉肝内门体分流术与药物联合内镜治疗肝硬化食管胃静脉曲张出血患者五年生存状况比较[J]. 中华消化杂志, 2021, 41(5): 323-329. DOI: 10.3760/cma.j.cn311367-20200828-00518.
[32]	WANG CY, XIONG B, LIU JC, et al. Effect of underdilated stent on the occurrence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation[J]. Chin J Intern Med, 2022, 61(5): 537-542. DOI: 10.3760/cma.j.cn112138-20211010-00685. 王朝阳, 熊斌, 刘家成, 等. 支架亚扩张对经颈静脉肝内门体分流术后肝性脑病发生率的影响分析[J]. 中华内科杂志, 2022, 61(5): 537-542. DOI: 10.3760/cma.j.cn112138-20211010-00685.
[33]	YANG MZ, WU D, TANG L, et al. Clinical features of hepatic myelopathy: An analysis of 562 cases[J]. J Clin Hepatol, 2021, 37(1): 115-119. DOI: 10.3969/j.issn.1001-5256.2021.01.023. 杨明芝, 吴丹, 唐亮, 等. 562例肝性脊髓病的临床特征分析[J]. 临床肝胆病杂志, 2021, 37(1): 115-119. DOI: 10.3969/j.issn.1001-5256.2021.01.023.
[34]	MA FQ, HUANG J, LI WZ, et al. Effects of reduced portosystemic flow on hepatic myelopathy in patients with cirrhosis after TIPS[J]. Chin J Hepatol, 2022, 30(10): 1063-1068. DOI: 10.3760/cma.j.cn501113-20201026-00580. 马富权, 黄金, 李伟之, 等. 减少门腔分流量对肝硬化患者经颈静脉肝内门体分流术后肝性脊髓病的影响[J]. 中华肝脏病杂志, 2022, 30(10): 1063-1068. DOI: 10.3760/cma.j.cn501113-20201026-00580.