肝静脉压力梯度在肝硬化门静脉高压症患者中的临床应用

Clinical utility of hepatic venous pressure gradient for predicting outcome and guiding treatment of cirrhosis and portal hypertension

测量肝静脉压力梯度(HVPG)是评估门静脉高压症最常用的方法。大量研究表明,HVPG可作为食管静脉曲张出血的预测因子,此外,HVPG还可作为一个预后指标,可方便临床医生以其做参考为静脉曲张出血的一级预防和二级预防来制定合适的治疗策略。现阶段的治疗目标是使HVPG下降到12 mm Hg以下或比基线值下降20%,达到此目标的患者其食管静脉曲张的首次出血和再出血的风险均大大降低。对于一级预防,非选择性的β受体阻滞剂,如心得安,临床已广泛应用;然而,再出血的发生率仍然很高,临床上常用包括非选择性β受体阻滞剂在内的药物联合治疗和内镜干预,如经颈静脉肝内门体静脉分流术(TIPS)、内镜下硬化剂注射和内镜下套扎。主要探讨目前HVPG的测量方法及其临床应用,并重点对在肝硬化中HVPG对食管静脉曲张出血和再出血及治疗反应的预测作用做详细阐述。

Measurement of the hepatic venous pressure gradient （HVPG） remains the most commonly used method to assess portal hypertension （clinically defined as above the normal range of 1-5 mm Hg）. HVPG measurement can also serve as a predictor of variceal bleeding （increased risk associated with 〉10-12 mm Hg） and as a prognostic indicator by which treating physicians may design appropriate therapeutic strategies for primary and secondary prophylaxis. The current treatments aim to reduce the HVPG to 〈12 mm Hg or achieve a 20% reduction from baseline, both of which are associated with significantly lower risk of variceal bleeding and rebleeding. For primary prevention, non-selective beta-blockers, such as propranolol, are currently used; however, rebleeding incidence remains high and is frequently treated by a combination of drugs, including the non-selective beta-blockers, and endoscopic management, such as transjugular intrahepatic portosystemic shunting, endoscopic sclerotherapy, and endoscopic band ligation. We discuss the current HVPG measurement methods as well as the clinical applications, detailing its potential as a prognostic indicator of variceal bleeding and rebleeding in various liver conditions, such as cirrhosis, and in response to treatment.