食管静脉曲张初级预防的循证治疗一例

Evidence-based Primary Prevention for One Patient with Cirrhosis and Esophageal Varices

目的针对1例无出血史的肝硬化食管静脉曲张患者,采用循证医学方法,检索当前最佳证据,探讨预防肝硬化食管静脉曲张初次出血的合理预防方案。方法 2013年11月2日收治1例食管静脉曲张患者。在充分评估其病情后,从Cochrane图书馆(1991年-2013年)、Embase(1991年-2013年)、Medline(1950年-2013年)、维普(1989年-2013年)、中国生物医学文献数据库(1990年-2013年)中,检索有关食管静脉曲张的高质量证据进行评价,并结合医生经验及患者愿望制定预防方案。结果共纳入9篇文献。内容包括食管静脉曲张是否应采取预防出血措施,套扎术和β受体阻滞剂在预防初次出血上的疗效及并发症、效价比差异。根据以上证据并结合患者意愿,给予非选择性β受体阻滞剂预防患者初次出血。结论采用循证医学方法为肝硬化食管静脉曲张患者确定预防初次出血的方案,不仅可有效预防初次出血,同时可让患者参与到自身疾病的了解和治疗当中。

Objective To explore an individualized treatment program to prevent the initial bleeding of a patient with cirrhosis and esophageal varices by the methods of evidence-based medicine. Methods One patient with cirrhosis and esophageal varices was admitted into our hospital on November 2, 2013. After evaluating the patient＇s condition adequately, we proposed the problem according to the PICOS principles. Then, we assessed the clinical evidence from the Cochrane Library （1990-2012）, Medline （1950-2012）, Embase （1991-2012）, VIP （1989-2013）, and CBM （1990-2013）. The individualized treatment plan was made through doctors＇ experiences and analysis of those high-quality evidences from the databases. Results Eight studies （randomized controlled trials and 5 meta-analysis） were included. We evaluated a series of associated problems： whether we should take measurement to prevent initial bleeding of esophageal varices; which one （β-oblockers or ligation of esophageal varices） was the best method to prevent the initial bleeding based on efficacy, complication and cost-effectiveness. Then, according to the evidences and the patient＇s view, we gave non- selective β-blocker as the primary prevention. After one-year followed-up, the initial bleeding of the patient did not occur. Conclusion Making the prevention plan for a patient with cirrhosis and esophageal varices can not only find out the individualized program, but also push the patient to make decision for their own health.