奥曲肽治疗肝炎后肝硬化门静脉高压上消化道出血的临床疗效

目的:探讨奥曲肽治疗肝炎后肝硬化门静脉高压上消化道出血的临床疗效。方法:将212例临床诊断为肝炎后肝硬化门静脉高压合并上消化道出血的患者随机分为治疗组和对照组各106例,分别用奥曲肽和垂体后叶素进行治疗,比较两组的临床疗效。结果:治疗组和对照组的总有效率分别为94.3%和88.7%,治疗组疗效优于对照组,两组总有效率比较差异有统计学意义(P<0.05)。治疗组和对照组不良反应发生率分别为13.5%和24.5%,两组比较差异有统计学意义(P<0.05)。结论:奥曲肽治疗肝炎后肝硬化门静脉高压上消化道出血疗效优于垂体后叶素,且不良反应发生较少,值得临床推广应用。

西藏地区门静脉CTA:胃左静脉最大直径与食管胃底静脉曲张破裂出血的相关性

目的研究胃左静脉直径测量(门静脉CT成像)应用在肝硬化静脉曲张(食道胃底)破裂出血的预测价值。方法应用门静脉CT成像对肝硬化患者进行筛查,评价胃左静脉及食管胃底静脉曲张的情况,多平面测量胃左静脉最大内径,并进行统计分析。病例组与对照组进行比较,结果显示出血组较未出血组胃左静脉最大内径明显增宽,(P<0.01),以胃左静脉最大内径6.5mm为出血预测指标。结论胃左静脉直径增宽是肝硬化食管胃底静脉曲张破裂出血的可能危险因素,门静脉CT成像测量肝硬化患者胃左静脉最大内径,从而预测出血具有较高的预测价值。

TIPS术治疗的肝硬化患者肝性脊髓病临床特征及其影响因素分析

目的观察经颈静脉肝内门体分流术(TIPS)治疗的肝硬化并发门静脉脉高压症患者术后肝性脊髓病(HM)的临床特征,并分析HM发病的危险因素。方法2017年4月~2022年10月我院收治的526例接受过TIPS治疗的肝硬化并发门静脉高压症患者,随访记录术后HM发生情况,应用二元Logistic回归模型分析影响TIPS术后HM发生的危险因素。结果在TIPS术后中位随访28(7~72)个月,发生HM者41例(7.8%),其中男性33例,女性8例,发病年龄为50(40,71)岁;并发肝性脑病(HE)34例(82.9%)、门静脉血栓13例(31.7%)、食管胃底静脉曲张破裂出血6例(14.6%);脊髓功能受损表现为肌力下降31例(75.6%,腱反射亢进21例(51.2%)、肌张力增高23例(56.1%)、病理征阳性22例(53.7%)、主观下肢麻木2例(4.9%)、肛门括约肌功能障碍1例(2.4%);死亡23例;绘制Kaplan-Meier生存曲线,HM患者1 a和3 a累积生存率分别为82.9%和58.5%;随机选择82例未发生HM患者为对照,结果HM组年龄和MELD评分分别为(50.9±12.9)岁和(11.3±2.6)分,显著高于对照组【分别为(47.0±11.3)岁和(10.1±2.1)分,P<0.05】,HM组男性、脾切除术、发生HE、PT延长和血氨升高占比分别为80.5%、26.8%、82.9%、51.2%和92.2%,显著高于非HM组的61.0%、12.2%、47.6%、31.7%和67.1%(P<0.05);二元多因素Logistic回归分析显示男性(OR=2.250,95%CI:1.654~3.735)、脾切除术(OR=1.840,95%CI:1.120~2.298)、血氨升高(OR=1.122,95%CI:1.054~1.605)和发生HE(OR=3.442,95%CI:2.248~6.779)是影响TIPS术后发生HM的独立危险因素(P<0.05)。结论肝硬化门静脉脉高压患者在接受TIPS术后有发生HM的风险,主要见于男性,了解风险因素并予以干预是今后研究的重点。

Effect of transjugular intrahepatic portosystemic shunt on pulmonary gas exchange in patients with portal hypertension and hepatopulmonary syndrome

AIM: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) on pulmonary gas exchange and to evaluate the use of TIPS for the treatment of hepatopulmonary syndrome (HPS).METHODS: Seven patients, three of them with advanced HPS, in whom detailed pulmonary function tests were performed before and after TIPS placementat the University of Alabama Hospital and at the Hospital Clinic, Barcelona, were considered.RESULTS: TIPS patency was confirmed by hemodynamic evaluation. No changes in arterial blood gases were observed in the overall subset of patients. Transient arterial oxygenation improvement was observed in only one HPS patient, early after TIPS, but this was not sustained 4 mo later.CONCLUSION: TIPS neither improved nor worsened pulmonary gas exchange in patients with portal hypertension. This data does not support the use of TIPS as a specific treatment for HPS. However, it does reinforce the view that TIPS can be safely performed for the treatment of other complications of portal hypertension in patients with HPS.

Effect of endotoxin on portal hemodynamic in rats

AIM: To study the effects of endotoxin on portal hemodynamic of normal and noncirrhotic portal hypertensive rats. METHODS: Normal rats were intraperitoneally injected with 0.1, 0.25, 0.5, 1.0, 2.0, 4.0mg.kg(-1) of lipopolysaccharide(LPS) respectively, portal vein ligation(PVL) and intrahepatic portal occlusion (IPO) rats as well as sham-operated rats were treated with an intraperitoneal injection of 1.0mg.kg(-1) of LPS, the portal vein pressure(PVP), portal venous flow(PVF), inferior vena cava pressure(IVCP) and portal vein resistance(PVR) were detected 4 hours after injection. RESULTS: PVF of the 5 groups of rats accepting intraperitoneal injection of LPS were increased from 14.0 to 18.0, 22.2, 26.2, 34.8, 39.6, 38.8 mL.min(-1) 4 hours after injection of LPS(P【0.01). PVP of the 4 groups of rats accepting more than 0.1mg/kg.b.w of LPS was increased from 1.04 to 1.25, 1.50, 1.80, 1.95, 2.05 kPa(P【0.01). The increments of PVF and PVP were in a dose-dependent manner of LPS. PVR of the 5 groups of rats was decreased from 51 to 42,44,48,45,44,47 kPa.min.L(-1) (P【0.05) and no dose-dependent manner was observed. PVF of PVL, IPO and sham-operated rats increased from 22.6 to 32.8, 22.0 to 28.0, 14.0 to 34.8 mL.min(-1) (P【0.01), and PVP increased from 1.86 to 2.24, 1.74 to 1.95, 1.04 to 1.80 kPa(P【0.01), PVR decreased from 71 to 61, 67 to 61, 52 to 44 kPa.min.L(-1) after intraperitoneal injection of 1mg.kg(-1) of LPS. The increments of PVF and PVP of PVL and IPO rats were significantly less than the sham-operated rats(P【0.01), There was no significant difference between the amounts of PVR decreased in the two groups of PHT model rats and sham-operated rats(P】0.05) after intraperitoneal injection 1mg.kg(-1) of LPS. CONCLUSION: Endotoxin could prompt portal hypertension of the normal and noncirrhotic portal hypertensive rats by increasing portal blood flow mainly.

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Arterioportal fistula(APF)is a rare cause of portal hypertension and may lead to death.APF can be congenital,post-traumatic,iatrogenic(transhepatic intervention or biopsy)or related to ruptured hepatic artery aneurysms.Congenital APF is a rare condition even in children.In this case report,we describe a 73-year-old woman diagnosed as APF by ultrasonography,computed tomography,and hepatic artery selective arteriography.The fistula was embolized twice but failed,and she still suffered from alimentary tract hemorrhage.Then,selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized.During the 2-year follow-up,the patient remained asymptomatic.We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.

Portal hypertension due to portal venous thrombosis:Etiology, clinical outcomes

The thrombophilia in adult life has major implications in the hepatic vessels. The resulting portal vein thrombosis has various outcomes and complications. Esophageal varices, portal gastropathy, ascites, severe hypersplenism and liver failure needing liver transplantation are known well. The newly formed collateral venous circulation showing itself as pseudocholangicarcinoma sign and its possible clinical reflection as cholestasis are also known from a long time. The management strategies for these complications of portal vein thrombosis are not different from their counterpart which is cirrhotic portal hypertension, but the prognosis is unquestionably better in former cases. In this review we present and discuss the portal vein thrombosis, etiology and the resulting dinical pictures. There are controversial issues in nomenclature, management （including anticoagulation problems）, follow up strategies and liver transplantation. In the light of the current knowledge, we discuss some controversial issues in literature and present our experience and our proposals about this group of patients.

Intraoperative pulmonary hypertension occurred in an asymptomatic patient with pre-existent liver cirrhotic and portal hypertension

Portopulmonary hypertension(PPH) is clinically defined as the development of pulmonary arterial hypertension complicated by portal hypertension,with or without advanced hepatic disease.Physical signs may be absent in mild to moderate PPH and only appear in a hyperdynamic circulatory state.Similar signs of advanced liver disease can be observed in severe PPH,with ascites and lower extremity edema.Pulmonary hypertension is usually diagnosed after anesthetic induction during liver transplantation(LT).We present intraoperative pulmonary hypertension in a 41-year-old male patient with hepatic cirrhosis.Since this patient had no preoperation laboratory data supporting the diagnosises of pulmonary hypertension and was asymptomatic for a number of years,it was necessary to send him to the intensive care unit after operation.Further study should be focued on the diagnosis and treatment of pulmonary arterial hypertension in order to reduce its mortality.

Clinical characteristics of idiopathic portal hypertension

Idiopathic portal hypertension is one of the interesting causes of portal hypertension. Even in very developed medical centers, this disorder is still one of the most important misdiagnoses of clinical practice. To inexperienced physicians, presenting esophageal varices and upper gastrointestinal bleeding usually prompt an unfortunate diagnosis of cirrhosis. A heterogenous clinical presentation and progression of this disorder should be recognized by physicians, and management should be directed towards some specific problems confined to this disorder. Although a genetic basis and other factors are implicated in its pathogenesis, exact underlying mechanism(s) is (are) unknown. In this review, we discuss the heterogeneity of idiopathic portal hypertension, its etiopathogenesis, clinical presentation and management issues. With the expectation of an excellent prognosis, a practicing gastroenterologist should be aware that "not all varices mean cirrhosis".

Gastric adenocarcinoma inducing portal hypertension:A rare presentation

Advanced gastric cancer usually presents with symptoms due to direct extension into adjacent viscera, distant metastases from lymphatic or hematogenic dissemination and peritoneal seeding. However, portal hypertension as a presentation of metastatic gastric cancer is rare and usually seen in association with other malignancies, e.g. hepatocellular and pancreatic carcinoma. We report a case of signet ring adenocarcinoma of the stomach that presented with esophageal and duodenal varices and bleeding due to portal hypertensive gastropathy. Pagetoid spread of cancer cells likely caused early metastasis and the unusual presentation. We also discussed the pathophysiology of development of portal hypertension in association with malignancies.

Oesophageal and gastric varices:historical aspects,classification and grading:everything in one place

Variceal disease and its management are of the utmost importance in the treatment of portal hypertension.Current guidelines are universal for management of variceal disease in portal hypertension.Classification and grading systems are numerous and differ according to geographical location.In this exhaustive review,the historical aspects of variceal disease,its classification and the grading systems in use are discussed,with self-explanatory tables and timelines.A better and clear understanding of the evolution of portal hypertension and variceal disease is provided.

Knowledge about non-invasive diagnostic tests for varices in liver cirrhosis:A questionnaire survey to the Gastroenterology Branch of the Liaoning Medical Association,China

Background and aims:Due to the invasiveness of upper gastrointestinal endoscopy,non-invasive diagnostic tests for varices in liver cirrhosis have been widely established by numerous studies.A questionnaire survey,which was aimed at understanding the current knowledge about non-invasive diagnostic tests for varices in liver cirrhosis,was distributed among the members of Gastroenterology Branch of the Liaoning Medical Association.Methods:A questionnaire assessing the knowledge about non-invasive diagnostic tests for varices was sent to 42 members who participated in the entire ninth committee.They were from 33 hospitals in 13 cities of Liaoning Province,China.Results:Overall,97.6%(41/42)of participants responded to the questionnaire.A majority of participants were chief physicians(85.4%),had>20 years of experience in clinical work of digestive diseases(80.5%)and worked at tertiary hospitals(97.6%).In 46.3%of participants’departments,there were>200 patients with liver cirrhosis and gastroesophageal varices admitted every year.In 90.2%of participants’departments,upper gastrointestinal endoscopy was regularly employed for the diagnosis of gastroesophageal varices.Only six(15%)participants often used non-invasive diagnostic tests for varices in clinical practice.Thirty(75%)participants knew at least one non-invasive diagnostic test for varices.The knowledge of at least one non-invasive diagnostic test was significantly associated with the number of cirrhotic patients with varices(P¼0.038)or the regular use of gastrointestinal endoscopy to diagnose varices(P¼0.022).Conclusions:This questionnaire survey suggested that non-invasive diagnostic tests for varices in liver cirrhosis were rarely or never used in clinical practices in Liaoning Province,China.Reliable,non-invasive indexes should be further explored in a well-designed multi-center observational study.

Novel treatment options for portal hypertension

Portal hypertension is most frequently associated with cirrhosis and is a major driver for associated complications,such as variceal bleeding,ascites or hepatic encephalopathy.As such,clinically significant portal hypertension forms the prelude to decompensation and impacts significantly on the prognosis of patients with liver cirrhosis.At present,non-selective bblockers,vasopressin analogues and somatostatin analogues are the mainstay of treatment but these strategies are far from satisfactory and only target splanchnic hyperemia.In contrast,safe and reliable strategies to reduce the increased intrahepatic resistance in cirrhotic patients still represent a pending issue.In recent years,several preclinical and clinical trials have focused on this latter component and other therapeutic avenues.In this review,we highlight novel data in this context and address potentially interesting therapeutic options for the future.