内镜下硬化剂注射与套扎治疗食管静脉曲张出血

发布时间：2018-01-26 12:46

本文关键词： 内镜下硬化剂注射套扎治疗食管静脉曲张出血　出处：《山东大学》2017年博士论文　论文类型：学位论文

【摘要】：简介本研究的主要目的是比较食管静脉曲张出血内镜下硬化剂注射治疗与套扎治疗的疗效及安全性。食管静脉曲张出血是肝硬化危及生命且易复发的一个并发症,具有较高的发病率和死亡率。静脉曲张出血是门脉高压的主要并发症,也是肝硬化患者死亡的主要原因之一。静脉曲张出血最常见的部位是食管,其他部位曲张静脉出血约占全部静脉曲张出血的30%。因患者的一般情况及肝功能差,急症手术的死亡率非常高。近年来急性静脉曲张出血的管理有了很大的提高。数据显示,经验丰富的多学科团队的综合管理对于肝硬化静脉曲张出血的最终预后起非常重要的作用。食管静脉曲张出学的治疗有诸多方法,但如球囊压迫止血、血管收缩药物、外科手术并不能减少再出血率及并发症,不能提高食管静脉曲张出血的生存率。经颈静脉肝内门腔静脉内支架分流术术后最常见的短期并发症是肝性脑病,这种风险抵消了其获益。近年来应用的内镜下硬化剂注射与内镜下套扎治疗能够有效的止血、降低再出血率及延长患者生存时间。硬化剂注射通过直接栓塞血管及局部炎症纤维化使血管表面粘膜增厚达到止血及预防再次出血的目的。硬化治疗时,硬化剂可注射至血管内或血管旁。许多技术因素可影响患者硬化治疗的疗程及临床效果,其中对并发症发生率有影响的重要因素有:内镜医生的临床经验,注射方法的选择,辅助设施的应用包括先端帽、球囊压迫止血、急症止血或择期治疗。其他相关的解剖学因素有食管与纵隔毗邻,硬化剂注射反复破坏食管黏膜,且硬化剂进入门静脉后有可能播散至肺及体循环引起异位栓塞。套扎治疗与硬化剂注射同样有效,但并发症更少,被认为可以取代硬化剂注射治疗食管静脉曲张出血。但是,内镜前端的套扎器是套扎治疗非常大的一个缺陷,它会使视野降低30%,尤其在急症止血时血液吸入套扎器使视野更差。新型套扎器可以明显提高视野。对于食管静脉曲张套扎治疗的效果,每2月行一次好于每2周一次,因有资料显示长间隔疗程套扎治疗食管静脉曲张清除率更高,复发率更低,且较少需要追加治疗。研究显示套扎联合药物可有效预防食管静脉曲张出血的复发。有学者认为套扎治疗可以完全取代硬化治疗,因为硬化剂注射并发症发生率明显高于套扎,但同样有学者认为硬化剂注射目前仍然是食管胃底静脉出血急症止血最有效的手段,是不能被完全取代的。硬化剂注射止血成功率高,扔是目前推荐的治疗食管静脉曲张出血的治疗方法之一。与套扎相比,硬化剂注射的疗效因操作者的技术往往有很大差异。套扎治疗联合小剂量硬化剂注射可能会结合二者优势,快速的实现静脉曲张的清除,降低静脉曲张的复发率,进而降低远期再出血率。病人及方法:本研究比较了套扎治疗与硬化剂注射治疗食管静脉曲张出血的安全性及疗效。这是一项前瞻性研究,124例内镜证实为食管静脉曲张出血患者,根据治疗方法随机分为EIS组及EVL组,其中EIS组64例行硬化剂注射治疗,EVL组60例行套扎治疗。所有病人随访2年,比较两组的并发症发生率、再出血率、静脉曲张清除所需的治疗次数、死亡率及生存率。结果:EIS组19例、EVL组16例患者行急症止血,均止血成功,EIS组与EVL组相比在早期再出血率(7.8%vs 11.7%,P=0.47)、远期再出血率(28.1%vs 23.3%,P=0.54)、静脉曲张清除率(79.7%vs 86.7%,P=0.30)、死亡率(1.6%vs 3.3%,P=0.61)及生存率(71.9%vs 78.3%,P=0.41)(all P0.05)方面均无统计学差异。但EIS组与EVL组相比术后发热的几率较高(n=17,26.6%vs n=6,10.0%,p=0.02).结论:硬化剂注射与套扎治疗食管静脉曲张安全、有效、简单、易接受,均能获得满意的疗效且并发症少,我们应该根据医院条件、操作者的经验以及静脉曲张的特点选择合适的治疗方式。
[Abstract]:The main purpose of this study was to compare the efficacy and safety of esophageal ligation in the treatment of endoscopic injection sclerotherapy with variceal bleeding. Esophageal variceal bleeding is a life-threatening complication of cirrhosis and recurrence, with high morbidity and mortality. Variceal bleeding is a major complication of portal hypertension. The main reason is the death of patients with cirrhosis. Variceal hemorrhage is the most common site of esophageal variceal bleeding in other parts, accounting for all variceal bleeding due to general 30%. and the liver function in patients with emergency operation, a very high mortality rate of acute variceal hemorrhage. In recent years, management has been greatly improved. The data shows comprehensive management, multidisciplinary team of experienced for final diagnosis of variceal bleeding in liver cirrhosis plays very important role in esophageal varices. Study of treatment of a number of methods, but such as balloon compression hemostasis, vasoconstrictor drugs, not surgery and reduce the rebleeding rate and complications of esophageal variceal bleeding can improve the survival rate. After a short period of the most common complications of transjugular intrahepatic portosystemic stent shunt postoperative hepatic encephalopathy is, the risk of cancellation the benefit. In recent years the application of endoscopic sclerotherapy and endoscopic ligation treatment can effectively stop bleeding, reduce the rebleeding rate and prolong the survival time of the patients. The injection of sclerosing agent through direct vascular embolism and local inflammation fibrosis causes blood vessels to stop bleeding and thickening of mucosal surfaces to prevent re bleeding. Hardening treatment, hardeners injected into blood vessels or blood vessels. Many factors can influence and clinical effects in patients with hardening treatment, which affect the rate of complications due to the important Known as the clinical experience of endoscopic doctors, the choice of injection method, application of auxiliary facilities including apex cap, balloon compression hemostasis, emergency hemostasis or elective treatment. Other related factors and the adjacent esophageal mediastinal anatomy, sclerotherapy repeated destruction of esophageal mucosa, and sclerosing agent into the portal vein is likely to spread to the lungs and body circulation caused by ectopic embolism. Ligation and sclerotherapy are equally effective, but fewer complications, is thought to replace injection sclerotherapy for esophageal variceal bleeding. However, the front end of the endoscope ligation ligation in the treatment of a defect is very large, it will make the vision is reduced by 30%, especially in the emergency hemostasis of blood inhalation ligation to make the vision worse. New ligation can significantly improve vision for esophageal variceal ligation treatment effect, every February a better than once every 2 weeks, because the data shows long The interval period of ligation in the treatment of esophageal varices clearance rate is higher, the recurrence rate is lower, and less need for additional treatment. Research shows that ligation combined with drugs can effectively prevent the recurrence of esophageal varices bleeding. Some scholars believe that the ligation can completely replace the hardening treatment, because the hardening agent injection rate of complications was significantly higher than that of ligation. But there are also scholars believe that sclerotherapy is still the most effective means of acute bleeding of esophageal gastric fundus vein bleeding, can not be completely replaced. Sclerotherapy hemostasis success rate is high, throw is one of the currently recommended treatment for the treatment of esophageal variceal bleeding. Compared with ligation, efficacy of injection sclerotherapy for the operator of technology are very different. Ligation injection combined with small dose of sclerosing agent may combine the advantages of two, remove varices quickly, reduce varicose veins The recurrence rate, thereby reducing the long-term rebleeding rate. Patients and methods: This study compared the ligation and sclerotherapy for esophageal varices bleeding in safety and efficacy. This is a prospective study of 124 cases of confirmed endoscopic esophageal variceal bleeding patients, according to the methods of treatment were randomly divided into EIS group and the EVL group, the EIS group of 64 cases of sclerosing agent injection therapy, 60 cases in group EVL ligation. All patients were followed up for 2 years, the incidence of complications of the two groups, the rate of re bleeding varices required to clear the number of treatment, mortality and survival rate. Results: 19 cases of EIS group, EVL group of 16 patients with acute bleeding, was successful, EIS group in the early rebleeding rate compared with EVL group (7.8%vs 11.7%, P=0.47), long-term rebleeding rate (28.1%vs 23.3%, P=0.54), the clearance rate of varices (79.7%vs 86.7%, P=0.30), the death rate (1.6%vs 3.3%, P=0.61) and survival rate (71. 9%vs 78.3%, P=0.41) (all P0.05) were not statistically significant. But the EIS group compared with EVL group, higher risk of postoperative fever (n=17,26.6%vs n=6,10.0%, p=0.02). Conclusion: sclerotherapy and ligation in treatment of esophageal varices is safe, effective, simple, easy to accept, can obtain satisfactory curative effect and complications less, we should according to the condition of hospital, the experience of the operator and the characteristics of varicose veins of the selection of appropriate treatment.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R575.2

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