目的: 探讨门静脉高压性胃病（portal hypertensive gastropathy,PHG）急性出血的临床诊断,分析PHG的病因、内镜下特点和治疗后转归。方法: 收集2013年1月至2016年6月间上海交通大学瑞金医院北院消化内科196例门静脉高压症（门脉高压症）出血的患者,分析其临床资料、内镜检查结果及治疗后转归情况。结果: 196例门脉高压出血患者中,内镜诊断为PHG 67例（34.2%）,其中轻度PHG 49例（25.0%）,重度PHG 18例（9.2%）。经内镜检查证实,5例重度PHG（2.6%）为本次出血的直接原因,13例重度PHG（6.6%）为本次出血的原因之一。所有重度PHG出血患者经血管活性药物及内镜治疗后,急性出血均得到控制。结论: PHG在门脉高压症患者中并不少见,轻度PHG一般不会出血,但应注意其临床演进;重度PHG在内镜下主要表现为广泛樱桃红样出血红斑及弥漫性出血性胃炎,可引起上消化道大量出血,各种降低门静脉压力的治疗方法能有效控制其出血。
Objective: To investigate the clinical diagnosis of acute hemorrhagic portal hypertensive gastropathy (PHG) and to analyze the endoscopic appearance and therapeutic outcome in PHG patients. Methods: Clinical data, endoscopic results and outcome of 196 patients with upper gastrointestinal bleeding caused by portal hypertension in Ruijin Hospital North were collected and analyzed. Results: Sixty-seven patients with PHG were verified by endoscopy, which comprised 34.2% of total patients, including 49 patients with mild PHG (25.0%), 18 patients with severe PHG(9.2%); 5 patients (2.6%) with gastrointestinal bleeding were caused by severe PHG solely, which were verified by endoscopy, and 13 patients (6.6%) with bleeding were partially caused by severe PHG. All of the acute bleeding caused by severe PHG were stopped after therapy with vasoactive agents and endoscopic sclerotherapy. Conclusions: PHG is common in patients with portal hypertension. Mild PHG usually does not tend to cause bleeding, but its progression merits attention. The main endoscopic pattern of severe PHG is extensive cherry-red spots and diffuse hemorrhagic gastritis, which may lead to massive upper gastrointestinal bleeding. Treatment for reducing portal hypertension can effectively control bleeding caused by PHG.
[1] 吴云林. 门脉高压性胃病的内镜识别与治疗[M]// 吴云林. 门脉高压出血的内镜按需治疗. 上海: 上海科技教育出版社,2014:159-182.
[2] Thuluvath PJ, Yoo HY.Portal Hypertensive gastropathy[J]. Am J Gastroenterol,2002,97(12):2973-2978.
[3] Lin Y.Cirrhosis[M]// Xie WF, Chen YX. Clinical Hepatology. Beijing: People's Medical Press,2012:243-255.
[4] Primignani M, Carpinelli L, Preatoni P, et al.Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC)[J]. Gastroenterology,2000,119(1):181-187.
[5] McCormack TT, Sims J, Eyre-Brook I, et al. Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?[J]. Gut,1985,26(11):1226-1232.
[6] D'Amico G, Montalbano L, Traina M, et al. Natural history of congestive gastropathy in cirrhosis. The Liver Study Group of V. Cervello Hospital[J]. Gastroenterology,1990,99(6):1558-1564.
[7] Gostout CJ, Viggiano TR, Balm RK.Acute gastrointestinal bleeding from portal hypertensive gastropathy: prevalence and clinical features[J]. Am J Gastroenterol,1993, 88(12):2030-2033.
[8] Merli M, Nicolini G, Angeloni S, et al.The natural history of portal hypertensive gastropathy in patients with liver cirrhosis and mild portal hypertension[J]. Am J Gastroenterol,2004,99(10):1959-1965.
[9] Toyonaga A, Iwao T, Shimotsuura Y, et al.Endoscopic, histologic and haemodynamic studies on portal hypertensive gastric mucosa[J]. J Gastroenterol Hepatol,1989,4(Suppl 1):132-135.
[10] Wang JY, Hsieh JS, Chen FM, et al.Influence of portal hypertension on secretion of gastric mucus in rats[J]. Eur J Surg,2000,166(2):170-174.
[11] 漆德芳. 肝硬化的胃肠、胆、胰并发症[M]// 漆德芳. 肝硬化. 北京:北京科学技术出版社,2002:670-687.
[12] 陈平, 吴云林. 食管静脉曲张内镜下治疗对门脉高压性胃病的影响机制研究[J]. 诊断学理论与实践,2016(5):455-458.
[13] Bosch J.Carvedilol for portal hypertension in patients with cirrhosis[J]. Hepatology,2010,51(6):2214-2218.
[14] Tripathi D, Ferguson JW, Kochar N, et al.Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed[J]. Hepatology,2009,50(3):825-833.
[15] Reiberger T, Ulbrich G, Ferlitsch A, et al.Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol[J]. Gut,2013,62(11):1634-1641.
[16] 中华医学会肝病学分会,中华医学会消化病学分会,中华医学会消化内镜学分会. 肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J]. 中华内科杂志,2016,55(1):57-72.
[17] 顾星石, 白旭明, 程龙, 等. 经颈静脉肝内门体静脉分流术治疗肝硬化上消化道出血的中远期疗效观察[J]. 内科理论与实践,2015,10(4):266-271.
