孤立性胃静脉曲张临床诊疗经验

doi:10.3877/cma.j.issn.2095-7157.2023.03.005

目的

探讨孤立性胃静脉曲张(IGV)的临床特点及相关诊疗经验。

方法

回顾性分析解放军总医院第一医学中心消化内科医学部2016年1月至2021年7月收治的IGV患者的临床资料。

结果

共纳入IGV患者57例，男38例、女19例，平均年龄(55.4±13.27)岁，肝硬化41例、非肝硬化16例，合并胃肾分流道者10例。基于LDRf分型，Lgf型IGV最常见，占73.7%(42/57)；IGV直径较为粗大，D2.0型及以上者占63.2%(36/57)。所有患者均成功接受了内镜下胃静脉曲张组织胶注射治疗，其中合并胃肾分流道者，均联合进行数字减影血管造影(DSA)下胃肾分流道球囊临时封堵术。术后所有患者均未出现异位栓塞、穿孔、脓毒症等严重并发症，术后1年内复发出血率为8.8%(5/57)，多数为排胶出血。

结论

IGV除多见于肝硬化之外，也可见于区域性门静脉高压等非肝硬化病因。内镜下以Lgf型最为常见，且直径较为粗大。内镜下组织胶注射治疗是IGV安全有效的治疗方法。对于合并胃肾分流道的IGV患者，联合DSA下胃肾分流道球囊临时封堵术，可减少组织胶异位栓塞的发生。

关键词: 孤立性胃静脉曲张, LDRf分型, 胃肾分流道, 内镜下组织胶注射治疗

Objective

The aim of the study is to explore the clinical characteristics of isolated gastric varices (IGV) and sunmarize the experience for the management.

Methods

Clinical data of IGV patients, who were admitted to the Department of Gastroenterology of the First Medical Center of Chinese PLA General Hospital during January 2016 and July 2021, were analyzed.

Results

A total of 57 patients were included in this study.38 were male and 19 were female, with the mean age of (55.4±13.27) years. There were 41 cases with cirrhosis and 16 with no cirrhosis. 10 patients were combined with gastrorenal shunt. Based on LDRf classification, the most typical type of IGV was Lgf, with a rate of 73.7% (42/57), and the rate of type D2.0 and above in varicose diameter was 63.2% (36/57). All patients were performed with endoscopic cyanoacrylate injection successfully.A special balloon was used to block the gastrorenal shunt temporarily during the process in 10 patients, who were combined with a gastrorenal shunt. None of the patients suffered serious complications, such as embolization, perforation and sepsis. The 1-year recurrent bleeding rate was 8.8% (5/57).

Conclusion

IGV is prevalent in cirrhotic individuals, while it can also be present in non-cirrhotic patients, such as regional portal hypertension. IGV is usually larger in diameter than esophageal varicose, and the most typical form is Lgf.For IGV, endoscopic cyanoacrylate injection is a safe and efficient approach. Blocking the gastrorenal shunt temporarily with a special balloon during the cyanoacrylate injection process can minimize the risk of ectopic embolism in IGV patients with gastrorenal shunt.

Key words: Isolated gastric varices, LDRf classification, Gastrorenal shunt, Endoscopic cyanoacrylate injection

表1 57例IGV患者的临床特征及治疗情况[例(%)]

项目	总体(n＝57)	肝硬化组(n＝41)	非肝硬化组(n＝16)
性别(男/女)	38/19	22/19	16/0^a
年龄(岁，±s)	55.4±13.27	56.6±12.99	52.3±13.89
出血史[n(%)]	50(87.7)	35(85.4)	15(93.8)
饮酒史[n(%)]	28(49.1)	15(36.6)	13(81.3)^a
主要疾病史[n(%)]
肝癌	5(8.8)	5(12.2)	0
高血压	23(40.4)	18(43.9)	5(31.3)
糖尿病	11(19.3)	8(19.5)	3(18.8)
冠心病	5(8.8)	3(7.3)	2(12.5)
血液系统疾病	3(5.3)	1(2.4)	2(12.5)
胰腺炎等胰腺疾病	14(24.6)	0	14(87.5)^a
Child分级(A/B/C)	36/19/2	24/15/2	12/4/0
血红蛋白(g/L，±s)	98.3±22.04	101.1±22.54	91.2±19.60
白细胞(×10⁹/L，±s)	3.9±1.77	4.0±1.88	3.7±1.48
血小板(×10⁹/L，±s)	109.2±55.84	110.8±57.43	105.2±53.14
门体分流道(胃肾/脾肾/无)	10/2/45	10/2/29	0/0/16^a
基于LDRf内镜下特点
位置(Lgf/Lgfb)	42/15	35/6	7/9^a
直径(D0-1.5/D2.0/D3.0及以上)	21/19/17	9/16/16	12/3/1^a
风险因素(Rf0/Rf1/Rf2)	4/33/20	4/23/14	0/10/6
内镜下治疗情况
首次治疗组织胶用量(ml，±s)	5.5±3.00	5.5±3.20	5.7±2.52
首次住院治疗次数(次，±s)	1.4±0.71	1.2±0.42	1.9±1.00^a
首次住院组织胶总用量(ml，±s)	7.7±5.24	6.3±3.52	11.3±7.04^a
术后并发症情况[n(%)]
发热	6(10.5)	5(12.2)	1(6.3)
腹痛	8(14.0)	7(17.1)	1(6.3)
异位栓塞	0	0	0
脓毒症	0	0	0
穿孔	0	0	0
术后1年内复发出血率[n(%)]	5(8.8)	4(9.8)	1(6.3)
术后1年内生存率[n(%)]	56(98.2)	40(97.6)	16(100)

表1 57例IGV患者的临床特征及治疗情况[例(%)]

项目	总体(n＝57)	肝硬化组(n＝41)	非肝硬化组(n＝16)
性别(男/女)	38/19	22/19	16/0^a
年龄(岁，±s)	55.4±13.27	56.6±12.99	52.3±13.89
出血史[n(%)]	50(87.7)	35(85.4)	15(93.8)
饮酒史[n(%)]	28(49.1)	15(36.6)	13(81.3)^a
主要疾病史[n(%)]
肝癌	5(8.8)	5(12.2)	0
高血压	23(40.4)	18(43.9)	5(31.3)
糖尿病	11(19.3)	8(19.5)	3(18.8)
冠心病	5(8.8)	3(7.3)	2(12.5)
血液系统疾病	3(5.3)	1(2.4)	2(12.5)
胰腺炎等胰腺疾病	14(24.6)	0	14(87.5)^a
Child分级(A/B/C)	36/19/2	24/15/2	12/4/0
血红蛋白(g/L，±s)	98.3±22.04	101.1±22.54	91.2±19.60
白细胞(×10⁹/L，±s)	3.9±1.77	4.0±1.88	3.7±1.48
血小板(×10⁹/L，±s)	109.2±55.84	110.8±57.43	105.2±53.14
门体分流道(胃肾/脾肾/无)	10/2/45	10/2/29	0/0/16^a
基于LDRf内镜下特点
位置(Lgf/Lgfb)	42/15	35/6	7/9^a
直径(D0-1.5/D2.0/D3.0及以上)	21/19/17	9/16/16	12/3/1^a
风险因素(Rf0/Rf1/Rf2)	4/33/20	4/23/14	0/10/6
内镜下治疗情况
首次治疗组织胶用量(ml，±s)	5.5±3.00	5.5±3.20	5.7±2.52
首次住院治疗次数(次，±s)	1.4±0.71	1.2±0.42	1.9±1.00^a
首次住院组织胶总用量(ml，±s)	7.7±5.24	6.3±3.52	11.3±7.04^a
术后并发症情况[n(%)]
发热	6(10.5)	5(12.2)	1(6.3)
腹痛	8(14.0)	7(17.1)	1(6.3)
异位栓塞	0	0	0
脓毒症	0	0	0
穿孔	0	0	0
术后1年内复发出血率[n(%)]	5(8.8)	4(9.8)	1(6.3)
术后1年内生存率[n(%)]	56(98.2)	40(97.6)	16(100)

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[1]	中华医学会消化内镜学分会食管胃静脉曲张内镜诊断与治疗学组. 肝硬化门静脉高压消化道静脉曲张内镜下组织胶注射治疗专家共识(2022，长沙)[J]. 中华胃肠内镜电子杂志, 2022, 09(04): 193-206.

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Experience for the management of isolated gastric varices

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Experience for the management of isolated gastric varices