Zoli M, Merkel C, Magalotti D, Gueli C, Grimaldi M, Gatta A, Bernardi M
Dipartimento di Medicina Interna, Cardioangiologia, Epatologia, Università di Bologna, Italy.
Am J Gastroenterol. 2000 Feb;95(2):503-8. doi: 10.1111/j.1572-0241.2000.01775.x.
Contrasting data are available on the natural history and bleeding risk of small esophageal varices. The aim of this prospective study was to evaluate a large series of consecutive cirrhotics with a first endoscopic diagnosis of small varices.
Between 1987 and 1992, 258 patients with small varices and no previous bleeding were enrolled. Patients were clinically examined every 6 months and were followed until a first episode of bleeding and/or death, or until June 1998. None received any treatment to prevent bleeding. Endoscopies were planned at 18-month intervals.
The cumulative risk of bleeding was low (3% at 2 yr and 8% at 4 yr) and remained low in patients in whom varices remained small at 2nd endoscopy, whereas it increased significantly when varices enlarged. The increase of varices appeared to be rather linear in time: at the 2nd endoscopy varices remained small in 79% of patients and increased in 21%; at the 3rd endoscopy varices remained small in 55%, whereas at the 4th 33% of patients still had small varices. Clinical and biochemical data at the 1st and 2nd endoscopy were included in a multiple logistic regression analysis. Only the increase in Child-Pugh score appeared to be a significant predictor of enlarged varices; the risk of aggravation increased by 37.5% for every unit of impairment of the score.
The present study shows that patients with small varices have a low bleeding risk. An increase in Child-Pugh score during follow-up suggests enlargement of varices, thus an increase in bleeding risk. In these patients closer endoscopic surveillance is recommended.
关于小食管静脉曲张的自然病史和出血风险存在相互矛盾的数据。这项前瞻性研究的目的是评估一大系列首次经内镜诊断为小静脉曲张的连续性肝硬化患者。
在1987年至1992年期间，纳入258例小静脉曲张且既往无出血史的患者。每6个月对患者进行一次临床检查，随访至首次出血和/或死亡事件发生，或至1998年6月。所有患者均未接受任何预防出血的治疗。计划每隔18个月进行一次内镜检查。
出血的累积风险较低（2年时为3%，4年时为8%），在第二次内镜检查时静脉曲张仍较小的患者中出血风险保持较低，而当静脉曲张增大时出血风险显著增加。静脉曲张的增大在时间上似乎呈相当线性的变化：在第二次内镜检查时，79%的患者静脉曲张仍较小，21%的患者静脉曲张增大；在第三次内镜检查时，55%的患者静脉曲张仍较小，而在第四次内镜检查时，33%的患者静脉曲张仍较小。第一次和第二次内镜检查时的临床和生化数据纳入多元逻辑回归分析。只有Child-Pugh评分的增加似乎是静脉曲张增大的显著预测因素；评分每增加一个单位，病情加重的风险增加37.5%。
本研究表明，小静脉曲张患者的出血风险较低。随访期间Child-Pugh评分增加提示静脉曲张增大，从而出血风险增加。对于这些患者，建议加强内镜监测。
