Escorsell A, Bordas J M, Castañeda B, Llach J, García-Pagán J C, Rodés J, Bosch J
Hepatic Hemodynamic Laboratory, Liver Unit, University of Barcelona, Barcelona, Spain.
Hepatology. 2000 May;31(5):1061-7. doi: 10.1053/he.2000.6779.
Noninvasive measurements of variceal pressure adequately reflect the hemodynamic effects of propranolol on portal hypertension. However, the prognostic value of variceal pressure responses during continued propranolol therapy has not been evaluated, and it is unclear whether this may substitute invasive measurements of portal pressure response. Fifty-five portal hypertensive patients with cirrhosis were studied before and at 4 months of continued propranolol therapy. Variceal pressure was measured using an endoscopic pressure gauge. Portal pressure was evaluated as the hepatic venous pressure gradient (HVPG). Over a 28 +/- 11 month follow-up, 16 patients experienced variceal bleeding. Baseline characteristics were similar in bleeders and nonbleeders. At 4 months, reduction in variceal pressure was less marked in bleeders than in nonbleeders (5% +/- 20% vs. -15% +/- 24%; P =.03). A fall in variceal pressure 20% or greater of baseline was an independent predictor of absence of variceal bleeding; which occurred in 5% of patients with a 20% or greater fall in variceal pressure versus 42% of patients with less than a 20% reduction (P =.004). The HVPG response had similar independent prognostic value (decrease > or =20%: 6% bleeding; decrease <20%: 45% bleeding; P =.004) but identified different patients. Achieving a 20% decrease in either variceal pressure or HVPG was highly sensitive (85%) and specific (93%) identifying patients not bleeding on follow-up. Endoscopic measurements of variceal pressure response to continued pharmacotherapy provide useful prognostic information on the risk of variceal bleeding. As with HVPG response, a fall in variceal pressure of 20% or greater is associated with a very low risk of variceal bleeding. The combination of both parameters allows almost optimal prognostication.
曲张静脉压力的非侵入性测量能充分反映普萘洛尔对门静脉高压的血流动力学影响。然而，持续普萘洛尔治疗期间曲张静脉压力反应的预后价值尚未得到评估，且尚不清楚这是否可替代门静脉压力反应的侵入性测量。对55例肝硬化门静脉高压患者在持续普萘洛尔治疗前及治疗4个月时进行了研究。使用内镜压力计测量曲张静脉压力。将门静脉压力评估为肝静脉压力梯度（HVPG）。在28±11个月的随访期内，16例患者发生了曲张静脉出血。出血者和未出血者的基线特征相似。4个月时，出血者曲张静脉压力的降低不如未出血者明显（5%±20%对-15%±24%；P=0.03）。曲张静脉压力下降至基线的20%或更多是曲张静脉未出血的独立预测因素；曲张静脉压力下降20%或更多的患者中5%未发生出血，而下降少于20%的患者中这一比例为42%（P=0.004）。HVPG反应具有相似的独立预后价值（下降≥20%：6%出血；下降<20%：45%出血；P=0.004），但识别出的患者不同。曲张静脉压力或HVPG下降20%对识别随访期间未出血的患者具有高度敏感性（85%）和特异性（93%）。内镜测量持续药物治疗后曲张静脉压力反应可为曲张静脉出血风险提供有用的预后信息。与HVPG反应一样，曲张静脉压力下降20%或更多与曲张静脉出血风险极低相关。这两个参数的联合使用几乎可实现最佳预后。
