Brandenburger Lisa A., Regenstein Fredric G.
Section of Gastroenterology and Hepatology, Tulane University Health Sciences Center, 1415 Tulane Avenue, New Orleans, LA 70112-2600, USA. E-mail
Curr Treat Options Gastroenterol. 2002 Feb;5(1):73-80. doi: 10.1007/s11938-002-0009-y.
Reducing morbidity and mortality from esophageal varices remains a challenge for physicians managing patients with chronic liver disease. For patients who have never bled from varices, prophylactic therapy with nonselective beta-blockers reduces the risk of initial variceal bleeding and bleeding-related death. Thus, patients with newly diagnosed cirrhosis should be considered for endoscopic variceal screening. All patients with Child's class B and C cirrhosis should be offered endoscopic screening, whereas those with Child's class A with evidence of portal hypertension (eg, platelet count less than 140,000 per milliliter, portal vein diameter larger than 13 mm, evidence of splenic varices on ultrasound) should be screened. The principal risk factors for variceal bleeding are variceal size, the presence of color changes on the variceal wall (indicative of decreased wall thickness), and degree of liver dysfunction. Patients with moderate or large sized varices and those with varices exhibiting color changes (eg, red wale marks, cherry red spots) should be treated with beta-blockers. Individuals without varices and those with small varices should undergo repeat endoscopy at approximately 2-year intervals. Patients unwilling or unable to take beta-blockers do not need to be screened. For patients with acute variceal bleeding, the combination of pharmacologic therapy plus endoscopic therapy is superior to either therapy alone. Octreotide is the drug most often used as initial therapy in the United States. Terlipressin is the preferred agent; however, it is not available in the United States. Endoscopy is performed as early as possible, and endoscopic injection sclerotherapy or endoscopic variceal band ligation is employed if variceal bleeding is confirmed or suspected. Endoscopic therapy should be repeated until the varices are obliterated completely. The addition of beta-blockers to endoscopic sclerotherapy or ligation may decrease the rate of rebleeding compared with receiving endoscopic treatment alone. Patients with bleeding refractory to combined medical plus endoscopic therapy should be considered for transjugular intrahepatic portosystemic shunts or shunt surgery.
降低食管静脉曲张的发病率和死亡率，对于治疗慢性肝病患者的医生而言仍是一项挑战。对于从未发生过静脉曲张出血的患者，使用非选择性β受体阻滞剂进行预防性治疗可降低初次静脉曲张出血及出血相关死亡的风险。因此，新诊断为肝硬化的患者应考虑接受内镜下静脉曲张筛查。所有Child B级和C级肝硬化患者均应接受内镜筛查，而Child A级且有门静脉高压证据（如血小板计数低于每毫升14万、门静脉直径大于13毫米、超声显示有脾静脉曲张）的患者也应进行筛查。静脉曲张出血的主要危险因素包括静脉曲张大小、静脉曲张壁颜色改变（提示壁厚变薄）以及肝功能障碍程度。中度或大型静脉曲张患者以及静脉曲张有颜色改变（如红色条纹、樱桃红点）的患者，应使用β受体阻滞剂治疗。无静脉曲张和小型静脉曲张患者应每隔约2年接受一次重复内镜检查。不愿或无法服用β受体阻滞剂的患者无需进行筛查。对于急性静脉曲张出血患者，药物治疗加内镜治疗联合使用优于单独任何一种治疗。在美国，奥曲肽是最常作为初始治疗使用的药物。特利加压素是首选药物；然而，在美国无法获得。应尽早进行内镜检查，若确诊或怀疑有静脉曲张出血，则采用内镜注射硬化疗法或内镜下静脉曲张套扎术。应重复进行内镜治疗，直至静脉曲张完全闭塞。与单纯接受内镜治疗相比，在内镜硬化疗法或套扎术中加用β受体阻滞剂可能会降低再出血率。对于药物联合内镜治疗难以控制出血的患者，应考虑行经颈静脉肝内门体分流术或分流手术。
