Burroughs A K, McCormick P A
University Department of Medicine, Royal Free Hospital and School of Medicine, London, England.
Gastroenterol Clin North Am. 1992 Mar;21(1):119-47.
Recurrent variceal hemorrhage occurs in 50% to 80% of cirrhotic patients who survive a variceal bleeding episode. The aim of preventing rebleeding is to improve survival by reducing the mortality associated with rebleeding; however, although shunt surgery is the most effective treatment to prevent recurrent bleeding, it does not increase survival and is associated with an increased incidence of chronic portosystemic encephalopathy. The distal splenorenal shunt is associated with a reduced incidence of encephalopathy, compared with nonselective shunts, but the true magnitude and longevity of this effect is still controversial. beta-Blockers reduce the incidence of rebleeding, but the effect is modest, and there is little or no effect on mortality when compared with no treatment. Injection sclerotherapy reduces the incidence of rebleeding and improves survival when a schedule of both emergency and long-term injection is compared with no sclerotherapy. No technical variation of injection sclerotherapy has been shown to be superior to another. Endoscopic variceal banding may result in fewer complications but the efficacy is similar to that of injection sclerotherapy. Trials of long-term sclerotherapy versus beta-blockers show very similar mortality and rebleeding rates. Addition of beta-blockade to sclerotherapy does not confer any advantages when compared with sclerotherapy alone. Improvements in pharmacologic therapy, such as the addition of isosorbide mononitrate to propranolol, may in the future make drug therapy the first treatment option to prevent rebleeding. Shunt surgery is superior to sclerotherapy in preventing rebleeding and has a similar mortality; however, liver transplantation is technically more difficult in shunted patients, but shunts do not adversely affect overall survival after transplantation. There are few data to allow optimal selection of a particular therapy or sequence of therapies to prevent variceal rebleeding for any individual patient. This will need to be studied in large trials and is a major issue in the current clinical management of cirrhotics who have bled from varices.
在静脉曲张出血发作后存活下来的肝硬化患者中，50%至80%会发生复发性静脉曲张出血。预防再出血的目的是通过降低与再出血相关的死亡率来提高生存率；然而，尽管分流手术是预防复发性出血最有效的治疗方法，但它并不能提高生存率，且与慢性门体性脑病发病率增加有关。与非选择性分流相比，远端脾肾分流与脑病发病率降低有关，但这种效果的真正程度和持久性仍存在争议。β受体阻滞剂可降低再出血发生率，但效果一般，与不治疗相比，对死亡率几乎没有影响。与不进行硬化治疗相比，当采用紧急和长期注射相结合的方案时，注射硬化疗法可降低再出血发生率并提高生存率。尚未证明注射硬化疗法的任何技术变体优于另一种。内镜下静脉曲张套扎术可能导致的并发症较少，但其疗效与注射硬化疗法相似。长期硬化疗法与β受体阻滞剂的试验显示死亡率和再出血率非常相似。与单独使用硬化疗法相比，在硬化疗法中添加β受体阻滞剂并无任何优势。药物治疗的改进，如在普萘洛尔中添加单硝酸异山梨酯，未来可能使药物治疗成为预防再出血的首选治疗方法。分流手术在预防再出血方面优于硬化疗法，且死亡率相似；然而，在接受分流的患者中进行肝移植技术上更困难，但分流术不会对移植后的总体生存率产生不利影响。几乎没有数据可用于为任何个体患者选择预防静脉曲张再出血的特定治疗方法或治疗顺序。这需要在大型试验中进行研究，并且是目前静脉曲张出血的肝硬化患者临床管理中的一个主要问题。
