Escorsell A, Bordas J M, Feu F, García-Pagán J C, Ginès A, Bosch J, Rodés J
Hospital Clinic, Department of Medicine, University of Barcelona, Spain.
Gastroenterology. 1997 Nov;113(5):1640-6. doi: 10.1053/gast.1997.v113.pm9352867.
BACKGROUND & AIMS: Variceal rupture is believed to occur when variceal wall tension is excessive. The combined use of endosonography, allowing the objective measurement of variceal radius, and endoscopic measurement of transmural variceal pressure may enable assessment of this important parameter. The aim of this study was to assess the effects on variceal hemodynamics of drugs acting through different mechanisms: decreasing portocollateral blood flow (propranolol) or resistance (isosorbide-5-mononitrate [ISMN]).
Repeated measurements of variceal radius, volume (by endosonography), and transmural pressure (using endoscopic gauge) were performed in 27 cirrhotic patients at baseline and 40 minutes after double-blind administration of placebo (n = 9), propranolol (n = 9), or ISMN (n = 9).
Placebo had no effect. Propranolol significantly reduced variceal volume (-32% +/- 26%; P = 0.01), radius (-12% +/- 9%; P < 0.005), and pressure (-26% +/- 10%; P < 0.0001). The resulting decrease in wall tension (-34% +/- 13%; P < 0.0005) exceeded that in transmural pressure (P < 0.01). ISMN reduced transmural variceal pressure (-26% +/- 21%; P < 0.005), but not radius (-3% +/-14%; NS) and volume (-9% +/- 31%; NS).
The combination of endosonography and endoscopic measurement of transmural variceal pressure allows quantitative estimation of variceal wall tension. Propranolol and ISMN reduce similarly transmural variceal pressure. Propranolol, but not ISMN, reduces variceal volume and radius. Therefore, despite similar decreases in variceal wall tension, propranolol may offer a greater therapeutic effect than ISMN in portal hypertension.
静脉曲张破裂被认为是在静脉曲张壁张力过大时发生。内镜超声检查可客观测量静脉曲张半径，联合内镜测量跨壁静脉曲张压力，可能有助于评估这一重要参数。本研究的目的是评估通过不同机制起作用的药物对静脉曲张血流动力学的影响：减少门体分流血流量（普萘洛尔）或阻力（5-单硝酸异山梨酯[ISMN]）。
对27例肝硬化患者在基线时以及双盲给予安慰剂（n = 9）、普萘洛尔（n = 9）或ISMN（n = 9）40分钟后，重复测量静脉曲张半径、体积（通过内镜超声检查）和跨壁压力（使用内镜测量仪）。
安慰剂无作用。普萘洛尔显著降低静脉曲张体积（-32%±26%；P = 0.01）、半径（-12%±9%；P < 0.005）和压力（-26%±10%；P < 0.0001）。由此导致的壁张力降低（-34%±13%；P < 0.0005）超过跨壁压力降低（P < 0.01）。ISMN降低跨壁静脉曲张压力（-26%±21%；P < 0.005），但不降低半径（-3%±14%；无显著性差异）和体积（-9%±31%；无显著性差异）。
内镜超声检查与内镜测量跨壁静脉曲张压力相结合，可对静脉曲张壁张力进行定量评估。普萘洛尔和ISMN同样降低跨壁静脉曲张压力。普萘洛尔可降低静脉曲张体积和半径，而ISMN不能。因此，尽管静脉曲张壁张力降低程度相似，但在门静脉高压症中，普萘洛尔可能比ISMN具有更大的治疗效果。
