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1、门静脉高压出血指南更新,2,门静脉高压症(portal hypertension, PH)：是指由各种原因引起的门静脉系统血流受阻和（或）血流量增加，导致门静脉及其属支血管压力升高，临床表现为脾大、门腔静脉侧支循环形成和开放以及腹水等。,3,肝脏血供特点,肝脏占体重的2.5%； 肝血流量25%的心输出量。 双重供血：门脉，肝动脉 独特的微血管系统：肝血窦。,4,肝脏血供,5,门静脉特点,门静脉特点：门静脉系统的两端都是毛细血管网，并且门静脉无瓣膜 （后面观） 14 门静脉 22 肠系膜上静脉 20 脾静脉,6,门静脉解剖特点,1.无静脉瓣膜（可逆流） 2.具动脉特性（远端为肝血窦） 3.与肝动
2、脉有交通支 4.通过侧支与体循环交通,7,门静脉压力,门静脉压力正常值为1324cmH2O，平均为18cmH2O。如果压力高于此界限，就定义为门静脉高压,8,门静脉超声诊断,确诊条件（具备条件之一）： 门静脉双向或离肝血流。 确认有门-体侧支循环。,9,门静脉高压的分型,10,门脉高压病因,11,门静脉高压形成的机制,12,13,指南推荐肝静脉压力梯度,推荐意见： 有条件的医院可行肝静脉压力检测（HVPG）检测，HVPG5 mmHg 存在门静脉高压，HVPG10 mmHg 可发生静脉曲张，HVPG12 mmHg 可发生 EVB，HVPG20 mmHg 提示预后不良（A，1）。,14,门脉高压临
3、床表现,15,食管胃底静脉曲张破裂出血,(Esophageal gastric variceal bleeding, EGVB) 是肝硬化门静脉高压症最严重的并发症之一。是失代偿期肝硬化患者死亡的主要原因。 死亡不仅仅由于失血性休克，往往发生于肝衰竭，感染或肾功能衰竭等。且死亡与肝脏基础相关。 优化管理不应仅达到止血的目的，同时应解决这些并发症。 Reverter, E., et al., A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroen
4、terology, 2014. 146(2): p. 412-19 e3.,16,相关指南,2015 年 10 月 24 日在北京召开的感染病学分会年会、肝病学分会年会上，发布了最新一版的肝硬化门静脉高压食管胃静脉曲张出血的防治指南,17,基本治疗原则,预防初次出血：一级预防 急性静脉曲张出血的治疗 预防再次出血：二级预防,18,一级预防的目的, 预防静脉曲张的形成； 阻止小曲张静脉向大的曲张静脉进展 预防中等-大的曲张静脉破裂出血。,19,一级预防,所有的肝硬化患者在诊断时应筛选静脉曲张(5;D)。 治疗基础肝脏疾病可降低门脉高压，并且预防其并发症(1b;A)。 使用-受体阻断剂预防静脉曲张
5、形成并无指征(1b;A） 有较大出血风险的小静脉曲张，推荐使用NSBB 中-大静脉推荐使用NSBB或内镜套扎,20,一级预防,21,胃镜检查时机指南更新,旧版指南建议 48 小时内进行胃镜检查，而新版指南更新为 12-24 小时之内行胃镜检查；应对食管胃静脉曲张进行分级 ，应指出静脉曲张轻中重度及曲张静脉所在的部位、直径等（A，1）。 旧版认为胃镜是诊断 EVB 的唯一可靠方法，而新版明确了 B 超、CT、MRI、肝弹性检测等在 EVB 诊断方面辅助价值。 胃镜检查：旧版建议无静脉曲张的代偿期肝硬化患者每 2-3 年检查 1 次胃镜，失代偿期肝硬化患者每年检查 1 次。新版更新为无静脉曲张的代
6、偿期肝硬化患者每 2 年检查 1 次胃镜，失代偿期肝硬化患者 0.5-1 年检查 1 次胃镜。,22,食管静脉曲张的分级,轻度（G1）为食管静脉曲张呈直线形或略有迂曲，无红色征； 中度（G2）为食管静脉曲张呈直线形或略有迂曲，有红色征或食管静脉曲张呈蛇形迂曲隆起但无红色征 重度（G3）为食管静脉曲张呈蛇形迂曲隆起且有红色征或食管静脉呈串珠状、结节状或瘤状（无论有无红色征）。,23,一级预防新旧指南异同,旧版主要推荐药物治疗应用非选择性 受体阻滞剂，而新版肯定了卡维地洛在食管静脉曲张出血一级预防方面的作用。 旧版对 ACEI/ARB 及螺内酯等可降低门脉压力的药物，因缺乏证据未作明确推荐，新版明
7、确指出不推荐 ACEI/ARB 及螺内酯用于一级预防。 明确规定：不推荐内镜下硬化剂治疗用于一级预防；不推荐各种外科手术和 TIPS 用于一级预防；不推荐 EVL 联合非选择性 受体阻滞剂同时用于一级预防。,24,急性EGVB的治疗,复苏和初步治疗 药物治疗 内镜治疗 介入治疗 外科手术治疗 预防并发症,25,复 苏,Initial resuscitation of patients with liver cirrhosis who have esophageal variceal bleeding corresponds to the general pattern of ABC (Airw
8、ay open + Breath + Circulation) and is aimed at maintaining optimal delivery of oxygen to the tissues. Due to the high risk of aspiration of gastric contents and blood, especially in patients with encephalopathy , it is important to pay special attention to airway patency, and in some cases to consi
9、der the need for intubation of trachea.,26,复 苏,The issue of optimal restoration of circulating blood volume is still being debated. It is known that hypovolemia and prolonged hypotension may lead to the development of renal failure and infectious complications. However,blood transfusion must be give
10、n with caution, maintaining systolic blood pressure at 100 mmHg. This will avoid increased portal pressure and recurrence of esophageal variceal bleeding.,27,复 苏,The guidelines of the American Association for the Study of Liver Diseases recommend maintaining hemoglobin within 8 g/dL, except in patie
11、nts with ongoing bleeding, coronary heart disease or brain ischemia. In a large multicenter randomized controlled trial on 849 patients with upper gastrointestinal bleeding, limited transfusion therapy maintaining hemoglobin level of 79 g/dL resulted in a significantly higher 45 day survival rate th
12、an a liberal transfusion strategy and maintaining hemoglobin at 911 g/dL. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W; Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and
13、management of gastroesophageal varices and variceal hemorrhagein cirrhosis. Hepatology 2007;46:922-38,28,抗生素,In a systematic review and meta-analysis,Chavez-Tapia et al.noted that the use of antibiotics significantly reduces total mortality, the frequency of recurrence of esophageal variceal bleedin
14、g and the length of hospitalization. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding an updated Cochrane review. Aliment Pharmacol Ther 2011;34:509-18 Tandon P, Abraldes JG, Keough A, et
15、 al. Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage, based on ChildPugh class, and effects of antibiotics. Clin Gastroenterol Hepatol 2015;13:1189-96,29,抗生素,However, in an era of antimicrobial stewardship driven by increasing bacterial resistance and high rates
16、of Clostridium difficile, it may be possible to identify and target high risk patients who may benefit most from antibiotics. A retrospective study has suggested that the rate of bacterialinfections and associated mortality is very low in patients with Child-Pugh A cirrhosis and gastrointestinal bleeding, and increases with the severity of liver disease . Tandon, P., et al., Risk of Bacterial Infection in Patients With Cirrhosis and Acute Variceal Hemorrhage, Based on Child-Pug
