Інформація призначена тільки для фахівців сфери охорони здоров'я, осіб,
які мають вищу або середню спеціальну медичну освіту.

Підтвердіть, що Ви є фахівцем у сфері охорони здоров'я.

Журнал «Медицина неотложных состояний» Том 20, №1, 2024

Вернуться к номеру

Декомпенсована портальна гіпертензія, ускладнена кровотечею

Авторы: Тутченко М.І., Рудик Д.В., Беседінський М.С.
Національний медичний університет імені О.О. Богомольця, м. Київ, Україна

Рубрики: Медицина неотложных состояний

Разделы: Справочник специалиста

Версия для печати


Резюме

Незважаючи на те, що ризик смерті від езофагогастральної варикозної кровотечі, спричиненої портальною гіпертензією (ПГ), найвищий у пацієнтів із шлунково-кишковою кровотечею, діагностика й лікування потребують подальшого вдосконалення. Дане дослідження виконано на основі аналізу науково-практичних даних щодо діагностики й лікування хворих на ускладнену ПГ, що дозволяє зрозуміти складність патологічного процесу, причини незадовільних результатів діагностики й лікування, можливості надання планової та екстреної допомоги. Лікування ПГ включає профілактику першої кровотечі, лікування гострої варикозної кровотечі та профілактику повторної кровотечі. Огляд літератури на підставі джерел з бази PubMed, MEDLINE має на меті продемонструвати методи діагностики й лікування кровотечі з вен стравоходу і шлунка в медичних установах з різним рівнем можливостей.

Despite the fact that the risk of death from esophagogastric variceal bleeding caused by portal hypertension is highest in patients with gastrointestinal bleeding, the diagnosis and treatment need to be further improved. This study is based on the analysis of scientific and practical data about the diagnosis and treatment of patients with complicated portal hypertension, which allows us to understand the complexity of the pathological process, the causes of unsatisfactory diagnostic and treatment results, and the possibility of providing routine and emergency care. Management of portal hypertension includes prevention of the first bleeding, treatment of acute variceal bleeding, and prevention of recurrent bleeding. The literature review based on sources from PubMed, MEDLINE aims to demonstrate the methods of diagnosing and treating bleeding from the esophageal and gastric veins in medical institutions with different levels of capacity.


Ключевые слова

портальна гіпертензія; варикозна кровотеча; інтервенційна терапія; діагностика; лапароскопічна хірургія

portal hypertension; variceal bleeding; interventional therapy; diagnosis; laparoscopic surgery


Для ознакомления с полным содержанием статьи необходимо оформить подписку на журнал.


Список литературы

  1. Henry Z., Patel K., Patton H., Saad W. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin. Gastroenterol. Hepatol. 2021 Jun. 19(6). 1098-1107.e1. doi: 10.1016/j.cgh.2021.01.027. Epub 2021 Jan 22. PMID: 33493693.
  2. Simonetto D.A., Liu M., Kamath P.S. Portal Hypertension and Related Complications: Diagnosis and Management. Mayo. Clin. Proc. 2019 Apr. 94(4). 714-726. doi: 10.1016/j.mayocp.2018.12.020. PMID: 30947834.
  3. Garcia-Tsao G., Abraldes J.G., Berzigotti A., Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan. 65(1). 310-335. doi: 10.1002/hep.28906. Epub 2016 Dec 1. Erratum in: Hepatology. 2017 Jul. 66(1). 304. PMID: 27786365.
  4. Calès P., Oberti F., Bernard-Chabert B., Payen J.L. Evaluation of Baveno recommendations for grading esophageal varices. J. Hepatol. 2003 Oct. 39(4). 657-9. doi: 10.1016/s0168-8278(03)00404-5. PMID: 12971983.
  5. de Franchis R., Bosch J., Garcia-Tsao G., Reiberger T., Ripoll C.; Baveno VII Faculty. Baveno VII — Renewing consensus in portal hypertension. J. Hepatol. 2022 Apr. 76(4). 959-974. doi: 10.1016/j.jhep.2021.12.022. Epub 2021 Dec 30. Erratum in: J. Hepatol. 2022 Apr 14; PMID: 35120736.
  6. Lu Q., Leong S., Lee K.A., Patel A., Chua J.M.E., Venkatanarasimha N. at al. Hepatic venous-portal gradient (HVPG) measurement: pearls and pitfalls. Br. J. Radiol. 2021 Aug 1. 94(1124). 20210061. doi: 10.1259/bjr.20210061. Epub 2021 Jun 9. PMID: 34106779; PMCID: PMC8764917.
  7. Groszmann R.J., Bosch J., Grace N.D., Conn H.O., Garcia-Tsao G., Navasa M. et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology. 1990 Nov. 99(5). 1401-7. doi: 10.1016/0016-5085(90)91168-6. PMID: 2210246.
  8. Zhang M., Jin H., Cao J., Ren R., Jia M., Yang Y. et al. Application of Ultrasound Elastography in Assessing Portal Hypertension. Diagnostics (Basel). 2022 Sep 29. 12(10). 2373. doi: 10.3390/diagnostics12102373. PMID: 36292062; PMCID: PMC9599976.
  9. Elkrief L., Lazareth M., Chevret S., Paradis V., Magaz M., Blaise L. et al. ANRS CO12 CirVir Group. Liver Stiffness by Transient Elastography to Detect Porto-Sinusoidal Vascular Liver Disease with Portal Hypertension. Hepatology. 2021 Jul. 74(1). 364-378. doi: 10.1002/hep.31688. Epub 2021 Jun 11. PMID: 33345307.
  10. Kennedy P., Bane O., Hectors S.J., Fischman A., Schiano T., Lewis S., Taouli B. Noninvasive imaging assessment of portal hypertension. Abdom. Radiol. (NY). 2020 Nov. 45(11). 3473-3495. doi: 10.1007/s00261-020-02729-7. Epub 2020 Sep 14. PMID: 32926209; PMCID: PMC10124623.
  11. Khakwani A., Trivedi M., Afzal M., Kahlon P., Khola, Patel P. et al. Use of Balloon Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: A Narrative Review. Cureus. 2023 Apr 28. 15(4). e38233. doi: 10.7759/cureus.38233. PMID: 37257163; PMCID: PMC10225054.
  12. Altamirano J., Zapata L., Agustin S., Muntaner L., González-Angulo A., Ortiz A.L. et al. Predicting 6-week mortality after acute variceal bleeding: role of Classification and Regression Tree analysis. Ann. Hepatol. 2009 Oct-Dec. 8(4). 308-15. PMID: 20009129.
  13. Kang S.H. et al. Proton pump inhibitor therapy is associated with reduction of early bleeding risk after prophylactic endoscopic variceal band ligation: a retrospective cohort study. Medicine. 2016. 95. 8.
  14. Long L., Wang Q., Xiang H.; Members of the Expert Consensus Steering Committee (in alphabetical order). Expert consensus on emergency procedures for portal hypertension bleeding. J. Interv. Med. 2023 Jan 12. 6(1). 1-9. doi: 10.1016/j.jimed.2022.10.006. PMID: 37180370; PMCID: PMC10167519.
  15. Cheng L.F., Wang Z.Q., Li C.Z., Lin W., Yeo A.E., Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin. Gastroenterol. Hepatol. 2010 Sep. 8(9). 760-6. doi: 10.1016/j.cgh.2010.05.019. Epub 2010 May 31. PMID: 20621678.
  16. Sarin S.K., Lahoti D., Saxena S.P., Murthy N.S., Makwana U.K. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992 Dec. 16(6). 1343-9. doi: 10.1002/hep.1840160607. PMID: 1446890.
  17. Ibrahim M., Mostafa I., Devière J. New Developments in Managing Variceal Bleeding. Gastroenterology. 2018 May. 154(7). 1964-1969. doi: 10.1053/j.gastro.2018.02.023. Epub 2018 Mar 2. PMID: 29481777.
  18. Poza Cordon J., Froilan Torres C., Burgos García A., Gea Rodriguez F., Suárez de Parga J.M. Endoscopic management of esophageal varices. World J. Gastrointest. Endosc. 2012 Jul 16. 4(7). 312-22. doi: 10.4253/wjge.v4.i7.312. PMID: 22816012; PMCID: PMC3399010.
  19. Romano G., Agrusa A., Amato G., De Vita G., Frazzetta G., Chianetta D. et al. Endoscopic sclerotherapy for hemostasis of acute esophageal variceal bleeding. G. Chir. 2014 Mar-Apr. 35(3-4). 61-4. PMID: 24841679; PMCID: PMC4321587.
  20. Yan P., Tian X., Li J. Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis? A systematic review and meta-analysis. Medicine (Baltimore). 2018 Oct. 97(41). e12826. doi: 10.1097/MD.0000000000012826. PMID: 30313117; PMCID: PMC6203467.
  21. Rodge G.A., Goenka U., Goenka M.K. Management of Refractory Variceal Bleed in Cirrhosis. J. Clin. Exp. Hepatol. 2022 Mar-Apr. 12(2). 595-602. doi: 10.1016/j.jceh.2021.08.030. Epub 2021 Sep 4. PMID: 35535060; PMCID: PMC9077219.
  22. Powell M., Journey J.D. Sengstaken-Blakemore Tube. 2023 May 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023 Jan. PMID: 32644350.
  23. Bhasin D.K., Malhi N.J. Variceal bleeding and portal hypertension: much to learn, much to explore. Endoscopy. 2002 Feb. 34(2). 119-28. doi: 10.1055/s-2002-19845. PMID: 11822007.
  24. Garbuzenko D.V. Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. Curr. Med. Res. Opin. 2016. 32(3). 467-75. doi: 10.1185/03007995.2015.1124846. Epub 2016 Jan 25. PMID: 26804426.
  25. García-Pagán J.C., Reverter E., Abraldes J.G., Bosch J. Acute variceal bleeding. Semin. Respir. Crit. Care Med. 2012 Feb. 33(1). 46-54. doi: 10.1055/s-0032-1301734. Epub 2012 Mar 23. PMID: 22447260.
  26. Chong C.F. Esophageal rupture due to Sengstaken-Blakemore tube misplacement. World J. Gastroenterol. 2005 Nov 7. 11(41). 6563-5. doi: 10.3748/wjg.v11.i41.6563. PMID: 16425437; PMCID: PMC4355807.
  27. Khan S., Gilhotra R., Di Jiang C., Rowbotham D., Chong A., Majumdar A. et al. The role of a novel self-expanding metal stent in variceal bleeding: a multicenter Australian and New Zealand experience. Endosc. Int Open. 2022 Mar 14. 10(3). E238-E245. doi: 10.1055/a-1729-0104. PMID: 35295239; PMCID: PMC8920596.
  28. Pfisterer N., Riedl F., Pachofszky T., Gschwantler M., König K., Schuster B. et al. Outcomes after placement of a 
  29. SX-ELLA oesophageal stent for refractory variceal bleeding-A national multicentre study. Liver Int. 2019 Feb. 39(2). 290-298. doi: 10.1111/liv.13971. Epub 2018 Oct 17. PMID: 30248224; PMCID: PMC6587452.
  30. Clark W., Hernandez J., McKeon B., Villadolid D., Al-Sa-adi S. et al. Surgical shunting versus transjugular intrahepatic portasystemic shunting for bleeding varices resulting from portal hypertension and cirrhosis: a meta-analysis. Am. Surg. 2010 Aug. 76(8). 857-64. PMID: 20726417.
  31. de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J. Hepatol. 2015 Sep. 63(3). 743-52. doi: 10.1016/j.jhep.2015.05.022. Epub 2015 Jun 3. PMID: 26047908.
  32. Sauerbruch T., Schierwagen R., Trebicka J. Managing portal hypertension in patients with liver cirrhosis. F1000Res. 2018 May 2. 7. F1000 Faculty Rev-533. doi: 10.12688/f1000research.13943.1. PMID: 29780579; PMCID: PMC5934688.
  33. Amesur N.B., Novelli P. Transjugular Intrahepatic Portosystemic Shunt. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023 Jan. PMID: 30020640.
  34. Bandali M.F., Mirakhur A., Lee E.W., Ferris M.C., Sadler D.J., Gray R.R., Wong J.K. Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy. World J. Gastroenterol. 2017 Mar 14. 23(10). 1735-1746. doi: 10.3748/wjg.v23.i10.1735. PMID: 28348478; PMCID: PMC5352913.
  35. Balcar L., Mandorfer M., Hernández-Gea V., Procopet B., Meyer E.L., Giráldez Á. et al.; International Variceal Bleeding Observational Study Group by the Baveno Cooperation: an EASL consortium. Predicting survival in patients with ‘non-high-risk’ acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J. Hepatol. 2023 Oct 16. S0168-8278. (23)05171-1. doi: 10.1016/j.jhep.2023.10.007. Epub ahead of print. PMID: 37852414.
  36. Nicoară-Farcău O., Han G., Rudler M., Angrisani D., Monescillo A., Torres F. et al.; Preemptive TIPS Individual Data Metanalysis, International Variceal Bleeding Study and Baveno Cooperation Study groups. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data. Gastroenterology. 2021 Jan. 160(1). 193-205.e10. doi: 10.1053/j.gastro.2020.09.026. Epub 2020 Sep 24. PMID: 32980344.
  37. Khera P.S., Myungsu L., Joonsung C. Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows. Indian J. Radiol. Imaging. 2017 Jan-Mar. 27(1). 100-104. doi: 10.4103/0971-3026.202952. PMID: 28515596; PMCID: PMC5385763.
  38. Al-Osaimi A.M., Sabri S.S., Caldwell S.H. Balloon-occlu-ded Retrograde Transvenous Obliteration (BRTO): Preprocedural Evaluation and Imaging. Semin. Intervent. Radiol. 2011 Sep. 28(3). 288-95. doi: 10.1055/s-0031-1284455. PMID: 22942546; PMCID: PMC3312157.
  39. Liu J., Meng J., Yang M., Zhou C., Yang C., Huang S. et al. Two-step complete splenic artery embolization for the management of symptomatic sinistral portal hypertension. Scand. J. Gastroenterol. 2022 Jan. 57(1). 78-84. doi: 10.1080/00365521.2021.1983641. Epub 2021 Sep 28. PMID: 34581650.
  40. Klinger C., Riecken B., Schmidt A., De Gottardi A., Meier B., Bosch J., Caca K. Transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis. Z. Gastroenterol. 2018 Mar. 56(3). 221-237. English. doi: 10.1055/s-0043-121348. Epub 2017 Nov 7. PMID: 29113006.
  41. Mansour N., Öcal O., Gerwing M., Köhler M., Deniz S., Heinzow H. et al. Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access. Abdom. Radiol. (NY). 2022 Mar. 47(3). 1177-1186. doi: 10.1007/s00261-022-03411-w. Epub 2022 Jan 12. PMID: 35020007; PMCID: PMC8863683.
  42. Leggeri A., Roseano M., Gobessi V., Eramo R. L’anastomosi porto-cava latero-laterale nel trattamento chirurgico dell'ipertensione portale: valutazione su un follow-up medio di 14 anni [Latero-lateral portocaval anastomosis in the surgical treatment of portal hypertension: evaluation of a mean follow up of 14 years]. Ann. Ital. Chir. 1996 Jan-Feb. 67(1). 49-58. discussion 58-9. Italian. PMID: 8712617.
  43. Shah O.J., Robbani I. A simplified technique of performing splenorenal shunt (Omar’s technique). Tex. Heart Inst. J. 2005. 32(4). 549-54. PMID: 16429901; PMCID: PMC1351828.
  44. Dołowy J., Stoinska A., Kuśmierska M., Kuniej T., Plucińska I., Jaźwiec P. A case of a spontaneous splenorenal shunt associated with the nutcracker syndrome. Pol. J. Radiol. 2011 Oct. 76(4). 49-51. PMID: 22802855; PMCID: PMC3389944.
  45. Yin L., Liu H., Zhang Y., Rong W. The surgical treatment for portal hypertension: a systematic review and meta-analysis. ISRN Gastroenterol. 2013. 2013. 464053. doi: 10.1155/2013/464053. Epub 2013 Jan 27. PMID: 23509634; PMCID: PMC3594950.
  46. Descottes B., Lachachi F., Maisonnette F., Durand-Fonta-nier S., Abita T., Geballa R., Valleix D. Long-term results of mesocaval shunts with polytetrafluoroethylene grafts. Int. Surg. 2008 Sep-Oct. 93(5). 268-73. PMID: 19943428.
  47. Zhang Z., Chen X., Li C., Feng H., Yu H., Zhu R., Wang T. Foam Sclerotherapy during Shunt Surgery for Portal Hypertension and Varices. Open Med. (Wars). 2017 Nov 22. 12. 384-390. doi: 10.1515/med-2017-0055. PMID: 29177197; PMCID: PMC5700258.
  48. Zhang Z., Chen X., Li C., Feng H., Yu H., Zhu R., Wang T. Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study. Clinics (Sao Paulo). 2019. 74. e704. doi: 10.6061/clinics/2019/e704. Epub 2019 Aug 19. PMID: 31433045; PMCID: PMC6691837.
  49. Yu T.J., Cheng K.K., Lai S.T., Cheng M.S., Kuo S.M., Chang Y., Lee P.C. [A new operation for the management of gastric varix bleeding]. Zhonghua Yi Xue Za Zhi (Taipei). 1989 Jan. 43(1). 49-56. Chinese. PMID: 2788484.
  50. Sugiura M., Futagawa S. A new technique for treating esophageal varices. J. Thorac. Cardiovasc. Surg. 1973 Nov. 66(5). 677-85. PMID: 4355662.
  51. Idezuki Y., Kokudo N., Sanjo K., Bandai Y. Sugiura procedure for management of variceal bleeding in Japan. World J. Surg. 1994 Mar-Apr. 18(2). 216-21. doi: 10.1007/BF00294404. PMID: 8042326.
  52. Fujisaki H., Fukami Y., Arikawa T., Saito T., Osawa T., Komatsu S. et al. Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension. Asian J. Endosc. Surg. 2022 Jul. 15(3). 505-512. doi: 10.1111/ases.13038. Epub 2022 Feb 8. PMID: 35132809.
  53. Kawanaka H., Akahoshi T., Kinjo N., Harimoto N., Itoh S., Tsutsumi N. et al. Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension. J. Am. Coll. Surg. 2015 Aug. 221(2). 354-66. doi: 10.1016/j.jamcollsurg.2015.04.011. Epub 2015 Apr 23. PMID: 26206637.
  54. Hassab M. Gastroesophageal deconestion and splenectomy. A method of prevention and treatment of bleeding from esophageal varices associated with bilharzial hepatic fibrosis: preliminary report. J. Int. Coll. Surg. 1964 Mar. 41. 232-48. PMID: 14128327.
  55. Zhou J., Wu Z., Wu J., Peng B., Wang X., Wang M. Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab’s operation) for control of severe varices due to portal hypertension. Surg. Endosc. 2013 Nov. 27(11). 4371-7. doi: 10.1007/s00464-013-3057-6. Epub 2013 Jul 12. PMID: 23846362.
  56. Tanaka M., Ikeda Y., Matsui S., Kato A., Nitori N., Kadomura T., Hatori T., Kitajima M. Right lateral decubitus approach to a laparoscopic modified Hassab’s operation. Asian J. Endosc Surg. 2016 Feb. 9(1). 97-100. doi: 10.1111/ases.12252. PMID: 26781539.
  57. Inokuchi K. Improved survival after prophylactic portal nondecompression surgery for esophageal varices: a randomized clinical trial. Cooperative Study Group of Portal Hypertension of Japan. Hepatology. 1990 Jul. 12(1). 1-6. doi: 10.1002/hep.1840120102. PMID: 2197208.
  58. Mitsis M., Katsanos K.H., Fatouros M., Tsianos E.V. Hassab’s operation for bleeding gastric varices. Ann. Gastroenterol. 2012. 25(2). 182. PMID: 24714238; PMCID: PMC3959383.
  59. Orozco H., Mercado M.A., Chan C., Ramos-Gallard G., Gálvez-Treviño R., Salgado-Nesme N., Cisneros De-ajuria R., Anthón F.J. Current role of surgery for the treatment of portal hypertension. Ann. Hepatol. 2002 Oct-Dec. 1(4). 175-8. PMID: 15280803.
  60. Deng Z.C., Jiang W.Z., Chen L., Tang X.D., Liu S.H. Laparoscopic V.S. Open splenectomy and oesophagogastric devascularisation for liver cirrhosis and portal hypertension: A retrospective cohort study. Int. J. Surg. 2020 Aug. 80. 79-83. doi: 10.1016/j.ijsu.2020.06.026. Epub 2020 Jun 30. PMID: 32619623.
  61. Jikai Y., Dong W., Li Z., Rui D., Tao Y., Bo H. et al. Individualized total laparoscopic surgery based on 3D remodeling for portal hypertension: A single surgical team experience. Front. Surg. 2022 Aug 10. 9. 905385. doi: 10.3389/fsurg.2022.905385. PMID: 36034363; PMCID: PMC9399457.
  62. Maruyama H., Shiina S. Collaterals in portal hypertension: anatomy and clinical relevance. Quant Imaging Med. Surg. 2021 Aug. 11(8). 3867-3881. doi: 10.21037/qims-20-1328. PMID: 34341755; PMCID: PMC8245950.
  63. Alvizuri Gómez C., Romaní Pozo D., Herrera Chávez G., Laso Suárez C., Carrasco Mascaro F., Moreno Gonzáles M., Poggi Machuca L. Laparoscopic splenectomy and proximal splenorenal shunt for portal hypertension due to portal vein thrombosis in a patient with protein S deficiency. Rev. Gastroenterol. Peru. 2021 Jan-Mar. 41(1). 48-51. English. PMID: 34347772.
  64. Zhang J.S., Cheng W., Li L. Laparoscopic distal splenoadrenal shunt for the treatment of portal hypertension in children with congenital hepatic fibrosis: A case report. Medicine (Baltimore). 2017 Jan. 96(3). e5843. doi: 10.1097/MD.0000000000005843. PMID: 28099341; PMCID: PMC5279086.
  65. Zhang L., Luo H.P., Liu F.L., Zhang W.G. Prior Esophagogastric Devascularization Followed by Splenectomy for Liver Cirrhosis with Portal Hypertension: A Modified Laparoscopic Technique. Gastroenterol Res. Pract. 2019 Feb 3. 2019. 2623749. doi: 10.1155/2019/2623749. PMID: 30863438; PMCID: PMC6377971.

Вернуться к номеру