肝硬化合併食道靜脈曲張出血：最新預防與治療之原則

Cirrhosis with Esophageal Variceal Hemorrhage: Updated Principles of Prophylaxis and Treatment

蕭家仁(Chia-Jen Hsiao)

《內科學誌》 27卷6期 (2016/12) Pp. 309-316

https://doi.org/10.6314/JIMT.2016.27(6).03

摘要

肝硬化患者中50%有胃／食道靜脈曲張，其每年發生出血的機率為5-15%；出血的風險與靜脈曲張的大小、肝硬化程度及靜脈曲張的赤色徵象有關。上消化道內視鏡是診斷食道靜脈曲張的黃金標準，患者一經診斷為肝硬化，均應接受上消化道內視鏡檢查；檢查若無食道靜脈曲張，對肝硬化之形成因素已消除者，三年做一次內視鏡篩檢；對肝硬化之形成因素未消除者，則二年做一次內視鏡篩檢。若是Child A患者，有小型靜脈曲張（直徑小於5mm），對肝硬化之形成因素已消除者，需每二年做一次內視鏡篩檢；對肝硬化之形成因素未消除者，需每一年做一次內視鏡篩檢。若為失代償患者或為大型之靜脈曲張（直徑大於5mm）或有赤色徵象，則建議以非專一性貝它阻斷劑治療或預防性經內視鏡靜脈曲張結紮術作首次出血之預防。已出血之患者則在穩定生命徵象、施打抗生素及血管收縮劑後，於12小時內施予經內視鏡靜脈曲張結紮術，爾後配合長期非專一性貝它阻斷劑治療。急性出血若無法以藥物及內視鏡成功治療，則可考慮使用食道氣球或經頸靜脈肝內門體靜脈支架分流術治療，若仍反覆出血，應積極考慮換肝手術。

關鍵字

食道靜脈曲張(Esophageal varices) ； 上消化道內視鏡(Esophagogastroduodenoscopy) ； 非專一性貝它阻斷劑(Non-selective beta blockers) ； 經內視鏡靜脈曲張結紮術(Endoscopic variceal ligation)

並列摘要

Gastroesophageal varices are present in approximately 50% of patients with cirrhosis, and hemorrhage of the varices serves as an important factor of death in cirrhotic patients. Patients without varices develop them at a rate of 8% per year, and the strongest predictor for development of varices is a hepatic venous pressure gradient (HVPG) ＞10 mmHg. The predictors of variceal bleeding are: 1. Size of the varices. 2. Severity of cirrhosis. 3. Endoscopic presentation of red color signs. The gold standard in the diagnosis of varices is esophagogastroduodenoscopy (EGD). EGD should be performed once the diagnosis of cirrhosis is established. In patients with compensated cirrhosis who have no varices on screening endoscopy and whom the etiologic factors were removed, the EGD should be repeated in 3 years. In those who have small varices and whom the etiologic factors were removed, or in those without varices but are with ongoing liver injury, the EGD should be repeated in 2 years. In the presence of decompensated cirrhosis or large varices, EGD should be repeated at yearly intervals. Non-selective beta blockers therapy or prophylactic endoscopic variceal ligation (EVL) should be underwent to prevent first variceal bleeding in patients with small varices and decompensated cirrhosis, large varices or those with red color signs. In acute esophageal variceal hemorrhage, intravascular volume support and blood transfusion to keep hemoglobin around 7-8 g/dl are optimal. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and variceal hemorrhage. Pharmacological therapy (somatostatin or its analogues: octreotide and vapreotide; vasopressin or its analogue: terlipressin) should be initiated as soon as variceal hemorrhage is suspected and continued for 3-5 days after diagnosis is confirmed. EGD, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with EVL or sclerotherapy. Transjugular intrahepatic portosystemic shunt (TIPS) and balloon tamponade could be used if combined pharmacological and endoscopic control fails.