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[摘要] 目的：观察肝硬化食管胃底静脉曲张破裂出血患者，内镜下硬化剂注射联合口服普萘洛尔与单纯内镜下硬化剂注射，治疗止血成功率及再出血发生率。方法：入选有效随访患者115例，其中59例采用硬化剂注射治疗，56例采用硬化剂注射联合口服普萘洛尔治疗，全部患者观察12个月，比较两组间的止血成功率及再出血发生率。结果：硬化剂治疗组及联合治疗组治疗前各级别构成及Child-Pugh评分值组间比较，差异无统计学意义（P＞0.05）。硬化剂治疗组及联合治疗组的止血成功率差异无统计学意义（P＞0.05）。但再出血发生率，联合治疗组较硬化剂治疗组明显降低（P＜0.05）。结论：硬化剂治疗组及联合治疗组均有较高止血成功率，联合治疗组可显著降低再出血发生率。
[关键词] 食管胃底静脉曲张破裂出血；内镜下硬化剂注射；普萘洛尔
[中图分类号] R571.3 [文献标识码]A[文章编号]1674-4721（2010）11（a）-019-02
The clinical study of treatment of esophageal and gastric varices bleeding by endoscopic injection scolerotherapy combined with propranolol
ZHEN Zhongwei, TONG Xuecheng, ZHEN Jian, CHEN Dinggui
(Department of Hepatology, the Third People′s Hospital of Changzhou City, Jiangsu Province, Changzhou 213001, China)
[Abstract] Objective: To observe the cirrhotic patients with bleeding esophageal varices endoscopic sclerotherapy combined with oral propranolol, and simple endoscopic sclerotherapy hemostasis success rate and rebleeding rate. Methods: 115 patients were selected for effective follow-up, 59 were treated with sclerotherapy, and 56 were treated with sclerotherapy combined with oral propranolol therapy, all patients observed for 12 months, compared the success rate of bleeding between the two groups and re-bleeding incidence. Results: The sclerotherapy group and combined treatment group before treatment and at all levels constitutes the value of Child-Pugh score differences between groups was not significant(P>0.05). Sclerotherapy group and combined treatment group success rate of hemostasis was no significant difference(P>0.05). However, rebleeding rate, combined treatment group than in the sclerotherapy group was significantly lower(P 内镜下硬化剂治疗已有50年历史，被公认为治疗和预防食管胃底静脉曲张出血的有效方法之一。硬化剂注入曲张静脉内可引起血管壁凝固坏死和静脉血栓形成，产生止血效果，随后周围组织出现炎症、瘢痕致血管消失。急诊止血时间短，止血有效率高[8]。与三腔双囊管压迫及静脉注射生长抑素相比，硬化剂注射止血在控制出血及降低病死率方面均优于前者[9]。本研究表明单纯硬化剂治疗组及联合治疗组均有较高的止血成功率。
预防止血后食管胃底静脉曲张再出血的关健是积极降低门静脉压力和血流量。普萘洛尔为非选择性β受体阻滞剂，通过阻滞β肾上腺受体减慢心率，降低心输出量及收缩内脏血管，内脏循环血容量相对减少，从而减少门静脉血流量，肝窦内压降低，降低门静脉压力；普萘洛尔还可抑制α受体引起的内脏动脉血管收缩，血流量减少致门脉压下降。有研究指出普萘洛尔可使首次出血危险性降低40%[10]。硬化剂注射后继以普萘洛尔长期维持治疗可使门静脉血流量减少及改变肝窦前阻力，使进入胃-食管侧支循环的血流量减少，这使硬化剂注射治疗后残留的较小曲张静脉承受的压力减少，从而延缓静脉曲张的加重，降低硬化剂注射后再出血率[11]。本研究表明，在应用硬化剂治疗止血后长期服用普萘洛尔预防再出血发生率较单纯硬化剂治疗更好。笔者认为内镜下硬化剂注射治疗食管胃底静脉曲张破裂出血的高止血率及普萘洛尔降低门静脉压力较好疗效，使其联合应用疗效更佳，值得临床推广。
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（收稿日期：2010-08-13）
