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发表于 2002-1-13 01:51
Am J Gastroenterol 2001 Dec;96(12):3379-83
How much reduction in portal pressure is necessary to prevent variceal
rebleeding? A longitudinal study in 225 patients with transjugular
intrahepatic portosystemic shunts.
Rossle M, Siegerstetter V, Olschewski M, Ochs A, Berger E, Haag K
Department of Gastroenterology, University Hospital, Freiburg, Germany.
[Medline record in process]
OBJECTIVES: This longitudinal study determines the risk of rebleeding in
relation to the reduction of the portosystemic pressure gradient in patients
with a transjugular intrahepatic portosystemic shunt (TIPS) for variceal
bleeding. METHODS: The study included 225 patients in whom a TIPS revision
was indicated by the endoscopic finding of varices with a high risk for
rebleeding (n = 167) or a recent variceal rebleed (n = 58). The
portosystemic pressure gradient was determined before and after TIPS
placement and at revision performed after a mean of 10 +/- 15 months.
RESULTS: The portosystemic pressure gradient at revision approached the
index pressure gradient before TIPS implantation (23.1 +/- 5.5 mm Hg) by 8.4
+/- 31%. Rebleeding was inversely correlated with the reduction in index
pressure gradient found at revision. Thus, 80% of rebleedings occurred with
pressure gradients close to the index pressure gradient (< 25% reduction) or
with gradients equal to or greater than the index pressure gradient. In
contrast, only one patient (0.4%) and three patients (1.3%) rebled with a
pressure gradient of < 12 mm Hg or a reduction of the index pressure
gradient by > 50%, respectively. Kaplan-Meier analysis of rebleeding, which
included the 225 patients at risk, showed a probability of rebleeding of
18%, 7%, and 1% for a reduction of the index pressure gradient by 0%,
25-50%, and > 50%, respectively. CONCLUSIONS: Most rebleedings occurred with
pressure gradients similar to the index-pressure gradient measured at first
bleeding. Accordingly, a graded reduction by 25-50% sufficiently prevents
rebleeding. It can be assumed that, in comparison with the widely used
threshold value of 12 mm Hg, a reduction by 25-50% may have a favorable
benefit-to-risk ratio with respect to shunt-induced hepatic encephalopathy
and liver failure. It should therefore be a goal in the decompressive
treatment of portal hypertension and maintained during follow-up of patients
with variceal bleeding.
PMID: 11774952, UI: 21630690
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Sheree Martin mailto:[email protected]
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