修回日期: 2017-04-28
接受日期: 2017-05-08
在线出版日期: 2017-07-18
肝硬化可以导致门静脉高压, 并通过形成侧支循环和自发性分流来降低门静脉压力, 其中以食管、胃静脉曲张及胃肾、脾肾分流最多见. 因为随机对照研究的缺乏, 规范化治疗胃底静脉曲张破裂出血的临床方案仍未能统一, 现最有效且常用的方法是内镜下组织胶黏合剂注射, 但对于合并自发性分流者可导致异位栓塞等严重并发症; 自发性分流道的存在也影响着胃底曲张静脉治疗方案的选择. 本文就近年来对自发性分流道的研究及其对胃底曲张静脉内镜治疗方案的选择及疗效作一简要综述.
核心提要: 门脉高压胃底静脉曲张患者多合并自发性分流道形成, 以致内镜下组织胶注射时可导致严重的并发症, 如异位栓塞; 分流道的存在也影响着内镜治疗方案的选择. 充分了解自发性分流道的特点而进一步指导治疗策略可收获更大的临床疗效.
引文著录: 李会贤, 孔德润. 胃肾及脾肾分流道对胃底曲张静脉内镜治疗的影响. 世界华人消化杂志 2017; 25(20): 1805-1810
Revised: April 28, 2017
Accepted: May 8, 2017
Published online: July 18, 2017
Liver cirrhosis can result in portal hypertension, which can consequently induce the formation of collateral circulation and spontaneous shunts to relieve the pressure. As a result, esophageal-gastric varices and gastrorenal shunt/splenorenal shunt are common in liver cirrhosis patients with portal hypertension. Due to the lack of randomized controlled studies on gastric variceal bleeding, there has not been a standardized and unified treatment for this condition. Although endoscopic tissue adhesive injection is the most commonly used therapy, patients with severe ectopic embolism caused by spontaneous shunts cannot benefit much, and spontaneous shunts also affect gastric varices treatment. In this paper, we summarize the recent studies on spontaneous shunts as well as the efficacy and selection of treatments for gastric varices.
- Citation: Li HX, Kong DR. Effect of gastrorenal shunt and splenorenal shunt on endoscopic treatment of gastric varices. Shijie Huaren Xiaohua Zazhi 2017; 25(20): 1805-1810
- URL: https://www.wjgnet.com/1009-3079/full/v25/i20/1805.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v25.i20.1805
肝硬化可以导致门静脉高压[1,2]. 当门脉压力达到一定阈值时, 会通过与上、下腔静脉系统形成侧支循环和自发性分流来缓解门脉压力[3], 其中最为常见的是食管、胃底静脉曲张及胃肾、脾肾分流道[4-6]. 在门静脉高压中, 胃底静脉曲张(gastric varices, GV)发生率约占25%[7], 胃肾分流(gastro-renal shunt, GRS)及脾肾分流道(spleno-renal shunt, SRS)发生率约占15%-20%[8-10], 胃底静脉曲张伴胃肾分流道者约达60%-85%[11,12]. 本文就近年来对自发性分流道的研究及其对胃底曲张静脉内镜治疗方案选择及疗效作一简要综述, 期望提供临床参考.
GRS及SRS在临床上并不十分常见, 往往存在于严重的门静脉高压中, 尤其是门静脉压力梯度超过10 mmHg时[13]. 有研究[10]发现伴自发性分流的肝硬化患者, 其重度食管胃底静脉曲张、严重的门脉高压性胃病及大量腹水的发生率均低于不伴分流者. 国外学者Culafic等[14]认为伴自发性分流者消化道出血的风险与不伴分流者相似, 我国学者亦得出此观点[15]. 自发性分流的存在也可减少肝脏灌注, 最终使肝脏体积及相关功能减低[16], 且容易引起肝性脑病、慢性血氨升高、败血症及肝脏恶性肿瘤等并发症[8,14,17,18].
胃底静脉曲张目前最常用的为Sarin's分型[7], GOV1型发病率最高(74%), GOV2及IGV1型胃静脉曲张出血率(55%、78%)相对较高. 但是该分型缺少对曲张静脉严重程度的描述, 参照Hashizume对GV形态的分类, 分为迂曲形(曲张静脉呈蔓状隆起于胃黏膜表面, 往往与胃皱襞黏膜难以区分), 结节形(数个结节状曲张静脉突出于胃黏膜表面), 瘤形(较大的孤立或者多个曲张静脉团, 直径>2 cm) [19].
我国学者[20,21]通过门静脉血管造影(com-puted tomographic angiography, CTA)研究GV的部位、形态及侧支循环血供的关系发现: 在GOV1型, GV主要供应血管为胃左静脉, 多为迂曲型, 较少合并GRS和SRS; GOV2型GV流入血管大多为胃后静脉和/或胃短静脉, 部分伴分流道; IGV1型主要流入血管为胃短静脉和/或胃后静脉, 较多伴分流道; 后两者GV内镜下形态以结节型和瘤型较多见. 安徽医科大学第一附属医院曾通过回顾40例门脉高压患者内镜下GV形态及侧支循环特点发现: 迂曲型GV, 其血供来源主要为胃左静脉或以胃左静脉为主; 结节型或瘤型GV, 血供来源以胃后静脉和/或胃短静脉单独或为主提供[22]. Zhao等[23]通过64排螺旋CT门静脉造影研究不同类型GV者"流入""流出"血管的特点得出GOV1型主要由来源于胃左静脉并通过奇静脉进入上腔静脉(89.58%); GOV2型主要来源于胃后和/或胃短静脉, 一部分通过奇静脉流出到上腔静脉(62.5%), 一部分经GRS/SRS分流进入下腔静脉(56.25%); IGV型主要来源于胃短和/或胃后静脉, 经GRS/SRS分流至下腔静脉(90.91%). 国外学者通过回顾分析GV者内镜及门脉血管造影表现得出了与之相似的结论[24-26]. 近年国内外学者通过内镜分析得出, 伴分流道者食管静脉曲张程度较GV轻, 且位置更低; 而胃底多表现有较大扩张扭曲的曲张静脉, 且面积大于无分流患者[10,15]. 当"流入"血管从外侧胃壁进入胃黏膜时, 由于胃壁肌层的挤压, 入口处血管较细且远离贲门, 出口处血管扩张成结节形或瘤型盘旋于近贲门处, 且易破裂出血而可见表面多覆着红色或白色血栓头.
因此, 当内镜发现胃底曲张静脉为GOV1型, 其主要"流出"道为奇静脉, 可行内镜下组织胶注射治疗; 当为GOV2或IGV1型、结节形或瘤型、扩张扭曲胃底曲张静脉或胃底曲张静脉面积较大时, 需高度警惕是否伴发自发性分流; 建议其进一步完善CTA检查排除自发性分流或了解分流道情况后, 再行内镜下组织胶或硬化剂注射治疗, 从而避免不当治疗后异位栓塞的发生.
虽然目前规范化治疗胃底静脉曲张破裂出血的临床方案仍未统一, 但内镜下组织胶注射控制出血和预防再出血的治疗方案已得到国内外学者的共识.
内镜下组织胶注射后相关并发症有发热、胸骨后疼痛、感染、早期排胶溃疡、异位栓塞等, 其中以异位栓塞罕见但严重. 国外学者对组织胶治疗后形成异位栓塞者尸检结果发现: 患者合并存在自发性分流道[27]. 早期Cheng等[28]统计分析了753例组织胶注射治疗胃底曲张静脉出血患者资料显示, 异位栓塞发生率达0.7%. 近年来更多关注报道组织胶注射后异位栓塞的发生(脾、肾、肺、脑等), 其中以肺栓塞致呼吸衰竭最为凶险[29-33]. Golse等[34]也报道了内镜下注射治疗增加了肝移植后异位栓塞的发生率. 安徽省曾有2例合并较大分流道的胃底静脉曲张患者在接受组织胶治疗后, 发生一侧肢体肌力的减退, 完善头颅CT提示颅内多发高密度灶, 诊断考虑黏合剂产生的固化物经自发性分流道通过体循环到达脑组织而形成异位栓塞[35]. 目前, 国外有学者报道[36-40]经超声内镜引导下组织胶注射治疗, 此方法不仅能判断各型GV的来源及存在的自发性分流道, 避免了不当治疗后异位栓塞的发生; 还可将合适剂量的组织胶准确注射到GV内, 减少组织胶对周围组织损伤, 同时可评估注射后GV是否闭塞; 但此种方法因对操作者的技术要求高且耗时较长, 限制了在国内外的推广及应用. 因此, 对择期手术者内镜下治疗前应予充分评估, 完善内镜及门脉CTA检查了解分流道情况, 从而进一步指导治疗策略, 避免因不当治疗而发生异位栓塞.
GOV1型胃底曲张静脉的治疗方法同食管静脉曲张相似, 多首选内镜下套扎治疗. 对于不伴分流道, 或伴发小分流道的GOV2型和IGV1型胃底静脉曲张, 首选方案仍为内镜下组织胶注射治疗.
当胃底曲张静脉伴较大胃(脾)肾分流道者: 若直径超过5 mm者, 需慎用内镜下组织胶注射治疗; 直径>1 cm者则考虑行球囊导管逆行性静脉栓塞术(balloon-occluded retrograde transvenous obliteration, BRTO)或经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt, TIPS)治疗. 我们曾按此参考校准, 通过TIPS联合胃底曲张静脉栓塞术成功治疗18例GV伴直径超过5 mm的GSR患者, 未见异位栓塞发生[41].
我们目前的治疗方案是: (1)当存在较大分流道并有条件(未存在严重肝性脑病或肝功能损害, 无恶性腹水、系统性栓塞或门静脉血栓等)或内镜治疗后仍难以控制出血的GV患者, 可行TIPS或BRTO等介入治疗[42-44]; (2)若无上述治疗条件或需行急诊止血的GV患者, 需根据内镜下GV表现及参考内镜镜身(约1 cm)来评估: 若<1 cm者, 可以直接行组织胶注射; 若≥1 cm者, 先予钛夹阻断血流, 再于钛夹两端注射适量组织胶; 此种改良内镜下止血技术暂未见国内外相关的报道, 目前我们多中心、随机、对照研究正在进行中; 初步未发现异位栓塞事件; (3)改良的"三明治"夹心注射法治疗. 最初的"三明治"注射方案为液态碘化油(法国加柏公司生产)-组织胶-碘化油, 但随着国内外多例异位栓塞事件的报道, 加上碘油本身较黏稠, 推注费力及碘油过敏反应的发生[45-47], 现已改良为高渗糖、生理盐水或聚桂醇作为媒介, 其中以聚桂醇为媒介的三明治疗法应用较为普遍[48-51]. 我们以此行GV治疗中未见异位栓塞发生, 且推注顺利. 但提醒行GV治疗时, 因注射时可出现空气经破损处进入曲张静脉血流, 造成空气栓塞; 可能发生的部位是右侧大脑中动脉, 但如果出现肺栓塞, 则后果极其严重, 应高度警惕, 并做好术前评估.
目前控制胃底静脉曲张出血最常用的方法是内镜下注射组织胶黏合剂, 但对于合并自发性分流者可产生严重的并发症异位栓塞. 结合胃镜下所观胃底静脉曲张的分型、形态学特点及完善CTA等检查, 充分了解分流道情况, 从而选择最佳治疗策略, 避免并发症发生. 但目前关于多大分流道直径慎用组织黏合剂治疗; 伴大分流道者通过钛夹阻断再行注射后的疗效; 进一步判断胃底曲张静脉"出入口", 并从"入口"以量化注射组织黏合剂, 达到最大的栓塞作用及减少相关并发症, 均需不断探索及大规模临床随机对照试验研究.
胃肾分流(gastro-renal shunt, GRS)及脾肾分流道(spleno-renal shunt, SRS)在临床上并不十分常见, 但胃底静脉曲张(gastric varices, GV)合并GRS者高达60%-85%; 对于伴分流道的GV者行内镜下组织胶注射治疗可发生异位栓塞等严重并发症; 因此, 术前对GV者进行充分评估并选择合适的临床治疗方案是非常必要的.
为了避免治疗后严重并发症的发生, 术前通过内镜及门脉血管造影等检查充分了解GRS/SRS情况, 进而选择最佳治疗方案, 如介入治疗、内镜下钛夹阻断、改良"三明治"夹心法等.
姜琴等通过经颈静脉肝内门体分流联合GV栓塞术成功治疗了18例伴较大分流道的GV者, 未见异位栓塞事件的发生.
本文主要就近年来对自发性分流道的研究及其对GV内镜下治疗方案的选择及疗效作一简要综述. 并简要介绍了安徽医科大学第一附属医院近期开展的内镜下钛夹阻断联合组织胶注射治疗的方法及疗效.
本文通过分析总结GV伴明显GRS/SRS的内镜下表现、GRS/SRS对GV内镜治疗安全性影响及目前应用介入、钛夹阻断及改良"三明治"夹心法取得的疗效, 期望为临床提供治疗参考.
郝英霞, 主任医师, 保定市第一中心医院消化科; 向晓星, 主任医师, 苏北人民医院消化科, 扬州大学临床医学院
本文选题内容紧贴临床, 较好地反映我国或国际胃肠病学临床和基础研究的先进水平, 对临床工作有较大的指导价值.
手稿来源: 邀请约稿
学科分类: 胃肠病学和肝病学
手稿来源地: 安徽省
同行评议报告分类
A级 (优秀): A
B级 (非常好): B
C级 (良好): 0
D级 (一般): 0
E级 (差): 0
编辑:闫晋利 电编:李瑞芳
| 1. | Suk KT, Kim DJ. Staging of liver fibrosis or cirrhosis: The role of hepatic venous pressure gradient measurement. World J Hepatol. 2015;7:607-615. [PubMed] [DOI] |
| 2. | Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clin Mol Hepatol. 2014;20:6-14. [PubMed] [DOI] |
| 3. | Pillai AK, Andring B, Patel A, Trimmer C, Kalva SP. Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clin Radiol. 2015;70:1047-1059. [PubMed] [DOI] |
| 4. | Wind P, Alves A, Chevallier JM, Gillot C, Sales JP, Sauvanet A, Cuénod CA, Vilgrain V, Cugnenc PH, Delmas V. Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses. Review of the literature. Surg Radiol Anat. 1998;20:129-134. [PubMed] [DOI] |
| 5. | Zardi EM, Uwechie V, Caccavo D, Pellegrino NM, Cacciapaglia F, Di Matteo F, Dobrina A, Laghi V, Afeltra A. Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance. J Gastroenterol. 2009;44:76-83. [PubMed] [DOI] |
| 6. | Elliott SP, Yeh B, Stoller ML. Radiologic appreciation of a spontaneous splenorenal shunt. Urology. 2004;63:776-777. [PubMed] [DOI] |
| 7. | Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16:1343-1349. [PubMed] [DOI] |
| 8. | Tarantino G, Citro V, Conca P, Riccio A, Tarantino M, Capone D, Cirillo M, Lobello R, Iaccarino V. What are the implications of the spontaneous spleno-renal shunts in liver cirrhosis? BMC Gastroenterol. 2009;9:89. [PubMed] [DOI] |
| 9. | von Herbay A, Frieling T, Häussinger D. Color Doppler sonographic evaluation of spontaneous portosystemic shunts and inversion of portal venous flow in patients with cirrhosis. J Clin Ultrasound. 2000;28:332-339. [PubMed] [DOI] |
| 10. | Wu Q, Shen L, Chu J, Ma X, Jin B, Meng F, Chen J, Wang Y, Wu L, Han J. Characterization of uncommon portosystemic collateral circulations in patients with hepatic cirrhosis. Oncol Lett. 2015;9:347-350. [PubMed] [DOI] |
| 11. | Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology. 1988;95:434-440. [PubMed] [DOI] |
| 12. | Matsumoto A, Hamamoto N, Nomura T, Hongou Y, Arisaka Y, Morikawa H, Hirata I, Katsu K. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices. Am J Gastroenterol. 1999;94:643-649. [PubMed] [DOI] |
| 13. | Martínez-Noguera A, Montserrat E, Torrubia S, Villalba J. Doppler in hepatic cirrhosis and chronic hepatitis. Semin Ultrasound CT MR. 2002;23:19-36. [PubMed] [DOI] |
| 14. | Culafic D, Perisic M, Vojinovic-Culafic V, Sagic D, Kerkez M. Spontaneous splenorenal shunt in a patient with liver cirrhosis and hypertrophic caudal lobe. J Gastrointestin Liver Dis. 2006;15:289-292. [PubMed] |
| 15. | 赵 雅莹, 俞 陌桑, 王 哲民, 孟 凡升, 季 峰. 门静脉高压自发性分流患者食管胃底静脉曲张特点. 浙江大学学报(医学版). 2016;45:75-80. |
| 16. | Sato Y, Mitsuma C, Iwaya A, Kurosaki I, Shirai Y, Hatakeyama K. Resection of spleno-renal shunt resulting in enhanced liver volume in a patient with congenital portosystemic shunt concomitant with early gastric cancer. Review of Japanese cases. Dig Surg. 2001;18:74-78. [PubMed] [DOI] |
| 17. | D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19:475-505. [PubMed] [DOI] |
| 18. | Franzoni Lde C, de Carvalho FC, Garzon RG, Yamashiro Fda S, Augusti L, Santos LA, Dorna Mde S, Baima JP, Lima TB, Caramori CA. Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy. World J Gastroenterol. 2014;20:15910-15915. [PubMed] [DOI] |
| 19. | Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc. 1990;36:276-280. [PubMed] [DOI] |
| 23. | Zhao LQ, He W, Ji M, Liu P, Li P. 64-row multidetector computed tomography portal venography of gastric variceal collateral circulation. World J Gastroenterol. 2010;16:1003-1007. [PubMed] [DOI] |
| 24. | Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg. 2001;18:176-181. [PubMed] [DOI] |
| 25. | Gaba RC, Couture PM, Lakhoo J. Gastroesophageal Variceal Filling and Drainage Pathways: An Angiographic Description of Afferent and Efferent Venous Anatomic Patterns. J Clin Imaging Sci. 2015;5:61. [PubMed] [DOI] |
| 26. | Kiyosue H, Ibukuro K, Maruno M, Tanoue S, Hongo N, Mori H. Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review. Radiographics. 2013;33:87-100. [PubMed] [DOI] |
| 27. | Saracco G, Giordanino C, Roberto N, Ezio D, Luca T, Caronna S, Carucci P, De Bernardi Venon W, Barletti C, Bruno M. Fatal multiple systemic embolisms after injection of cyanoacrylate in bleeding gastric varices of a patient who was noncirrhotic but with idiopathic portal hypertension. Gastrointest Endosc. 2007;65:345-347. [PubMed] [DOI] |
| 28. | Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AE, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol. 2010;8:760-766. [PubMed] [DOI] |
| 29. | Chan RS, Vijayananthan A, Kumar G, Hilmi IN. Imaging findings of extensive splenic infarction after cyanoacrylate injection for gastric varices--a case report. Med J Malaysia. 2012;67:424-425. [PubMed] |
| 30. | Kang EJ, Jeong SW, Jang JY, Cho JY, Lee SH, Kim HG, Kim SG, Kim YS, Cheon YK, Cho YD. Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices. World J Gastroenterol. 2011;17:1494-1500. [PubMed] [DOI] |
| 31. | Robaina G, Albertini R, Carranza M, Herrena Najum P. Pulmonary embolism after endoscopic injection with N-butyl-2-cyanoacrylate for gastric varices. Medicina (B Aires). 2016;76:373-375. [PubMed] |
| 32. | Chang CJ, Shiau YT, Chen TL, Hou MC, Sun CH, Liao WC, Lin HC, Lee SD. Pyogenic portal vein thrombosis as a reservoir of persistent septicemia after cyanoacrylate injection for bleeding gastric varices. Digestion. 2008;78:139-143. [PubMed] [DOI] |
| 33. | Burke MP, O'Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection. Forensic Sci Med Pathol. 2017;13:82-85. [PubMed] [DOI] |
| 34. | Golse N, Bucur PO, Faitot F, Bekheit M, Pittau G, Ciacio O, Sa Cunha A, Adam R, Castaing D, Samuel D. Spontaneous Splenorenal Shunt in Liver Transplantation: Results of Left Renal Vein Ligation Versus Renoportal Anastomosis. Transplantation. 2015;99:2576-2585. [PubMed] [DOI] |
| 36. | Fujii-Lau LL, Law R, Wong Kee Song LM, Levy MJ. Novel techniques for gastric variceal obliteration. Dig Endosc. 2015;27:189-196. [PubMed] [DOI] |
| 37. | Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc. 2011;74:1019-1025. [PubMed] [DOI] |
| 38. | Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, Subtil-Inigo JC, Junquera-Florez F, Gornals JB, Repiso-Ortega A, Vila-Costas J, Marcos-Sanchez F, Muñoz-Navas M. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc. 2013;78:711-721. [PubMed] [DOI] |
| 39. | Gubler C, Bauerfeind P. Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection. Scand J Gastroenterol. 2014;49:1136-1142. [PubMed] [DOI] |
| 40. | Gonzalez JM, Giacino C, Pioche M, Vanbiervliet G, Brardjanian S, Ah-Soune P, Vitton V, Grimaud JC, Barthet M. Endoscopic ultrasound-guided vascular therapy: is it safe and effective? Endoscopy. 2012;44:539-542. [PubMed] [DOI] |
| 41. | 姜 琴, 汪 名权, 张 国兵, 孙 斌, 吴 琼, 许 建明, 孔 德润. 经颈静脉肝内门体静脉分流术联合食管胃底曲张静脉栓塞术治疗门静脉高压胃底静脉曲张伴胃肾分流18例的疗效. 中华消化杂志. 2015;35:744-749. |
| 42. | Park JK, Saab S, Kee ST, Busuttil RW, Kim HJ, Durazo F, Cho SK, Lee EW. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: Review and Meta-Analysis. Dig Dis Sci. 2015;60:1543-1553. [PubMed] [DOI] |
| 43. | Wang YB, Zhang JY, Gong JP, Zhang F, Zhao Y. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis. J Gastroenterol Hepatol. 2016;31:727-733. [PubMed] [DOI] |
| 44. | Garcia-Pagán JC, Barrufet M, Cardenas A, Escorsell A. Management of gastric varices. Clin Gastroenterol Hepatol. 2014;12:919-928.e1; quiz e51-e52. [PubMed] [DOI] |
| 45. | Marion-Audibert AM, Schoeffler M, Wallet F, Duperret S, Mabrut JY, Bancel B, Pere-Verge D, Wander L, Souquet JC. Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices. Gastroenterol Clin Biol. 2008;32:926-930. [PubMed] [DOI] |
| 46. | Cheng LF, Wang ZQ, Li CZ, Cai FC, Huang QY, Linghu EQ, Li W, Chai GJ, Sun GH, Mao YP. Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years' experience of 635 cases. Chin Med J (Engl). 2007;120:2081-2085. [PubMed] |
| 47. | Hong CH, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim BI, Hong HP, Shin JH. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2009;24:372-378. [PubMed] [DOI] |