肝硬化门静脉高压食管胃静脉曲张出血防治指南推荐意见2023.docx

肝硬化门静脉高压食管胃静脉曲张出血防治指南推荐意见2023概述门静脉高压症是指由各种原因导致的门静脉系统压力升高所引起的一组临床综合征，其最常见病因为各种原因所致的肝硬化。门静脉高压症临床主要表现为腹水、食管胃静脉曲张(gastroesophagealvarices,GOV)、食管胃静脉曲张破裂出血(esophagogastricvaricealbleeding,EVB)和肝性脑病等,其中EVB病死率高，是最常见的消化系统急症之一。为帮助二级以上医院从事肝病、消化或感染等专业的临床医生在肝硬化门静脉高压EVB的临床诊治决策中做参考，中华医学会肝病学分会、消化病学分会和消化内镜学分会组建指导委员会、秘书组、专家组(包括通信专家)等，与肝病、消化、内镜、感染、外科、介入、肿瘤、中医、药理、护理和临床研究方法学等领域专家共同携手，颁布肝硬化门静脉高压食管胃静脉曲张出血防治指南，并在英文期刊JournaIofCIinicaIandTranslationalHePatOIOgy上发表。肝硬化门静脉高压食管胃静脉曲张出血防治指南推荐意见达30条，对GoV的自然史、发病机制和GOV的分级，食管胃静脉曲张出血的一级预防，急性食管胃静脉曲张出血的治疗，食管静脉曲张出血的二级预防，特殊类型静脉曲张的处理，待解决的问题及展望等均作出了详细阐述。现在，30条推荐意见奉上，快来一睹为快吧！推荐意见Recommendation1:Cirrhosiscanbeclassifiedintocompensatedstage,decompensatedstage,recompensatedstage；and/orcirrhosisreversion(B1).TheLSMcombinedwithplateletcountandmultislicecontrast-enhancedCTcanbeusedasnoninvasiveexaminationsforthediagnosisofportalhypertensionincirrhosis.(B1)推荐意见1:肝硬化分为代偿期、失代偿期、再代偿期和/或肝硬化逆转(B1)。肝脏弹性检测、B超、CT和MRI可用于肝硬化及门静脉高压的辅助诊断(B1)。Recommendation2:GastroscopyisthegoldstandardforthediagnosisofGOVandEVB.ItissuggestedtousegastroscopycombinedwiththenoninvasiveexaminationresultstoconfirmthepresenceofGOVandassessseverityincirrhoticpatients(A1).GOVshouldbegradedintomildzmoderate,andsevere,andberecordedwithsites,diameter,andRfsforbleeding；etc.推荐意见2:胃镜检查是诊断GOV和EVB的金标准，初次确诊肝硬化的患者均应常规行胃镜检查筛查是否存在GOV及其严重程度(B1);对GOV进行分级指出静脉曲张轻、中、重度及曲张静脉所在的部位、直径、有无出血的相关危险因素等(A1)。Recommendation3:ItisrecommendedthatcirrhoticpatientswithCSPHbutwithoutGOVshouldbefollowedupwithgastroscopeexaminationeverytwoyears,withonceayearbeingacceptableformildGOV(C1).推荐意见3:无静脉曲张的代偿期肝硬化患者建议每2年检查1次胃镜(C1),有轻度静脉曲张每年检查1次胃镜。失代偿期肝硬化患者0.5-1年检查1次胃镜(C1)oRecommendation4:WhenCSPHisidentifiedthroughnoninvasiveexaminations,andportalhypertensionincirrhosisisdiagnosedusingmultislicecontrast-enhancedCTandgastroscopy,invasiveHVPGdetectionisnotrecommendedforthesolepurposeofconfirmingthepresenceofCSPH(B1).HVPG>5mmHgindicatesportalhypertension;HVPG>10mmHgsuggeststhepossibilityofdevelopingvaricoseveins;HVPG>12mmHgmaysuggestthepossibilityoftheoccurrenceEVB,andHVPG>20mmHgindicatesapoorprognosis(A1).推荐意见4:能明确门静脉高压相关的研究终点或肝硬化结局者，不建议单纯为了解门静脉压力而行有创性HVPG检测(B1)。HVPG>5mmHg存在门脉高压，HVPG>10mmHg可发生静脉曲张，HVPG>12mmHg可发生EVB,HVPG>20mmHg提示预后不阅A1)0Recommendation5:EVBmanagementstrategiesinclude(1)preventionofthefirstEVB(primaryprevention);(2)controlofAEVB;(3)preventionofthesecondEVB(secondaryprevention);and(4)improvementofliverfunctionalreserve(A1).推荐意见5:EVB的管理策略包括：(1)预防首次EVB(一级预防)；(2)控制AEVB;(3)预防再次EVB(二级预防)(4)改善肝脏功能储备(A1)oRecommendation6:Attentionshouldbepaidtoetiologicaltreatmentaswellasantiviraltherapyandantihepaticfibrosistreatment(A1).TCMssuchasAnluoHuaxianpills,FuzhengHuayucapsules,andFufangBiejiaRuangantabletscanbeusedtorelieveliverfibrosis；livercirrhosis,andGOV(B1).推荐意见6重视病因治疗,积极进行抗病毒和抗肝纤维化等治疗(A1)。安络化纤丸、扶正化瘀胶囊、复方鳖甲软肝片等中药可用于缓解肝纤维化、肝硬化及GoV等(B1)oRecommendation7:InprimarypreventionzcontrolofAEVBrandsecondarypreventionoflivercirrhosis,attentionshouldbepaidtoserumalbuminlevelofthepatients,withtimelysupplementationofhumanserumalbuminifnecessary(B1).推荐意见7:肝硬化在一级预防、控制AEVBx二级预防时应注意患者白蛋白水平，及时补充人血白蛋白(B1)。Recommendation8:NSBBisnotrecommendedforprimarypreventioninpatientswithoutGOV(B1).推荐意见8:不推荐无GOV者使用NSBB用于一级预防(B1)。Recommendation9:FormildGOVpatientswithChild-PughBandC1orpositiveRCsign,NSBBisrecommendedtopreventthefirstvaricealbleeding(B1).InpatientswithmildGOVatlowriskofbleeding,NSBBisnotrecommended(B2).ForpatientswithmildGOVwithoutNSBB,gastroscopyshouldbereviewedregularly(B1).推荐意见9:ChiId-PughBxC级或红色征阳性的轻度GOV推荐使用NSBB预防首次静脉曲张出血(B1)。出血风险不大的轻度GOV,不推荐使用NSBB(B2)o对于轻度GOV未使用NSBB者,应定期复查胃镜(Bl)oRecommendation10:ForpatientswithmoderateorsevereGOVandrelativelyhighriskofbleeding(Child-PughB,C1orpositiveRCsign),NSBBorEVLisrecommendedtopreventthefirstvaricealbleeding(A1).Forthoseatlowriskofbleeding,NSBBisthefirst-linechoice.EVLisalternativeforpatientswithcontraindicationsorintolerancetoNSBBorpoorcompliance(B2).推荐意见10：中、重度GOV、出血风险较大者(Child-PUghB、C级或红色征阳性)推荐使用NSBB或EVL预防首次静脉曲张出皿A1)出血风险不大者，首选NSBB,对NSBB有禁忌症、不耐受或依从性差者可选EVL(B2)oRecommendation11:TheinitialdoseofCarvedilolis6.25mgd,whichcanbeincreasedto12.5mgafter1weekifthepriordosewaswelltolerated;theinitialdoseofpropranololis10mgtwiceaday,whichcanbegraduallyincreasedtothemaximumtolerateddose;andtheinitialdoseofnadololis20mgperday,followedbyescalationtoamaximumtolerateddose.Responsecriteria:therestingheartratedecreasedto75%ofbasalheartrateor50-60beats/m(A1);HVPG12mmHgordecreased10%frombaseline(B2).推荐意见11:卡维地洛起始剂量6.25mg,如耐受可1周后增至12.5mgs每日1次；普蔡洛尔起始剂量Iomg、每日2次，渐增至最大耐受剂量；纳多洛尔起始剂量20mg.每日1次，渐增至最大耐受剂量。应答标准：静息心率下降到基础心率的75%或50-60次min(A1);HVPG12mmHg或较基线下降10%(B2)oRecommendation12:NitratesaloneorincombinationwithNSBBarenotrecommendedforprimaryprevention(A2).ACEI/ARBdrugsarenotrecommendedforprimaryprevention(B2).Spironolactoneisnotrecommendedforprimaryprevention(C2).推荐意见12:不推荐单用硝酸酯类药物或与NSBB联用进行一级预防(A2)不推荐血管紧张素转换酶抑制剂/血管紧张素II受体拮抗剂(ACEI/ARB)类药物进行一级预防(B2)o不推荐螺内酯用于一级预防(C2)。Recommendation13:SurgicalproceduresandTIPSarenotrecommendedforprimaryprevention(A2).ConcomitantuseofEVLandNSBBforprimarypreventionisnotrecommended(C2).推荐意见13:不推荐各种外科手术和TIPS用于一级预防(A2)。不推荐EVL联合NSBB同时用于一级预防(C2)oRecommendation14:NSBBcanbeusedforprimarypreventionofgastricvaricealbleeding(B2).推荐意见14:NSBB可用于胃静脉曲张出血的一级预防(B2)oRecommendation15:LDRfclassificationshouldbeusedtoguidepatientmonitoringandtimingoftreatment.RfOzDO.3:(primaryprevention)Notreatment,follow-upwithendoscopyonceayear.D1.0:ElectiveEVLorfollow-upwithendoscopyeveryhalfyear(B1).D1.5:日ectiveendoscopicinjectionsclerotherapy(EIS)foresophagealvaricesplustissueglueinjectionforgastriccardia,orendoscopyevery3monthstohalfayear;tissueglueinjectionforvariceslocatedoutsidetheesophagusorendoscopyevery3monthstohalfayear(C2).Rf1ztreatmentin3months.推荐意见15:根据LDRf分型进行监测和治疗时机选择：Rfo,D0.3:(一级预防)不治疗，每年一次内镜检查；DLO:择期EVL,或每半年一次内镜检查(Bl)。D1.5:食管静脉曲张择期EIS+贲门部组织胶注射，或每3个月到半年一次内镜检查；食管以外曲张静脉组织胶注射，或每3个月到半年一次内镜检查(C2)。Rfl,3个月内进行治疗。Recommendation16:DrugsarethepreferredtreatmentforEVB(A1).Thevasoactivedrugterlipressin(maintainon2-12mg/dinfusion),somatostatin(250-500gh),oroctreotide(25-50gh)arethefirst-linetreatmentdrugsforAEVBzandthetreatmentdurationis3-5days(A1).推荐意见16:血管活性药物是EVB的首选治疗方法(A1)。特利加压素(2-12mg天，持续滴注)、生长抑素(250-500ugh)或奥曲肽(25-50ugh),是AEVB一线治疗药物，疗程3-5天(A1)。(修订)Recommendation17:AntibioticsareimportanttherapeuticdrugsofAEVBincirrhosis,whichcanreducetheincidenceofrecurrentbleedingandbleeding-relatedmortalityinesophagogastricvarices(A1).推荐意见17:抗菌药物可降低食管胃静脉曲张再出血率及出血相关病死率，是肝硬化AEVB的重要治疗药物(A1)。Recommendation18:EVLandEIScanbeusedinpatientswithesophagealvaricoseveinsandtypeGOV1EVB(A1);tissueadhesiveinjectionisindicatedforGOV2andIGVvaricealbleeding(A1).推荐意见18:EVL、ElS可用于食管静脉曲张或GOV1型EVB患者(A1);组织黏合剂注射治疗适合GoV2型、IGV型静脉曲张出血(A1)o(修订)Recommendation19:Terlipressinzsomatostatin,andoctreotide,incombinationwithendoscopictherapy,canimprovethesafetyandefficacyofendoscopictherapy,reducetheincidenceofrecentrecurrentbleedingafterendoscopictherapy（A1）.推荐意见19:特利加压素、生长抑素及奥曲肽辅助内镜治疗，可提高内镜治疗的安全性和效果，降低内镜治疗后近期再出血率（A1）o（修订）Recommendation20:Forpatientswhodonotrespondtotherapeuticdrugs,earlyendoscopicorvascularinterventionaltherapyshouldbeimplementedaccordingtotheconditionsofthehospitalandexperiencesofmultidisciplinaryteam（B1）.推荐意见20:药物治疗无应答的患者，根据医院多学科协作诊治团队的条件和医生的经验，早期实施内镜或血管介入治疗（B1）。Recommendation21:CompressionhemostasiswithaSengstaken-Blakemoretubecanbeusedasatemporarytransitiontherapyforpatientswhodonotrespondtodrugsorendoscopictherapywhenemergencyendoscopic/TIPStherapy（B1）isnotavailable.推荐意见21:三腔二囊管压迫止血可作为药物或内镜治疗无应答，或无条件进行急诊内镜/TIPS治疗的暂时过渡治疗方法（B1）。Recommendation22:AnesthesiaintubationandICUsupportcanimprovetheefficacyandsafetyoftheemergentendoscopictreatmentofEVB（B1）.推荐意见22:麻醉插管及ICU支持,可提高急诊内镜治疗EVB的效果和安全性（B1）。（修订）Recommendation23:InpatientswithChild-PughA/Bclass,surgicaldevascularizationisstillaneffectivetechniquetocontrolAEVBinpatientswhoareunresponsivetodrugsorendoscopictherapywhenTIPSisnotavailable（B1）.推荐意见23:Child-PughA/B级患者，药物或内镜治疗无应答或无急诊TIPS条件，外科断流术仍是控制AEVB的有效方法（B1）。（修订）Recommendation24:EndoscopycombinedwithNSBBisthestandardregimenforsecondarypreventionofEVB.（A1）Ifpatientsareintoleranttocombinationtherapy,monotherapywitheithertechniquecanbeusedforsecondaryprevention.推荐意见24:内镜联合NSBB,是EVB二级预防标准方案（A1）,如不能耐受，可选择单一方法预防。Recommendation25:Gastroscopyshouldbeperformed2-4weeksaftertheinitialendoscopictreatmenttoevaluatetheeffectoftreatment.Multiplecyclesofsequentialtreatmentcanbeperformedatintervalsof2-4weeks,withGOVeradicationornoriskofrebleedingastheendpointoftreatment.Endoscopyshouldbeperformedatleast12monthsaftereliminatingorsignificantlyreducingGOVtoassesstheriskofGOVrecurrenceandrebleeding(C1).推荐意见25:首次内镜治疗后2-4周应胃镜检查，评估治疗效果。可间隔2-4周序贯性治疗多个周期以GOV消失或无再出血风险为治疗终点；GOV消除或明显减轻后至少12个月胃镜检查一次，评估GOV复发及再出血的风险(C1)。(修订)Recommendation26:NSBBisnotrecommendedintheprimaryorsecondarypreventionofEVBinpatientswithlivercirrhosiscomplicatedbyrefractoryascitesoracutekidneyinjury(B1).推荐意见26:肝硬化合并顽固性腹水或急性肾损伤患者，无论EVB一级或二级预防，均不建议使用NSBB(B1)oRecommendation27:Tissueadhesiveinjection,EISzEVLandTIPSareeffectivetreatmenttechniquesforvaricealbleedingatraresiteszwhichcanbedeterminedaccordingtothepatient'swishesandthetechnicaladvantagesofacollaborativemultidisciplinaryteamfordiagnosisandtreatment(C1).推荐意见27:组织黏合剂注射、EISxEVL及TIPS,是少见部位静脉曲张出血的有效治疗方法，根据患者意愿和多学科协作诊治团队的技术优势选择(U)。(修订)Recommendation28:ForthosewhohavecompleteorpartialPVT(>50%)ofthemainportalvein,PVTinvolvingthemesenterywiththeriskofbleedingofGOVzorsymptomaticPVTorthosewhoareonthewaitinglistforlivertransplantation,lowmolecularweightheparinanticoagulationisrecommended(B1).推荐意见28:门静脉主干完全或部分PVT(>50%),或累及肠系膜的PVT伴GOV出血风险、有症状或等待肝移植PVTz推荐低分子肝素抗凝治疗(B1)。(新)Recommendation29:ForpatientswithcirrhosiswithPVTandEVB,endoscopictherapyorTIPScanbeusedtocontrolacutebleeding.InthepreventionofrebleedingzthetreatmenteffectofTIPSissuperiortothatofendoscopictherapy(A1).EarlyinitiationofanticoagulationtherapycanimprovethetherapeuticeffectofendoscopyorTIPSafterbleedinghasbeencontrolled(B1).推荐意见29:肝硬化PVT伴EVB,可选择内镜治疗或TIPS控制急性出血；预防再出血，TIPS优于内镜治疗（A1）o出血控制后，早期启动抗凝治疗，可提高内镜或TIPS的治疗效果（B1）。（新）Recommendation30:ForcirrhoticpatientswithEVBandportalveintumorthrombus,endoscopictherapyorTIPScanbechosentocontrolacutebleedingandpreventrecurrence（B1）.推荐意见30:肝硬化合并门静脉癌栓EVB,可选择内镜治疗或TIPS控制急性出血，预防再出血（B1）。（新）引用本文S.XuXzTangC,LinghuE1DingHfChineseSocietyofHepatologyzChineseMedicalAssociation;ChineseSocietyofGastroenterologyzChineseMedicalAssociation;ChineseSocietyofDigestiveEndoscopyzChineseMedicalAssociation.GuidelinesfortheManagementofEsophagogastricVaricealBleedinginCirrhoticPortalHypertension.JClinTranslHepatol.Publishedonline:Oct17z2023.doi:10.14218JCTH.2023.00061.