How to diagnose such upper gastrointestinal bleeding?The new version of the guide is here

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The door vein hypertension refers to a group of clinical syndrome caused by the increased pressure of the door venous system caused by various reasons, and its most common diseases are cirrhosis due to various reasons.The clinical clinic of door vein hypertension is ascites, esophageal gastric venous veins (GOV) and its rupture bleeding (EVB) and hepatic encephalopathy (HE). Among them, EVB’s mortality rate is high, which is one of the most common digestive system acute.

In order to regulate the prevention, diagnosis and treatment of hepatic hardening door vein hypertension EVB, the Chinese Medical Association Hepatosis Branch, Gastrointestinal Disease Branch, and Gastrointestinal Endoscopy Organization have formulated relevant experts in the "Prevention Guidelines for the Prevention of Hypertensive Energy Varic vein bleeding of liver hardened doorsteps."(Hereinafter referred to as the new version of the guide), this article summarizes the relevant opinions. Let’s take a look together ~

GOV’s natural history, pathogenesis and GOV classification

Recommended opinion 1:

Hepatitis cirrhosis is divided into compensation period, disorderly compensation period, re -compensation period, and/or liver cirrhosis reversal (B1).Liver hardness testing combined with platelet count, multi -layer spiral enhancement CT can be used for non -invasive diagnosis (B1) that can be used for liver cirrhosis door vein hypertension (B1).

Recommended opinion 2:

Gastroscopy is a gold standard diagnosis of GOV and EVB.Patients who confirmed liver cirrhosis should combine the results of non -invasive testing, to understand whether there is GOV and severity through gastroscopy, and classify GOV.(A1).

[Note]: About GOV endoscopes and classification standards, different at home and abroad, often use SARIN typing abroad.The new version of Guide recommends LDRF typing as a classification record method for GOV in my country.In addition, ultrasonic endoscopy (EUS) can provide more information on changes in esophageal and gastric mucosal blood flow, especially for differential diagnosis of early gastrointestinal vein tension and other lesions under the stomach mucosa.

Recommended Opinions 3:

Patients without GOV CSPH liver cirrhosis are recommended to check the gastroscopy once every 2 years. Mild GOV can check the gastroscopy once a year (C1).

Recommended opinion 4:

The non -invasive detection method is evaluated as CSPH, multi -layer spiral enhancement CT and gastroscopy that when the hepatic hardening door vein hypertension is clear, it is not recommended to have a creative HVPG detection (B1) for the solid vein pressure of the door (B1).HVPG > 5 mmHg exists with venous hypertension, HVPG> 10 mmHg can occur veins, HVPG> 12 mmHg can occur EVB, HVPG> 20 mmHg prompts poor prognosis (A1).

[Description]: The detection of HVPG is an invasive operation. When the non -invasive detection method is evaluated as CSPH, multi -layer spiral enhancement CT and gastroscopy, they are not recommended. It is not recommended to simply understand HVPG for the purpose of creative HVPG testing.

EVB’s first -level prevention

The purpose of EVB first prevention is to treat primary diseases, anti-fibrosis, prevent the formation and progress of varicose veins, prevent medium-severe chanting vein rupture and bleeding, prevent the occurrence of complications, and increase survival rate.

Recommended opinion 5:

EVB’s management strategies include: (1) Prevention of EVB for the first time (first level prevention); (2) control the acute esophageal gastric varicose vein bleeding (AEVB); (3) prevent again EVB (secondary prevention); (4) improve liver functionReserve (A1).

Recommended opinion 6:

Attach importance to the treatment of the cause and actively treat antiviral and anti -liver fibrosis (A1).Traditional Chinese medicines such as Anluohua chemical fiber pills, Fang Zhenghua Capsules, and compound tadpole softened liver tablets can be used to alleviate liver fibrosis, liver cirrhosis and GOV (B1).

Recommended opinion 7:

Pay attention to the patient’s albumin level in the first level of prevention, control of AEVB, and secondary prevention, and timely supplement human hemoglobin (B1) in time.

[Description]: Replenishing human lean protein in time in the first level prevention, control of AEVB, and secondary prevention, which will help the healing of the wound, indirectly improve the effect of hemostasis, and reduce the occurrence of infection.

Recommended opinion 8:

Those who are not recommended to use non -selective β -blockers (NSBB) are not recommended for first -level prevention (B1).

[Description]: Studies have shown that NSBB is not beneficial to those without Gov.

Recommended Opinions 9:

Child-PUGH B, C-Class or red positive mild GOV, it is recommended to use NSBB to prevent the first venous hemorrhage (B1).The mild GOV with little risk of bleeding is not recommended to use NSBB (B2).For those who do not use NSBB mild GOV, gastroscopy (B1) should be reviewed regularly.

Recommended opinion 10:

Medium and severe GOV and hemorrhagic risk (Child-PUGH B, C-Class, or Class) are recommended to use NSBB or EVL to prevent the first varicose vein bleeding (A1).If the risk of bleeding is not high, the nsbb is preferred, and EVL (B2) can be selected for those with NSBB taboos, tolerance or poor compliance.

Recommended opinion 11:

The starting dose of Kavidelo is 6.25 mg. If the tolerance can be increased to 12.5 mg, it can be increased once a day; the starting dose of the Pumelol is 10 mg, 2 times a day, and gradually increases to the maximum tolerance dose; NadoThe starting dose of Lore is 20 mg, once a day, and gradually increases to the maximum tolerance dose.Response standard: Static heart rate drops to 75%or 50 to 60 times/min (A1) of the basic heart rate; HVPG ≤ 12 mmHg or a lower baseline decrease of ≥10%(B2).

Recommended opinion 12:

It is not recommended to use nitrate drugs or use it with NSBB for first -level prevention (A2).It is not recommended for vascular tensionase converting enzyme inhibitors/vascular tensionin II receptor antagonists (ACEI/ARB) drugs for first -level prevention (B2).It is not recommended for splittering for first -level prevention (C2).

Recommended opinion 13:

It is not recommended for various surgery and TIPS for first -level prevention (A2).It is not recommended for EVL combined with NSBB for first -level prevention (C2).

Recommended opinion 14:

NSBB can be used for first -level prevention of gastric vein bleeding (B2).

Recommended opinion 15:

Monitor and treat the timing of monitoring and treatment according to the LDRF typing: RF0, D0.3: (first level prevention) is not treated, and endoscopic examination once a year.D1.0: Optional EVL, or endoscopic examination every half a year (B1).D1.5: The esophageal veins are selected from EIS+Cardiac Department to tissue glue injection, or endoscopic examinations every 3 months to half a year;To.RFL, treatment within 3 months.

AEVB treatment

Recommended Opinions 16:

Drugs are EVB’s preferred treatment (A1).Vascular active drug Telitadin (2 to 12 mg/d, continuous dripping), growth citrotin (250-500 μg/h), or octotide (25-50 μg/h), which is AEVB first -line therapy drug, 3 ~ 3 ~5 d (A1).

Recommended Opinions 17:

Antibacterial drugs can reduce the recurrence of esophageal gastric vein bleeding and bleeding -related mortality, which is an important therapeutic drug for liver cirrhosis AEVB (A1).

Recommended Opinions 18:

EVL and EIS can be used in patients with esophageal veins or GOV1 EVB patients (A1); tissue adhesive injection therapy is suitable for GOV2 and IGV venous vein bleeding (A1).

[Description]: Absolute taboos of endoscopic treatment: (1) Taboo taboos with digestive tract endoscopic; (2) The affected party did not sign the informed consent form;Endoscopy treatment is relatively contraindicated; (1) Unwavering hepatic encephalopathy or hemorrhagic shock; (2) patients with severe liver, renal dysfunction, and a large number of ascites.

Recommended opinion 19:

Teligatin, growth citrotin, and octon peptide auxiliary endoscopic treatment can improve the safety and effect of endoscopic therapy, reduce the recent re -bleeding rate (A1) after endoscopic treatment (A1).

Recommended opinion 20:

Patients with no response to drug treatment, according to the conditions of the hospital’s multidisciplinary cooperation and diagnosis and treatment team and the experience of doctors, early endoscopy or blood vessel intervention therapy (B1).

Recommended Opinions 21:

The compression of the triocyte di cannibal hemostasis can be used as a temporary transitional treatment method (B1) for the treatment of emergency endoscopy/TIPS treatment without conditions, or the emergency endoscopy/TIPS treatment.

Recommended opinion 22:

Anesthesia intubation and ICU support can improve the effect and safety of EVB for emergency endoscopy (B1).

Recommended opinion 23:

Child-PUGH A/B patients, drugs or endoscopic treatment without answering or urgent Tips conditions, surgery is still an effective method for controlling AEVB (B1).

[Description]: The refractory EVB generally refers to patients with active EVB in 5 days after drug or/and endoscopic treatment.Patients are more clinically common in patients with Child-Puff C-Class or ACLF; or patients with HVPG> 20 mmHg.Patients with liver cirrhosis and refractory EVB need to choose TIPS or liver transplantation according to the technical advantages of the many hospitals of liver cirrhosis doorsal hypertension. They are accompanied by ACLF patients to enter the list of liver transplantation first.

EVB’s secondary prevention

The purpose of secondary prevention is to eradicate or reduce GOV, reduce re -bleeding rate and reduce the mortality of the disease.The second -level prevention timing is that there are EVB history or AEVB 5D in the past, and secondary prevention can be started.

Recommended opinion 24:

Endoscopy combined with NSBB is the standard scheme (A1) for EVB secondary prevention. If you cannot tolerate it, you can choose a single method to prevent it.

Recommended opinion 25:

The gastroscopy examination is 2 to 4 weeks after the first endoscopy treatment, and the treatment effect is evaluated.It can be treated with multiple cycles for 2 to 4 weeks, and the gastroscopy is checked at at least 12 months after GOV disappear or no re -bleeding risk; GOV is eliminated or significantly reduced at least 12 months to evaluate the risk of GOV recurrence and re -bleeding (C1To.

Recommended opinion 26:

Patients with hardrims of stubborn ascites or acute renal injuries, regardless of EVB first or second -level prevention, are not recommended to use NSBB (B1).

Special type of varicose veins

Recommended opinion 27:

Organizational adhesive injection, EIS, EVL and TIPS are effective treatment methods for venous vein bleeding in rare parts. They can choose according to the patient’s wishes and the technical advantages of the multidisciplinary collaborative diagnosis and treatment team (C1).

Recommended opinion 28:

The door vein is complete or part of PVT (> 50%), or PVT with GOV bleeding risk, symptoms or waiting for liver transplantation PVT, which is involved in the intestinal membrane, and is recommended for low molecular heparin anticoagulation therapy (B1).

Recommended opinion 29:

PVT with liver cirrhosis is accompanied by EVB, which can choose endoscopic treatment or Tips to control acute bleeding; prevent re -bleeding, TIPS is better than endoscopic therapy (A1).After bleeding control, early starting anticoagulation treatment can improve the treatment effect of endoscopy or TIPS (B1).

Recommended opinion 30:

EVB of Hepatotic Cumulative Varicular Tumor Cancer can choose endoscopic treatment or TIPS to control acute bleeding to prevent re -bleeding (B1).

References: [1] Chinese Medical Association Liver Disease Branch, Chinese Medical Association Gastroenterology Branch, Chinese Medical Association digestive endoscopic branch. Hepatorate door varicose vein high -pressure esophageal gastrointestinal bleeding guidelines. Chinese Medical Medicine Magazine, 2023, 62, 62(01): 7-22.Doi: 10.3760/CMA.J.CN50113-20220824-00436.

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