2023肝硬化门静脉高压食管胃静脉曲张出血防治指南30条推荐意见.docx

2023肝硬化门静脉高压食管胃静脉曲张出血防治指南30条推荐意见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(gastroesophagealvariceszGOV)、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JournalofClinicalandTranslationalHepatology上发表。GuidelinesfortheManagementofEsophagogastricVaricealBleedinginCirrhoticPortalHypertensionXiaoyuanXu1'©,Chengweifang2'G,EnqiangLinghu3*0,HuiguoDing4OandChineseSocietyofHepatology,ChineseMedicalAssociation;ChineseSietyofGastroenterology.ChineseMedicalAssiation;ChineseSietyofDigestiveEndoscopy,ChineseMedicalAssociationKAuthorInformationJournalOfCIinicaIandTranslationalHepatology2023doi:10.14218/JCTH.2023.00061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。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提示预后不良A1)oRecommendation5: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)o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(Bl)oRecommendation7:Inprimaryprevention,controlofAEVBzandsecondarypreventionoflivercirrhosis,attentionshouldbepaidtoserumalbuminlevelofthepatientszwithtimelysupplementationofhumanserumalbuminifnecessary(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)对于轻度GOV未使用NSBB者，应定期复查胃镜(Bl)Recommendation10:ForpatientswithmoderateorsevereGOVandrelativelyhighriskofbleeding(Child-PughB,C,orpositiveRCsign),NSBBorEVLisrecommendedtopreventthefirstvaricealbleeding(A1).Forthoseatlowriskofbleeding,NSBBisthefirst-linechoice.EVLisalternativeforpatientswithcontraindicationsorintolerancetoNSBBorpoorcompliance(B2).推荐意见10：中、重度GoV、出血风险较大者(ChiId-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20mgx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-