目的 旨在评估经颈静脉肝内门体分流术(TIPS)治疗原发性胆汁性胆管炎合并门静脉高压的长期疗效.方法 回顾性纳入2015年1月1日—2021年8月30日南京大学医学院附属鼓楼医院收治的接受TIPS治疗的102例患者,并分为原发性胆汁性胆管炎(PBC)组(n=41)及病毒性肝炎肝硬化组(n=81).收集患者入院初的血常规、肝肾功能、凝血功能、门静脉血栓、肝性脑病、接受TIPS治疗的病因,术前的门静脉压力及手术使用的支架情况,同时计算Child-Pugh评分.随访资料收集术后上消化道再出血、支架失功、肝性脑病及生存预后相关资料,并进行分析.符合正态分布的计量资料2组间比较采用独立样本t检验;偏态分布的计量资料2组间比较采用Mann-Whitney U检验.计数资料2组间比较采用χ2检验.采用Kaplan-Meier法进行生存分析,采用Log-rank检验比较生存差异.结果 PBC组和病毒性肝炎肝硬化组患者门静脉压力较术前降低的中位百分比分别为33.00％和35.00％,2组比较差异无统计学意义(P>0.05).随访结束时,PBC组和病毒性肝炎肝硬化组在支架失功率(14.63％vs 24.69％)、上消化道再出血率(17.07％vs 24.69％)、显性肝性脑病发生率(12.20％vs 7.41％)和疾病相关死亡率(14.63％vs 9.88％)方面的差异均无统计学意义(χ2值分别为1.642、0.917、0.289、0.229,P值均>0.05).结论 TIPS治疗伴有门静脉高压的PBC患者,可达到治疗病毒性肝炎肝硬化所致门静脉高压的同等疗效,可有效降低门静脉高压,且不增加并发症发生率及疾病相关死亡率,是一种安全有效的治疗方法.

目的 胃静脉曲张(GV)破裂出血是肝硬化门脉高压性出血的一种少见类型,但其出血风险最高,内镜下治疗不易控制.本研究旨在探讨球囊导管闭塞下逆行性静脉栓塞术(BRTO)治疗GV破裂出血患者的安全性和短期疗效.方法 2018年11月～2020年1月南京鼓楼医院消化科诊治的13例肝硬化并发GV患者,均接受BRTO治疗.随访观察治疗成功率、技术相关并发症和短期生存等.结果 本组BRTO技术成功实施12例(92.3％),术后短期内未出现严重的致死性并发症,术后2例(16.7％)经超声检查发现新发门静脉血栓形成,给予低分子肝素抗凝治疗后血栓消失;在短期随访期间,未发生食管胃静脉曲张破裂出血,1例(7.7％)患者死于原发性肝癌导致的肝衰竭;新发轻度腹腔积液1例,1例肝性脑病患者术后血氨下降,临床症状缓解.结论 BRTO是一项安全、有效的介入技术,可有效预防胃静脉曲张破裂出血,值得进一步扩大应用和观察.

Objective:To explore the role of serum pyrrole-protein-adduct (PPA) in evaluating the severity and predicting the anticoagulant efficacy in patients with pyrrolidine alkaloid-related hepatic sinusoidal obstruction syndrome (PA-HSOS).Methods:From April 2018 to December 2019, the data of 48 patients with PA-HSOS admitted and treated at Drum Tower Hospital, Affiliated Medical College of Nangjing University were collected, which included PPA level, portal vein velocity (PVV), ascites grading, PA-HSOS severity grading (according to the new severity grading criteria for suspected hepatic sinusoidal obstruction syndrome in adults by the European Society of Blood and Bone Marrow Transplantation and adjusted) and the outcome of anticoagulation. Patients with acute onset (onset of symptoms within 1 month after consuming pyrrolizidine alkaloid-containing plants) were taken as research subjects. The combination of PPA with PVV or with ascites classification of PA-HSOS severity assessment model was fitted by logistic regression, and the logit values of 2 combination models were calculated, the formula was logit 1=0.034×PPA(nmol/L)+ 0.055×PVV(cm/s)-3.287, logit 2=0.039×PPA(nmol/L)-2.712×ascites grade 2 (Yes=1, No=0)-0.388×ascites grade 3 (Yes=1, No=0)-0.899. The patients received initial anticoagulation therapy at Drum Tower Hospital, Affiliated Medical College of Nanjing University were selected as research subjects. The anticoagulant efficacy prediction model of combination of PPA with serum creatinine (SCR) and with hepatic venous pressure gradient (HVPG) was fitted by logistic regression, and the logit value was calculated, the formula was logit 3=0.013×PPA(nmol/L)+ 0.064×SCR (mol/L)+ 0.542×HVPG (mmHg, 1 mmHg=0.133 kPa)-16.005. The predictive value of PPA in evaluating the severity of PA-HSOS and anticoagulant efficacy was evaluated. Receiver operating characteristic curve analysis was performed for statistical analysis. Results:The serum PPA level of 48 patients was 10.81 nmol/L (3.91 nmol/L, 32.04 nmol/L). Among them, 33 cases (68.8%) were mild PA-HSOS, 3 cases (6.2%) were moderate PA-HSOS, no severe PA-HSOS case and 12 cases (25.0%) were very severe PA-HSOS. Among 23 patients received initial anticoagulant therapy at Drum Tower Hospital, Affiliated Medical College of Nanjing University and with complete data, 8 patients responded and survived, and 15 patients did not respond (5 patients died, 1 patient relieved after continue anticoagulant therapy, and 9 patients survived after switching to anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) treatment). One patient without initial anticoagulant therapy, survived after TIPS treatment because of the progress of the disease. Area under the curve (AUC) of PPA to assess the severity of acute onset PA-HSOS was 0.75, 95% confidence interval ( CI) was 0.52 to 0.98 ( P=0.047). When PPA≥45.519 nmol/L, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 100.0% and 57.1%, respectively. AUC of combination of PPA and PVV to assess the severity of PA-HSOS was 0.77, 95% CI was 0.55 to 1.00 ( P=0.032). When the logit of combination model≥0.180, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 71.4% and 81.8%, respectively. AUC of combination of PPA and ascites grade (grade 1, 2 or 3) to assess the severity of PA-HSOS was 0.85, 95% CI was 0.63 to 1.00 ( P=0.005). When the logit of combination model≥0.347, the specificity and sensitivity in evaluating severe and very severe PA-HSOS was 85.7% and 92.0%, respectively. AUC of combination of PPA, SCR and HVPG to predict anticoagulation efficacy was 0.85, 95% CI was 0.69 to 1.00 ( P=0.009). When the logit≥0.393, the specificity and sensitivity in predicting anticoagulation efficacy was 62.5% and 91.7%, respectively. Conclusions:PPA can be used to assess the severity of acute onset PA-HSOS patients, and combined with ascites grading can significantly improve its efficiency. PPA combined with SCR and HVPG can better predict anticoagulant efficacy.

Objective:To develop an online interactive cytopathological training program, and to evaluate it for improving the cytopathological diagnostic ability of endoscopists in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreas.Methods:A total of 5 500 cytopathological images were collected from 194 patients with pancreatic solid mass who underwent EUS-FNA in Nanjing Drum Tower Hospital from August 2018 to August 2019. The cell type in each cytopathological picture was labeled by senior cellular pathologists, which was used to build a learning and testing platform for online interactive cytopathological training. Five endoscopists without cytopathological background were invited to participate in this training. Sensitivity, specificity, positive predictive value and negative predictive value of endoscopists in differential diagnosis of cancer and non-cancer before and after training were compared to evaluate the effect of the online interactive cytopathological training program on improving the ability of endoscopists in diagnosis of cytopathology.Results:A cytopathological training platform for endoscopists to learn and take online test was successfully built. Before training, sensitivity, specificity, positive predictive value, negative predictive value and accuracy of diagnosis of cancer and non-cancer for endoscopists were 0.55 (95% CI: 0.53-0.58), 0.32 (95% CI: 0.30-0.35), 0.43 (95% CI: 0.41-0.45), 0.44 (95% CI: 0.41-0.47) and 0.43 (95% CI: 0.42-0.45), respectively. After training, the above indicators were 0.96 (95% CI: 0.95-0.97), 0.70 (95% CI: 0.68-0.73), 0.74 (95% CI: 0.72-0.76), 0.95 (95% CI: 0.94-0.96) and 0.81 (95% CI: 0.80-0.83), respectively, which were significantly improved compared with those before ( P<0.001). Conclusion:The online interactive cytopathological training program can improve the understanding and diagnostic ability of endoscopists in pancreatic cytopathology, help to implement rapid on-site evaluation in the process of EUS-FNA, and improve the diagnostic efficiency of EUS-FNA.

Objective:To investigate the relationship between hepatic venous pressure gradient (HVPG) and parameters of Doppler ultrasound in patients with pyrroidine alkaloid-related hepatic sinusoidal obstruction syndrome (PA-HSOS).Methods:From February 17, 2017 to April 22, 2020, the clinical data of 68 patients with PA-HSOS who underwent HVPG manometry and Doppler ultrasound examination at Drum Tower Hospital, the Affiliated Medical College of Nanjing University were retrospectively analyzed, which included HVPG, Drum Tower severity scoring (DTSS), time from PA-HSOS related symptoms appeared to diagnosis after taking pyrroidine alkaloid (hereinafter referred to as diagnosis time), and parameters of Doppler ultrasound induding portal vein trunk diameter (PD), peak portal vein velocity (PPV), splenic vein trunk diameter (SD) and peak splenic vein velocity (PSV). Receiver operating characteristic curve (ROC) was used to determine the optimal cut-off value of HVPG for predicting non-response to anticoagulation therapy. Binary logistic regression was used to analyze the independent risk factors for non-response to anticoagulation therapy, and Kaplan-Meier survival curve was used to analyze the prognostic survival rate of patients with different HVPG levels. Unitary linear regression was applied to analyze the correlation of HVPG with PD, PPV, SD and PSV in patients with different HVPG levels, patients with mild, moderate and severe DTSS, and patients with diagnosis time >1 month or ≤ 1 month. Chi-square test was used for statistical analysis.Results:The results of ROC analysis showed that the optimal cut-off value of HVPG for predicting non-response to anticoagulant therapy was 20.165 mmHg(1 mmHg=0.133 kPa). The result of multivariate analysis indicated that high HVPG (HVPG>20.165 mmHg) was an independent risk factor for predicting non-response to anticoagulant therapy ( OR (95% confidence interval)=6.039(1.466 to 24.869), P=0.013). Kaplan-Meier survival curve demonstrated that prognostic survival rate of patients with high HVPG was lower than that of patients with low HVPG (HVPG≤20.165 mmHg) (78.4% vs.96.8%), and the difference was statistically significant( χ2=4.74, P=0.030). The results of unitary linear regression analysis showed that there was a negative correlation between HVPG and PPV in 68 patients with PA-HSOS( r=-0.330, P=0.006); HVPG was positively correlated with PD and SD in patients with high HVPG ( r=0.540 and 0.341, P=0.001 and 0.039); there was a negative correlation between HVPG and PSV in patients with mild DTSS ( r=-0.519, P=0.019), HVPG was negatively correlated with PPV in patients with moderate DTSS ( r=-0.400, P=0.014). In patients with diagnosis time ≤1 month, there was a negative correlation between HVPG and PPV ( r=-0.391, P=0.010). Conclusions:HVPG can assist in judging the response to anticoagulation therapy and the prognosis of patients with PA-HSOS. Parameters of Doppler ultrasound can help to assess the degree of HVPG elevation in patients with PA-HSOS under certain conditions.

Objective:To evaluate the feasibility and safety of Magnetic Anchor-Guided Endoscopic Submucosal Dissection(MAG-ESD).Methods:Patients with early gastric antral cancer were treated with MAG-ESD, and operation time, complete resection and complications were recorded.Results:The surgical treatment of ESD was successfully completed. The magnetic device took 3.0 minutes from the beginning of preparation to the completion of the labeling, of which the magnetic labeling took 1.3minutes.After the traction was completed, it was about 4.5 minutes for completely cut.There were no complications such as bleeding and perforation.Conclusion:MAG-ESD can well expose the surgical field. This method is simple, effective, low cost, and suitable for further promotion.

ObjectiveTo investigate the prognostic and risk factors for cirrhotic patients undergoing recanalization due to shunt dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). MethodsA retrospective analysis was performed for the clinical data of 69 cirrhotic patients who were admitted to Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2013 to February 2019 and underwent TIPS due to esophagogastric variceal bleeding and recanalization due to shunt dysfunction after TIPS. Related clinical data included preoperative, intraoperative, and postoperative data of TIPS and recanalization, stent parameters, hepatic venous pressure gradient, site of puncture of the portal vein, and laboratory markers. The Kaplan-Meier curve was used to evaluate the cumulative rate of shunt dysfunction and cumulative survival rate after recanalization, and the log-rank test was used for comparison of cumulative patency rate between two groups. The Cox regression model was used to investigate the influencing factors for secondary shunt dysfunction and survival after recanalization. ResultsOf all patients undergoing recanalization, 28 (40.6%) experienced secondary shunt dysfunction and 15(217%) died. The median time to secondary shunt dysfunction was 11.3 months. The 1-, 2-, 3-, and 5-year cumulative incidence rates of secondary shunt dysfunction were 29.8%, 41.6%, 48.0%, and 52.7%, respectively, and the 1-, 2-, 3-, and 5-year cumulative survival rates were 96.9%, 94.8%, 83.0%, and 62.6%, respectively. There was a significant difference in cumulative patency rate between the patients undergoing balloon dilatation of stent alone and those undergoing stent implantation (χ2=9.494, P=0.009). Child-Turcotte-Pugh (CTP) grade before first TIPS, stent diameter for first surgery, and international normalized ratio (INR) and prothrombin time (PT) before recanalization were associated with secondary shunt dysfunction (all P＜0.05), and an increase in INR before recanalization was an independent risk factor for secondary shunt dysfunction (hazard ratio ［HR］=4.398, 95% confidence interval ［CI］: 1.848-10.467, P=0.001), while stent implantation during recanalization was an independent protective predictor against secondary shunt dysfunction (HR=0.370, 95%CI: 0.194-0.704, P=0.002). CTP grade before first TIPS and Model for End-Stage Liver Disease (MELD) score were associated with patients’ survival after recanalization (both P＜0.05), and an increase in MELD score was the only independent risk factor for death after recanalization (HR=1.293, 95%CI: 1.054-1.627, P=0.026). ConclusionFor patients undergoing recanalization due to shunt dysfunction after TIPS, stent implantation during recanalization is a reasonable choice, while an increase in MELD score is associated with poor prognosis of patients.

Hepatic sinusoidal obstruction syndrome (HSOS) is a kind of hepatic vascular disease which is characterized by damage to hepatic sinusoidal endothelial cells, centrilobular hepatic vein and/or interlobular vein, resulting in stenosis or lumen occlusion, hepatic injury and acute sinusoidal portal hypertension. Generally, most patients with HSOS have mild manifestations, but in severely ill patients, the disease can lead to multiple organ dysfunction/failure, and the mortality rate can be as high as 70%-80%. Therefore, it is important to identify and treat HSOS as soon as possible. This paper introduces the current clinical diagnostic criteria of HSOS, including the Modified Seattle and Baltimore Criteria along with "Nanjing Criteria", and reviews their characteristics, scope of application and limitations.

Objective:To analyze the application value of rapid on-site evaluation by endoscopic physicians themselves (self-ROSE)of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions.Methods:Data of 124 consecutive patients who underwent EUS-FNA for solid pancreatic lesions from January 2017 to December 2017 in Nanjing Drum Tower Hospital were retrospectively analyzed. The patients were divided into self-ROSE group (n=60, patients who received self-ROSE from July to December in 2017) and non-self-ROSE group (n=64, patients who didn’t receive self-ROSE from January to June in 2017). Diagnostic efficiency including sensitivity, specificity, positive predictive value, negative predictive value and accuracy, the number of punctures and complication incidence of EUS-FNA in self-ROSE group and non-self-ROSE group was compared.Results:The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS-FNA were 98.21% (55/56), 4/4, 100.00% (55/55), 4/5 and 98.33% (59/60), respectively in self-ROSE group. While in non-self-ROSE group, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 81.82% (45/55), 9/9, 100.00% (45/45), 47.37% (9/19) and 84.38% (54/64), respectively. The sensitivity ( P=0.004) and accuracy ( P=0.009) were both significantly higher during EUS-FNA in self-ROSE group than those in non-self-ROSE group. There was a high degree of consistency between endoscopists and pathologists in the evaluation of sample satisfaction ( Kappa=1.000, P<0.05) and cytopathological diagnosis ( Kappa=0.815, P<0.05). There was no significant difference in the number of punctures between the two groups (2.78±0.83 VS 2.61±0.75, P>0.05). No complication occurred in either group. Conclusion:Self-ROSE is valuable for EUS-FNA in the diagnosis of solid pancreatic lesions, which could be an important strategy to increase the accuracy of EUS-FNA.

经颈静脉肝内门体分流术是门静脉高压的一种重要治疗方法，但该方法技术难度高，可能导致严重并发症，故临床推广受到限制。内镜超声引导下肝内门体分流术如以人体自然腔道为入路，有望通过内镜超声的精准定位放置肝内门体分流支架。本文报道国内首例该技术的动物实验过程，为该技术的可行性和进一步研究提供依据。

糖皮质激素治疗吡咯生物碱相关肝小静脉闭塞症(PA-HVOD)的疗效仍存争议,且其感染风险需要重视.本研究分析了4例PA-HVOD患者糖皮质激素治疗导致侵袭性肺真菌感染的临床特征,结果表明PA-HVOD患者使用糖皮质激素治疗可能诱发肺侵袭性真菌感染,且预后不佳.

患者男,62岁,因"恶心腹胀伴乏力纳差2个月"入院.患者起病前曾有"土三七"服用史. 体检:皮肤巩膜无黄染,腹膨隆,腹软,无明显压痛、反跳痛. 肝区叩痛(+),移动性浊音阳性. 辅助检查:生化示碱性磷酸酶 203. 2 U/L,谷酰转肽酶 142. 6 U/L,总胆红素 21. 9 μmol/L,直接胆红素11. 7 μmol/L,白蛋白 29. 3 g/L. 全腹增强CT:肝脏淤血表现,结合病史考虑肝小静脉闭塞症可能;胆囊壁肿胀,门脉周围水肿,腹盆腔系膜渗出,多发淋巴结显示,腹水;脾肿大.诊断考虑肝小静脉闭塞症. 入院后为进一步评估患者病情,指导下一步治疗,行内镜超声引导下门静脉压力梯度测定.患者仰卧位,静脉麻醉,内镜超声见肝脏体积增大,门静脉主干及左支未见扩张,多普勒显示门静脉内血流信号(图1),肝静脉显示不清,下腔静脉受压变窄(图2);测压导管于腋中线水平调零,内镜超声确定门静脉主干,多普勒确定穿刺部位无血流信号,肝素生理盐水预充22G COOK穿刺针,穿刺至门静脉主干内(图3) ,回抽有回血,分3次测压,压力分别为 25、26、25 mmHg ( 1 mmHg= 0. 133 kPa ) ,平均压力25. 33 mmHg;再次选择下腔静脉(图4 ) ,回抽见回血,分3次测压,压力分别为4、5、4 mmHg,平均压力4. 33 mmHg,最终门静脉压力梯度( portal pressure gradient, PPG ) 为21 mmHg. 多普勒确认穿刺道无血流后退镜.

胶囊内镜是目前检查小肠疾病的重要方法,尤其是在不明原因消化道出血以及可疑克罗恩病等诊断方面具有重要价值[1-2].该检查具有无创、痛苦小的优点,但由于其在体内运行无法干预,肠道准备的好坏对最终获得的图片质量影响极大,故而影响阅片医师的诊断.目前国内外对于胶囊内镜检查的肠道准备方案尚无定论,多选用检查前一日服用聚乙二醇1~2 L,当日检查前服用祛泡剂的方案进行准备[3-4].我科在传统肠道准备的基础上采用潜水胶囊内镜法改良肠道准备,现比较其与传统胶囊内镜的肠道准备质量以及病变检出率等情况,报道如下.

<正>鼻咽癌是指发生于鼻咽粘膜的恶性肿瘤。中国的广东、广西、福建、湖南等地为多发区,男多于女。发病年龄大多为中年人,亦有青少年患病[1]。病因与种族易感性(黄种人较白种人患病多)、遗传因素及EB病毒感染等有关,鼻咽癌恶性程度较

鼻出血又称鼻衄,是耳鼻喉科常见病,而且是一种急症,轻者仅涕中带血,重者可引起休克、窒息,反复出血可导致贫血.鼻出血是一种症状,引起鼻出血的原因很多,可因全身或局部原因引起,全身原因为高血压、血液病、化学药物中毒等.常见鼻腔疾病,如鼻外伤、鼻腔异物、鼻腔肿瘤或鼻腔急性炎症等.亦可见于鼻腔干燥时,或全身疾病的局部表现,如高热、血管疾病、血液病及维生素C、维生素K缺乏症等,还可由颅底、鼻窦、鼻咽部等处疾病引起.其出血量多少不一,轻者涕中带血,重者出血量大,出血迅猛,甚至休克[1],在治疗及护理上十分棘手,若不及时抢救可危及生命.