臨牀消化器内科 Vol.33 No.5(3)


特集名 緊急内視鏡の適応と実際
題名 上部消化管出血(静脈瘤)
発刊年月 2018年 05月
著者 中村 真一 東京女子医科大学消化器内視鏡科
著者 岸野 真衣子 東京女子医科大学消化器内視鏡科
著者 山本 浩隆 東京女子医科大学消化器内科
著者 小林 亜也子 東京女子医科大学消化器内科
著者 山本 果奈 東京女子医科大学消化器内科
著者 徳重 克年 東京女子医科大学消化器内科
【 要旨 】 食道・胃静脈瘤出血の診断と治療に緊急内視鏡が重要な役割を担っている.まずは食道・胃静脈瘤内視鏡所見記載基準による発赤所見や出血所見の診断,治療適応の理解が重要である.食道静脈瘤に対する内視鏡治療として,内視鏡的静脈瘤結紮術(endoscopic variceal ligation;EVL)と内視鏡的硬化療法(endoscopic injection sclerotherapy;EIS)が実施されている.とくにEVLは手技の簡便性と確実性から止血法の第一選択となっている.ただし,EVLでの治療困難例があり,EISにも習熟しておく必要がある.胃静脈瘤(Lg-f)に対してはヒストアクリル®による内視鏡的塞栓療法が止血法の第一選択となりつつある.各施設で経験できる症例が少なく,指導医のもと安全に配慮し実施すべきである.
Theme Indications and Standards of Practice for Emergency Endoscopy
Title Current Status of Emergency Endoscopy for Esophagogastric Variceal Bleeding
Author Shinichi Nakamura Department of Endoscopy, Tokyo Women's Medical University
Author Maiko Kishino Department of Endoscopy, Tokyo Women's Medical University
Author Hirotaka Yamamoto Department of Gastroenterology, Tokyo Women's Medical University
Author Ayako Kobayashi Department of Gastroenterology, Tokyo Women's Medical University
Author Kana Yamamoto Department of Gastroenterology, Tokyo Women's Medical University
Author Katsutoshi Tokushige Department of Gastroenterology, Tokyo Women's Medical University
[ Summary ] Esophagogastric varices are a known manifestation of portal hypertension associated with liver cirrhosis. Esophagogastric varices can be managed using endoscopic treatment, interventional radiology techniques, or surgery; however, presently endoscopic therapy such as the use of endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) remains the primary approach. Emergency endoscopy plays an important role in the diagnosis and treatment of esophagogastric variceal bleeding. EVL was introduced clinically by Stiegmann et al. in 1988 and has gained rapid acceptance because it is a simple procedure that is not associated with any risk of bleeding from a variceal puncture site or the adverse reactions that could occur with sclerotherapy. The introduction of EVL has allowed the implementation of prophylactic treatment and also simplified the process of achieving hemostasis in patients with bleeding varices. The EIS-intravariceal technique is being widely used in Japan over 30 years. EIS using 5 % ethanolamine oleate (5%EO) is highly effective to sclerose esophageal varices and the associated blood vessels. Endoscopists should also acquire skills relating to EIS to enable them to use this technique in difficult cases wherein EVL might not be possible. Endoscopic obliteration of varices using Histoacryl has been introduced clinically and is accepted as first-line treatment for gastric variceal bleeding. It is important to establish and promote the use of guidelines regarding a safe and standard technique.
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