Endoscopic treatment is the main therapy for controlling variceal bleeding and secondary prophylaxis of rebleeding of gastroesophageal varices of portal hypertension. Endoscopic treatment of gastroesophageal varices are developing towards individualization, precision and whole management in recent years. We can diagnose the etiology and characteristic of portal hypertension through medical history, physical examination, laboratory and radiological tests. It is important to identify the etiology of portal hypertension that can control the progress of varices. There is a complex classification of varices. Individualized stratification and treatment selection are based on the results of endoscopic finding, contrast computed tomography (CT), hepatic venous pressure gradient, etc. Modified precise endoscopic injection of cyanoacrylate is important part to improve the efficacy and reduce the complications of endoscopic treatment. We need to pay attention to the complications and comorbidities of portal hypertension, comprehensive management with the multidisciplinary teams, that is the most important thing to improve the efficacy of endoscopic treatment and the prognosis of patients with portal hypertension.

By analysing the new requirements of higher medical education curriculum in the new era,making curriculum changes of Nanjing Medical University as an analysed object,the arti-cle analyses the existing problems and shortcomings of China's current medical education course system,puts forward optimizing the course system further by running clear thinking,construction of composite course system,innovating teaching methods,strengthening the building of teaching mate-rials,the establishment of curriculum assessment mechanisms.

Objective:To analyze the clinicopathological characteristics of patients with unknown etiology of portal hypertension and investigate the efficacy of endoscopic management of gastroesophageal varices in these patients.Methods:Patients with unknown etiology of portal hypertension and gastroesophageal varices who received liver biopsy between January, 2017 and January, 2020 in Zhongshan Hospital were included. The characteristics of pathology, portal computed tomography (CT) angiography, and endoscopy were recorded and follow-up for the occurrence of bleeding after treatment.Results:A total of 31 patients were included and divided into cirrhosis with unknown etiology group ( n=10) and non-cirrhotic portal hypertension group ( n=21). Patients in the non-cirrhotic group were younger [28.0(29.5-49.5) vs 58.5(43.5-65.8), P=0.004] and mostly male (71.4%), and fewer comorbidities including diabetes (4.8% vs 40.0%, P=0.027). The features of pathology finding including vasculopathy, cholestasis, and hepatic sinusoidal dilatation as well as the Sarin classification and bleeding rate of gastroesophageal varices, proportion of patients receiving endoscopic treatment were shown similar between the two groups ( P>0.05). The hepatic venous pressure gradient (HVPG) was significantly lower in the non-cirrhotic group [4.5(2.8-12.8)mmHg vs 12(8-18)mmHg, P=0.018]. Among them, 21 patients received endoscopic treatment, and the bleeding rate had no difference between these two groups after endoscopic treatment ( P=0.751). Conclusions:Non-cirrhotic portal hypertension in a predominantly young male population has similar clinicalpathological characteristics when compared to cirrhotic portal hypertension with unknown etiology. HVPG can not reflect the actual portal pressure in these patients. Endoscopic treatment is the effective treatment option for the prevention of variceal bleeding.

Objective:The aim of this study was to investigate the prognostic value of vitamin B12 as the non-invasive biomarker to predict long-term rebleeding rate in cirrhotic patients with esophagogastric varices.Methods:From Dec 1, 2016 to Dec 31, 2017, cirrhotic patients with esophagogastric varices who had been admitted to Zhongshan Hospital affiliated to Fudan University were enrolled. All these patients received endoscopic treatment to prevent variceal rebleeding. The serum vitamin B12 and folic acid levels were measured in all of them. The receiver operating characteristic (ROC) analysis, Kaplan-Meier analysis, univariate and multivariate cox regression analysis were conducted to explore the value of vitamin B12 in predicting 3-year variceal rebleeding in cirrhotic patients with esophagogastric varices after endoscopic treatment.Results:115 patients were included. The ROC curve analysis indicated that the optimal cutoff value of vitamin B12 for 3-year variceal rebleeding was 567.25 pg/ml. According to the cut-off value, the patients were divided into high-level vitamin B12 group ( n=49) and low-level vitamin B12 group ( n=66). Compared with the low vitamin B12 group, the high vitamin B12 group had lower albumin level, less male (63.3% vs 80.3%), and higher 3-year rebleeding rate ( P<0.05). Cox analysis showed that vitamin B12 and platelet were independent prognostic factors for 3-year rebleeding in patients with variceal bleeding. Conclusions:Elevated peripheral blood vitamin B12 predicts a higher risk of long-term rebleeding in patients with liver cirrhosis and esophagogastric varices.

Objective:To investigate the correlation between thromboelastography (TEG) and portal vein thrombosis in patients with cirrhotic esophagogastric varices.Methods:210 hospitalized patients with cirrhotic esophagogastric varices treated in Zhongshan Hospital Affiliated to Fudan University from December 2016 to December 2017 were retrospectively included. They were divided into portal vein thrombosis group (PVT group) and non portal vein thrombosis group (NPVT group) according to whether they were complicated with portal vein thrombosis. The correlation between the results of TEG coagulation reaction time (R value), coagulation time (K value), αAngle, maximum amplitude (MA) and coagulation composite index (CI) and portal vein thrombosis was analyzed. The characteristics of coagulation status in patients with portal vein thrombosis in cirrhosis were compared.Results:A total of 91 patients (43.3%) were complicated with portal vein thrombosis. The R value in the PVT group was significantly lower than that of NPVT group [5.49(5.22-5.77) vs 5.98(5.76-6.20), P=0.006]. Logistic regression analysis showed that Child Pugh grade ( OR=2.883, 95% CI: 1.630-5.098, P<0.001) and R value ( OR=0.739, 95% CI: 0.575-0.950, P=0.018) were independently associated risk factors of PVT. The R value of patients was significantly correlated with Child Pugh grade ( r=0.147, P=0.034), platelet ( r=-0.358, P<0.001), prothrombin time (PT) ( r=0.334, P<0.001) and international standardized ratio (INR) ( r=0.328, P<0.001). Conclusions:The decrease of TEG-R value is closely related to PVT in liver cirrhosis.

According to the pathophysiological characteristics, upper gastrointestinal bleeding can be divided into acid related disease bleeding and esophageal and gastric varices bleeding. Esophageal and gastric variceal bleeding is a common critical condition of Portal hypertension, with dangerous onset and high mortality. With the improvement of endoscopic treatment technology, endoscopy has become the first line treatment plan for esophageal and gastric variceal bleeding. The commonly used endoscopic management methods for varicose veins include variceal ligation, tissue glue combined with sclerosing agent embolization, ultrasound guided coil combined with tissue glue embolization, and other management measures. Early identification of gastrointestinal bleeding related to varicose veins, stratified diagnosis and treatment of high-risk patients, reasonable selection of endoscopic examination timing, and personalized decision-making of treatment choices are key to improving efficacy.

To assess relationships between xanthine oxidase (XOD) and nephropathogenic infectious bronchitis virus (NIBV) infection, 240 growing layers (35 days old) were randomly divided into two groups (infected and control) of 120 chickens each. Each chicken in the control and infected group was intranasally inoculated with 0.2 mL sterile physiological saline and virus, respectively, after which serum antioxidant parameters and renal XOD mRNA expression in growing layers were evaluated at 8, 15 and 22 days post-inoculation (dpi). The results showed that serum glutathione peroxidase and superoxide dismutase activities in the infected group were significantly lower than in the control group at 8 and 15 dpi (p < 0.01), while serum malondialdehyde concentrations were significantly higher (p < 0.01). The serum uric acid was significantly higher than that of the control group at 15 dpi (p < 0.01). In addition, the kidney mRNA transcript level and serum activity of XOD in the infected group was significantly higher than that of the control group at 8, 15 and 22 dpi (p < 0.05). The results indicated that NIBV infection could cause the increases of renal XOD gene transcription and serum XOD activity, leading to hyperuricemia and reduction of antioxidants in the body.
Antioxidants ; Chickens ; Glutathione Peroxidase ; Hyperuricemia ; Infectious bronchitis virus* ; Kidney ; Malondialdehyde ; RNA, Messenger* ; Superoxide Dismutase ; Uric Acid ; Xanthine Oxidase* ; Xanthine*

Objective:To investigate the safety and efficacy of endoscopic ultrasound-guided coil embolization for gastric varices.Methods:Patients with portal hypertension who received endoscopic ultrasound-guided coil embolization for the prophylaxis of gastric variceal bleeding between November 2016 and August 2020 at Zhongshan Hospital, Fudan University were included in the study. The primary evaluation index was the post-operative loss of blood flow in gastric varices, and the secondary indices included the safety of coil embolization, rebleeding rate, portal vein thrombosis changes and patient survival.Results:A total of 13 patients with isolated gastric varices and portal systemic shunt were enrolled, including 6 males and 7 females with the median age of 58 years. The median maximum diameter of the target vessel was 40 mm and the median number of coils used was 2.7. All puncture sites were in the lower part of the esophagus near the cardia, and no active bleeding occurred after deployment of coils. Flow in the gastric varices were confirmed absent by Doppler imaging. In a median follow-up period of 403 days, 2 patients had rebleeding, with the one-year rebleeding rate of 9.1%.Two patients developed portal venous thrombosis after the operation. Two patients died, and the one-year survival rate was 90.0%.Conclusion:Endoscopic ultrasound-guided coil embolization might be an effective option for the treatment of isolated gastric varices with portal systemic shunts.

Objective:This study aimed to evaluate the rebleeding risk and prognosis of patients being treated after acute esophageal varices bleeding by two different treatment strategies: sclerosing agent combined with tissue glue injection, esophageal varices ligation (EVL), through comparing the therapeutic effects and securities.Methods:A total of 76 patients who underwent endoscopy and received treatment in Zhongshan Hospital Affiliated to Fudan University due to acute esophageal variceal bleeding were included retrospectively. 6 patients with active bleeding and 70 patients with thrombus in esophagus varices under gastroscopy. Among them, 21 cases were treated with sclerosing agent combined with tissue glue injection (sclerosing tissue glue group), and 55 cases were treated with EVL (EVL group). The emergency endoscopic diagnosis and treatment of the two groups were compared, and the risk factors of rebleeding 6 months after endoscopic treatment were analyzed by univariate and multivariate analysis.Results:All patients received endoscopic treatment successfully. During the follow-up period of 6 months after endoscopic treatment, rebleeding occurred in 13 cases. Kaplan Meier analysis showed that the 6-month rebleeding rate in the sclerosing tissue glue group was significantly higher than that in the EVL group (41.6% vs 12.3%, P=0.011). There were 8 deaths in total. Kaplan Meier analysis showed that there was no significant difference in 6-month mortality between the two groups (17.5% vs 10.1%, P=0.616). Multivariate analysis further showed that malignant tumor ( HR=3.700, 95% CI: 1.187-11.536, P=0.024) and treatment mode of esophageal variceal bleeding ( HR=4.834, 95% CI: 1.443-16.193, P=0.011) were independent risk factors for rebleeding 6 months after endoscopic treatment of acute esophageal variceal bleeding. Conclusions:This study found that EVL and the combining injection of lauromacrogol and cyanoacrylate could be used in emergent hemostatic treatment for acute esophageal varices bleeding. Moreover, EVL is the prioritized approach in endoscopic emergency treatment with a lower rebleeding rate and fewer complications. Sclerotherapy combined with tissue glue can be used as one of the measures of emergency treatment, which is not better than ligation.

Objective:In this study, the liver, spleen, and hepatic portal vein in the portal venous phase images of abdominal enhanced computed tomography (CT) are artificially segmented and annotated, and the radiomics features are extracted from them. A model for predicting portal pressure in patients with hepatitis B virus (HBV) related cirrhosis is constructed by combining radiomics features with clinical indicators.Methods:A total of 171 patients who had abdominal enhancement CT examination and trans-jugular hepatic venous pressure gradient (HVPG) measurement at the same time were enrolled from January 2016 to May 2020 in the Zhongshan Hospital Affiliated to Fudan University. The liver, spleen, and hepatic portal vein in the portal venous phase images of the CT were manually labeled by using ITK-SNAP 3.8 software. The radiomics features of these three sites were extracted using Python programming, and an HVPG prediction model was established.Results:A total of 171 patients was included in the study. The average age was (51.1±10.3)years, of which 134(78.4%) were males, and the average HVPG was 16.87±5.695. A total of 2 553 radiomics features were extracted from three sites of the portal venous phase images of abdominal enhanced CT in each patient. The 2 553 features extracted were screened using LASSO, and by combing with clinical features and radiomics features, the predictive model of HVPG was obtained: m_HVPG=31.622+ 0.028 8T×total bile acids-6.31(portal venous wavelet-LHH_glcm_ClusterShade)=0.253(portal venous wavelet-LHL_glszm_LargeAreaLowGrayLevelEmphasis)-20.9(spleen wavelet-LLH_glcm_Correlation)-0.000 127(liver original_shape_SurfaceArea)+ 2.79(liver wavelet-LLH_glcm_ClusterShade). The coefficient of determination R2 was 0.345. Conclusions:The study suggests that radiomics features of the liver, spleen, and portal venous combined with clinical features may be used as a non-invasive method to assess the portal pressure in patients with HBV-related cirrhosis.