凝血试验指标对肝硬化合并急性上消化道出血的预测价值

张丽航; 王善娟; 陆伦根; 刘艳丽; 王一飞; 谢津璧

doi:10.3969/j.issn.1001-5256.2018.10.014

凝血试验指标对肝硬化合并急性上消化道出血的预测价值

DOI: 10.3969/j.issn.1001-5256.2018.10.014

1. 上海市健康医学院附属嘉定区中心医院消化内科
2. 上海交通大学附属第一人民医院消化科

基金项目:

上海市嘉定区卫计委2017年重点学科消化学科(2017ZD01)；

详细信息

中图分类号: R575.2;R573.2
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出版历程
- 出版日期: 2018-10-20

Predictive value of coagulation test parameters for acute upper gastrointestinal bleeding in patients with liver cirrhosis

Department of Gastroenterology, Jiading District Central Hospital, Shanghai University of Medicine & Health Sciences

Research funding:

摘要

摘要: 目的探讨凝血试验指标与肝硬化合并急性上消化道出血（AUGIB）之间的关系。方法收集2013年1月-2016年12月在上海市健康医学院附属嘉定区中心医院消化内科住院的肝硬化患者233例,根据患者有无合并上消化道出血分为AUGIB组（n=87）和无AUGIB组（n=146）。收集患者姓名、性别、年龄、肝硬化原因、评价腹水情况、肝性脑病情况,入院时第1次验血指标,包括血常规、TBil、Alb、肌酐、凝血试验[包括PT、PTA、活化部分凝血活酶时间（APTT）、国际标准化比值（INR）、纤维蛋白原（FIB）、凝血酶时间（TT）]、D-二聚体。根据收集到的数据计算Child-Pugh评分和终末期肝病模型（MELD）评分。计量资料2组间比较采用独立样本t检验,多组间比较采用方差分析。logistic回归分析对各变量进行单变量和多变量分析。结果 Child-Pugh C级的患者,其PT、APTT、TT和INR较A、B级延长,PTA、FIB水平下降,TBil、MELD评分明显升高（F值分别为62. 706、33. 858、17. 781、63. 025、46. 907、7. 514、23. 020、2...
- 血液凝固试验 /
- 肝硬化 /
- 出血 /
- 预测
Abstract: Objective To investigate the association between coagulation test parameters and acute upper gastrointestinal bleeding ( AUGIB) in patients with liver cirrhosis. Methods A total of 233 patients with liver cirrhosis who were hospitalized in Department of Gastroenterology, Jiading District Central Hospital, Shanghai University of Medicine & Health Sciences, from January 2013 to December 2016, and according to the presence or absence of AUGIB, they were divided into AUGIB group with 87 patients and non-AUGIB group with 146 patients. Related clinical data were collected, including name, sex, age, cause of liver cirrhosis, ascites, hepatic encephalopathy, blood parameters of the first blood test after admission [routine blood test results, total bilirubin ( TBil) , albumin, and creatinine], coagulation test results [prothrombin time ( PT) , prothrombin time activity ( PTA) , activated partial thromboplastin time ( APTT) , international normalized ratio ( INR) , fibrinogen ( FIB) , thrombin time ( TT) ], and D-dimer. The Child-Pugh score and Model for End-Stage Liver Disease ( MELD) score were calculated based on these data. The independent samples t-test was used for comparison of continuous data between two groups, and an analysis of variance was used for comparison between multiple groups. Logistic regression was used for univariate and multivariate analyses of related variables. Results Compared with the patients with Child-Pugh class A/B liver cirrhosis, the patients with Child-Pugh class C liver cirrhosis had significantly longer PT, APTT, and TT, a significantly higher INR, significant reductions in PTA and FIB, and significant increases in TBil and MELD score ( F = 62. 706, 33. 858, 17. 781, 63. 025, 46. 907, 7. 514, 23. 020, and20. 519, all P < 0. 05) . Of all 233 patients, only 175 underwent the measurement of D-dimer, and D-dimer was not measured for 58 patients, which caused data loss. According to the Child-Pugh class, the 175 patients who underwent D-dimer measurement were divided into Child-Pugh class A group with 33 patients, Child-Pugh class B group with 93 patients, and Child-Pugh class C group with 49 patients, and there was a significant difference in the level of D-dimer between these three groups ( 1. 63 ± 2. 15 mg/L vs 3. 48 ± 4. 25 mg/L vs 4. 24 ± 4. 79 mg/L, F = 4. 089, P = 0. 018) . Compared with the MELD ≥13 group, the MELD < 13 group had significantly longer PT, INR, and APTT and a significant reduction in PTA ( t = 7. 307, 7. 602, 3. 650, and 5. 546, all P < 0. 05) . Among the 87 patients in the AUGIB group, 76 had esophagogastric variceal bleeding, 9 had peptic ulcer, 1 had bleeding due to portal hypertensive gastropathy, and 1 had bleeding due to gastric carcinoma. Compared with the non-AUGIB group, the AUGIB group had a significantly longer APTT, a significantly higher FIB level, and a significantly higher Child-Pugh class ( t = 7. 178, 14. 644, and 30. 082, all P < 0. 05) . APTT and FIB were significantly associated with AUGIB ( APTT: likelihood ratio [LR]= 1. 09, 95% confidence interval [CI]: 1. 04-1. 14, P < 0. 001; FIB:LR = 2. 34, 95% CI: 1. 61-3. 41, P < 0. 001) . Conclusion The increases in PT, INR, and APTT parallel with Child-Pugh class and MELD score in patients with liver cirrhosis, and the prolongation of APTT and the increase in FIB can predict the possibility of AUGIB in patients with liver cirrhosis.
- blood coagulation tests /
- liver cirrhosis /
- hemorrhage /
- forecasting

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参考文献(34)

[1]JAIRATH V, REHAL S, LOGAN R, et al.Acute variceal haemorrhage in the United Kingdom:Patient characteristics, management and outcomes in a nationwide audit[J].Dig Liver Dis, 2014, 46 (5) :419-426.

[2]SVOBODA P, KONECNY M, MARTINEK A, et al.Acute upper gastrointestinal bleeding in liver cirrhosis patients[J].Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 2012, 156 (3) :266-270.

[3]KUJOVICH JL.Coagulopathy in liver diseas:A balancing act[J].Hematology Am Soc Hematol Educ Program, 2015, 2015 (1) :243-249.

[4]LI J, QI X, DENG H, et al.Association of conventional haemostasis and coagulation tests with the risk of acute upper gastrointestinal bleeding in liver cirrhosis:A retrospective study[J].Gastroenterol Rep (Oxf) , 2016, 4 (4) :315-319.

[5]KAMATH PS, WIESNER RH, MALINCHOC M, et al.A model to predict survival in patients with end-stage liver disease[J].Hepatology, 2001, 33 (2) :464-470.

[6]CHAWLA YK, KASHINATH RC, DUSEJA A, et al.Predicting mortality across a broad spectrum of liver disease:An assessment of model for end-stage liver disease (meld) , child-turcotte-pugh (CTP) , and creatinine-modified ctp scores[J].J Clin Exp Hepatol, 2011, 1 (1) :161-168.

[7]TRIPODI A.The coagulopathy of chronic liver disease:Is there a causal relationship with bleeding?NO[J].Eur J Intern Med, 2010, 21 (2) :65-69.

[8]BASILI S, RAPARELLI V, VIOLI F.The coagulopathy of chronic liver disease:Is there a causal relationship with bleeding?Yes[J].Eur J Intern Med, 2010, 21 (2) :62-64.

[9]JAMIL Z, MALIK M, DURRANI AA.Platelet count to splenic diameter ratio and other noninvasive markers as predictors of esophageal varices in patients with liver cirrhosis[J].Turk J Gastroenterol, 2017, 28 (5) :347-352.

[10]PENG Y, QI X, DAI J, et al.Child-Pugh versus MELD score for predicting the in-hospital mortality of acute upper gastrointestinal bleeding in liver cirrhosis[J].Int J Clin Exp Med, 2015, 8 (1) :751-757.

[11]ZOCCO MA, di STASIO E, de CRISTOFARO R, et al.Thrombotic risk factors in patients with liver cirrhosis:Correlation with MELD scoring system and portal vein thrombosis development[J].J Hepatol, 2009, 51 (4) :682-689.

[12]LISMAN T, PORTE RJ.Rebalanced hemostasis in patients with liver disease:evidence and clinical consequences[J].Blood, 2010, 116 (6) :878-885.

[13]TRIPODI A, MANNUCCI PM.The coagulopathy of chronic liver disease[J].N Engl J Med, 2011, 365 (2) :147-156.

[14]LEE JH, KWEON OJ, LEE MK, et al.Clinical usefulness of international normalized ratio calibration of prothrombin time in patients with chronic liver disease[J].Int J Hematol, 2015, 102 (2) :163-169.

[15]TRIPODI A, PRIMIGNANI M, LEMMA L, et al.Detection of the imbalance of procoagulant versus anticoagulant factors in cirrhosis by a simple laboratory method[J].Hepatology, 2010, 52 (1) :249-255.

[16]FENG L, SUN K, ZHANG J, et al.A novel non-invasive index using AFP and APTT is associated with liver fibrosis in patients with chronic hepatitis B infection:A retrospective cohort study[J].BMJOpen, 2015, 5 (9) :e008032.

[17]TRIPODI A, PRIMIGNANI M, CHANTARANGKUL V, et al.An imbalance of pro-vs anti-coagulation factors in plasma from patients with cirrhosis[J].Gastroenterology, 2009, 137 (6) :2105-2111.

[18]TROTTER JF, BRIMHALL B, ARJAL R, et al.Specific laboratory methodologies achieve higher model for endstage liver disease (MELD) scores for patients listed for liver transplantation[J].Liver Transpl, 2004, 10 (8) :995-1000.

[19]TRIPODI A, SALERNO F, CHANTARANGKUL V, et al.Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests[J].Hepatology, 2005, 41 (3) :553-558.

[20]LIAO WC, HOU MC, CHANG CJ, et al.Potential precipitating factors of esophageal variceal bleeding:A case-control study[J].Am J Gastroenterol, 2011, 106 (1) :96-103.

[21]GIANNINI EG, GRECO A, MARENCO S, et al.Incidence of bleeding following invasive procedures in patients with thrombocytopenia and advanced liver disease[J].Clin Gastroenterol Hepatol, 2010, 8 (10) :899-902.

[22]HONG WD, DONG LM, JIANG ZC, et al.Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis[J].Clinics (Sao Paulo) , 2011, 66 (1) :119-124.

[23]MADHOTRA R, MULCAHY HE, WILLNER I, et al.Prediction of esophageal varices in patients with cirrhosis[J].J Clin Gastroenterol, 2002, 34 (1) :81-85.

[24]ZAMAN A, BECKER T, LAPIDUS J, et al.Risk factors for the presence of varices in cirrhotic patients without a history of variceal hemorrhage[J].Arch Intern Med, 2001, 161 (21) :2564-2570.

[25]LALOSEVIC MS, STOJKOVIC M, NAUMOVIC T, et al.Clinical scores for the prediction of esophageal varices in patients with liver cirrhosis[J].Acta Gastroenterol Belg, 2016, 79 (1) :14-17.

[26]SHARARA AI, ROCKEY DC.Gastroesophageal variceal hemorrhage[J].N Engl J Med, 2001, 345 (9) :669-681.

[27]QI X, CHEN H, HAN G.Effect of antithrombin, protein C and protein S on portal vein thrombosis in liver cirrhosis:A meta-analysis[J].Am J Med Sci, 2013, 346 (1) :38-44.

[28]TISCHENDORF M, MIESBACH W, CHATTAH U, et al.Differential kinetics of coagulation factors and natural anticoagulants in patients with liver cirrhosis:Potential clinical implications[J].PLo S One, 2016, 11 (5) :1-9.

[29]TRIPODI A, CALDWELL SH, HOFFMAN M, et al.Review article:The prothrombin time test as a measure of bleeding risk and prognosis in liver disease[J].Aliment Pharmacol Ther, 2007, 26 (2) :141-148.

[30]SEGAL J, DZIK W.Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures:An evidence-based review[J].Transfusion, 2005, 45 (9) :1413-1425.

[31]TACKE F, FIEDLER K, von DEPKA M, et al.Clinical and prognostic role of plasma coagulation factor XIII activity for bleeding disorders and 6-year survival in patients with chronic liver disease[J].Liver Int, 2006, 26 (2) :173-181.

[32]GARBUZENKO DV.Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding[J].Curr Med Res Opin, 2016, 32 (3) :467-475.

[33]BENDTSEN F, D'AMICO G, RUSCH E, et al.Effect of recombinant factor VIIa on outcome of acute variceal bleeding:an individual patient based meta-analysis of two controlled trials[J].J Hepatol, 2014, 61 (2) :252-259.

[34]BOSCH J, THABUT D, ALBILLOS A, et al.Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis:A randomized, controlled trial[J].Hepatology, 2008, 47 (5) :1604-1614.

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