伴门静脉栓子的食管胃静脉曲张破裂出血急诊胃镜下硬化术联合组织胶注射术止血失败的危险因素分析

丁鹏鹏; 王沧海; 李莉; 陈建宏; 祁小宝; 王艳玲; 路筝; 张文辉; 刘红

doi:10.3969/j.issn.1001-5256.2021.01.014

伴门静脉栓子的食管胃静脉曲张破裂出血急诊胃镜下硬化术联合组织胶注射术止血失败的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2021.01.014

1.
首都医科大学附属北京世纪坛医院消化内科，北京 100038
2.
解放军总医院第五医学中心肝硬化诊疗一中心，北京 100039

基金项目:

国家自然科学基金青年科学基金项目 (81900505)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。

作者贡献声明：丁鹏鹏、陈建宏负责课题设计，资料分析，撰写论文；李莉、祁小宝、王艳玲参与收集数据，修改论文；王沧海、路筝、张文辉、刘红负责拟定写作思路，指导撰写文章，并最后定稿。

详细信息

作者简介:
丁鹏鹏(1985—)，男，主治医师，主要从事肝病、消化内镜方面的研究

通信作者:
刘红，liuhong_sjt@ccmu.edu.cn

中图分类号: R575.2
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- 被引次数: 34
出版历程
- 收稿日期: 2020-07-27
- 录用日期: 2020-09-07
- 出版日期: 2021-01-20

Risk factors for hemostatic failure in emergency gastroscopic sclerotherapy combined with tissue adhesive injection for esophagogastric variceal bleeding with portal vein embolus

1.
Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
2.
First Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China

摘要

摘要: 目的探讨急诊胃镜下硬化术(EIS)序贯联合组织胶注射术(HI)在合并门静脉栓子(PVE)的肝硬化食管胃静脉曲张破裂出血(EGVB)治疗中失败的危险因素。方法选取2018年1月—2019年12月首都医科大学附属北京世纪坛医院和解放军总医院第五医学中心急诊胃镜治疗的合并PVE的EGVB患者共109例，按照急诊胃镜下止血疗效分为止血失败组(n=28)和止血成功组(n=81)，比较两组间的一般资料、胃镜下静脉曲张及出血表现、血液生化指标、Child-Pugh分级及MELD评分，分析其止血失败的危险因素。计量资料两组间比较采用t检验或Mann-Whitney U秩和检验，计数资料两组间比较采用χ²检验，多因素分析采用logisitc回归分析。结果止血失败组外周血WBC、TBil、Child-Pugh分级、MELD评分均显著高于止血成功组(统计值分别为Z=3.794、Z=4.751、χ²=40.104、Z=6.412，P值均＜0.001)，而PTA、Alb、CHE均显著低于止血成功组(统计值分别为t=9.653、Z=3.093、Z=4.092，P值分别为＜0.001、0.002、＜0.001)；其中WBC、PTA、TBil、Alb、Child-Pugh分级为其止血治疗失败的独立危险因素[OR(95%CI)分别为：28.543(1.285~634.113)、0.194(0.045~0.835)、2.197(1.004~4.810)、0.448(0.209~0.961)、5.164(1.307~20.406)，P值均＜0.05]。结论 WBC、PTA、TBil、Alb、Child-Pugh分级为急诊EIS序贯联合HI治疗合并PVE的EGVB失败的独立危险因素，术前充分评估并纠正有助于提高止血成功率。
- 肝硬化 /
- 静脉血栓形成 /
- 食管和胃静脉曲张 /
- 出血 /
- 止血, 内窥镜
Abstract: Objective To investigate the risk factors for failure in emergency endoscopic injection sclerotherapy (EIS) combined with sequential histoacryl injection (HI) for esophagogastric variceal bleeding (EGVB) with portal vein embolus (PVE). Methods A total of 109 EGVB patients with PVE who underwent emergency gastroscopy in Beijing Shijitan Hospital, Capital Medical University, and The Fifth Medical Center of Chinese PLA General Hospital from January 2018 to December 2019 were enrolled, and according to the outcome of hemostatic treatment under emergency gastroscopy, the patients were divided into hemostatic failure group with 28 patients and hemostatic success group with 81 patients. The two groups were compared in terms of general information, varices and bleeding manifestations under gastroscopy, blood biochemical parameters, Child-Pugh class, and Model for End-Stage Liver Disease (MELD) score, and the risk factors for hemostatic failure were analyzed. The t-test or the Mann-Whitney U test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups; a logistic regression analysis was used for multivariate analysis. Results Compared with the hemostatic success group, the hemostatic failure group had significantly higher peripheral white blood cell count (WBC), total bilirubin (TBil), Child-Pugh class, and MELD score (Z=3.794, Z=4.751, χ²=40.104, Z=6.412, all P < 0.001) and significantly lower prothrombin time activity (PTA), albumin (Alb), and cholinesterase (CHE) (t=9.653, Z=3.093, Z=4.092, P < 0.001, P=0.002, and P < 0.001). WBC (odds ratio [OR]=28.543, 95% confidence interval [CI]: 1.285-634.113, P < 0.05), PTA(OR=0.194, 95%CI: 0.045-0.835, P < 0.05), TBil (OR=2.197, 95%CI: 1.004-4.810, P < 0.05), Alb (OR=0.448, 95%CI: 0.209-0.961, P < 0.05), and Child-Pugh class (OR=5.164, 95%CI: 1.307-20.406, P < 0.05) were independent risk factors for hemostatic failure. Conclusion WBC, PTA, TBil, Alb, and Child-Pugh class are independent risk factors for failure in emergency EIS combined with sequential HI in the treatment of EGVB with PVE, and adequate preoperative evaluation and correction may help to improve the success rate of hemostasis.
- Liver Cirrhosis /
- Venous Thrombosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Hemostasis, Endoscopic

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表 1 两组一般资料比较

项目	成功组(n=81)	失败组(n=28)	统计值	P值
男[例(%)]	55(67.9)	23(82.1)	χ²=2.074	0.150
年龄(岁)	57.44±9.63	55.04±9.00	t=1.160	0.249
肝硬化病因[例(%)]			χ²=2.531	0.112
病毒性肝炎	71(87.7)	21(75.0)
非病毒性肝炎	10(12.3)	7(25.0)
肝硬化病程(年)	7.44(2.00~9.00)	4.39(1.00~6.75)	Z=1.894	0.058
合并肝癌[例(%)]	28(34.6)	14(50.0)	χ²=2.092	0.148
首次出血[例(%)]	35(43.2)	8(28.6)	χ²=1.867	0.172

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表 2 两组静脉曲张情况比较

胃镜下表现	成功组(n=81)	失败组(n=28)	χ²值	P值
静脉曲张程度[例(%)]			2.771	0.096
重度中度	64(79.0) 17(21.0)	26(92.9) 2(7.1)
静脉曲张出血部位[例(%)]			4.773	0.092
食管贲门胃底	54(66.7) 19(23.5) 8(9.9)	17(60.7) 11(39.3) 0
胃镜下出血表现[例(%)]			0.131	0.717
活动性出血¹⁾	46(56.8)	17(60.7)
其他²⁾	35(43.2)	11(39.3)
注：1)活动性出血指静脉曲张喷血、涌血或渗血; 2)其他指曲张静脉有糜烂、血栓及镜下能够见到新鲜血液，并能排除非静脉曲张出血因素。

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表 3 两组血液生化指标比较

项目	成功组(n=81)	失败组(n=28)	统计值	P值
WBC(10⁹/L)	4.29(1.51~5.88)	8.10(3.75~11.03)	Z=3.794	＜0.001
Hb(g/L)	92.78(83.50~102.50)	88.50(71.25~99.75)	Z=1.467	0.142
PLT(10⁹/L)	125.44(80.50~131.00)	91.89(50.50~135.75)	Z=1.876	0.061
PTA(%)	76.62±7.40	53.60±17.51	t=9.653	＜0.001
ALT(U/L)	28.05(19.00~35.00)	53.50(20.75~70.50)	Z=1.657	0.098
AST(U/L)	51.11(31.50~57.00)	139.50(32.00~177.50)	Z=1.758	0.079
TBil(μmol/L)	18.83(10.65~19.25)	69.49(19.00~79.80)	Z=4.751	＜0.001
Alb(g/L)	32.33(29.00~36.50)	28.11(24.00~33.75)	Z=3.093	0.002
ChE(U/L)	3445(2487~4260)	2327(1579~2772)	Z=4.092	＜0.001
Child-Pugh分级[例(%)]			χ²=40.104	＜0.001
A级 B级 C级	33(40.7) 42(51.9) 6(7.4)	011(39.3) 17(60.7)
MELD评分	8.59(7~8)	14.68(10~17)	Z=6.412	P＜0.001

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表 4 止血疗效影响因素的logistics回归分析

变量	B值	SE	Wald值	P值	OR(95%CI)
WBC	3.351	1.582	4.487	0.034	28.543(1.285~634.113)
PTA	1.641	0.746	4.846	0.028	0.194(0.045~0.835)
TBil	0.787	0.400	3.880	0.049	2.197(1.004~4.810)
Alb	0.802	0.389	4.261	0.039	0.448(0.209~0.961)
ChE	0.002	0.002	2.180	0.140	0.998(0.994~1.001)
MELD评分	0.066	0.909	0.005	0.942	1.068(0.180~6.329)
Child-Pugh分级¹⁾(B级=0，C级=1)	1.642	0.701	5.483	0.019	5.164(1.307~20.406)
注：1)因止血失败组Child-Pugh A级为0例，仅纳入两组间Child-Pugh B级C级进行比较。

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