肝硬化食管静脉曲张内镜治疗术后早期再出血的危险因素分析

张妍; 丁惠国

doi:10.3969/j.issn.1001-5256.2021.09.017

肝硬化食管静脉曲张内镜治疗术后早期再出血的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2021.09.017

张妍¹,
丁惠国^2, ,

1.
首都医科大学附属北京友谊医院医疗保健中心，北京 100050
2.
首都医科大学附属北京佑安医院肝病消化中心，北京 100069

基金项目:

病毒性肝炎和艾滋病等重大传染病防治专项 (2017ZX10203202-004);

北京市医院管理中心消化内科学科协同发展中心 (XXZ0801)

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。

作者贡献声明：张妍负责课题设计，收集及分析资料，撰写论文; 丁惠国负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
丁惠国，dinghuiguo@ccmu.edu.cn

中图分类号: R575.2
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出版历程
- 收稿日期: 2021-05-16
- 录用日期: 2021-06-07
- 出版日期: 2021-09-20

Risk factors for early rebleeding after endoscopic therapy for esophageal varices in cirrhotic patients

Yan ZHANG¹,
Huiguo DING^{2
, ,}

1.
Health Care Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
2.
Center of Hepatic and Digestive Diseases, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China

Research funding:

The State Key Projects Specialized on Infectious Diseases (2017ZX10203202-004);

The Digestive Medical Coordinated Development Center of Beijing Hospitals Authority (XXZ0801)

摘要

摘要: 目的探讨肝硬化食管静脉曲张破裂出血患者经内镜下套扎治疗、硬化剂治疗后早期再出血的危险因素。方法回顾性分析2017年5月—2019年5月于首都医科大学附属北京佑安医院行内镜下套扎治疗或者硬化剂治疗的153例肝硬化食管静脉曲张破裂出血患者的临床资料。根据内镜治疗后72 h~6周内有无再出血分为早期再出血组和未出血组，应用logistic回归分析，分析早期再出血的独立危险因素。正态分布的计量资料2组间比较采用t检验，非正态分布的计量资料2组间比较采用Mann-Whitney U检验; 计数资料2组间比较采用χ²检验或Fisher精确概率法。结果早期再出血率为24.8%(38/153)。早期再出血组的Alb低于未出血组，APTT、PT高于未出血组，差异均有统计意义(P值均＜0.05);男性、曲张静脉程度、红色征、门静脉血栓、腹水程度和肝功能分级在两组间差异均有统计意义(P值均＜0.05)。logistic回归分析显示，伴发门静脉血栓(OR=9.781，95%CI：2.248~42.556，P=0.002)、大量腹水(OR=6.195, 95%CI：1.053~36.447，P=0.044)及肝功能Child-Pugh C级(OR=6.434，95%CI：1.067~38.786，P=0.042)是早期再出血的独立危险因素; Alb(OR=0.806，95%CI：0.685~0.947，P=0.009)是早期再出血的保护因素。结论门静脉血栓、大量腹水、肝硬化Child C级及低蛋白血症是肝硬化食管静脉曲张破裂出血患者内镜治疗术后早期再出血的独立危险因素，临床上应引起足够重视。
- 肝硬化 /
- 食管和胃静脉曲张 /
- 出血 /
- 内窥镜检查, 胃肠道
Abstract: Objective To investigate the risk factors for early rebleeding after endoscopic ligation or sclerotherapy for esophageal variceal bleeding in cirrhotic patients. Methods A retrospective analysis was performed for the clinical data of 153 cirrhotic patients with esophageal variceal bleeding who underwent endoscopic ligation or sclerotherapy in Beijing YouAn Hospital, Capital Medical University, from May 2017 to May 2019, and according to the presence or absence of rebleeding from 72 hours to 6 weeks after endoscopic therapy, the patients were divided into rebleeding group and non-rebleeding group. A logistic regression analysis was performed to investigate independent risk factors for early rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. Results Early rebleeding rate was 24.8% (38/153). Compared with the non-rebleeding group, the rebleeding group had a significantly lower albumin (Alb) and significantly higher activated partial thromboplastin time and prothrombin time (all P < 0.05), and there were also significant differences between the two groups in proportion of male sex, degree of varicose veins, red color sign, portal vein thrombosis, severity of ascites, and liver function grade (all P < 0.05). The multivariate logistic regression analysis showed that portal vein thrombosis (odds ratio [OR]=9.781, 95% confidence interval [CI]: 2.248-42.556, P=0.002), massive ascites (OR=6.195, 95%CI: 1.053-36.447, P=0.044), and Child-Pugh class C liver function (OR=6.434, 95%CI: 1.067-38.786, P=0.042) were independent risk factors for early rebleeding, while Alb (OR=0.806, 95%CI: 0.685-0.947, P=0.009) was a protective factor against early rebleeding. Conclusion Portal vein thrombosis, massive ascites, Child-Pugh C liver cirrhosis, and hypoproteinemia are independent risk factors for early rebleeding after endoscopic therapy in cirrhotic patients with esophageal variceal bleeding, which should be taken seriously in clinical practice.
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Endoscopy, Gastrointestinal

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表 1 治疗后早期再出血组与未出血组患者的单因素分析

指标	未出血组(n=115)	早期再出血组(n=38)	统计值	P值
年龄(岁)	55±11	56±13	t=-0.088	0.930
白细胞(×10⁹/L)	2.55(1.87~3.43)	2.74(2.23~3.68)	Z=-0.853	0.394
红细胞(×10⁹/L)	2.93(2.51~3.34)	2.71(2.42~3.00)	Z=-1.727	0.084
血红蛋白(g/L)	84(70~99)	76(68~93)	Z=-1.274	0.203
血小板(×10⁹/L)	68(48~101)	65(47~101)	Z=-0.232	0.816
ALT(U/L)	21.8(13.2~35.7)	23.7(15.9~35.7)	Z=-0.823	0.410
AST(U/L)	32.3(22.0~43.6)	32.9(25.8~43.2)	Z=-0.443	0.657
TBil(μmol/L)	18.3(14.2~32.2)	18.4(15.4~34.3)	Z=-0.424	0.671
ALP(U/L)	78.5(56.1~108.0)	77.5(63.5~95.5)	Z=-0.108	0.914
GGT(U/L)	35.8(21.1~69.8)	36.6(24.8~69.2)	Z=-0.695	0.487
PTA(%)	76(61~85)	78(61~89)	Z=-0.667	0.504
Alb(g/L)	35.8±4.5	30.1±4.3	t=6.828	＜0.001
APTT(s)	33.6(30.1~35.9)	34.5(32.0~39.6)	Z=-2.703	0.007
PT(s)	13.0(11.7~14.5)	13.6(12.2~16.9)	Z=-2.562	0.010
门静脉宽(cm)	1.4(1.2~1.5)	1.3(1.2~1.4)	Z=-0.878	0.380
UREA(mmol/L)	4.24(2.87~5.3)	4.38(3.39~6.00)	Z=-0.807	0.420
CR(μmol/L)	64.7(57.7~78.1)	62.0(56.1~80.2)	Z=-0.490	0.624
治疗方法[例(%)]			χ²=0.183	0.669
硬化	62(53.9)	22(57.9)
套扎	53(46.1)	16(42.1)
性别[例(%)]			χ²=4.15	0.042
女	55(47.8)	11(28.9)
男	60(52.2)	27(71.1)
合并糖尿病[例(%)]			χ²=0.33	0.566
无	92(80.0)	32(84.2)
有	23(20.0)	6(15.8)
肝硬化病因[例(%)]				0.470
病毒性	75(65.2)	25(65.8)
免疫性	17(14.8)	9(23.7)
酒精性	8(7.0)	1(2.6)
其他	15(13.0)	3(7.9)
抗病毒治疗[例(%)]			χ²=1.683	0.194
无	85(73.9)	32(84.2)
有	30(26.1)	6(15.8)
胃底静脉曲张[例(%)]			χ²=1.702	0.192
无	37(32.2)	8(21.1)
有	78(67.8)	30(78.9)
曲张静脉位置[例(%)]				0.399
中下段	47(40.9)	12(31.6)
下段	3(2.6)	0(0)
全程	65(56.5)	26(68.4)
曲张静脉程度[例(%)]			χ²=6.515	0.011
中度	23(20.0)	1(2.6)
重度	92(80.0)	37(97.4)
红色征[例(%)]			χ²=6.600	0.010
无	28(24.3)	2(5.3)
有	87(75.7)	36(94.7)
门静脉血栓[例(%)]			χ²=21.106	＜0.001
无	91(79.1)	15(39.5)
有	24(20.9)	23(60.5)
腹水程度[例(%)]			χ²=48.601	＜0.001
无	50(43.5)	7(18.4)
1级	48(41.7)	3(7.9)
2级	6(5.2)	8(21.1)
3级	11(9.6)	20(52.6)
肝功能分级[例(%)]			χ²=50.746	＜0.001
Child-Pugh A	62(53.9)	9(23.7)
Child-Pugh B	45(39.1)	6(15.8)
Child-Pugh C	8(7.0)	23(60.5)
注：UREA, 尿素氮; CR, 肌酐。

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表 2 内镜治疗后早期再出血的多因素分析

指标	B值	SE	Wald	P值	OR	95%CI
男性	0.322	0.716	0.203	0.653	1.380	0.339~5.620
红色征	1.745	1.023	2.909	0.088	5.727	0.771~42.548
门静脉血栓	2.280	0.750	9.241	0.002	9.781	2.248~42.556
腹水程度
无腹水			8.268	0.041
腹水1级	-0.951	0.969	0.962	0.327	0.386	0.058~2.584
腹水2级	1.466	0.983	2.224	0.136	4.333	0.631~29.759
腹水3级	1.824	0.904	4.069	0.044	6.195	1.053~36.447
重度静脉曲张	1.699	1.412	1.447	0.229	5.467	0.343~87.016
肝功能分级
Child-Pugh A			6.335	0.042
Child-Pugh B	-0.102	0.840	0.015	0.903	0.903	0.174~4.682
Child-Pugh C	1.862	0.917	4.125	0.042	6.434	1.067~38.786
Alb	-0.216	0.083	6.858	0.009	0.806	0.685~0.947
APTT	-0.012	0.083	0.022	0.882	0.988	0.840~1.162
PT	0.125	0.148	0.716	0.398	1.134	0.848~1.516
常量	-0.376	4.326	0.008	0.931	0.686

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参考文献(18)

[1]	CERINI F, GONZALEZ JM, TORRES F, et al. Impact of anticoagulation on upper-gastrointestinal bleeding in cirrhosis A retrospective multicenter study[J]. Hepatology, 2015, 62(2): 575-583. DOI: 10.1002/hep.27783.
[2]	TOSHIKUNI N, TAKUMA Y, TSUTSUMI M. Management of gastroesophageal varices in cirrhotic patients: Current status and future directions[J]. Ann Hepatol, 2016, 15(3): 314-25. DOI: 10.5604/16652681.1198800.
[3]	LO GH. Endoscopic treatments for portal hypertension[J]. Hepatol Int, 2018, 12(Suppl 1): 91-101. DOI: 10.1007/s12072-017-9828-8.
[4]	WANG J, ZHENG GZ. Factors related to esophageal variceal bleeding in patients with liver cirrhosis[J/CD]. Chin J Liver Dis(Electronic Version), 2019, 11(1): 42-46. DOI: 10.3969/j.issn.1674-7380.2019.01.008. 王娟, 郑鸽之. 肝硬化食管静脉曲张破裂出血相关因素分析[J/CD]. 中国肝脏病杂志(电子版), 2019, 11(1): 42-46. DOI: 10.3969/j.issn.1674-7380.2019.01.008.
[5]	Chinese Society of Spleen and Portal Hypertension Surgery, Chinese Society of Surgery, Chinese Medical Association. Expert consensus on diagnosis and treatment of esophagogastric variceal bleeding in cirrhotic portal hypertension (2019 edition)[J]. Chin J Dig Surg, 2019, 18 (12): 1087-1093. DOI: 10.3760/cma.j.issn.1673-9752.2019.12.001. 中华医学会外科学分会脾及门静脉高压外科学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2019版)[J]. 中华消化外科杂志, 2019, 18(12): 1087-1093. DOI: 10.3760/cma.j.issn.1673-9752.2019.12.001.
[6]	Chinese Society of Hepatology, Chinese Medical Association. Chinese guidelines on the management of liver cirrhosis[J]. J Clin Hepatol, 2019, 35(11): 2408-2425. DOI: 10.3969/j. issn.1001-5256.2019.11.006. 中华医学会肝病学分会. 肝硬化诊治指南[J]. 临床肝胆病杂志, 2019, 35(11): 2408-2425. DOI: 10.3969/j. issn.1001-5256.2019.11.006.
[7]	CHEN LL, HAN W. The current status of endoscopic treatment of esophagogastric variceal bleeding[J]. Int J Dig Dis, 2018, 38(5): 283-286. DOI: 10.3969/j. issn.1673-534X.2018.05.001. 陈兰兰, 韩文. 门静脉高压食管胃底静脉曲张破裂出血内镜下治疗现状[J]. 国际消化病杂志, 2018, 38(5): 283-286. DOI: 10.3969/j. issn.1673-534X.2018.05.001.
[8]	Esophageal and Gastric Varices Group, Chinese Society of Endoscopy, Chinese Medical Association. Tentative guidelines for endoscopic diagnosis and treatment of varicosity and Variceal bleeding in digestive tract(2009)[J]. Chin J Dig Endosc, 2010, 27(1): 1-4. DOI: 10.3760/cma. j. issn.1007-5232.2010.01.001. 中华医学会消化内镜学分会食管胃静脉曲张学组. 消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年)[J]. 中华消化内镜杂志, 2010, 27(1): 1-4. DOI: 10.3760/cma. j. issn.1007-5232.2010.01.001.
[9]	LU ZY, ZHONG NS. Internal Medicine[M]. 7th ed. Beijng: People 's Medical Publishing House, 2008: 453. 陆再英, 钟南山. 内科学[M]. 第7版. 北京: 人民卫生出版社, 2008: 453.
[10]	Chinese Society of Hepatology, Chinese Medical Association, Chinese Society of Gastroenterology, Chinese Medical Association, Chinese Society of Endoscopy, Chinese Medical Association. Guidelines for the diagnosis and treatment of esophageal and gastric variceal bleeding in cirrhotic portal hypertension[J]. J Clin Hepatol, 2016, 32(2): 203-219. DOI: 10.3969/j.issn.1672-5069.2016.05.036. 中华医学会肝病学分会, 中华医学会消化病学分会, 中华医学会内镜学分会. 肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J]. 临床肝胆病杂志, 2016, 32(2): 203-219. DOI: 10.3969/j.issn.1672-5069.2016.05.036.
[11]	ZHANG QM, LIU H, CHANG ZW, et al. Progress in endoscopic and interventional therapy for secondary prevention of esophagogastric variceal bleeding[J]. J North China Univ Sci Technol (Health Sciences Edition), 2020, 22(3): 247-252. DOI: 10.19539/j.cnki.2095-2694.2020.03.016. 张秋萌, 刘辉, 常紫薇, 等. 食管胃静脉曲张出血二级预防的内镜和介入治疗研究进展[J]. 华北理工大学学报(医学版), 2020, 22(3): 247-252. DOI: 10.19539/j.cnki.2095-2694.2020.03.016.
[12]	ZHOU JN, WEI Z, SUN ZQ. Risk factors for early rebleeding after esophageal Variceal ligation in patients with liver cirrhosis[J]. Chin J Hepatol, 2016, 24(7): 486-492. DOI: 10.3760/cma. j. issn.1007-3418.2016.07.002. 周嘉宁, 魏志, 孙自勤. 肝硬化食管静脉曲张套扎后早期再出血相关危险因素的多中心研究[J]. 中华肝脏病杂志, 2016, 24(7): 486-492. DOI: 10.3760/cma. j. issn.1007-3418.2016.07.002.
[13]	WANG X, MEI XC, ZHANG N, et al. Effects of diabetes on rebleeding after endoscopic treatment in liver cirrhosis patients with esophageal varices[J]. Chin J Dig Endosc, 2020, 37(1): 33-37. DOI: 10.3760/cma. j. issn.1007-5232.2020.01.007. 王曦, 梅雪灿, 张娜, 等. 糖尿病对肝硬化食管静脉曲张内镜治疗后再出血影响的临床研究[J]. 中华消化内镜杂志, 2020, 37(1): 33-37. DOI: 10.3760/cma. j. issn.1007-5232.2020.01.007.
[14]	FOUAD TR, ABDELSAMEEA E, ABDEL-RAZEK W et al. Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: Post-therapeutic outcome and prognostic indicators[J]. J Gastroenterol Hepatol, 2019, 34(9): 1604-1610. DOI: 10.1111/jgh.14659.
[15]	SUN YN, LI P, DING HG, et al. Risk factors for early rebleeding after initial sclerotherapy for esophageal varices[J]. J Clin Hepatol, 2019, 35(1): 93-98. DOI: 10.3969/j.issn.1001-5256.2019.01.017. 孙亚男, 李鹏, 丁惠国, 等. 食管静脉曲张首次硬化剂治疗后早期再出血的危险因素[J]. 临床肝胆病杂志, 2019, 35(1): 93-98. DOI: 10.3969/j.issn.1001-5256.2019.01.017.
[16]	倪猛, 张海洋. 内镜下套扎联合硬化剂注射治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者疗效及其再出血危险因素分析[J]. 实用肝脏病杂志, 2018, 21(2): 241-244. DOI: 10.3969/j.issn.1672-5069.2018.02.021.
[17]	CUl CC, LI DD, LI CF, et al. Risk factors for early rebleeding after first-time endoscopic variceal ligation[J]. J Clin Hepatol, 2018, 34(7): 1445-1451. DOI: 10.3969/j.issn.1001-5256.2018.07.017. 崔璨璨, 李丹丹, 李长锋, 等. 食管静脉曲张首次套扎术后早期再出血的危险因素分析[J]. 临床肝胆病杂志, 2018, 34(7): 1445-1451. DOI: 10.3969/j.issn.1001-5256.2018.07.017.
[18]	LOFFREDO L, PASTORI D, FARCOMENI A, et al. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: A systematic review and meta-analysis[J]. Gastroenterology, 2017, 153(2): 480-487. DOI: 10.1053/j.gastro.2017.04.042.