内镜下精准食管胃静脉曲张断流术治疗乙型肝炎肝硬化伴急性静脉曲张出血患者再出血的危险因素分析

马佳丽; 蒋煜; 胡居龙; 艾正琳; 何玲玲; 周玉玲; 梁秀霞; 林毅军; 魏红山; 李坪

doi:10.3969/j.issn.1001-5256.2021.11.017

内镜下精准食管胃静脉曲张断流术治疗乙型肝炎肝硬化伴急性静脉曲张出血患者再出血的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2021.11.017

首都医科大学附属北京地坛医院消化内科，北京 100015

基金项目:

首都医科大学附属北京地坛医院青年人才发展基金“萌芽”支持计划项目 (DTMY201807);

首都临床特色应用研究 (Z181100001718084);

北京市医院管理中心消化内科学科协同发展中心专项 (XXZ0404)

详细信息

通信作者:
李坪，enlp@ccmu.edu.cn

中图分类号: R575.2
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出版历程
- 收稿日期: 2021-03-23
- 录用日期: 2021-05-11
- 出版日期: 2021-11-20

Risk factors for rebleeding after endoscopic selective variceal devascularization in patients with hepatitis B cirrhosis and acute variceal bleeding

Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China

Research funding:

Capital Medical University Affiliated Beijing Ditan Hospital Young Talent Development Fund "Sprout" Project (DTMY201807);

Capital Foundation for Clinical Characteristic Applied Research Projects (Z181100001718084);

The Digestive Medical Coordinated Development Center of Beijing Hospitals Authority (XXZ0404)

摘要

摘要: 目的明确乙型肝炎肝硬化伴食管胃静脉曲张破裂出血(EVB)患者行内镜下精准食管胃静脉曲张断流术(ESVD)后的再出血率及再出血的预测因素。方法纳入2010年10月—2019年12月因乙型肝炎肝硬化伴EVB，于首都医科大学附属北京地坛医院就诊，并行首次ESVD治疗的患者，根据纳入和排除标准共筛选出患者442例。对患者的常规临床、实验室、影像学及内镜等指标进行比较，随访患者的再出血情况。正态分布的计量资料两组间比较采用t检验，非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ²检验。采用Kaplan-Meier法描述再出血和生存情况，采用Cox回归明确静脉曲张再出血的独立危险因素。结果首次ESVD治疗后1、2、3、4、5年累积再出血率分别为25.11%、33.94%、39.82%、42.08%和45.02%。单因素分析结果显示，年龄、收缩压、抗病毒疗程≥1年、腹水、WBC、中性粒细胞、直接胆红素与再出血相关(P值均＜0.05)；多因素分析结果显示，抗病毒疗程≥1年(HR=0.504，95%CI：0.357~0.711，P＜0.001)和腹水(HR=1.424，95%CI：1.184~1.714，P＜0.001)是静脉曲张再出血的独立影响因素。结论 ESVD治疗乙型肝炎肝硬化伴EVB，再出血率低，合并腹水或抗病毒时间短是治疗后再出血的独立危险因素。
- 肝硬化 /
- 食管胃静脉曲张 /
- 出血 /
- 危险因素
Abstract: Objective To investigate the rebleeding rate after endoscopic selective variceal devascularization (ESVD) and the predictive factors for rebleeding in patients with hepatitis B cirrhosis and esophageal variceal bleeding (EVB). Methods The patients with hepatitis B cirrhosis and EVB who attended Beijing Ditan Hospital, Capital Medical University, from October 2010 to December 2019 and underwent ESVD for the first time were enrolled, and a total of 442 patients were screened out based on inclusion and exclusion criteria. Routine clinical indices, laboratory markers, imaging findings, and endoscopic findings were compared between patients, and the patients were followed up to observe 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 was used for comparison of categorical data between two groups. The Kaplan-Meier method was used to describe rebleeding and survival status, and a Cox regression analysis was used to determine the independent risk factors for variceal rebleeding. Results The 1-, 2-, 3-, 4-, and 5-year cumulative rebleeding rates after first ESVD treatment were 25.11%, 33.94%, 39.82%, 42.08%, and 45.02%, respectively. The univariate analysis showed that age, systolic pressure, duration of antiviral therapy ≥1 year, ascites, white blood cell count, neutrophil, and direct bilirubin were associated with rebleeding (all P < 0.05), and the multivariate analysis showed that duration of antiviral therapy ≥1 year (hazard ratio [HR]=0.504, 95% confidence interval [CI]: 0.357-0.711, P < 0.001) and ascites (HR=1.424, 95%CI: 1.184-1.714, P < 0.001) were independent influencing factors for variceal rebleeding. Conclusion ESVD has a low rebleeding rate in the treatment of hepatitis B cirrhosis with EVB, and presence of ascites and a short duration of antiviral therapy are independent risk factors for rebleeding after treatment.
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Risk Factors

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图 1 患者筛选流程图

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图 2 ESVD术后患者累积再出血率

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图 3 ESVD术后不同亚组患者的累积再出血率

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表 1 患者基线人口学及临床数据

参数	再出血组(n=203)	无再出血组(n=239)	统计值	P值
年龄(岁)	49.38±10.40	49.54±10.21	t=-0.163	0.870
男性(例)	157	168	χ²=2.801	0.105
SBP (mmHg)	110(80~160)	110(72~120)	Z=-0.724	0.469
输血量(U)	0(0~14)	0(0~22)	Z=-1.024	0.306
并发症(例)
腹水	159	172	χ²=2.360	0.152
肝性脑病	17	23	χ²=0.208	0.704
门静脉栓塞	58	52	χ²=2.726	0.122
现症吸烟(例)	66	57	χ²=4.102	0.044
现症饮酒(例)	46	42	χ²=1.781	0.220
胃静脉曲张出血(例)	64	52	χ²=5.413	0.023
首次组织胶注射量(mL)	1(0~10)	1(0~6)	Z=-0.364	0.716
首次聚桂醇注射量(mL)	20(0~60)	20(0~70)	Z=-0.129	0.898
抗病毒治疗(例)	157	196	χ²=1.488	0.236
门静脉内径(mm)	12(8~20)	12(7~19)	Z=-0.667	0.505
脾脏厚度(mm)	53.63±9.51	52.83±9.99	t=0.728	0.435
WBC(×10⁹/L)	3.75(1.10~26.87)	3.50(0.81~26.22)	Z=-1.274	0.203
NEU(×10⁹/L)	2.64(0.43~23.67)	2.57(0.38~23.47)	Z=-0.883	0.377
LYM(×10⁹/L)	0.79(0.15~4.20)	0.70(0.19~3.37)	Z=-1.704	0.088
HCT	27.01±7.70	28.17±7.65	t=-1.575	0.116
Hb(g/L)	90.10±27.46	94.64±27.68	t=-1.723	0.086
Hb下降＞30 g/dL(例)	62	79	χ²=0.319	0.609
PLT(×10⁹/L)	60.40(18.00~314.40)	57.00(18.20~258.00)	Z=-0.793	0.428
ALT(U/L)	26.90(8.20~363.60)	29.20(0.00~641.20)	Z=-1.527	0.127
AST(U/L)	32.50(10.40~572.80)	37.10(9.20~917.60)	Z=-2.452	0.014
TBil(μmol/L)	20.10(4.50~470.30)	20.10(5.20~615.60)	Z=-1.492	0.136
DBil(μmol/L)	8.00(1.30~308.30)	8.10(1.90~483.10)	Z=-1.554	0.120
TBA(μmol/L)	6.80(0.00~379.30)	11.25(0.10~336.60)	Z=-2.485	0.013
Cr(μmol/L)	65.00(19.00~277.00)	64.00(17.00~1 296.00)	Z=-0.126	0.900
TP(g/L)	58.65±10.31	59.99±10.31	t=0.977	0.181
Alb(g/L)	32.02±6.22	31.73±5.62	t=0.509	0.611
GLO(g/L)	26.69±6.36	28.29±7.52	t′=-2.387¹⁾	0.017
A/G	1.20(0.50~2.20)	1.20(0.40~2.20)	Z=1.787	0.074
GGT(U/L)	27.40(6.40~207.70)	29.30(2.90~369.90)	Z=-0.609	0.543
ALP(U/L)	64.80(18.60~226.10)	69.55(20.90~270.00)	Z=-1.897	0.058
ChE(U/L)	3 229.00(795.00~9 297.00)	2 899.50(705.00~8 306.00)	Z=-1.678	0.093
TC(mmol/L)	2.68±0.84	2.74±0.89	t=-0.675	0.500
TG(mmol/L)	0.59(0.00~9.10)	0.60(0.00~1.70)	Z=-0.476	0.634
PA(g/L)	84.36±33.78	77.66±39.27	t=1.786	0.075
PTA (%)	60.65±13.00	59.86±14.66	t=0.596	0.552
CRP (mg/L)	2.25(0.00~56.40)	3.15(0.00~49.30)	Z=-1.941	0.052
Child-Pugh评分(分)	8(5~14)	8(5~15)	Z=-0120	0.905
Child-Pugh分级(A/B/C，例)	49/108/46	61/112/66	χ²=1.969	0.374
MELD评分	6.54(-6.00~25.00)	6.88(-6.00~31.00)	Z=-1.282	0.200
注：LYM，淋巴细胞；HCT，红细胞压积；TP，总蛋白；A/G，白球比；PA，前白蛋白；CRP，C反应蛋白；1)方差不齐，采用t′检验。

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表 2 ESVD术后静脉曲张再出血的影响因素

变量	单因素分析		多因素分析
变量	HR(95%CI)	P值	HR (95%CI)	P值
年龄(岁)	1.014(1.000~1.028)	0.045
收缩压(mmHg)	0.988(0.978~0.998)	0.024
抗病毒疗程≥1年	0.523(0.373~0.731)	＜0.001	0.504(0.357~0.711)	＜0.001
腹水	1.442(1.210~1.719)	＜0.001	1.424(1.184~1.714)	＜0.001
WBC(×10⁹/L)	1.049(1.009~1.092)	0.017
NEU(×10⁹/L)	1.049(1.004~1.096)	0.031
DBil(μmol/L)	1.005(1.000~1.010)	0.049

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