肝硬化食管静脉曲张急诊套扎术后再出血的影响因素
DOI: 10.3969/j.issn.1001-5256.2022.08.016
Risk factors for rebleeding after emergency esophageal variceal ligation in patients with liver cirrhosis
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摘要:
目的 探讨影响肝硬化食管静脉曲张急诊套扎术后再出血的危险因素。 方法 回顾性分析2016年1月—2019年12月解放军总医院第五医学中心290例行急诊食管静脉套扎术治疗的肝硬化患者的临床和实验室资料,根据患者随访1年时有无再出血,分为再出血组和未出血组各145例。符合正态分布的计量资料两组间比较采用t检验,不符合正态分布的计量资料两组间比较采用Wilcoxn秩和检验,计数资料两组间比较采用χ2检验,以筛选出的有统计学意义的因素为自变量进行多因素logistic回归分析,筛选出急诊食管静脉套扎术后再出血的独立相关因素,通过绘制受试者工作特征曲线,获得预测再出血概率的指标并建立模型。 结果 单因素分析显示两组间血小板计数(PLT)(t=-1.888,P=0.047)、Child-Pugh评分(χ2=5.975,P=0.049)、白蛋白(Alb)水平(t=-2.229,P=0.029)、脾静脉直径(DSV)(t=3.808,P=0.001)比较,差异均有统计学意义。多因素logistic回归分析结果显示,Child-Pugh评分[比值比(OR)=0.280,95%CI: 0.108~0.729,P=0.009]、DSV(OR=1.549,95%CI: 1.197~2.005, P=0.001)和Alb(OR=0.832, 95%CI: 0.729~0.949,P=0.006)是食管静脉套扎术后再出血的影响因素。3个因素联合建立预测模型的受试者工作特征曲线下面积0.796,敏感度为83.7%,特异度为74.5%,界值为-0.086。 结论 Child-Pugh评分、Alb水平、DSV为急诊食管静脉套扎术后再出血的独立相关因素,三者联合预测再出血的敏感度和特异度最高。 Abstract:Objective To investigate the risk factors for rebleeding after emergency esophageal variceal ligation (EVL) in patients with liver cirrhosis. Methods A retrospective analysis was performed for the clinical and laboratory data of 290 patients with liver cirrhosis who underwent emergency EVL in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to December 2019, and according to the presence or absence of rebleeding within 1-year follow-up, they were divided into rebleeding group and non-rebleeding group. The t-test was used for comparison of normally distributed continuous data between two groups, and the Wilcoxon rank sum 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. A multivariate logistic regression analysis was performed with the statistically significant factors as independent variables to screen out the independent risk factors for rebleeding after emergency EVL, and the receiver operating characteristic (ROC) curve was plotted to obtain the indices for predicting the probability of rebleeding and establish a predictive model. Results The univariate analysis showed that there were significant differences between the two groups in platelet count (t=-1.888, P=0.047), Child-Pugh score (χ2=5.975, P=0.049), albumin level (t=-2.229, P=0.029), and splenic vein diameter (t=3.808, P=0.001). The multivariate logistic regression analysis showed that Child-Pugh score (odds ratio [OR]=0.280, 95% confidence interval [CI]: 0.108-0.729, P=0.009), splenic vein diameter (OR=1.549, 95%CI: 1.197-2.005, P=0.001) and albumin level (OR=0.832, 95%CI: 0.729-0.949, P=0.006) were independent influencing factors for rebleeding after EVL. The predictive model based on these three factors had an area under the ROC curve of 0.796, with a sensitivity of 83.7% and a specificity of 74.5% at the cut-off value of -0.086. Conclusion Child-Pugh score, albumin level, and splenic vein diameter are independent risk factors for rebleeding after emergency EVL, and the combination of the three indices has the highest sensitivity and specificity in predicting rebleeding. -
Key words:
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Secondary Prevention /
- Risk Factors
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表 1 再出血组和未出血组患者一般资料比较
Table 1. Comparison of general data between rebleeding group and non bleeding group
项目 再出血组(n=145) 未出血组(n=145) 统计值 P值 性别[例(%)] χ2=2.382 0.115 男 83(57.2) 88(60.7) 女 62(42.8) 57(39.3) 年龄(岁) 54.3±10.8 52.6±10.3 t=0.734 0.486 病因[例(%)] χ2=1.791 0.145 肝炎肝硬化 82(56.6) 78(53.8) 酒精性肝硬化 29(20.0) 30(20.7) 胆汁淤积性肝硬化 15(10.3) 18(12.4) 自身免疫性肝硬化 9 (6.2) 11(7.6) 其他原因肝硬化 10(6.9) 8(5.5) 曲张静脉程度(例) χ2=7.648 0.132 轻/中/重 24/46/75 28/39/78 表 2 急诊食管套扎术后再出血的单因素分析
Table 2. Single factor analysis of rebleeding after emergency esophageal ligation
项目 未出血组(n=145) 再出血组(n=145) 统计值 P值 Child-Pugh分级[例(%)] χ2=5.975 0.049 A级
B级
C级40(27.6)
67(46.2)
38(26.2)30(20.7)
101(69.6)
14(9.7)WBC(×1012/L) 5.18±3.79 5.04±3.15 t=-0.188 0.852 Hb(g/L) 79.26±21.07 80.91±22.96 t=0.356 0.723 PLT(×109/L) 98.83±92.12 66.63±34.74 t=-1.888 0.047 ALT(U/L) 33.06±32.73 73.40±25.24 t=1.086 0.280 AST(U/L) 38(26~74) 38(24~59) Z=-0.727 0.467 GGT(U/L) 52(22~149) 34(20~108) Z=-1.293 0.196 ALP(U/L) 144.20±148.48 105.44±61.00 t=-1.596 0.114 Alb(g/L) 30.57±7.06 27.72±4.98 t=-2.229 0.029 TBil(μmol/L) 18.50(14.10~43.70) 19(15.10~30.80) Z=-0.12 0.990 GLU(mmol/L) 8.70±6.03 8.48±4.79 t=-0.191 0.849 ChE(mmol/L) 2 673.00±1 194.99 2 706.88±1 134.84 t=0.138 0.891 UN(mmol/L) 8.17±5.97 7.46±3.36 t=-0.689 0.492 Cr(μmol/L) 75.11±51.02 69.26±15.60 t=-0.721 0.473 PT(s) 14.36±1.90 14.46±2.35 t=0.215 0.830 PTA(%) 61.11±13.48 62.08±16.05 t=0.312 0.756 INR 1.26±0.17 1.26±0.21 t=0.078 0.938 脾脏长度(mm) 161.36±25.80 165.81±25.50 t=0.823 0.413 DSV(mm) 10.57±2.05 12.25±2.14 t=3.808 0.001 DPV(mm) 12.95±2.05 13.70±3.70 t=1.201 0.233 表 3 影响急诊食管套扎术后再次出血的logistic多因素分析
Table 3. Effect of independent variables on rebleeding after emergency esophageal ligation
变量 B值 标准误 Wald值 OR(95%CI) P值 PLT 0.997(0.987~1.008) 0.595 Alb -0.183 0.070 7.914 0.832(0.729~0.949) 0.006 DSV 0.437 0.142 10.578 1.549(1.197~2.005) 0.001 Child-Pugh分级 -1.272 0.810 10.310 0.280(0.108~0.729) 0.009 -
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