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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

马佳丽,蒋煜,胡居龙, 等. 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[J]. 临床肝胆病杂志, 2021, 37(11): 2569-2574. DOI: 10.3969/j.issn.1001-5256.2021.11.017
引用本文: 马佳丽,蒋煜,胡居龙, 等. 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[J]. 临床肝胆病杂志, 2021, 37(11): 2569-2574. DOI: 10.3969/j.issn.1001-5256.2021.11.017
MA JL, JIANG Y, HU JL, et al. Risk factors for rebleeding after endoscopic selective variceal devascularization in patients with hepatitis B cirrhosis and acute variceal bleeding[J]. J Clin Hepatol, 2021, 37(11): 2569-2574. DOI: 10.3969/j.issn.1001-5256.2021.11.017
Citation: MA JL, JIANG Y, HU JL, et al. Risk factors for rebleeding after endoscopic selective variceal devascularization in patients with hepatitis B cirrhosis and acute variceal bleeding[J]. J Clin Hepatol, 2021, 37(11): 2569-2574. 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
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
    通讯作者:

    李坪,enlp@ccmu.edu.cn

  • 中图分类号: R575.2

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

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:   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。

     

  • 图  1  患者筛选流程图

    图  2  ESVD术后患者累积再出血率

    图  3  ESVD术后不同亚组患者的累积再出血率

    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
    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。
    下载: 导出CSV

    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
    HR(95%CI) P HR (95%CI) P
    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
    下载: 导出CSV
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