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肝硬化食管胃静脉曲张出血后肝静脉压力梯度测定指导二级预防的临床应用
application of hepatic venous pressure gradient measurement after esophagogastric variceal bleeding in guiding secondary prevention for patients with liver cirrhosis
文章发布日期:2019年12月20日  来源:  作者:路筝,金波,张文辉,等  点击次数:134次  下载次数:23次

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【摘要】:目的 探讨食管胃静脉曲张出血后行内镜二级预防或TIPS二级预防的选择依据,评估肝静脉压力梯度(HVPG)协助临床决策的价值。方法 回顾性分析了2016年1月-2018年2月解放军总医院第五医学中心食管胃静脉曲张出血后测得HVPG在12 mm Hg以上并接受内镜或TIPS二级预防的患者148例,依据指南意见,HVPG>18 mm Hg是食管胃静脉曲张再出血的高危因素,将148例患者分为中压力组(HVPG 12~18 mm Hg)78例和高压力组(HVPG>18 mm Hg)70例,归纳两组的临床特点和内镜表现。再细化为12~16 mm Hg、>16~18 mm Hg、>18~20 mm Hg和>20 mm Hg 4组,对比各组行不同二级预防方式的安全性和有效性,重点关注再出血及预后情况。计量资料2组间比较采用独立样本t检验,计数资料2组间比较采用χ2检验,等级资料多组间比较采用Kruskal-Wallis H检验。结果 二级预防前中压力组和高压力组的血红蛋白、血小板、白蛋白、胆红素、肌酐、血氨和凝血酶原时间、Child-Pugh评分和MELD评分比较,差异均无统计学意义(P值均>0.05),中压力组有67.95%的患者存在侧支循环开放,显著多于高压力组的50.00%(χ2=11.250,P=0.004)。中压力组和高压力组的食管胃静脉曲张LDRf分型差异无统计学意义(P>0.05)。高压力组选择TIPS的患者比例(28.57%)较中压力组患者(10.26%)显著增多 (χ2=8.067,P=0.005)。二级预防后,平均随访(28.66±11.20)个月,未发生严重并发症,各组各预防方式患者肝硬化病程没有明显进展,腹水情况好转。随着HVPG值的增高,内镜二级预防后的1年内再出血率呈现增高趋势,HVPG>20 mm Hg的患者中有41.03%在1年内追加预防治疗。HVPG 12~16 mm Hg的患者,内镜预防疗效好,一年内再出血率为14.63%。 HVPG>20 mm Hg组内镜预防1年内再出血率为34.48%,TIPS预防1年内再出血率为10%。结论 建议基于HVPG值指导静脉曲张出血二级预防方式的选择,制订不同HVPG值患者二级预防后的随访计划,开展个体化治疗。
【Abstract】:Objective To investigate the basis for the selection of secondary prevention with endoscopy or transjugular intrahepatic portosystemic shunt (TIPS) after esophagogastric variceal bleeding and the value of hepatic venous pressure gradient (HVPG) in clinical decision-making. Methods A retrospective analysis was performed for 148 patients who had an HVPG of above 12 mm Hg after esophagogastric variceal bleeding and received secondary prevention with endoscopy or TIPS in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to February 2018. According to related guidelines, HVPG >18 mm Hg was a high-risk factor for esophagogastric variceal rebleeding, and the patients were divided into medium pressure group (HVPG 12-18 mm Hg) with 78 patients and high pressure group (HVPG >18 mm Hg) with 70 patients. Clinical features and endoscopic findings were summarized for both groups. The patients were further divided into four groups with an HVPG of 12-16 mm Hg, >16-18 mm Hg, >18-20 mm Hg, and >20 mm Hg, respectively, and the four groups were compared in terms of the safety and efficacy of secondary prevention, with focuses on rebleeding and prognosis. The two-independent-samples t test was used for comparison of continuous data between groups, the chi-square test was used for comparison of categorical data between groups, the Kruskal-Wallis H test was used for comparison of ranked data between groups. Results Before secondary prevention, there were no significant differences between the medium pressure group and the high pressure group in hemoglobin, platelet, albumin, bilirubin, creatinine, blood ammonia, prothrombin time, Child-Pugh score, and Model for End-Stage Liver Disease score, and the medium pressure group had a significantly higher proportion of patients with opening of collateral circulation than the high pressure group (67.95% vs 50.00%, χ2=11.250,P=0.004). There was no significant difference in the LDRf type of esophageal and gastric varices between the two groups. The high pressure group had a significantly higher proportion of patients who selected TIPS than the medium pressure group (28.57% vs 10.26%, χ2=8.067,P=0.005). After secondary prevention, the mean follow-up time was 28.66±11.20 months, and no serious complications were observed. No patients experienced the progression of liver cirrhosis, and there was an improvement in ascites. Rebleeding rate within 1 year after secondary prevention with endoscopy tended to increase with the increase in HVPG, and 41.03% of the patients with HVPG >20 mm Hg underwent the preventive treatment for the second time within 1 year. Secondary prevention with endoscopy had a good clinical effect in the patients with an HVPG of 12-16 mm Hg, with a rebleeding rate of 14.63% within 1 year. The patients with an HVPG of >20 mm Hg who underwent secondary prevention with TIPS had a significantly lower rebleeding rate within 1 year than those who underwent secondary prevention with endoscopy (10% vs 34.48%). Conclusion It is recommended to select secondary prevention for variceal bleeding based on HVPG, develop a follow-up plan for patients with different HVPG values after secondary prevention, and give individualized treatment.
【关键字】:肝硬化; 食管和胃静脉曲张; 出血; 肝静脉压力梯度; 二级预防
【Key words】:liver cirrhosis; esophageal and gastric varices; hemorrhage; hepatic venous pressure gradient; secondary prevention
【引证本文】:LU Z, JIN B, ZHANG WH, et al. Clinical application of hepatic venous pressure gradient measurement after esophagogastric variceal bleeding in guiding secondary prevention for patients with liver cirrhosis[J]. J Clin Hepatol, 2020, 36(1): 107-112. (in Chinese)
路筝, 金波, 张文辉, 等. 肝硬化食管胃静脉曲张出血后肝静脉压力梯度测定指导二级预防的临床应用[J]. 临床肝胆病杂志, 2020, 36(1): 107-112.

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