急诊内镜治疗慢加急性肝衰竭合并食管胃静脉曲张破裂出血效果的影响因素

李莉; 丁鹏鹏; 陈建宏; 王亚丹; 郭春梅; 孟明明; 王艳玲; 祁小宝; 张文辉; 刘红

doi:10.3969/j.issn.1001-5256.2021.05.032

急诊内镜治疗慢加急性肝衰竭合并食管胃静脉曲张破裂出血效果的影响因素

DOI: 10.3969/j.issn.1001-5256.2021.05.032

1.
首都医科大学附属北京世纪坛医院消化内科，北京 100038
2.
解放军总医院第五医学中心肝硬化诊疗一中心，北京 100039

基金项目:

国家自然科学基金青年科学基金 (81900505)

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：李莉、丁鹏鹏、陈建宏负责课题设计，资料分析，撰写论文；王亚丹、郭春梅、孟明明、王艳玲、祁小宝参与收集数据，修改论文；张文辉、刘红负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
李莉(1978—)，女，主治医师，博士，主要从事消化系统疾病、肝病、消化内镜方面的研究

通信作者:
刘红，liuhong1118@126.com

中图分类号: R575.2;R575.3
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- 被引次数: 0
出版历程
- 收稿日期: 2020-10-23
- 录用日期: 2020-11-25
- 出版日期: 2021-05-20

Influencing factors for the clinical effect of emergency endoscopic therapy in treatment of acute-on-chronic liver failure with gastroesophageal variceal bleeding

1.
Department of Gastroenterology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
2.
First Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China

摘要

摘要: 目的探讨慢加急性肝衰竭患者合并食管胃静脉曲张破裂出血行急诊内镜下止血治疗的相关影响因素。方法选取2016年1月—2018年12月北京世纪坛医院和解放军总医院第五医学中心急诊内镜治疗的慢加急性肝衰竭合并食管胃静脉曲张破裂出血患者共51例，其中止血成功26例，止血失败25例。比较两组间的一般资料、内镜下静脉曲张分级及出血表现、血液生化指标、超声表现、Child-Pugh分级及MELD评分，分析其止血疗效的影响因素。计量资料两组间比较采用t检验或Mann-Whitney U秩和检验，计数资料两组间比较采用χ²检验，多因素分析采用logisitc回归分析。结果本组患者成功止血26例，止血成功率为51%。两组性别、年龄、肝硬化病因、是否合并肝癌、是否合并门静脉血栓、是否首次出血、WBC、Hb、PLT、PTA、ALT、TBil、Alb、ChE、MELD评分、胃镜下出血部位、出血表现等差异均无统计学意义(P值均>0.05)。止血成功组病程时间长于失败组(t=2.760，P=0.008)，门静脉直径和内镜下曲张静脉直径均小于失败组(t=-4.847、χ²=-6.590，P值均 < 0.05)，失败组Child-Pugh C级比例明显高于成功组(χ²=5.684，P=0.017)。肝硬化病程(OR=0.913，95%CI：0.838~0.994)、门静脉直径(OR=1.925，95%CI：1.516~2.443)和曲张静脉直径(OR=23.254，95%CI：2.250~240.352)是影响内镜下止血疗效的独立因素(P值均 < 0.05)。结论慢加急性肝衰竭患者急诊内镜止血成功率较低，肝硬化病程、门静脉直径和曲张静脉直径是影响内镜下止血疗效的独立因素。
- 慢加急性肝功能衰竭 /
- 食管和胃静脉曲张 /
- 出血 /
- 内窥镜
Abstract: Objective To investigate the influencing factors for the clinical effect of emergency endoscopic therapy in the treatment of patients with acute-on-chronic liver failure and gastroesophageal variceal bleeding. Methods A total of 51 patients with acute-on-chronic liver failure and gastroesophageal variceal bleeding who underwent emergency endoscopic therapy in Beijing Shijitan Hospital and The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to December 2018 were enrolled, among whom 26 had successful hemostasis and 25 had failed hemostasis. The two groups were compared in terms of general information, varices grade and bleeding manifestations under endoscope, blood biochemical parameters, ultrasound findings, Child-Pugh class, and Model for End-Stage Liver Disease (MELD) score, and the influencing factors for the outcome of hemostasis were analyzed. The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups; the logistic regression model was used to perform the multivariate analysis. Results Of all patients, 26 achieved successful hemostasis, with a success rate of hemostasis of 51%. There were no significant differences between the two groups in sex, age, etiology of liver cirrhosis, presence or absence of liver cancer, presence or absence of portal vein thrombosis, bleeding for the first time or not, white blood cell count, hemoglobin, platelet count, prothrombin time activity, alanine aminotransferase, total bilirubin, albumin, cholinesterase, MELD score, and bleeding site and bleeding manifestations under gastroscope (all P>0.05). Compared with the failed hemostasis group, the successful hemostasis group had a significantly longer course of disease (t=2.760, P=0.008) and significantly larger portal vein diameter and diameter of varicose veins under endoscope (t=-4.847, χ²=-6.590, both P < 0.05), and the failed hemostasis group had a significantly higher proportion of patients with Child-Pugh class C disease than the successful hemostasis group (χ²=5.684, P=0.017). Course of liver cirrhosis (odds ratio [OR]=0.913, 95% confidence interval [CI]: 0.838-0.994, P < 0.05), portal vein diameter (OR=1.925, 95%CI: 1.516-2.443, P < 0.05), and diameter of varicose veins (OR=23.254, 95%CI: 2.250-240.352, P < 0.05) were independent influencing factors for the clinical effect of endoscopic hemostasis. Conclusion There is a relatively low success rate of emergency endoscopic hemostasis in patients with acute-on-chronic liver failure, and course of liver cirrhosis, portal vein diameter, and diameter of varicose veins are independent influencing factors for the clinical effect of endoscopic hemostasis.
- Acute-On-Chronic Liver Failure /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Endoscopes

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表 1 两组一般资料比较

指标	成功组(n=26)	失败组(n=25)	统计值	P值
男性[例(%)]	21(80.8)	22(88.0)	χ²=0.538	0.703
年龄(岁)	48.08±10.22	51.4±10.84	t=-1.127	0.265
肝硬化病因[例(%)]			χ²=24.403	0.356
病毒性肝炎	20(76.9)	14(56.0)
酒精性肝炎	0	7(28.0)
原发性胆汁性胆管炎	1(3.8)	2(8.0)
药物性肝炎	1(3.8)	1(4.0)
其他及不明	4(15.4)	1(4.0)
肝硬化病程(年)	10.69±8.50	5.28±4.99	t=2.760	0.008
合并肝癌[例(%)]	8(30.8)	8(32.0)	χ²=0.009	0.925
首次出血[例(%)]	18(69.2)	13(52.0)	χ²=1.588	0.208
合并门静脉血栓[例(%)]	7(26.9)	10(40.0)	χ²=0.981	0.322
门静脉直径(mm)	12.69±2.14	16.00±2.97	t=-4.847	< 0.001

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表 2 两组静脉曲张情况比较

指标	成功组(n=26)	失败组(n=25)	χ²值	P值
曲张静脉直径[例(%)]			-6.590	0.016
D≤0.5 cm	1(3.8)	0
0.5cm < D≤1.0cm	13(50.0)	5(20.0)
1.0 cm < D≤1.5 cm	10(38.5) 2(7.7)	16(64.0)
1.5 cm < D≤2.0 cm	2(7.7)	4(16.0)
出血部位[例(%)]			3.384	0.150
食管	9(34.6)	12(48.0)
贲门	11(42.3)	12(48.0)
胃底/体	6(23.1)	1(4.0)
胃镜下出血表现[例(%)]			0.573	0.811
活动性出血¹⁾	19(73.1)	19(76.0)
其他²⁾	7(26.9)	6(24.0)
注：D, 指直径。1)指静脉曲张喷血、涌血或渗血；2)指曲张静脉有糜烂、血栓及镜下能够见到新鲜血液，并能排除非静脉曲张出血因素。

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表 3 两组血液生化指标比较

指标	成功组(n=26)	失败组(n=25)	统计值	P值
WBC(×10⁹/L)	8.91(3.80~38.70)	10.19(2.48~34.49)	Z=-0.565	0.572
Hb (g/L)	83.34(61.00~122.00)	93.20(56.00~162.00)	Z=-1.32	0.187
PLT(×10⁹/L)	70.90(10.00~166.00)	92.24(33.00~183.00)	Z=-1.828	0.069
PTA(%)	33.73±9.45	33.70±14.80	t=0.009	0.993
ALT(U/L)	61.19(10.00~456.00)	299.56(13.00~4689.00)	Z=-0.933	0.356
TBil (μmol/L)	209.69(19.00~548.80)	223.92(12.80~574.50)	Z=-0.207	0.836
Alb (g/L)	26.00(19.00~32.00)	27.88(17.00~45.00)	Z=-0.881	0.378
ChE (U/L)	1830.46(808.00~3731.00)	1935.40(827.00~4068.00)	Z=-2.157	0.890
Child-Pugh分级(A/B/C, 例)	0/17/9	0/8/17	χ²=5.684	0.017
MELD评分	23.27(12.00~44.00)	22.84(10.00~42.00)	Z=-0.142	0.887

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表 4 止血疗效影响因素的logistics回归分析

因素	B值	SE	Wald	P值	OR(95%CI)
肝硬化曲张静脉直径	3.146	1.192	6.972	0.008	23.254(2.250~240.352)
肝硬化病程	-0.091	0.043	4.402	0.036	0.913(0.838~0.994)
Child-Pugh分级	-0.23	0.857	0.001	0.979	0.977(0.182~5.244)
门静脉直径	0.655	0.122	28.982	< 0.001	1.925(1.516~2.443)

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