内镜下曲张静脉套扎术治疗肝硬化并发食管静脉曲张破裂出血患者肝静脉压力梯度变化及其评估再出血风险的价值

摘要/Abstract

摘要： 目的探讨血清Ⅳ型胶原(CⅣ)、维生素B12及肝静脉压力梯度(HVPG)测定值评估肝硬化食管静脉曲张破裂出血(EVB)患者经内镜治疗后再出血风险的价值。方法采取病例对照研究方法,将威远县人民医院2019年4月—2021年4月采取内镜下静脉套扎手术治疗的肝硬化EVB且术后24个月内再次出血的患者61例作为再出血组、另外选取同期手术且术后随访24个月内未再次出血的患者80例作为未再出血组,对比两组患者术前血清CⅣ、维生素B12及HVPG测定值,通过受试者工作曲线(ROC)分析上述三项指标预测患者术后再出血的价值,绘制logistic回归模型分析上述三项指标与患者术后再出血的关系。结果再出血患者的术前血清CⅣ、维生素B12及HVPG测定值分别为(117.4±28.0)μg/L、(498.6±84.0)pg/mL和(21.9±4.4)mmHg,均显著高于未再出血组[分别为(96.3±17.5)μg/L、(421.8±78.0)pg/mL、(15.6±3.3)mmHg, P<0.05];术前血清CⅣ、维生素B12及HVPG测定值预测患者发生术后出血的灵敏度为68.27%、73.81%、90.66%,特异度为65.43%、76.46%、81.52%,AUC值为0.716、0.791、0.893;logistic回归模型显示,患者肝硬化食管静脉曲张病程越长、合并门静脉血栓、INR值增大、CⅣ增大、维生素B12升高、HVPG测定值是患者经内镜治疗后再出血的风险因素(OR值分别为1.636、2.079、1.493、1.402、1.507、1.790,P<0.05),PLT、Alb升高是患者经内镜治疗后再出血的保护性因素(OR值分别为0.531、0.618,P<0.05)。结论根据肝硬化EVB患者经内镜治疗前的血清CⅣ、维生素B12及HVPG测定值可有效预测患者发生术后再出血的风险,并且与患者再出血关系密切,对于指导临床治疗有重要意义。

关键词: Ⅳ型胶原, 维生素B12, 肝静脉压力梯度, 肝硬化, 食管静脉曲张破裂出血

Abstract: Objective To explore the values of serum type IV collagen (CIV) and vitamin B12 levels, and hepatic vein pressure gradient (HVPG) measurements in assessing the risk of rebleeding after endoscopic treatment in patients with esophageal variceal bleeding (EVB) due to cirrhosis. Methods A case-control study was performed on 61 patients with cirrhosis and EVB who underwent endoscopic venous ligation surgery in Weiyuan County People's Hospital between April 2019 and April 2021. These patients experienced recurrent bleeding within 24 months after surgery and were selected as the bleeding group. Additionally, 80 patients who underwent the same surgery without experiencing recurrent bleeding within 24 months of follow-up post surgery were selected as the control group. The preoperative serum levels of CIV and vitamin B12, and the measured value of HVPG of the two groups of patients were compared, The values of the aboval three indicators in predicting postoperative rebleeding in patients were compared with receiver operating curve (ROC) analysis and logistic regression model. Results The preoperative serum levels of CIV and vitamin B12, and the value of HVPG in patients with recurrent bleeding were (117.4 ± 28.0) μg/L, (498.6 ± 84.0) pg/mL, and (21.9 ± 4.4) mmHg, respectively, which were significantly higher than those of [96.3 ± 17.5] μg/L, (421.8 ± 78.0) pg/mL, (15.6 ± 3.3) mmHg, respectively in the non-rebleeding group (P<0.05); The sensitivities of preoperative CIV, vitamin B12, and HVPG for predicting postoperative bleeding were 68.27%, 73.81%, and 90.66%; the specificities were 65.43%, 76.46%, and 81.52%, respectively; and AUC values were 0.716,0.791, 0.893.The logistic regression model showed that the longer the course of esophageal varices in cirrhotic patients, complicated with portal vein thrombosis, the increments in INR value, CIV value, vitamin B12 level, and the measured value of hepatic vein pressure gradient are risk factors for rebleeding after endoscopic treatment (OR values=1.636, 2.079, 1.493, 1.402, 1.507, 1.790, respectively, all P<0.05), The elevations of PLT count and Alb level were protective factors for patients with recurrent bleeding after endoscopic treatment (POR values were 0.531 and 0.618, respectively, P<0.05). Conclusion The serum levels of CIV and vitamin B12, and HVPG measurement before endoscopic treatment in cirrhotic patients with EVB were closely related to the risk of postoperative bleeding, which is of great significance for predicting the prognosis of EVB and for guiding the clinical treatment.

Key words: Type IV collagen, Vitamin B12, Hepatic vein pressure gradient, Liver cirrhosis, Esophageal variceal bleeding

刘婕, 刘唐, 温伟, 唐世孝. 内镜下曲张静脉套扎术治疗肝硬化并发食管静脉曲张破裂出血患者肝静脉压力梯度变化及其评估再出血风险的价值[J]. 肝脏, 2023, 28(10): 1162-1166.

LIU Jie¹, LIU Tang², WEN Wei¹, TANG Shi-xiao³. The value of hepatic vein pressure gradient in assessing the risk of rebleeding after endoscopic treatment of esophageal variceal bleeding in cirrhotic patients[J]. Chinese Hepatolgy, 2023, 28(10): 1162-1166.

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