门静脉血栓形成在肝硬化患者食管胃底静脉曲张破裂出血中的意义及相关危险因素分析

摘要/Abstract

摘要： 目的研究门静脉血栓(portal vein thrombosis, PVT)在肝硬化患者食管胃底静脉曲张出血(esophageal and gastric variceal bleeding, EGVB)中的意义以及抗凝治疗的安全性,并分析该群患者EGVB发生相关危险因素。方法收集2012年1月—2022年12月间龙岩人民医院就诊的肝硬化患者,通过彩色多普勒超声和上腹部增强CT诊断PVT,并进行为期1年的临床随访,以确定EGVB的发生。应用Cox比例风险回归和Kaplan-Meier分析确定EGVB相关的独立危险因素。结果共518例患者完成1年随访,其中167例合并PVT。与非PVT患者相比,合并PVT患者重度静脉曲张患者比例显著升高(91.0% vs 82.1%)(P<0.05)。对全部肝硬化患者进行Cox回归分析证实PVT(HR: 1.482, 95% CI: 1.051-2.090)、Child-Pugh评分(HR: 1.446, 95% CI: 1.270-1.645)、AST(HR: 1.010, 95% CI: 1.006-1.014)以及INR(HR: 0.341, 95% CI: 0.155-0.751)与肝硬化患者1年EGVB风险独立相关(均P<0.05)。对肝硬化合并PVT患者进行Cox回归分析发现,慢性PVT(HR: 4.089, 95% CI: 2.247-7.441)、Child-Pugh评分升高(HR: 1.787, 95% CI: 1.335-2.392)以及AST升高(HR: 1.008, 95% CI: 1.003-1.013)与肝硬化患者1年内EGVB发生显著相关(均P<0.05)。而与PVT位置及抗凝治疗无显著性联系(均P>0.05)。结论 PVT可增加肝硬化患者EGVB风险;在肝硬化合并PVT患者中,EGVB与抗凝治疗无关,而与慢性PVT、Child-Pugh评分和AST水平显著相关。

关键词: 肝硬化, 食管胃底静脉曲张出血, 门静脉血栓, 预后分析

Abstract: Objective To investigate the significance of portal vein thrombosis (PVT) in patients with cirrhosis experiencing esophageal and gastric variceal bleeding (EGVB) as well as the safety of anticoagulation therapy. Additionally, it analyzes the risk factors associated with the occurrence of EGVB in this patient group.Methods Patients with cirrhosis treated at our hospital from January 2012 to December 2022 were enrolled and followed clinically for one year to ascertain the incidence of EGVB. The color Doppler ultrasonography and enhanced CT of the upper abdomen were applied to diagnose PVT. Cox proportional hazards regression and Kaplan-Meier analysis were utilized to identify independent risk factors related to EGVB.Results Out of 518 patients followed for one year, 167 were diagnosed with PVT. Compared with patients without PVT, those with PVT exhibited a significantly higher proportion of severe variceal patients (91.0% vs 82.1%) (P<0.05). Cox regression analysis of all cirrhotic patients confirmed that portal vein thrombosis (HR: 1.482, 95% CI: 1.051-2.090), Child-Pugh score (HR: 1.446, 95% CI: 1.270-1.645), AST levels (HR: 1.010, 95% CI: 1.006-1.014), and international normalized ratio (INR) (HR: 0.341, 95% CI: 0.155-0.751) were independently associated with the risk of EGVB within one year (all P<0.05). Cox regression analysis of patients with cirrhosis and PVT found that chronic PVT (HR: 4.089, 95% CI: 2.247-7.441), elevated Child-Pugh score (HR: 1.787, 95% CI: 1.335-2.392), and increased AST levels (HR: 1.008, 95% CI: 1.003-1.013) significantly correlated with the occurrence of EGVB within one year (all P<0.05). However, there was no significant association with the location of PVT and anticoagulation therapy (all P>0.05).Conclusion PVT increases the risk of EGVB in patients with cirrhosis. Among those with cirrhosis and PVT, EGVB occurrence is unrelated to anticoagulation therapy but significantly associated with chronic PVT, Child-Pugh score, and AST levels.

Key words: Cirrhosis, Esophageal and gastric variceal bleeding, Portal vein thrombosis, Prognostic analysis

罗钻. 门静脉血栓形成在肝硬化患者食管胃底静脉曲张破裂出血中的意义及相关危险因素分析[J]. 肝脏, 2024, 29(12): 1512-1516.

LUO Zuan. The implications and risk factor analysis of portal vein thrombosis in esophageal and gastric variceal bleeding in cirrhotic patients[J]. Chinese Hepatolgy, 2024, 29(12): 1512-1516.

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参考文献

[1] Giuli L, Pallozzi M, Venturini G, et al. Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis[J]. Int J Mol Sci,2023,24(16):12754.
[2] Zhang Y, Xu BY, Wang XB, et al. Prevalence and Clinical Significance of Portal Vein Thrombosis in Patients With Cirrhosis and Acute Decompensation[J]. Clin Gastroenterol Hepatol,2020,18(11):2564-2572.e1.
[3] Gao Z, Zhao J, Liu X, et al. Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case-control study[J]. Hepatol Int,2021,15(5):1183-1195.
[4] Intagliata NM, Argo CK, Stine JG, et al. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference[J]. Thromb Haemost,2018,118(8):1491-1506.
[5] Senzolo M, Garcia-Tsao G, García-Pagán JC. Current knowledge and management of portal vein thrombosis in cirrhosis[J]. J Hepatol,2021,75(2):442-453.
[6] Yang L, Sun R, Wei N, et al. Systematic review and meta-analysis of risk scores in prediction for the clinical outcomes in patients with acute variceal bleeding[J]. Ann Med,2021,53(1):1806-1815.
[7] Tantai XX, Liu N, Yang LB, et al. Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding[J]. World J Gastroenterol,2019,25(45):6668-6680.
[8] 中华医学会肝病学分会. 肝硬化诊治指南[J]. 中华肝脏病杂志,2019,27(11):846-865.
[9] O'Leary JG, Greenberg CS, Patton HM, et al. AGA Clinical Practice Update: Coagulation in Cirrhosis[J]. Gastroenterology,2019,157(1):34-43.e1.
[10] Pettinari I, Vukotic R, Stefanescu H, et al. Clinical Impact and Safety of Anticoagulants for Portal Vein Thrombosis in Cirrhosis[J]. Am J Gastroenterol,2019,114(2):258-266.
[11] Loffredo L, Pastori D, Farcomeni A, et al. Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis: A Systematic Review and Meta-analysis[J]. Gastroenterology,2017,153(2):480-487.e1.
[12] Bosch J, Chung C, Carrasco-Zevallos OM, et al. A Machine Learning Approach to Liver Histological Evaluation Predicts Clinically Significant Portal Hypertension in NASH Cirrhosis[J]. Hepatology,2021,74(6):3146-3160.
[13] Bass LM, Ye W, Hawthorne K, et al. Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia[J]. Hepatology,2022,76(3):712-726.
[14] Prakash S, Bies J, Hassan M, et al. Portal vein thrombosis in cirrhosis: A literature review[J]. Front Med (Lausanne). 2023,10:1134801.
[15] Abraldes JG, Caraceni P, Ghabril M, et al. Update in the Treatment of the Complications of Cirrhosis[J]. Clin Gastroenterol Hepatol,2023,21(8):2100-2109.