血栓弹力图参数评估乙型肝炎肝硬化合并食管胃底静脉曲张破裂出血的意义

摘要/Abstract

摘要： 目的探究血栓弹力图参数(TEG)评估乙型肝炎肝硬化合并食管胃底静脉曲张破裂出血的意义。方法选取徐州市中心医院于2021年2月—2023年2月收治的40例乙型肝炎肝硬化患者以及同期20例行健康体检人群为研究对象。将健康体检人群纳为对照组,将乙型肝炎肝硬化患者分为出血组(n=20)和未出血组(n=20)。将出血组随机分为A组(n=10)和B组(n=10),A组给予常规凝血试验指导输血,B组给予TEG试验指导输血。比较出血组、未出血组与对照组的常规凝血功能指标以及TEG检验结果,绘制ROC曲线来分析TEG检验结果与常规凝血实验的评估价值,比较A、B两组预后情况和输血成分用量。结果乙型肝炎肝硬化患者出血组和未出血组血小板计数(PLT)及纤维蛋白原(FIB)水平均显著小于对照组,而凝血酶原时间(PT)、国际标准化比值(INR)、活化部分凝血活酶时间(APTT)水平均显著大于对照组(P<0.05);出血组的PLT及FIB水平显著小于未出血组[PLT:(67.13±33.18)vs.(84.23±29.34)×10⁹/L;FIB:(1.47±0.49)vs.(1.97±0.52)g/L,P<0.05];出血组和未出血组的血凝块形成时间(K)显著高于对照组,凝固角(α)、最大振辐(MA)水平显著低于对照组(P<0.05);出血组的α角及MA水平[分别为(45.45±5.79)deg和(40.71±5.25)mm]显著小于未出血组[分别为(51.34±5.14)deg和(48.46±6.08)mm,P<0.05];PLT、FIB、α角及MA曲线下面积均超过0.5(P<0.05),且α角曲线下面积最大;B组预后好转率显著大于A组(100% vs. 60%),住院天数为(9.12±1.02)d,显著小于A组(11.48±1.25)d,(P<0.05);B组红细胞和血浆[分别为(3.14±0.67)U和(534.07±80.42)mL]用量小于A组[分别为(4.11±0.74)U和(617.18±90.51)mL],血小板和冷沉淀用量[分别为(0.32±0.07)U和(33.48±6.25)U]显著大于A组[分别为(0.25±0.06)U和(28.12±5.02)U](P<0.05)。结论 TEG凝血测试比标准凝血酶原时间、血小板计数和国际标准化比值等常规凝血测试更能指导患者输血管理,其中α角参数诊断效能最高。TEG通过精准指导输血治疗可较好改善患者预后。

关键词: 血栓弹力图参数, 乙型肝炎肝硬化, 食管胃底静脉曲张破裂出血

Abstract: Objective To investigate the importance of thromboelastography (TEG) in the evaluation of hepatitis B liver cirrhosis associated with esophageal and gastric varicose bleeding. Methods A total of 40 patients with hepatitis B liver cirrhosis admitted to Xuzhou Central Hospital from February 2021 to February 2023 and 20 patients who underwent a healthy physical examination during the same period were included. The healthy physical examination population was included as a control group, and patients with hepatitis B cirrhosis were divided into a bleeding group (n=20) and a non-bleeding group (n=20). The bleeding group was randomly divided into group A (n=10) and group B (n=10), with group A and group B taking a routine coagulation test and a TEG test to guide blood transfusion respectively. The ROC curve was designed to compare the results of the TEG test with the index of agglutination function in the bleeding group, non-bleeding group and control group, and to analyze the equilibrium value of the results of the TEG test and conventional coagulation test, as well as the prognosis and dosage of the transfusion components of groups A and B. Results The platelet count (PLT) and fibrinogen (FIB) levels in the bleeding group and the non-bleeding group were significantly lower than those in the control group, while the levels of prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (APTT) were significantly higher than those in the control group (P<0.05). The levels of PLT and FIB in the bleeding group were significantly lower than those in the non-bleeding group [PLT: (67.13±33.18) vs. (84.23±29.34) ×10⁹/L; FIB: (1.47±0.49) vs. (1.97±0.52) g/L, P<0.05]; The blood clot formation time (K) of the bleeding group and the non-bleeding group were significantly higher than those in the control group, and the coagulation angle (α) and maximum vibration radiation (MA) levels were significantly lower than those in the control group (P<0.05). The α angle and MA levels in the bleeding group [(45.45±5.79) deg and (40.71±5.25) mm, respectively] were significantly lower than those in the non-bleeding group [(51.34±5.14) deg and (48.46±6.08) mm, P<0.05], respectively; The area under the PLT, FIB, α angle and MA curve exceeded 0.5 (P<0.05), and the area under the α angle curve was the largest. The improvement rate of prognosis in group B was significantly higher than that of group A (100% vs. 60%), and the number of days of hospital stay was (9.12±1.02) d, which was significantly lower than that of group A (11.48±1.25) d (P<0.05); The dosage of red blood cells and plasma in group B [(3.14±0.67) U and (534.07±80.42) mL, respectively] was less than that of group A [(4.11±0.74) U and (617.18±90.51) mL], respectively, and the dosage of platelets and cryoprecipitate [(0.32±0.07) U and (33.48±6.25) U, respectively] was significantly greater than that of group A [(0.25±0.06) U and (28.12±5.02) U] (P<0.05), respectively]. Conclusion The TEG coagulation test can better guide the management of blood transfusion than traditional coagulation tests such as standard PT, PLT and INR, and has the highest diagnostic efficiency of α angular parameters. TEG can improve patient outcomes by providing accurate guidance for transfusion treatment.

Key words: Thromboelastography parameters, Hepatitis B cirrhosis, Gastrointestinal bleeding

孙梦秋, 张爱霞, 张莉, 林子曦. 血栓弹力图参数评估乙型肝炎肝硬化合并食管胃底静脉曲张破裂出血的意义[J]. 肝脏, 2024, 29(9): 1091-1095.

SUN Meng-qiu, ZHANG Ai-xia, ZHANG Li, LIN Zi-xi. Significance of thromboelastography parameters in evaluating hepatitis B cirrhosis complicated with esophageal-gastric varices bleeding[J]. Chinese Hepatolgy, 2024, 29(9): 1091-1095.

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参考文献

[1] Cai X, Liu X, Xie W, et al. Hydronidone for the treatment of liver fibrosis related to chronic hepatitis B: A phase 2 randomized controlled trial. Clin Gastroenterol Hepatol,2023,21(7):1893-1901.e7.
[2] Wang Y, Li XY, Wu LL, et al. Dynamic prediction of liver cirrhosis risk in chronic hepatitis B patients using longitudinal clinical data. Eur J Gastroenterol Hepatol, 2020, 32(1):120-126.
[3] Liu P, Hum J, Jou J, et al. Transfusion strategies in patients with cirrhosis. Eur J Haematol,2020,104(1):15-25.
[4] 李晓珂, 杨新乐, 王彤, 等. 肝硬化合并门静脉血栓治疗进展. 临床肝胆病杂志, 2021,37(7):1690-1693.
[5] Jakab SS, Garcia-Tsao G. Evaluation and management of esophageal and gastric varices in patients with cirrhosis. Clin Liver Dis,2020,24(3):335-350.
[6] Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol,2022,76(6):1291-1305.
[7] Katsaras GΝ, Sokou R, Tsantes AG, et al. The use of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) in neonates: a systematic review. Eur J Pediatr,2021,180(12):3455-3470.
[8] Konstantinidi A, Sokou R, Parastatidou S, et al. Clinical application of thromboelastography/thromboelastometry (TEG/TEM) in the neonatal population: A narrative review. Semin Thromb Hemost,2019,45(5):449-457.
[9] Kumar M, Ahmad J, Maiwall R, et al. Thromboelastography-guided blood component use in patients with cirrhosis with nonvariceal bleeding: A randomized controlled trial. Hepatology,2020,71(1):235-246.
[10] Kohli R, Shingina A, New S, et al. Thromboelastography parameters are associated with cirrhosis severity. Dig Dis Sci,2019,64(9):2661-2670.
[11] 李晓彤, 李鑫, 孙旖旎, 等. 相同国际血栓与止血协会评分下血栓弹力图参数在创伤大失血及脓毒症中的差异及意义. 中国实用内科杂志,2021,41(6):515-520.
[12] 蔡培培, 张威, 周连群, 等. 家用便携式凝血检测仪的一致性分析. 国际检验医学杂志,2019,40(1):37-39.
[13] 张芷薇, 玄飞越, 郑法康, 等. 血栓弹力图及基因检测技术在支架辅助栓塞颅内动脉瘤老年患者中的应用. 中华老年心脑血管病杂志,2023,25(04):340-343.
[14] 徐新, 尚峰, 曲鑫, 等. 创伤性脑损伤诱发的凝血功能障碍研究进展. 中国现代神经疾病杂志,2020,20(8):674-681.
[15] Du L, Ma Y, Zhou S, et al. A prognostic score for patients with acute-on-chronic liver failure treated with plasma exchange-centered artificial liver support system. Sci Rep,2021,11(1):1469.
[16] Alkarithi G, Duval C, Shi Y, et al. Thrombus structural composition in cardiovascular disease. Arterioscler Thromb Vasc Biol,2021,41(9):2370-2383.
[17] Zhou W, Zhou W, Bai J, et al. TEG in the monitoring of coagulation changes in patients with sepsis and the clinical significance. Exp Ther Med,2019,17(5):3373-3382.
[18] Li Y, Chang H, Ni L, et al. Analysis of thrombelastogram-guided medication in patients with coronary heart disease after percutaneous coronary intervention. Exp Ther Med,2019,17(4):3047-3052.
[19] Hasan O, Tung RC, Freeman H, et al. Thromboelastography after cardiopulmonary bypass: Does it save blood products?. Kans J Med,2022,15:27-30.
[20] Zhou H, Chen L, He H. Intraoperative and postoperative effects of TEG-guided platelet transfusion on antiplatelet drug-related intracerebral hemorrhage patients. Exp Ther Med,2019,17(3):2263-2267.