肝硬化食管胃底静脉曲张出血内镜套扎术后1年预后的影响因素观察

摘要/Abstract

摘要： 目的了解肝硬化食管胃底静脉曲张出血(EGVB)患者内镜套扎术1年预后及其影响因素。方法纳入2017年11月至2018年12月324例行内镜套扎术的EGVB患者,随访患者1年预后,以发生出血再入院或死亡为不良预后。采用Logistic多因素分析影响患者不良预后的影响因素,并建立预测模型,分析其临床应用价值。结果 324例患者术后随访12至25个月,46例(14.2%)患者发生不良预后事件,为观察组。另278例为对照组。观察组Child-Pugh分级中A级5例,B级10例,C级31例,曲张静脉直径为(1.1±0.4)cm,对照组分别为103例、120例及55例,曲张静脉直径为(0.8±0.5)cm。两组间肝功能分级和曲张静脉直径差异有统计学意义(P<0.05)。观察组患者血红蛋白(Hb)为(78.6±10.0)g/L,低于对照组的(85.4±8.9)g/L,差异有统计学意义(P<0.05)。观察组血清总胆红素(TBil)、γ-谷氨酰转肽酶(GGT)分别为(42.8±4.9)μmol/L和(76.4±24.1)U/L,高于对照组的(27.3±5.2)μmol/L和(37.9±14.8)U/L,差异有统计学意义(P<0.05)。观察组CTP评分、MELD评分及MELD-Na分别为(9.4±2.3)分、(10.8±2.2)分和(11.2±2.5)分,高于对照组的(7.8±3.1)分、(8.7±3.0)分和(9.6±2.4)分,差异有统计学意义(P<0.05)。logistic多因素分析结果显示Child-pugh分级(OR=2.181,95%CI=1.475~3.225)、TBil(OR=1.789,95%CI=1.241~2.579)、CTP(OR=2.518,95%CI=1.763~3.596)及MELD-Na(OR=1.484,95%CI=1.084~2.032)是肝硬化食管胃底静脉曲张患者发生不良预后的高危因素(P<0.05)。Nomogram列线图判断患者不良预后的预测模型内部检验C-index为0.630。结论 EGVB患者内镜套扎术1年预后与患者肝功能水平和MELD-Na相关,建立Nomogram列线图对判断预后具有较高的准确性。

关键词: 肝硬化食管胃底静脉曲张出血, 内镜套扎术, 预后, 影响因素

Abstract: Objective To study factors influencing prognosis for cirrhotic patients with esophagogastric variceal bleeding within 1 year after endoscopic variceal ligation (EVL).Methods Three hundred and twenty-four cirrhotic patients with esophagogastric variceal bleeding receiving EVL from November 2017 to December 2018 were followed up for at least 1 year. Readmission for hemorrhage and death were regarded as poor prognosis. The multivariate logistic regression analysis was used to define factors influencing prognosis of patients, and a nomogram was developed to predict poor prognosis. Results All the patients were followed up for 12 to 25 months. Forty-six patients with poor prognosis were enrolled as observation group, the other 278 patients as control group. The incidence of poor prognosis was 14.2%. In observation group, there were 5, 10 and 31 patients classified as Child-Pugh grade A, B and C. In control group, there were 103, 120 and 55 patients classified as Child-Pugh grade A, B and C. The average diameter of varicose veins was (1.1±0.4) cm in observation group, and (0.8±0.5) cm in control group. There were significant differences in Child-Pugh grade and varicose vein diameter between the 2 groups (P<0.05). The hemoglobin of (78.6±10.0) g/L in observation group, was significantly lower than (85.4±8.9) g/L in control group (P<0.05). The total bilirubin (TBil) and γ-glutamyltranspeptidase were (42.8±4.9) μmol/L and (76.4±24.1) U/L in observation group, significantly higher than (27.3±5.2) μmol/L and (37.9±14.8) U/L in control group (P<0.05). The Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease score and model for end-stage liver disease includes serum sodium (MELD-Na) score were (9.4±2.3), (10.8±2.2) and (11.2±2.5) in observation group, significantly higher than (7.8±3.1), (8.7±3.0) and (9.6±2.4) in control group (P<0.05). The multivariate logistic regression analysis showed that Child-Pugh grade [odds ratio (OR)=2.181, 95% confidence interval (CI): 1.475-3.225], TBil (OR=1.789, 95%CI: 1.241-2.579), CTP score (OR=2.518, 95%CI: 1.763-3.596) and MELD-Na score (OR=1.484, 95%CI: 1.084-2.032) were risk factors for poor prognosis in cirrhotic patients with esophagogastric variceal bleeding (P<0.05). The concordance index of nomogram to predict poor prognosis was 0.630.Conclusion The prognosis in cirrhotic patients with esophageal variceal bleeding within 1 year after EVL is related to liver function and MELD-Na score. The nomogram has high accuracy in predicting prognosis.

Key words: Esophagogastric variceal bleeding in cirrhosis, Endoscopic variceal ligation, Prognosis, Influencing factors

张生燕, 黄宏春, 王秀敏. 肝硬化食管胃底静脉曲张出血内镜套扎术后1年预后的影响因素观察[J]. 肝脏, 2021, 26(2): 155-158.

ZHANG Sheng-yan, HUANG Hong-chun, WANG Xiu-min. Factors influencing prognosis for cirrhotic patients with esophagogastric variceal bleeding within 1 year after endoscopic variceal ligation[J]. Chinese Hepatolgy, 2021, 26(2): 155-158.

参考文献

[1] 诸葛宇征. 经颈静脉肝内门体分流术治疗肝硬化食管胃静脉曲张破裂出血:基于风险分层的个体化治疗.中华消化杂志,2017,37:649-651.
[2] Kamal A, Abd Elmoety AA, Hamza Y, et al. Endoscopic variceal ligation followed by argon plasma coagulation against endoscopic variceal ligation alone.J Clin Gastroenterol,2017,51:49-55.
[3] Ravaioli F, Colecchia A. Sound conclusions: how splenic elastography may decrease the need for endoscopic variceal surveillance.Digest Dis Sci,2019,64:2381-2383.
[4] 卢承毅,陈永忠.药物联合内镜治疗与经颈静脉肝内门体分流术对肝硬化食管胃静脉曲张出血的疗效分析.中国内镜杂志,2018,24:34-38.
[5] 中华医学会外科学分会门静脉高压学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血的诊治共识(2015版).中华外科杂志,2015,53:917-921.
[6] 张其坤,王孟龙,卢实春,等.终末期肝病模型联合血清钠(MELD-Na)评分预测重型肝炎肝移植术后并发症等级的价值.中华肝胆外科杂志,2017,23:793-798.
[7] Villanueva C, Albillos A, Genescà J, et al. Preventing decompensation of cirrhosis with clinically significant portal hypertension and without high-risk varices: a new indication for non-selective beta-blockers (NSBB).J Hepatol,2017, 66:S97-S98.
[8] Abougergi MS, Peluso H, Mrad C, et al. The impact of obesity on mortality and other outcomes in patients with nonvariceal upper gastrointestinal hemorrhage in the united states.J Clin Gastroenterol, 2019, 53:114-119.
[9] Belghiti J,Dokmak S, Schadde E. Commentary on: associating liver partition and portal vein ligation in staged hepatectomy (ALPPS): innovation for innovation's sake. Surgery, 2016, 159:1287-1296.
[10] Rosenqvist K, Eriksson LG, Rorsman F, et al. Endovascular treatment of acute and chronic portal vein thrombosis in patients with cirrhotic and non-cirrhotic liver. Acta Radiol, 2015, 57:572-579.
[11] 黄鼎祥. 多层螺旋CT门静脉成像对食管胃底静脉曲张出血风险评估的价值分析.实用肝脏病杂志,2015,18:302-303.
[12] De Oliveira AC.Short article: noninvasive assessment of portal hypertension and detection of esophageal varices in cirrhosis: state-of-the-art.Eur J Gastroenterol Hepat,2017,29:531-534.
[13] Northup PG, Intagliata NM, Shah NL, et al. Excess mortality on the liver transplant waiting list: unintended policy consequences and model for end-stage liver disease (MELD) inflation. Hepatology, 2015, 61:285-291.
[14] 沈玲燕, 王彩芽, 周贤斌,等.BioCliM指数对食管胃底静脉曲张出血内镜下治疗后1年和2年预后的预测价值.中华消化杂志, 2018, 38:226-231.
[15] Koo JK, Kim JH, Choi YJ, et al. Predictive value of refit model for end-stage liver disease, refit model for end-stage liver disease-Na, and pre-existing scoring system for 3-month mortality in Korean patients with cirrhosis.J Gastroen Hepatol,2013,28:1209-1216.
[16] Wu CK, Liang CM, Hsu CN, et al. The role of adjuvant acid suppression on the outcomes of bleeding esophageal varices after endoscopic variceal ligation. Plos One, 2017, 12:169-178.