肝硬化食管胃静脉曲张出血患者内镜治疗后再出血的危险因素分析

摘要/Abstract

摘要： 目的探究肝硬化食管胃静脉曲张破裂出血(esophageal gastric variceal bleeding, EGVB)患者内镜治疗后再出血的危险因素。方法回顾性分析2019年11月1日至2021年11月31日湖北省人民医院诊断为肝硬化EGVB的患者142例,将其分为再出血组和无出血组,比较两组基线资料。应用单因素及多因素Cox比例风险回归确定再出血的独立预测因素。使用受试者工作特征曲线(receiver operating characteristic, ROC)评估Cox多因素预测模型与CTP、MELD、MELD-Na及CAGIB对180 d再出血概率的预测性能。使用DeLong法比较预测模型之间的受试者工作特征曲线下面积(area under the receiver operating characteristic, AUROC)。结果随访180 d,61例(43.0%)患者发生再出血,81例(57.0%)无出血。Cox单因素回归分析显示,病因(HR=1.970, 95%CI: 1.155~3.362, P<0.013)、门静脉血栓(HR=2.605, 95%CI: 1.102~3.869, P=0.024)、ApoA1(HR=2.009, 95%CI: 1.196~3.374, P=0.008)、纤维蛋白原(HR=2.683, 95%CI: 1.558~4.621, P<0.01)等与再出血相关。Cox多因素回归分析显示,病因(HR=3.922, 95%CI: 1.843~8.346, P<0.01)、门静脉血栓(HR=2.798, 95%CI: 1.385~5.652, P=0.004)、ApoA1(HR=2.207, 95%CI: 1.122~4.340, P=0.022)、纤维蛋白原(HR=2.729, 95%CI: 1.405~5.300, P=0.003)与180 d内再出血独立相关。ROC曲线分析显示Cox多因素混合模型(AUC=0.773, P<0.01)优于MELD(AUC=0.602, P=0.0388)、iMELD(AUC=0.620, P=0.0145)、MELD-Na(AUC=0.618, P=0.0166)、CTP评分(AUC=0.688, P<0.01)及CAGIB(AUC=0.625, P=0.0108)。结论联合肝硬化病因、门静脉血栓、ApoA1及纤维蛋白原的混合模型,对于肝硬化静脉曲张再出血具有更好的预测价值。

关键词: 肝硬化, 食管胃静脉曲张破裂出血, 再出血, 危险因素

Abstract: Objective To investigate the risk factors for rebleeding within 180 days after endoscopic treatment in cirrhotic patients with esophageal gastric variceal bleeding (EGVB), and to compare the risk factors with child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD), MELD-Na, and integrated MELD (iMELD) and cirrhosis acute gastrointestinal bleeding (CAGIB). Methods A total of 142 cirrhotic patients with EGVB in our hospital from November 1, 2019 to November 31, 2021 were retrospective included, they were divided into rebleeding group and no bleeding group. The baseline data differences between the 2 groups were compared by t-test and non-parameter test. Univariate and multifactor Cox proportional risk regression was used to determine independent predictors of rebleeding. The performance of the Cox multifactor predictive model and CTP, MELD-Na, and CAGIB on the probability of rebleeding at 180 days was evaluated by the receiver operating characteristic (ROC). The area under the receiver operating characteristic (AUROC) was compared among prediction models through the DeLong method. Results During the 180-day follow-up period, rebleeding occurred in 61 (43.0%) patients, and 81 (57.0%) patients without rebleeding. Cox univariate regression analysis showed that the etiology (HR=1.970, 95%CI: 1.155~3.362, P<0.013), portal vein thrombosis (HR=2.605, 95%CI: 1.102~3.869, P=0.024), ApoA1 (HR=2.009, 95%CI: 1.196~3.374, P=0.008), fibrinogen (HR=2.683, 95%CI: 1.558~4.621, P<0.001) were associated with rebleeding; Cox multivariate regression analysis showed that the etiology (HR=3.922, 95%CI: 1.843~8.346, P<0.001), portal vein thrombosis (HR=2.798, 95%CI: 1.385~5.652, P=0.004), ApoA1 (HR=2.207, 95%CI: 1.122~4.340, P=0.022), fibrinogen (HR=2.729, 95%CI: 1.405~5.300, P=0.003) were independently associated with rebleeding within 180 days. ROC curve analysis showed that the predictive value of Cox multivariate hybrid models (AUROC 0.773, P<0.001) was better than MELD (AUROC 0.602, P=0.0388), iMELD (AUROC 0.620, P=0.0145), MELD-Na (AUROC 0.618, P=0.0166), CTP score (AUROC 0.688, P<0.001) and CAGIB (AUROC 0.625, P=0.0108).Conclusion The performance of combined model composed of etiology of cirrhosis, portal vein thrombosis, ApoA1 and fibrinogen had better predictive value for rebleeding in cirrhotic patients with EVGB after endoscopic treatment.

Key words: Liver Cirrhosis, Esophageal gastric variceal bleeding, Rebleeding, Risk factors

何青莲, 余保平, 肖勇. 肝硬化食管胃静脉曲张出血患者内镜治疗后再出血的危险因素分析[J]. 肝脏, 2023, 28(1): 55-60.

HE Qing-lian, YU Bao-ping, XIAO Yong. Risk factors of rebleeding in cirrhotic patients with esophageal gastric variceal bleeding after endoscopic treatment[J]. Chinese Hepatolgy, 2023, 28(1): 55-60.

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