食管静脉曲张首次硬化剂治疗后早期再出血的危险因素
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摘要
目的探讨首次食管静脉曲张硬化剂治疗(EVS)对肝硬化患者肝功能、血生化的影响,分析术后早期再出血的危险因素。方法回顾性分析2016年1月-2017年12月于首都医科大学附属北京佑安医院住院,经首次EVS治疗的120例肝硬化伴食管静脉曲张破裂出血患者的临床资料,按照不同肝功能Child-Pugh分级,对比EVS治疗前后的肝功能、血生化检测结果,评价EVS对上述指标的影响;并将术后14 d内出血的患者定义为早期再出血,分为出血组与未出血组,应用logistic回归分析,分析影响再出血的主要危险因素。正态分布的计量资料2组间比较采用t检验,非正态分布的计量资料2组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ2检验或Fisher确切概率法。结果 Child-Pugh A级、B级患者EVS治疗前后,TBil(Z=-3. 975,P <0. 001; Z=-3. 670,P <0. 001)、DBil(Z=-3. 455,P=0. 001; Z=-3. 086,P=0. 002)、WBC(Z=-2. 811,P=0. 005; Z=-3. 683,P <0. 001)的变化差异均有统计学意义。EVS术后早期再出血率为10%(12/120),logistic回归分析提示腹水量(比值比=2. 92,P=0. 047)及伴有门静脉血栓(比值比=4. 94,P=0. 018)均是导致EVS术后早期再出血的独立危险因素。结论 EVS治疗对肝功能影响不大,应警惕治疗过程中细菌感染的可能。术前应及时减少腹水量,从而降低EVS后早期再出血的发生率。对于伴有门静脉血栓的患者,应结合患者病情,评估治疗风险,选择更适当的治疗方案。
Objective To investigate the effect of initial esophageal variceal sclerotherapy( EVS) on liver function and blood biochemistry in patients with liver cirrhosis and the risk factors for early rebleeding after initial EVS. Methods A retrospective analysis was performed for the clinical data of 120 cirrhotic patients with esophageal variceal bleeding who were hospitalized in Beijing YouAn Hospital,Capital Medical University,from January 2016 to December 2017 and received initial EVS. The patients were divided into groups according to the Child-Pugh class,and liver function and blood biochemistry were compared between groups before and after treatment to evaluate the effect of EVS on the above indices. Early rebleeding after surgery was defined as bleeding within 14 days after surgery. The patients were divided into bleeding group and non-bleeding group according to the presence or absence of early rebleeding,and a logistic regression analysis was performed to investigate the main risk factors for early rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test or the Fisher' s exact test was used for comparison of categorical data between groups. Results After treatment,Child-Pugh class A/B patients had significant changes in total bilirubin( Z =-3. 975 and-3. 670,both P < 0. 001),direct bilirubin( Z =-3. 455 and-3. 086,P = 0. 001 and 0. 002),and white blood cell count( Z =-2. 811 and-3. 683,P = 0. 005 and P <0. 001). Early rebleeding rate after EVS was 10%( 12/120). The logistic regression analysis showed that the amount of ascites( odds ratio[OR]= 2. 92,P = 0. 047) and presence of portal vein thrombosis( OR = 4. 94,P = 0. 018) were independent risk factors for early rebleeding after EVS. Conclusion EVS does not have a significant impact on liver function,and bacterial infection should be taken seriously during treatment. The amount of ascites should be reduced before surgery,in order to reduce the incidence rate of early rebleeding after EVS.For patients with portal vein thrombosis,the risk of treatment should be evaluated and an appropriate treatment regimen should be selected based on patient's conditions.
Objective To investigate the effect of initial esophageal variceal sclerotherapy( EVS) on liver function and blood biochemistry in patients with liver cirrhosis and the risk factors for early rebleeding after initial EVS. Methods A retrospective analysis was performed for the clinical data of 120 cirrhotic patients with esophageal variceal bleeding who were hospitalized in Beijing YouAn Hospital,Capital Medical University,from January 2016 to December 2017 and received initial EVS. The patients were divided into groups according to the Child-Pugh class,and liver function and blood biochemistry were compared between groups before and after treatment to evaluate the effect of EVS on the above indices. Early rebleeding after surgery was defined as bleeding within 14 days after surgery. The patients were divided into bleeding group and non-bleeding group according to the presence or absence of early rebleeding,and a logistic regression analysis was performed to investigate the main risk factors for early rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test or the Fisher' s exact test was used for comparison of categorical data between groups. Results After treatment,Child-Pugh class A/B patients had significant changes in total bilirubin( Z =-3. 975 and-3. 670,both P < 0. 001),direct bilirubin( Z =-3. 455 and-3. 086,P = 0. 001 and 0. 002),and white blood cell count( Z =-2. 811 and-3. 683,P = 0. 005 and P <0. 001). Early rebleeding rate after EVS was 10%( 12/120). The logistic regression analysis showed that the amount of ascites( odds ratio[OR]= 2. 92,P = 0. 047) and presence of portal vein thrombosis( OR = 4. 94,P = 0. 018) were independent risk factors for early rebleeding after EVS. Conclusion EVS does not have a significant impact on liver function,and bacterial infection should be taken seriously during treatment. The amount of ascites should be reduced before surgery,in order to reduce the incidence rate of early rebleeding after EVS.For patients with portal vein thrombosis,the risk of treatment should be evaluated and an appropriate treatment regimen should be selected based on patient's conditions.
引文
[1]DING HG,XU XY,LINGHU EQ,et al.Interpretation of guidelines for the diagnosis and treatment of esophageal and gastric variceal bleeding in cirrhotic portal hypertension[J].J Clin Hepatol,2016,32(2):220-222.(in Chinese)丁惠国,徐小元,令狐恩强,等.《肝硬化门静脉高压食管胃静脉曲张出血的防治指南》解读[J].临床肝胆病杂志,2016,32(2):220-222.
[2]MAO P,XIANG YL.Cause of early and late rebleeding after endoscopic variceal ligation and the nursing[J].China J Endosc,2013,19(7):732-735.(in Chinese)毛平,向亚利.内镜下套扎治疗食管静脉曲张术后早、晚期再出血的原因分析及处理[J].中国内镜杂志,2013,19(7):732-735.
[3]Chinese Society of Infectious Diseases and Parasitology,Chinese Society of Hepatology,Chinese Medical Association.Prevention and treatment of viral hepatitis[J].Chin J Infect Dis,2001,19(1):56-62.(in Chinese)中华医学会传染病与寄生虫病学分会,中华医学会肝病学分会.病毒性肝炎防治方案[J].中华传染病杂志,2001,19(1):56-62.
[4]Chinese Society of Hepatology,Chinese Medical Association;Chinese Society of Gastroenterology,Chinese Medical Association;Chinese Society of Endoscopy,Chinese Medical Association.Guidelines for the diagnosis and treatment of esophageal and gastric variceal bleeding in cirrhotic portal hypertension[J].J Clin Hepatol,2016,32(2):203-219.(in Chinese)中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].临床肝胆病杂志,2016,32(2):203-219.
[5]Study Group of Esophageal and Gastric Varices,Chinese Society of Endoscopy,Chinese Medical Association.Endoscopic diagnosis and treatment standard for gastroesophageal varices and bleeding(2009,on trial)[J].Chin J Dig Endosc,2010,27(1):1-4.(in Chinese)中华医学会消化内镜学分会食管胃静脉曲张学组.消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年)[J].中华消化内镜杂志,2010,27(1):1-4.
[6]LU ZY,ZHONG NS.Internal Medicine[M].7th version.Beijing:People's Medical Publishing House,2008:453.(in Chinese)陆再英,钟南山.内科学[M].7版.北京:人民卫生出版社,2008:453.
[7]ASCHA M,ABUQAYYAS S,HANOUNEH I,et al.Predictors of mortality after transjugular portosystemic shunt[J].World JHepatol,2016,8(11):520-529.
[8]JU W,ZHANG BJ,HAN GH.Long-term therapeutic effect of transjugular intrahepatic portosystemic shunt in patients with intractable cirrhotic ascites and prognostic factors[J].J Clin Hepatol,2016,32(8):1529-1533.(in Chinese)巨伟,张博静,韩国宏.经颈静脉肝内门体分流术治疗肝硬化顽固性腹水的长期效果及预后因素分析[J].临床肝胆病杂志,2016,32(8):1529-1533.
[9]PAN MX,ZHANG SQ,LIU HF.Analysis of risk factors of septicemia in esophageal and gastric varices after endoscopic injection of cyanoacrylate[J].Inter J Epidemiol Infect Dis,2010,37(6):368-371.(in Chinese)潘明霞,张思泉,刘华峰.食管胃底静脉曲张内镜硬化剂治疗并发败血症危险因素分析[J].国际流行病学传染病学杂志,2010,37(6):368-371.
[10]WANG XY,MAO YP,GUO MZ.Influence of esophageal and gastric variceal endoscopic therapy on liver function[J].Chin JGastroenterol Hepatol,2010,19(5):481-482.(in Chinese)王晓燕,毛永平,郭明洲.食管胃静脉曲张内镜治疗对肝功能的影响[J].胃肠病学和肝病学杂志,2010,19(5):481-482.
[11]VOROBIOFF JD,GROSZMANN RJ.Prevention of portal hypertension:From variceal development to clinical decompensation[J].Hepatology,2015,61(1):375-381.
[12]CUI ML,JIA YS,KANG HY,et al.Efficacy of endoscopic sclerotherapy with lauromacrogol in treatment of severe esophageal variceal bleeding[J].J Clin Hepatol,2017,33(12):2321-2325.(in Chinese)崔美兰,贾彦生,康海燕,等.内镜下聚桂醇硬化洽疗重度食管静脉曲张破裂出血的效果观察[J].临床肝胆病杂志,2017,33(12):2321-2325.
[13]WANG JG,KONG DR.Efficacy of endoscopic intervention alone versus endoscopic intervention plus propranolol in the prophylaxis of esophageal variceal rebleeding[J].World Chin J Dig,2012,20(30):2944-2950.(in Chinese)王进广,孔德润.内镜干预及联合普萘洛尔预防食管静脉曲张破裂再出血的疗效[J].世界华人消化杂志,2012,20(30):2944-2950.
[14]GUO YL,XU BH,LIU X,et al.Risk factors analysis of early rebleeding after endoscopic treatment of esophageal varices[J].Chin J Dig Endosc,2018,35(2):89-93.(in Chinese)郭雅丽,徐宝宏,刘贤,等.食管静脉曲张内镜治疗术后早期再出血的危险因素分析[J].中华消化内镜杂志,2018,35(2):89-93.
[15]WU DJ,LUO C.Factors influencing early rebleeding after emergency endoscopic treatment for esophagogastric variceal bleeding in patients with cirrhosis[J].Pract Clin Med,2013,14(10):22-25.(in Chinese)吴达军,罗超.肝硬化食管胃底静脉曲张破裂出血急诊内镜下治疗后早期再出血的影响因素[J].实用临床医学,2013,14(10):22-25.
[16]LOFFREDO L,PASTORI D,FARCOMENI A,et al.A effects of anticoagulants in patients with cirrhosis and portal vein thrombosis:A systematic review and meta-analysis[J].Gastroenterology,2017,153(2):480-487.
[17]ZHANG JY,WANG YB,GONG JP,et al.Postoperative anticoagulants in preventing portal vein thrombosis in patients undergoing splenectomy because of liver cirrhosis:A meta-analysis[J].Am Surg,2016,82(12):1169-1177.
[18]ZHANG X,WANG Y,YU M,et al.Effective prevention for portal venous system thrombosis after splenectomy:A meta-analysis[J].J Laparoendosc Adv Surg Tech A,2017,27(3):247-252.
[2]MAO P,XIANG YL.Cause of early and late rebleeding after endoscopic variceal ligation and the nursing[J].China J Endosc,2013,19(7):732-735.(in Chinese)毛平,向亚利.内镜下套扎治疗食管静脉曲张术后早、晚期再出血的原因分析及处理[J].中国内镜杂志,2013,19(7):732-735.
[3]Chinese Society of Infectious Diseases and Parasitology,Chinese Society of Hepatology,Chinese Medical Association.Prevention and treatment of viral hepatitis[J].Chin J Infect Dis,2001,19(1):56-62.(in Chinese)中华医学会传染病与寄生虫病学分会,中华医学会肝病学分会.病毒性肝炎防治方案[J].中华传染病杂志,2001,19(1):56-62.
[4]Chinese Society of Hepatology,Chinese Medical Association;Chinese Society of Gastroenterology,Chinese Medical Association;Chinese Society of Endoscopy,Chinese Medical Association.Guidelines for the diagnosis and treatment of esophageal and gastric variceal bleeding in cirrhotic portal hypertension[J].J Clin Hepatol,2016,32(2):203-219.(in Chinese)中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].临床肝胆病杂志,2016,32(2):203-219.
[5]Study Group of Esophageal and Gastric Varices,Chinese Society of Endoscopy,Chinese Medical Association.Endoscopic diagnosis and treatment standard for gastroesophageal varices and bleeding(2009,on trial)[J].Chin J Dig Endosc,2010,27(1):1-4.(in Chinese)中华医学会消化内镜学分会食管胃静脉曲张学组.消化道静脉曲张及出血的内镜诊断和治疗规范试行方案(2009年)[J].中华消化内镜杂志,2010,27(1):1-4.
[6]LU ZY,ZHONG NS.Internal Medicine[M].7th version.Beijing:People's Medical Publishing House,2008:453.(in Chinese)陆再英,钟南山.内科学[M].7版.北京:人民卫生出版社,2008:453.
[7]ASCHA M,ABUQAYYAS S,HANOUNEH I,et al.Predictors of mortality after transjugular portosystemic shunt[J].World JHepatol,2016,8(11):520-529.
[8]JU W,ZHANG BJ,HAN GH.Long-term therapeutic effect of transjugular intrahepatic portosystemic shunt in patients with intractable cirrhotic ascites and prognostic factors[J].J Clin Hepatol,2016,32(8):1529-1533.(in Chinese)巨伟,张博静,韩国宏.经颈静脉肝内门体分流术治疗肝硬化顽固性腹水的长期效果及预后因素分析[J].临床肝胆病杂志,2016,32(8):1529-1533.
[9]PAN MX,ZHANG SQ,LIU HF.Analysis of risk factors of septicemia in esophageal and gastric varices after endoscopic injection of cyanoacrylate[J].Inter J Epidemiol Infect Dis,2010,37(6):368-371.(in Chinese)潘明霞,张思泉,刘华峰.食管胃底静脉曲张内镜硬化剂治疗并发败血症危险因素分析[J].国际流行病学传染病学杂志,2010,37(6):368-371.
[10]WANG XY,MAO YP,GUO MZ.Influence of esophageal and gastric variceal endoscopic therapy on liver function[J].Chin JGastroenterol Hepatol,2010,19(5):481-482.(in Chinese)王晓燕,毛永平,郭明洲.食管胃静脉曲张内镜治疗对肝功能的影响[J].胃肠病学和肝病学杂志,2010,19(5):481-482.
[11]VOROBIOFF JD,GROSZMANN RJ.Prevention of portal hypertension:From variceal development to clinical decompensation[J].Hepatology,2015,61(1):375-381.
[12]CUI ML,JIA YS,KANG HY,et al.Efficacy of endoscopic sclerotherapy with lauromacrogol in treatment of severe esophageal variceal bleeding[J].J Clin Hepatol,2017,33(12):2321-2325.(in Chinese)崔美兰,贾彦生,康海燕,等.内镜下聚桂醇硬化洽疗重度食管静脉曲张破裂出血的效果观察[J].临床肝胆病杂志,2017,33(12):2321-2325.
[13]WANG JG,KONG DR.Efficacy of endoscopic intervention alone versus endoscopic intervention plus propranolol in the prophylaxis of esophageal variceal rebleeding[J].World Chin J Dig,2012,20(30):2944-2950.(in Chinese)王进广,孔德润.内镜干预及联合普萘洛尔预防食管静脉曲张破裂再出血的疗效[J].世界华人消化杂志,2012,20(30):2944-2950.
[14]GUO YL,XU BH,LIU X,et al.Risk factors analysis of early rebleeding after endoscopic treatment of esophageal varices[J].Chin J Dig Endosc,2018,35(2):89-93.(in Chinese)郭雅丽,徐宝宏,刘贤,等.食管静脉曲张内镜治疗术后早期再出血的危险因素分析[J].中华消化内镜杂志,2018,35(2):89-93.
[15]WU DJ,LUO C.Factors influencing early rebleeding after emergency endoscopic treatment for esophagogastric variceal bleeding in patients with cirrhosis[J].Pract Clin Med,2013,14(10):22-25.(in Chinese)吴达军,罗超.肝硬化食管胃底静脉曲张破裂出血急诊内镜下治疗后早期再出血的影响因素[J].实用临床医学,2013,14(10):22-25.
[16]LOFFREDO L,PASTORI D,FARCOMENI A,et al.A effects of anticoagulants in patients with cirrhosis and portal vein thrombosis:A systematic review and meta-analysis[J].Gastroenterology,2017,153(2):480-487.
[17]ZHANG JY,WANG YB,GONG JP,et al.Postoperative anticoagulants in preventing portal vein thrombosis in patients undergoing splenectomy because of liver cirrhosis:A meta-analysis[J].Am Surg,2016,82(12):1169-1177.
[18]ZHANG X,WANG Y,YU M,et al.Effective prevention for portal venous system thrombosis after splenectomy:A meta-analysis[J].J Laparoendosc Adv Surg Tech A,2017,27(3):247-252.