内镜下食管静脉曲张套扎术治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者再出血风险观察*

doi:10.3969/j.issn.1672-5069.2021.06.028

摘要/Abstract

摘要： 目的研究采用内镜下食管静脉曲张套扎术(EVL)治疗乙型肝炎肝硬化(LC)并发食管静脉曲张(EV)破裂出血患者治疗后再出血的风险。方法 2016年4月～2019年10月我科诊治的178例乙型肝炎肝硬化并发食管静脉曲张破裂出血(EVB)患者,在止血后采用EVL治疗,随访再出血发生情况,应用Cox风险回归模型进行多因素分析,建立Nomogram模型,预测再出血。结果 178例患者急性出血后,死亡12例(6.7%),166例接受EVL术,均获得成功;术后随访12～54个月,27例(16.3%)发生再出血;入院时,27例再出血组外周血Hb和血清白蛋白水平显著低于139例未再出血组(P<0.05),而空腹血糖(FPG)和糖化血红蛋白(HbA1c)水平显著高于未再出血组,差异均有统计学意义(P<0.05);入院止血后检查,发现再出血患者门静脉和脾静脉宽度显著大于未再出血组(P<0.05);Cox风险模型分析显示Child-Pugh分级(95%CI=1.125～3.439,HR=1.967,P=0.018)、腹水(95%CI=1.754～2.329,HR=2.021,P=0.000)、HbA1c(95%CI=1.173～1.921,HR=1.501,P=0.001)、FPG(95%CI=1.379～3.152,HR=2.085,P=0.000)和肝性糖尿病(95%CI=1.321～2.945,HR=2.076,P=0.006)是EVL术后再出血的独立影响因素;根据Cox建立Nomogram模型,ROC分析结果显示Nomogram判断术后再出血的AUC为0.804(SE=0.053,95%CI=0.700～0.907,P=0.000),其敏感度为0.857,特异度为0.565。结论采取EVL治疗LC并发EVB患者术后再出血发生率较高,除常见的风险因素外,伴有肝性糖尿病也可能是重要的原因,临床应加强对血糖的控制,减少再出血的发生。

关键词: 肝硬化, 食管静脉曲张破裂出血, 内镜下食管静脉曲张套扎术, 肝性糖尿病, 再出血

Abstract: Objective The paper aimed to investigate the risk factors of rebleeding in hepatitis B liver cirrhotics with esophageal varices bleeding (EVB) after endoscopic variceal ligation (EVL). Methods 178 patients with hepatitis B liver cirrhosis (LC) with EVB were enrolled in our hospital betweenApril 2016 and October 2019, and all underwent EVL after hemostasis. A Nomogram model was established to predict the risk factors of rebleeding after multivariate Cox Logistic analysis was done. Results 12 (6.7%)patients died out of the 178 patients with EVB, and 166 patients received successful EVL in our series; at the end of 12 to 54 month follow-up, 27 patients(16.3%) had rebleeding of esophageal varices; at presentation, the peripheral blood hemoglobin and serum albumin levels in the 27 patientswith rebleeding were significantly lower than, while the fasting plasma glucose (FPG) and HbA1c levels were significantly higher than those in 139 patients without(P<0.05);the checked-up after hemostasis showed that the diameters of portal and splenic veins in patients with rebleeding were significantly wider than those in without (P<0.05); the Cox risk model analysis showed that the Child-Pugh class(95%CI=1.125-3.439, HR=1.967, P=0.018), ascites (95%CI=1.754-2.329, HR=2.021, P=0.000), HbA1c(95%CI=1.173-1.921, HR=1.501, P=0.001), FPG(95%CI=1.379-3.152, HR=2.085, P=0.000) and hepatic diabetes (95%CI=1.321-2.945, HR=2.076, P=0.006) were the independent risk factors for rebleeding after EVL; the Nomogram model was established based on the Cox analysis, and the ROC analysis showed that the area under the ROC (AUC) by theNomogram was 0.804(SE=0.053, 95%CI=0.700-0.907, P=0.000), with the sensitivity of 0.857 and the specificity of 0.565, in predicting rebleeding after EVL. Conclusion The incidences rate of rebleeding in LC patients with EVB after EVL is higher, and among others, the hepatic diabetes might be the important risk factor for rebleeding in this setting, which should be dealt with appropriately.

Key words: Liver cirrhosis, Esophageal varices bleeding, Endoscopic variceal ligation, Hepatic diabetes, Rebleeding

叶东, 张俊霞, 李洁, 刘颖, 张丹, 郭永泽. 内镜下食管静脉曲张套扎术治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者再出血风险观察^*[J]. 实用肝脏病杂志, 2021, 24(6): 879-882.

Ye Dong, Zhang Junxia, LiJie, et al. Risk factors of rebleeding in hepatitis B liver cirrhotics with esophageal varices bleeding after endoscopic variceal ligation[J]. Journal of Practical Hepatology, 2021, 24(6): 879-882.

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内镜下食管静脉曲张套扎术治疗乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者再出血风险观察^*

Risk factors of rebleeding in hepatitis B liver cirrhotics with esophageal varices bleeding after endoscopic variceal ligation

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