肝硬化食管静脉曲张急诊套扎术后再出血的影响因素

贺庆娟; 房英霞; 刘旭臣; 李忠斌

doi:10.3969/j.issn.1001-5256.2022.08.016

肝硬化食管静脉曲张急诊套扎术后再出血的影响因素

DOI: 10.3969/j.issn.1001-5256.2022.08.016

1.
青岛市第八人民医院消化内二科，山东青岛 266100
2.
解放军总医院第五医学中心肝病医学部，北京 100039

基金项目:

国家“十三五”重大专项课题 (2017ZX10203202-003)

伦理学声明：本研究方案于2020年7月14日经由中国人民解放军总医院第五医学中心伦理委员会审批，批号：2020056D。

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：贺庆娟负责课题设计，收集数据，撰写论文；刘旭臣、房英霞参与资料分析，数据统计；李忠斌负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
李忠斌，302lizhongbin@sina.com

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出版历程
- 收稿日期: 2021-12-10
- 录用日期: 2022-02-03
- 出版日期: 2022-08-20

Risk factors for rebleeding after emergency esophageal variceal ligation in patients with liver cirrhosis

1.
Second Department of Gastroenterology, Qingdao Eighth People's Hospital, Qingdao, Shandong 266100, China
2.
Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China

Research funding:

National Science and Technology Major Project during the 13th Five-Year Plan Period (2017ZX10203202-003)

More Information

Corresponding author: LI Zhongbin, 302lizhongbin@sina.com(ORCID: 0000-0003-4878-7634)

摘要

摘要: 目的探讨影响肝硬化食管静脉曲张急诊套扎术后再出血的危险因素。方法回顾性分析2016年1月—2019年12月解放军总医院第五医学中心290例行急诊食管静脉套扎术治疗的肝硬化患者的临床和实验室资料，根据患者随访1年时有无再出血，分为再出血组和未出血组各145例。符合正态分布的计量资料两组间比较采用t检验，不符合正态分布的计量资料两组间比较采用Wilcoxn秩和检验，计数资料两组间比较采用χ²检验，以筛选出的有统计学意义的因素为自变量进行多因素logistic回归分析，筛选出急诊食管静脉套扎术后再出血的独立相关因素，通过绘制受试者工作特征曲线，获得预测再出血概率的指标并建立模型。结果单因素分析显示两组间血小板计数(PLT)(t=-1.888，P=0.047)、Child-Pugh评分(χ²=5.975，P=0.049)、白蛋白(Alb)水平(t=-2.229，P=0.029)、脾静脉直径(DSV)(t=3.808，P=0.001)比较，差异均有统计学意义。多因素logistic回归分析结果显示，Child-Pugh评分[比值比(OR)=0.280，95%CI: 0.108~0.729，P=0.009]、DSV(OR=1.549，95%CI: 1.197~2.005, P=0.001)和Alb(OR=0.832, 95%CI: 0.729~0.949，P=0.006)是食管静脉套扎术后再出血的影响因素。3个因素联合建立预测模型的受试者工作特征曲线下面积0.796，敏感度为83.7%，特异度为74.5%，界值为-0.086。结论 Child-Pugh评分、Alb水平、DSV为急诊食管静脉套扎术后再出血的独立相关因素，三者联合预测再出血的敏感度和特异度最高。
- 肝硬化 /
- 食管和胃静脉曲张 /
- 出血 /
- 二级预防 /
- 危险因素
Abstract: Objective To investigate the risk factors for rebleeding after emergency esophageal variceal ligation (EVL) in patients with liver cirrhosis. Methods A retrospective analysis was performed for the clinical and laboratory data of 290 patients with liver cirrhosis who underwent emergency EVL in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to December 2019, and according to the presence or absence of rebleeding within 1-year follow-up, they were divided into rebleeding group and non-rebleeding group. The t-test was used for comparison of normally distributed continuous data between two groups, and the Wilcoxon rank sum test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was performed with the statistically significant factors as independent variables to screen out the independent risk factors for rebleeding after emergency EVL, and the receiver operating characteristic (ROC) curve was plotted to obtain the indices for predicting the probability of rebleeding and establish a predictive model. Results The univariate analysis showed that there were significant differences between the two groups in platelet count (t=-1.888, P=0.047), Child-Pugh score (χ²=5.975, P=0.049), albumin level (t=-2.229, P=0.029), and splenic vein diameter (t=3.808, P=0.001). The multivariate logistic regression analysis showed that Child-Pugh score (odds ratio [OR]=0.280, 95% confidence interval [CI]: 0.108-0.729, P=0.009), splenic vein diameter (OR=1.549, 95%CI: 1.197-2.005, P=0.001) and albumin level (OR=0.832, 95%CI: 0.729-0.949, P=0.006) were independent influencing factors for rebleeding after EVL. The predictive model based on these three factors had an area under the ROC curve of 0.796, with a sensitivity of 83.7% and a specificity of 74.5% at the cut-off value of -0.086. Conclusion Child-Pugh score, albumin level, and splenic vein diameter are independent risk factors for rebleeding after emergency EVL, and the combination of the three indices has the highest sensitivity and specificity in predicting rebleeding.
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Hemorrhage /
- Secondary Prevention /
- Risk Factors

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图 1 logistic回归模型预测内镜下治疗后再出血的ROC曲线

Figure 1. ROC curve of logistic regression model predicting rebleeding after endoscopic treatment

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表 1 再出血组和未出血组患者一般资料比较

Table 1. Comparison of general data between rebleeding group and non bleeding group

项目	再出血组(n=145)	未出血组(n=145)	统计值	P值
性别[例(%)]			χ²=2.382	0.115
男	83(57.2)	88(60.7)
女	62(42.8)	57(39.3)
年龄(岁)	54.3±10.8	52.6±10.3	t=0.734	0.486
病因[例(%)]			χ²=1.791	0.145
肝炎肝硬化	82(56.6)	78(53.8)
酒精性肝硬化	29(20.0)	30(20.7)
胆汁淤积性肝硬化	15(10.3)	18(12.4)
自身免疫性肝硬化	9 (6.2)	11(7.6)
其他原因肝硬化	10(6.9)	8(5.5)
曲张静脉程度(例)			χ²=7.648	0.132
轻/中/重	24/46/75	28/39/78

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表 2 急诊食管套扎术后再出血的单因素分析

Table 2. Single factor analysis of rebleeding after emergency esophageal ligation

项目	未出血组(n=145)	再出血组(n=145)	统计值	P值
Child-Pugh分级[例(%)]			χ²=5.975	0.049
A级 B级 C级	40(27.6) 67(46.2) 38(26.2)	30(20.7) 101(69.6) 14(9.7)
WBC(×10¹²/L)	5.18±3.79	5.04±3.15	t=-0.188	0.852
Hb(g/L)	79.26±21.07	80.91±22.96	t=0.356	0.723
PLT(×10⁹/L)	98.83±92.12	66.63±34.74	t=-1.888	0.047
ALT(U/L)	33.06±32.73	73.40±25.24	t=1.086	0.280
AST(U/L)	38(26~74)	38(24~59)	Z=-0.727	0.467
GGT(U/L)	52(22~149)	34(20~108)	Z=-1.293	0.196
ALP(U/L)	144.20±148.48	105.44±61.00	t=-1.596	0.114
Alb(g/L)	30.57±7.06	27.72±4.98	t=-2.229	0.029
TBil(μmol/L)	18.50(14.10~43.70)	19(15.10~30.80)	Z=-0.12	0.990
GLU(mmol/L)	8.70±6.03	8.48±4.79	t=-0.191	0.849
ChE(mmol/L)	2 673.00±1 194.99	2 706.88±1 134.84	t=0.138	0.891
UN(mmol/L)	8.17±5.97	7.46±3.36	t=-0.689	0.492
Cr(μmol/L)	75.11±51.02	69.26±15.60	t=-0.721	0.473
PT(s)	14.36±1.90	14.46±2.35	t=0.215	0.830
PTA(%)	61.11±13.48	62.08±16.05	t=0.312	0.756
INR	1.26±0.17	1.26±0.21	t=0.078	0.938
脾脏长度(mm)	161.36±25.80	165.81±25.50	t=0.823	0.413
DSV(mm)	10.57±2.05	12.25±2.14	t=3.808	0.001
DPV(mm)	12.95±2.05	13.70±3.70	t=1.201	0.233

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表 3 影响急诊食管套扎术后再次出血的logistic多因素分析

Table 3. Effect of independent variables on rebleeding after emergency esophageal ligation

变量	B值	标准误	Wald值	OR(95%CI)	P值
PLT				0.997(0.987~1.008)	0.595
Alb	-0.183	0.070	7.914	0.832(0.729~0.949)	0.006
DSV	0.437	0.142	10.578	1.549(1.197~2.005)	0.001
Child-Pugh分级	-1.272	0.810	10.310	0.280(0.108~0.729)	0.009

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