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凝血试验指标对肝硬化合并急性上消化道出血的预测价值
Predictive value of coagulation test parameters for acute upper gastrointestinal bleeding in patients with liver cirrhosis
文章发布日期:2018年09月10日  来源:  作者:张丽航,王善娟,陆伦根,等  点击次数:323次  下载次数:29次

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【摘要】:目的探讨凝血试验指标与肝硬化合并急性上消化道出血(AUGIB)之间的关系。方法收集2013年1月-2016年12月在上海市健康医学院附属嘉定区中心医院消化内科住院的肝硬化患者233例,根据患者有无合并上消化道出血分为AUGIB组(n=87)和无AUGIB组(n=146)。收集患者姓名、性别、年龄、肝硬化原因、评价腹水情况、肝性脑病情况,入院时第1次验血指标,包括血常规、TBil、Alb、肌酐、凝血试验[包括PT、PTA、活化部分凝血活酶时间(APTT)、国际标准化比值(INR)、纤维蛋白原(FIB)、凝血酶时间(TT)]、D-二聚体。根据收集到的数据计算Child-Pugh评分和终末期肝病模型(MELD)评分。计量资料2组间比较采用独立样本t检验,多组间比较采用方差分析。logistic回归分析对各变量进行单变量和多变量分析。结果Child-Pugh C级的患者,其PT 、APTT、TT和INR较A、B级延长,PTA、FIB水平下降,TBil、MELD评分明显升高(F值分别为62.706、33.858、17.781、63025、46907、7.514、23.020、20.519,P值均<0.05);233例中仅175例检测了D-二聚体,58例未常规检测D-二聚体。Child-Pugh A、B、C级3组D-二聚体(Child-Pugh A级33例,Child-Pugh B级93例,Child-Pugh C级49例)比较差异有统计学意义[(1.63±2.15) mg/L vs (3.48±4.25) mg/L vs (4.24±4.79) mg/L, F=4.089,P=0.018]。MELD≥13组比MELD<13组PT、INR、APTT延长,PTA下降(t值分别为 7.307、7.602、3.650、5.546,P值均<0.05);AUGIB组87例患者中因食管胃底静脉曲张破裂出血76例,消化性溃疡9例,门静脉高压性胃病出血的1例,胃癌出血1例。AUGIB组表现为APTT延长,FIB水平升高,Child-Pugh分级高(t值分别为7.178、14.644、30.082,P值均<0.05)。APTT和FIB与AUGIB有关(似然比=1.09,95%可信区间:1.04~114,P<0.001;似然比=2.34,95%可信区间:1.61~3.41,P<0.001)。结论PT、INR、APTT延长程度与肝硬化患者疾病严重度评分Child-Pugh分级和MELD评分的增加是平行的,而APTT延长与FIB水平升高可预测肝硬化患者更易发生急性上消化道出血。
【Abstract】:ObjectiveTo investigate the association between coagulation test parameters and acute upper gastrointestinal bleeding (AUGIB) in patients with liver cirrhosis. MethodsA total of 233 patients with liver cirrhosis who were hospitalized in Department of Gastroenterology, Jiading District Central Hospital, Shanghai University of Medicine & Health Sciences, from January 2013 to December 2016, and according to the presence or absence of AUGIB, they were divided into AUGIB group with 87 patients and non-AUGIB group with 146 patients. Related clinical data were collected, including name, sex, age, cause of liver cirrhosis, ascites, hepatic encephalopathy, blood parameters of the first blood test after admission [routine blood test results, total bilirubin (TBil), albumin, and creatinine], coagulation test results [prothrombin time (PT), prothrombin time activity (PTA), activated partial thromboplastin time (APTT), international normalized ratio (INR), fibrinogen (FIB), thrombin time (TT)], and D-dimer. The Child-Pugh score and Model for End-Stage Liver Disease (MELD) score were calculated based on these data. The independent samples t-test was used for comparison of continuous data between two groups, and an analysis of variance was used for comparison between multiple groups. Logistic regression was used for univariate and multivariate analyses of related variables. ResultsCompared with the patients with Child-Pugh class A/B liver cirrhosis, the patients with Child-Pugh class C liver cirrhosis had significantly longer PT, APTT, and TT, a significantly higher INR, significant reductions in PTA and FIB, and significant increases in TBil and MELD score (F=62.706, 33.858, 17.781, 63.025, 46.907, 7.514, 23.020, and 20.519, all P<0.05). Of all 233 patients, only 175 underwent the measurement of D-dimer, and D-dimer was not measured for 58 patients, which caused data loss. According to the Child-Pugh class, the 175 patients who underwent D-dimer measurement were divided into Child-Pugh class A group with 33 patients, Child-Pugh class B group with 93 patients, and Child-Pugh class C group with 49 patients, and there was a significant difference in the level of D-dimer between these three groups (1.63±2.15 mg/L vs 3.48±4.25 mg/L vs 4.24±4.79 mg/L, F=4.089, P=0.018). Compared with the MELD ≥13 group, the MELD <13 group had significantly longer PT, INR, and APTT and a significant reduction in PTA (t=7.307, 7.602, 3.650, and 5.546, all P<0.05). Among the 87 patients in the AUGIB group, 76 had esophagogastric variceal bleeding, 9 had peptic ulcer, 1 had bleeding due to portal hypertensive gastropathy, and 1 had bleeding due to gastric carcinoma. Compared with the non-AUGIB group, the AUGIB group had a significantly longer APTT, a significantly higher FIB level, and a significantly higher Child-Pugh class (t=7.178, 14.644, and 30.082, all P<0.05). APTT and FIB were significantly associated with AUGIB (APTT: likelihood ratio [LR]=1.09, 95% confidence interval [CI]: 1.04-1.14, P<0.001; FIB: LR=2.34, 95% CI: 1.61-3.41, P<0.001). ConclusionThe increases in PT, INR, and APTT parallel with Child-Pugh class and MELD score in patients with liver cirrhosis, and the prolongation of APTT and the increase in FIB can predict the possibility of AUGIB in patients with liver cirrhosis.
【关键字】:血液凝固试验; 肝硬化; 出血; 预测
【Key words】:blood coagulation tests; liver cirrhosis; hemorrhage; forecasting
【引证本文】:ZHANG LH, WANG SJ, LU LG, et al. Predictive value of coagulation test parameters for acute upper gastrointestinal bleeding in patients with liver cirrhosis[J]. J Clin Hepatol, 2018, 34(10): 2130-2135. (in Chinese)
张丽航, 王善娟, 陆伦根, 等. 凝血试验指标对肝硬化合并急性上消化道出血的预测价值[J]. 临床肝胆病杂志, 2018, 34(10): 2130-2135.

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