肝硬化上消化道出血并发缺血性肝炎的临床特征与预后

Ischemic hepatitis in hepatitis B related liver cirrhotic patients with upper gastrointestinal hemorrhage： clinical features and prognosticimplications

目的研究乙型肝炎肝硬化上消化道出血患者中缺血性肝炎的发生率、临床特点及其对预后的影响。方法回顾性分析了264例乙型肝炎肝硬化合并上消化道出血患者的资料，其中缺血性肝炎患者11例，分层随机抽样法选择同期无缺血性肝炎患者30例为对照，分析缺皿性肝炎的临床特点。各种构成比及率的比较采用χ^2检验或直接概率法；出血前后各指标比较采用配对t检验，组间比较采用两独立样本t检验。结果缺血性肝炎的发生率为4.17％，平均年龄为（43．1±5．7）岁，较对照组[（52．3±11．1）岁]年轻（P〈0．05）。ALT、AST快速升高超过正常值上限20倍，10d内迅速恢复，伴有总胆红素、乳酸脱氢酶、碱性磷酸酶、γ-谷氨酰转肽酶的明显升高，胆碱酯酶下降，尿素氮、肌酐及白细胞数明显升高，与对照组比较差异有统计学意义（P〈0．05）。缺血性肝炎组病死率为54．5％（6／11），明显高于对照组的16．7％（5／30），P〈0．05；感染、肝肾综合征、肝性脑病是其主要的死亡原因。缺血性肝炎组患者失血量200～3600ml不等，休克患者占63．6％（7／11），出血量与缺血性肝炎无明显的相关性。结论年龄小、失血性休克、肝脏储备功能差是乙型肝炎肝硬化患者发生缺血性肝炎的危险因素。肝硬化消化道出血并发缺血性肝炎患者，及时应用抗菌素防治感染、减少内毒素血痱对于改善预后很重要。

Objective To investigate the incidence, clinical features and prognostic implications of ischemic hepatitis in hepatitis B related liver cirrhotic patients with upper gastrointestinal hemorrhage. Methods By retrospective review of the medical records of all 264 inpatients with upper gastrointestinal hemorrhage of hepatitis B related liver cirrhosis from January 1st 2007 to November 30th 2008, 11 patients with ischemic hepatitis （IH） were identified. The clinical features and prognostic implications were compared between the IH patients and 30 patients without ischemic hepatitis （control group）. Results The incidence of ischemic hepatitis was 4.17% in hepatitis B related liver cirrhotic patients with upper gastrointestinal hemorrhage. The patients in IH group were younger than those in control group, the average age was （43.1 ± 5.7） in IH group and （52.3 ± 11.1） in control group （P = 0.013）. The serum alanine aminotransferase and aspartate aminotransferase were increased more than 20-fold above the upper limit of normal values, and returned to normal values within 10 days. Compared to the control group, total bilirubin, lactate dehydrogenase, alkaline phosphates, γ-glutamyltransferase, blood urea nitrogen, creatinine, and white blood cells were increased, while serum cholinesterase was decreased in IH group （P 〈 0.05）. The fatality rate of ischemic hepatitis was much higher than that of control group （54.5% vs 16.7%, P = 0.041）. The main causes of death in IH group were infection, hepatorenal syndrome and hepatic encephalopathy. The patients in IH group lost 200 to 3600 milliliter blood, and hemorrhagic shock occurred in 63.6% （7/11） of IH patients. Therefore the bleeding volume was not correlated with the occurrence rate of ishchemic hepatitis. Conclusion Ischemic hepatitis may occur secondary to upper gastrointestinal hemorrhage in hepatitis B related liver cirrhosis. The risk factors of ischemic hepatitis in cirrhositic patients with upper gastrointestinal hemorrhage are young and with hemorrhagic shock, and poor liver function. It is important to use antibiotics in time to improve the prognosis of these patients.