血小板计数/胆囊壁厚度对肝硬化食管静脉曲张的预测价值

Value of platelet count and gallbladder wall thickness in predicting esophageal varices in patients with liver cirrhosis

目的探讨PLT联合胆囊壁厚度(GBWT)对肝硬化食管静脉曲张的预测价值。方法回顾性分析2018年1月-2019年1月于邢台市人民医院临床确诊为乙型肝炎肝硬化患者100例,以胃镜做为判断食管静脉曲张(EV)的金标准,分成非EV组(n=50)和EV组(n=50)。所有患者行腹部超声(包括GBWT、门静脉直径、脾长径)及胃镜检查,以及血清学指标检查。正态分布的计量资料2组间比较采用独立样本t检验;非正态分布的计量资料2组间比较采用Mann Whitney U非参数检验。采用多因素logistic回归分析筛选预测肝硬化EV的无创指标。采用受试者工作特征曲线对比单指标及联合指标对EV的诊断效能。结果EV组GBWT、门静脉直径、脾长径均高于非EV组(Z值分别为-6.251、-2.611,t=-3.657,P值均<0.01),EV组PLT、PGR、PSR均低于非EV组(Z值分别为-5.403、-7.018、-6.015,P值均<0.001)。GBWT诊断乙型肝炎肝硬化EV的受试者工作特征曲线下面积(AUC)及95%可信区间为0.861(0.784~0.938),临界值为0.44 cm时,敏感度为0.76,特异度为0.86,阳性预测值及阴性预测值分别为0.86、0.78。PGR诊断EV、high-risk EV的AUC分别为0.907、0.823,敏感度分别为0.90、0.68,特异度分别为0.82、0.88,阳性预测值分别为0.91、0.89,阴性预测值分别为0.84、0.86。按照“GBWT<0.47 cm且PLT≥83×109/L”标准,本研究人群有46%(46/100)患者可暂时避免胃镜筛查,此时需要治疗的静脉曲张的漏诊率为4.2%(2/48)。结论GBWT有望成为预测EV的新指标。当GBWT<0.47 cm且PLT≥83×109/L时,乙型肝炎肝硬化患者发生EV的概率很低,建议暂缓胃镜筛查。结合此两项无创指标可以为临床医师判断肝硬化EV提供简易的初筛工具。

Objective To investigate the value of platelet count(PLT)and gallbladder wall thickness(GBWT)in predicting esophageal varices(EV)in patients with liver cirrhosis.Methods A retrospective analysis was performed for the clinical data of 100 patients who were diagnosed with hepatitis B cirrhosis in Xingtai People’s Hospital from January 2018 to January 2019,and according to the results of gastroscopy as the gold standard for EV,these patients were divided into non-EV group with 50 patients and EV group with 50 patients.All patients underwent abdominal ultrasound(including GBWT,portal vein diameter,and spleen length),gastroscopy,and serological examination.The independent samples t-test was used for comparison of normally distributed continuous data between groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups.A multivariate logistic regression analysis was used to screen out the noninvasive indices for predicting EV in liver cirrhosis.The receiver operating characteristic(ROC)curve was used to compare the diagnostic efficiency of a single index and combined indices.Results Compared with the non-EV group,the EV group had significantly higher GBWT,portal vein diameter,and spleen length(Z=-6.251 and-2.611,t=-3.657,all P<0.01)and significantly lower PLT,PGR,and PLT-to-spleen length ratio(Z=-5.403,-7.018,and-6.015,all P<0.001).At the optimal cut-off value of 0.44 cm,GBWT had an area under the ROC curve(AUC)of 0.861(95%confidence interval:0.784-0.938),a sensitivity of 0.76,a specificity of 0.86,a positive predictive value of 0.86,and a negative predictive value of 0.78 in the diagnosis of EV in hepatitis B cirrhosis.In the diagnosis of EV,PGR had an AUC of 0.907,a sensitivity of 0.90,a specificity of 0.82,a positive predictive value of 0.91,and a negative predictive value of 0.84;in the diagnosis of high-risk EV,PGR had an AUC of 0.823,a sensitivity of 0.68,a specificity of 0.88,a positive predictive value of 0.89,and a negative predictive value of 0.86.With the criteria of GBWT<0.47 cm and PLT≥83×109/L,46%of all patients(46/100)had no need for gastroscopy at the moment.Conclusion GBWT is expected to become a new index for predicting EV.Hepatitis B cirrhosis patients with GBWT<0.47 cm and PLT≥83×109/L have a low probability of EV,and thus it is recommended to postpone gastroscopy.The combination of these two noninvasive indices can provide a simple preliminary screening tool for clinicians to rule out esophageal varices in cirrhosis.