门静脉血栓影响内镜治疗预防乙型肝炎肝硬化食管胃静脉曲张破裂再出血的疗效

Impact of portal vein thrombosis on the efficacy of endoscopic treatment in preventing re-bleeding from ruptured gastroesophageal varices in hepatitis B-related liver cirrhosis

目的探究门静脉血栓是否影响内镜治疗预防乙型肝炎肝硬化食管胃静脉曲张破裂再出血的疗效。方法收集2013至2017年期间因乙型肝炎肝硬化食管胃静脉曲张破裂出血住院接受内镜治疗预防再出血的患者,随访治疗后1年再出血及生存状态。根据患者首次入院时是否合并门静脉血栓将患者分为血栓组和无血栓组,分析两组患者基线资料特点。通过Kaplan-Meier生存分析比较两组患者1年再出血率和生存率。通过单因素及多因素回归权衡影响静脉曲张内镜治疗后再出血的其他危险因素。结果共纳入124例乙型肝炎肝硬化食管胃静脉曲张破裂出血患者,平均年龄50.7岁,81.5%(101例)为男性,24.2%(30例)合并门静脉血栓。血栓组与非血栓组患者的平均年龄、性别、肝功能分级、经颈静脉门静脉压力梯度、抗病毒治疗情况及非选择性β受体阻滞剂服用情况等差异均无统计学意义。Kaplan-Meier分析比较血栓与非血栓患者内镜治疗后再出血率提示,血栓组患者内镜治疗后60 d、180 d和1年的无出血率显著低于非血栓组,分别为86.7%、80.0%、56.7%比95.7%、93.6%、87.2%(P=0.0001)。对门静脉血栓存在部位分析发现,存在门静脉主干及左右支血栓和肠系膜上静脉血栓的患者内镜治疗后1年的出血率显著增加,而脾静脉血栓不影响内镜治疗后的出血情况。单因素和多因素回归分析提示年龄(HR 1.05,95%CI:1.01~1.09,P=0.02)和门静脉主干及左右支血栓(HR 4.95,95%CI:2.05~11.95,P<0.01)是内镜治疗后1年再出血的独立危险因素。结论门静脉血栓是影响乙型肝炎肝硬化食管胃静脉曲张内镜治疗预防再出血治疗疗效的独立危险因素,合并血栓患者内镜治疗后再出血风险显著增加。

Objective To explore whether portal vein thrombosis affects the efficacy of endoscopic treatment in preventing re-bleeding from ruptured gastroesophageal varices in hepatitis B-related liver cirrhosis.Methods Hospitalized patients who received endoscopic therapy to prevent re-bleeding from ruptured gastroesophageal varices due to hepatitis B-related liver cirrhosis during 2013 to 2017 were selected,and followed up for 1 year after treatment for re-bleeding and survival status.Patients were divided into thrombotic and non-thrombotic group according to whether they were combined with portal vein thrombosis at the time of initial admission.The baseline data characteristics of the two groups were analyzed.The 1-year re-bleeding rate and survival rate of the two groups were compared by Kaplan-Meier survival analysis.The other risk factors for re-bleeding after endoscopic variceal therapy were evaluated by univariate and multivariate regression.Results A total of 124 cases with re-bleeding from ruptured gastroesophageal varices due to hepatitis B-related liver cirrhosis were included.The average age was 50.7 years old.81.5%(101 cases)were male,and 24.2%(30 cases)were combined with portal vein thrombosis.There were no statistically significant differences between the thrombotic and the non-thrombotic group in the average age,gender,liver function classification,transjugular portal pressure gradient,antiviral treatment,and non-selectiveβ-blockers.Kaplan-Meier analysis of the re-bleeding rate after endoscopic treatment indicated that the incidence of non-bleeding in patients with thrombotic group at 60 days,180 days and 1 year was significantly lower than that in the non-thrombotic group[86.7%,80.0%,56.7%vs.95.7%,93.6%,87.2%(P=0.0001)].Analysis of the location of portal vein thrombosis showed that the bleeding rate in the main portal trunk,left and right branches and superior mesenteric vein had increased significantly after endoscopic treatment,while the splenic vein had no effect on the bleeding after endoscopic treatment.Univariate and multivariate regression analysis indicated that age(HR 1.05,95%CI:1.01-1.09,P=0.02)and thrombosis in the main portal trunk,left and right branches(HR 4.95,95%CI:2.05-11.95,P<0.01)were independent risk factors for re-bleeding at 1 year after endoscopic treatment.Conclusion Portal vein thrombosis is an independent risk factor that affects the efficacy of endoscopic treatment in preventing re-bleeding from ruptured gastroesophageal varices in hepatitis B-related liver cirrhosis and the risk of re-bleeding increases significantly after endoscopic treatment in patients with thrombosis.