二维剪切波弹性成像测量脾硬度联合血小板/脾直径对乙型肝炎肝硬化患者中重度食管胃静脉曲张的评估价值

Value of spleen stiffness measured by two-dimensional shear wave elastography combined with platelet count/spleen diameter ratio in evaluating moderate-to-severe gastroesophageal varices in patients with hepatitis B cirrhosis

目的建立乙型肝炎肝硬化患者中重度食管胃静脉曲张(GEV)的无创性诊断模型。方法选取2017年10月—2019年12月于中国医科大学附属第一医院就诊的乙型肝炎肝硬化患者。以胃镜检查结果为金标准,分为无/轻度GEV组和中重度GEV组。不符合正态分布的计量资料两组间比较采用Mann-Whitney U检验;计数资料两组间比较采用χ^(2)检验。采用logistic回归分析乙型肝炎肝硬化患者中重度食管胃静脉发生与二维剪切波弹性成像(2D-SWE)测量脾硬度、PLT/脾直径之间的关系,以后退法作为自变量筛选方法,建立回归方程即诊断模型并进行检验。绘制受试者工作特征曲线(ROC曲线)判断肝和脾硬度、PLT/脾直径以及诊断模型等无创性检查指标的诊断价值,得出最佳截断值,DeLong检验比较几种无创性检查指标的ROC曲线之间是否具有统计学意义。结果共纳入168例乙型肝炎肝硬化患者,其中有67例诊断为中重度GEV。肝硬化无/轻度和中重度GEV组PLT、ALT、Alb、WBC以及INR比较差异均有统计学意义(Z值分别为-6.508、-2.132、-2.470、-4.510、-5.298,P值均<0.05)。2D-SWE测量的脾硬度、脾脏直径以及PLT/脾脏直径在两组间差异均有统计学意义(Z值分别为-7.264、-5.924、-7.028,P值均<0.05)。PLT/脾直径ROC曲线下面积(AUC)为0.821(95%CI:0.754-0.875),截断值为≤6.7,敏感度为83.58%,特异度为74.26%。脾硬度AUC为0.831(95%CI:0.766-0.885),脾硬度截断值≥34.2 kPa,敏感度为85.07%,特异度为73.27%。肝硬度AUC为0.557(95%CI:0.479-0.634),肝硬度的截断值≥10.8 kPa,特异度为79.10%,敏感度为40.59%。肝硬度与脾硬度、PLT/脾直径对GEV诊断价值的AUC比较,差异均有统计学意义(Z值分别为4.878、5.536,P值均<0.001)。建立判断乙型肝炎肝硬化患者中重度GEV模型:Y=-0.682+0.068×脾硬度-0.225(PLT/脾直径)。诊断模型AUC为0.860(95%CI:0.799-0.909),敏感度为79.10%,特异度为81.19%,准确度为79.1%。结论据2D-SWE测量的脾硬度联合PLT/脾直径建立的无创性诊断模型可用于辅助判断乙型肝炎肝硬化患者中重度GEV,准确度较单独使用肝硬度或脾硬度判断中重度GEV高。

Objective To establish a noninvasive diagnostic model for moderate-to-severe gastroesophageal varices( GEV) in patients with hepatitis B cirrhosis. Methods The patients with hepatitis B cirrhosis who attended The First Affiliated Hospital of China Medical University from October 2017 to December 2019 were enrolled,and with the results of gastroscopy as the gold standard,the patients were divided into none-to-mild GEV group and moderate-to-severe GEV group. The Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups,and the chi-square test was used for comparison of categorical data. A logistic regression analysis was used to investigate the association of moderate-to-severe GEV with spleen stiffness measured by two-dimensional shear wave elastography( 2D-SWE) and platelet count( PLT)/spleen diameter ratio in patients with hepatitis B cirrhosis,and with the backward method for independent variable screening,a regression equation,i. e.,a diagnostic model,was established and validated. The receiver operating characteristic( ROC) curve was plotted to investigate the diagnostic value of noninvasive examination indices including liver and spleen stiffness,PLT/spleen diameter ratio,and the above diagnostic model and obtain their cut-off values,the DeLong test was used to compare whether there is a statistical significance between the ROC curves of the above noninvasive indices. Results A total of 168 patients with hepatitis B cirrhosis were enrolled,among whom 67 were diagnosed with moderate-to-severe GEV. There were significant differences in PLT,alanine aminotransferase,albumin,white blood cell count,and international normalized ratio between the none-to-mild GEV group and the moderate-to-severe GEV group( Z =-6. 508,-2. 132,-2. 470,-4. 510,and-5. 298,all P < 0. 05). There were also significant differences in spleen stiffness measured by 2 D-SWE,spleen diameter,and PLT/spleen diameter ratio between the two groups( Z =-7. 264,-5. 924,and-7. 028,all P < 0. 05). The PLT/spleen diameter ratio had an area under the ROC curve( AUC) of0. 821( 95% confidence interval [CI]: 0. 754-0. 875) at the cut-off value of ≤6. 7,with a sensitivity of 83. 58% and a specificity of74. 26%;spleen stiffness had an AUC of 0. 831( 95% CI: 0. 766-0. 885) at the cut-off value of ≥34. 2 kPa,with a sensitivity of85. 07% and a specificity of 73. 27%;liver stiffness had an AUC of 0. 557( 95% CI: 0. 479-0. 634) at the cut-off value of ≥10. 8 kP a,with a specificity of 79. 10% and a sensitivity of 40. 59%. There was a significant difference in AUC between liver stiffness and spleen stiffness,as well as between liver stiffness and PLT/spleen diameter ratio( Z = 4. 878 and 5. 536,P < 0. 001). The model of Y =-0. 682 + 0. 068 ×spleen stiffness-0. 225( PLT/spleen diameter ratio) was established for predicting moderate-to-severe GEV in patients with hepatitis B cirrhosis,which had an AUC of 0. 860( 95% CI: 0. 799-0. 909),a sensitivity of 79. 10%,a specificity of 81. 19%,and an accuracy of 79. 1%. Conclusion The noninvasive diagnostic model based on spleen stiffness measured by 2 D-SWE and PLT/spleen diameter ratio can be used to assist the judgment of moderate-to-severe GEV in patients with hepatitis B cirrhosis,with a higher accuracy than liver stiffness or spleen stiffness alone.