内镜下精准食管胃静脉曲张断流术治疗乙型肝炎肝硬化伴急性静脉曲张出血患者再出血的危险因素分析

Risk factors for rebleeding after endoscopic selective variceal devascularization in patients with hepatitis B cirrhosis and acute variceal bleeding

目的明确乙型肝炎肝硬化伴食管胃静脉曲张破裂出血(EVB)患者行内镜下精准食管胃静脉曲张断流术(ESVD)后的再出血率及再出血的预测因素。方法纳入2010年10月—2019年12月因乙型肝炎肝硬化伴EVB,于首都医科大学附属北京地坛医院就诊,并行首次ESVD治疗的患者,根据纳入和排除标准共筛选出患者442例。对患者的常规临床、实验室、影像学及内镜等指标进行比较,随访患者的再出血情况。正态分布的计量资料两组间比较采用t检验,非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χ2检验。采用Kaplan-Meier法描述再出血和生存情况,采用Cox回归明确静脉曲张再出血的独立危险因素。结果首次ESVD治疗后1、2、3、4、5年累积再出血率分别为25.11%、33.94%、39.82%、42.08%和45.02%。单因素分析结果显示,年龄、收缩压、抗病毒疗程≥1年、腹水、WBC、中性粒细胞、直接胆红素与再出血相关(P值均<0.05);多因素分析结果显示,抗病毒疗程≥1年(HR=0.504,95%CI:0.357~0.711,P<0.001)和腹水(HR=1.424,95%CI:1.184~1.714,P<0.001)是静脉曲张再出血的独立影响因素。结论ESVD治疗乙型肝炎肝硬化伴EVB,再出血率低,合并腹水或抗病毒时间短是治疗后再出血的独立危险因素。

Objective To investigate the rebleeding rate after endoscopic selective variceal devascularization(ESVD)and the predictive factors for rebleeding in patients with hepatitis B cirrhosis and esophageal variceal bleeding(EVB).Methods The patients with hepatitis B cirrhosis and EVB who attended Beijing Ditan Hospital,Capital Medical University,from October 2010 to December 2019 and underwent ESVD for the first time were enrolled,and a total of 442 patients were screened out based on inclusion and exclusion criteria.Routine clinical indices,laboratory markers,imaging findings,and endoscopic findings were compared between patients,and the patients were followed up to observe rebleeding.The t-test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups;the chi-square test was used for comparison of categorical data between two groups.The Kaplan-Meier method was used to describe rebleeding and survival status,and a Cox regression analysis was used to determine the independent risk factors for variceal rebleeding.Results The 1-,2-,3-,4-,and 5-year cumulative rebleeding rates after first ESVD treatment were 25.11%,33.94%,39.82%,42.08%,and 45.02%,respectively.The univariate analysis showed that age,systolic pressure,duration of antiviral therapy≥1 year,ascites,white blood cell count,neutrophil,and direct bilirubin were associated with rebleeding(all P<0.05),and the multivariate analysis showed that duration of antiviral therapy≥1 year(hazard ratio[HR]=0.504,95%confidence interval[CI]:0.357-0.711,P<0.001)and ascites(HR=1.424,95%CI:1.184-1.714,P<0.001)were independent influencing factors for variceal rebleeding.Conclusion ESVD has a low rebleeding rate in the treatment of hepatitis B cirrhosis with EVB,and presence of ascites and a short duration of antiviral therapy are independent risk factors for rebleeding after treatment.