保守治疗克罗恩病合并急性肠梗阻疗效影响因素分析及预测模型构建研究

Influence factors analysis and the prediction model development for conservative management in Crohn's disease with acute intestinal obstruction

目的分析影响克罗恩病(CD)合并急性肠梗阻病人保守治疗效果的临床因素,并构建预测模型。方法回顾性分析2019-01-01至2021-12-31南京大学医学院附属金陵医院普通外科收治的因急性肠梗阻入院的86例CD病人的临床资料。根据诊治过程中是否进行手术干预,分为手术组(35例)与保守治疗组(51例)。比较两组病人临床指标及疗效差异,通过多因素Logistic回归模型分析独立危险因素并构建预测模型。结果CD合并急性肠梗阻病人保守治疗有效率为59.3%(51/86)。手术组中病人的激素使用率明显高于保守治疗组[22.9%(8/35)vs.7.8%(4/51),P=0.048],而治疗第3天时C-反应蛋白(CRP)下降程度[1.6(-2.0~16.8)mg/L vs.11.0(2.5~42.7)mg/L,P=0.009]、白蛋白上升程度[0.5(-3.0~3.9)g/L vs.2.5(0.1~4.6)g/L,P=0.041]及前白蛋白上升程度[18.0(-18.0~72.0)mg/L vs.46.0(12.5~89.0)mg/L,P=0.043]均低于保守治疗组。多因素Logistic回归分析显示,BMI>18.5(OR=0.189,95%CI 0.052-0.831,P=0.027)、治疗第3天CRP水平下降(OR=0.964,95%CI 0.938-0.991,P=0.010)以及前白蛋白水平升高(OR=0.811,95%CI 0.667-0.932,P=0.036)是保守治疗有效的预测指标,而病程中出现发热(OR=8.333,95%CI 1.133-16.250,P=0.037)和入院后肠外营养连续使用时间>1周(OR=8.621,95%CI1.082-83.333,P=0.043)是保守治疗效果不佳的预测指标。结论BMI>18.5、保守治疗第3天CRP水平下降和前白蛋白水平升高是CD合并急性肠梗阻病人接受保守治疗有效的预测指标,但当病程中出现发热以及入院后肠外营养连续使用时间>1周等危险因素时应及时考虑手术干预。

Objective To analyze the influence factors of conservative treatment for Crohn's disease(CD)patients with acute intestinal obstruction and construct a predictive model.Methods Data of a cohort consisting 86 CD cases with acute intestinal obstruction admitted to Affiliated Jinling Hospital,Medical School of Nanjing University from January 1,2019,to December 31,2021 were analyzed retrospectively.The eligible patients were divided into surgery group(n=35)and surgery-free group(n=51)according to the effectiveness of conservative treatment.The clinical factors affecting the efficacy of conservative treatment were analyzed by multivariate logistic regression analysis and then a Nomogram model was constructed to predict the probability of conservative treatment.Results The success rate of a conservative treatment to alleviate acute intestinal obstruction in CD was 59.3%(51/86).The steroid use was significantly more frequent in the surgery group than in the surgery-free group[22.9%(8/35)vs.7.8%(4/51),P=0.048],while the decrease of CRP[1.6(-2.0-16.8)mg/L vs.11.0(2.5-42.7)mg/L,P=0.009],and the increase of albumin[0.5(-3.0-3.9)g/L vs.2.5(0.1-4.6)g/L,P=0.041]and pre-albumin[18.0(-18.0-72.0)mg/L vs.46.0(12.5-89.0)mg/L,P=0.043]were lower than those in the surgery-free group at day 3 after treatment.The multivariate logistic results demonstrated that BMI>18.5 at admission(OR=0.189,95%CI 0.052-0.831,P=0.027)and the change of CRP(OR=0.964,95%CI 0.938-0.991,P=0.010)and pre-albumin(OR=0.811,95%CI 0.667-0.932,P=0.036)at day 3 after conservative treatment were associated the avoidance of urgent surgery.However,fever(OR=8.333,95%CI 1.133-16.250,P=0.037)and the use of parenteral nutrition for more than a week(OR=8.621,95%CI 1.082-83.333,P=0.043)were independent predict factors for failure of conservative treatment.Conclusion BMI>18.5,the decrease of CRP and the increase of pre-albumin at day 3 after treatment are protective factors for conservative treatment in CD patients with acute intestinal obstruction.Otherwise,urgent surgery should be promptly considered for those patients with factors associated with failure of conservative treatment such as fever and long-term parenteral nutrition usage.