门静脉血栓对内镜治疗急性食管胃静脉曲张破裂出血患者远期效果的影响

The impact of portal vein thrombosis on the long-term efficacy of endoscopic treatment for acute esophageal and gastric variceal bleeding patients

目的评估肝硬化急性食管胃静脉曲张破裂出血合并门静脉血栓患者内镜治疗后的远期再出血风险。方法纳入2022年1月至12月因急性食管胃静脉曲张破裂出血于复旦大学附属中山医院急诊就诊,行内镜检查并接受治疗的57例患者为研究对象,根据患者门脉血管CTA结果,分为血栓组和无血栓组。比较两组患者基本资料及内镜治疗情况。所有患者随访至内镜治疗后1年或2023年4月15日,记录随访期间再出血和生存情况,对治疗后1年再出血的影响因素进行分析。结果患者年龄(55.9±11.4)岁,男性为主[78.95%(45/57)]。所有患者从首次出血到内镜治疗的时间为(6.6±2.8)d。两组患者年龄、性别、合并肝恶性肿瘤、Child-pugh评分、首次出血形式、腹腔积液、首次实验室检查结果(包括血红蛋白、血小板、凝血酶原时间、肌酐)等比较差异均无统计学意义(均P>0.05)。两组患者既往内镜治疗史、出血距离胃镜治疗时间,合并食管静脉曲张、胃静脉曲张比例,食管静脉曲张套扎治疗、胃静脉曲张组织胶治疗比例,差异均无统计学意义(均P>0.05)。术后共2例患者死亡,12例患者发生再出血,其中血栓组10例,非血栓组2例。Kaplan-Meier分析提示血栓组患者1年再出血率明显高于无血栓组(59.02%vs 24.71%,RR=6.002,95%CI:1.06~34.00,P=0.0208)。Cox多因素回归分析提示合并门静脉血栓(HR=7.669,95%CI:1.453~40.472,P=0.016)是急性食管胃静脉曲张破裂出血内镜治疗后1年再出血的独立危险因素。结论肝硬化门静脉血栓形成增加急性食管胃静脉曲张破裂出血内镜治疗后1年再出血风险。对于合并门静脉血栓的急性上消化道出血患者,应规律进行内镜和超声随访,个体化内镜序贯和择期抗凝治疗。

Objective To evaluate the long-term risk of rebleeding in patients with acute esophageal and gastric variceal bleeding and portal vein thrombosis after endoscopic treatment in liver cirrhosis.Methods From January to December 2022,57 patients with acute esophageal and gastric variceal bleeding who were treated by endoscopy in the emergency department of the Zhongshan Hospital affiliated to the Fudan University were included in the study.According to the results of portal vein CT angiography(CTA),the patients were divided into thrombosis group and non thrombosis group.We compared the basic information and endoscopic treatment status of two groups of patients.All patients were followed up until 1 year after endoscopic treatment or April 15,2023,and re bleeding and survival were recorded during the follow-up period.The influencing factors of rebleeding after 1 year of treatment were analyzed.Results The patient′s age was(55.9±11.4)years old,mainly male[78.95%(45/57)].The average time from initial bleeding to endoscopic treatment for all patients was(6.6±2.8)days.There was no statistically significant difference between the two groups in terms of age,sex,combined liver malignancy,Child-pugh score,first bleeding form,ascites,and first laboratory examination results(including hemoglobin,platelet,Prothrombin time,creatinine)(all P>0.05).There was no statistically significant difference in the history of endoscopic treatment,bleeding distance from endoscopic treatment,the proportion of patients with esophageal varices and gastric varices,the proportion of patients with esophageal varices treated with ligation,and the proportion of patients with gastric varices treated with tissue glue between the two groups(all P>0.05).A total of 2 patients died after surgery,and 12 patients experienced rebleeding,including 10 in the thrombotic group and 2 in the non thrombotic group.Kaplan Meier analysis showed that the 1-year rebleeding rate in the thrombotic group was significantly higher than that in the non thrombotic group(59.02%vs 24.71%,RR=6.002,95%CI:1.06-34.00,P=0.0208).Cox multivariate regression analysis suggests that the presence of portal vein thrombosis(HR=7.669,95%CI:1.453-40.472,P=0.016)was an independent risk factor for recurrent bleeding after endoscopic treatment of acute esophageal and gastric variceal bleeding for one year.Conclusions Portal vein thrombosis in liver cirrhosis increases the risk of recurrent bleeding after endoscopic treatment for acute esophageal and gastric variceal bleeding for one year.For patients with acute Upper gastrointestinal bleeding complicated with portal vein thrombosis,regular endoscopic and ultrasonic follow-up,individualized endoscopic sequential and selective anticoagulation therapy should be carried out.