乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血患者再出血影响因素及预测模型的建立

Prediction of re-bleeding in patients with hepatitis B cirrhosis complicated by esophageal gastric variceal bleeding

目的 分析乙型肝炎肝硬化并发食管胃底静脉曲张破裂出血(EGVB)患者再出血的影响因素,并建立预测模型,评估预测再出血的效能。方法 2020年7月~2022年7月我院收治的乙型肝炎肝硬化并发EGVB患者119例,给予所有患者血管活性药物、血管加压素和内镜下止血治疗。记录治疗后3个月内再出血发生情况,采用Logistic回归分析影响患者再出血的危险因素,建立风险预测模型,应用ROC曲线评估预测模型预测再出血的价值。结果 在本组119例EGVB患者中,48例(40.3%)在止血成功后3个月内出现再出血,其中4例患者在出血72 h内死亡;再出血与未再出血患者在Child C级占比(97.7%对84.5%)、脾脏厚度【(67.5±5.3)mm对(59.1±5.7)mm】、门静脉内径【(16.8±2.1)mm对(14.5±2.3)mm】、脾静脉内径【(10.9±2.3)mm对(8.4±1.8)mm】、静脉曲张G3级(81.8%对46.5%)、内镜下红色征(88.6%对38.0%)、有腹水(38.6%对18.3%)、血清白蛋白水平【(29.1±4.2)g/L对(33.5±4.8)g/L】和凝血酶原时间【(16.3±2.6)s对(12.7±2.1)s】方面,差异显著(P<0.05);经Logistic回归分析发现,Child-Pugh分级差【OR(95%CI):2.3(1.3~3.8)】、脾脏厚度增加【OR(95%CI):1.8(1.2~2.9)】、门静脉内径【OR(95%CI):2.6(1.0~6.4)】、脾静脉内径增大【OR(95%CI):1.4(1.0~1.9)】、食管胃静脉曲张分级高【OR(95%CI):2.4(1.0~5.5)】、红色征【OR(95%CI):2.1(1.0~4.4)】、凝血酶原时间延长【OR(95%CI):1.8(1.1~2.9)】是EGVB患者再出血的影响因素;应用多元Logistic回归分析得到风险预测模型,即P=1/【1+e^((0.814X1+0.597X2+0.939X3+0.328X4+0.863X5+0.739X6+0.592X7-1.164))】,经Hosmer-Lemeshow检验其与标准曲线的拟合度较好(x2=3.711,P=0.882),预测EGVB患者再出血的AUC为0.966,SE为0.015,95%CI为0.938~0.995,其特异度为87.3%,敏感度为97.8%。结论 乙型肝炎肝硬化并发EGVB患者止血后再出血发生率较高,了解其影响因素并给予适当的预防处理,可能降低病死率,值得进一步研究。

Objective The aim of this study was to analyze the influencing factors of rebleeding in patients with hepatitis B liver cirrhosis complicated by esophageal gastric variceal bleeding(EGVB),and to establish a prediction model for early intervention.Methods 119 patients with hepatitis B cirrhosis and EGVB were encountered in our hospital between July 2020 and July 2022,and all patients received comprehensive internal medical treatment and even endoscopic intervention for hemostasis.The occurrence of re-bleeding within 3 months after hemostasis was recorded and statistically analyzed.The risk factors of re-bleeding were analyzed by multivariate Logistic regression analysis,and the ROC curve was applied to reveal the predictive performance of the model we established for re-bleeding.Results Out of our series,48 patients(40.3%)had re-bleeding within three months after hemostasis,and four patients died 72 hours after re-bleeding;there were significant differences as respect to the percentage of Child-Pugh class C(97.7%vs.84.5%),splenic thicknesses[(67.5±5.3)mm vs.(59.1±5.7)mm],diameters of portal vain[(16.8±2.1)mm vs.(14.5±2.3)mm],diameters of splenic vain[(10.9±2.3)mm vs.(8.4±1.8)mm],esophageal and gastric varices grade G3(81.8%vs.46.5%),endoscopic red-color sign(88.6%vs.38.0%),ascites(38.6%vs.18.3%),serum albumin levels[(29.1±4.2)g/L vs.(33.5±4.8)g/L]and prothrombin time(PT)[(16.3±2.6)s vs.(12.7±2.1)s]between 44 patients with re-bleeding and 71 patients without(P<0.05);the Logistic regression analysis showed that the Child-Pugh class C[OR(95%CI):2.3(1.3-3.8)],splenic thickness[OR(95%CI):1.8(1.2-2.9)],diameter of portal vain[OR(95%CI):2.6(1.0-6.4)],diameter of splenic vain[OR(95%CI):1.4(1.0-1.9)],varices grade G3[OR(95%CI):2.4(1.0-5.5)],red-color sign[OR(95%CI):2.1(1.0-4.4)]and prolonged PT[OR(95%CI):1.8(1.1-2.9)]were the risk factors for re-bleeding;we built up a formula as follows:P=1/[1+e^(0.814X1+0.597X2+0.939X3+0.328X4+0.863X5+0.739X6+0.592X7-1.164)]based on the Logistic analysis,and a good fitting degree between the prediction model and the standard curve was found by the Hosmer-Lemeshow test(x 2=3.711,P=0.882),and its AUC was 0.966(95%CI:0.938-0.995)with the specificity of 87.3%and the sensitivity of 97.8%in predicting re-bleeding.Conclusion The patients with liver cirrhosis and EGVB might have a high tendency of re-bleeding after emergent hemostasis,and the early prediction as well as appropriate management might decrease the mortality,and needs further investigation.