不同内镜表现食管胃底静脉曲张破裂出血临床特点分析

Analysis of clinical characteristics of esophageal and gastric variceal bleeding with different endoscopic performance

目的通过肝硬化急性食管胃底静脉曲张破裂出血(acute esophageal and gastric variceal bleeding,AEGVB)的临床特点预估急诊内镜表现。方法回顾性分析2019年1月—2021年12月接受急诊内镜治疗(入院12小时内)的AEGVB患者临床资料,根据内镜表现分为静脉红色征组(A组)、糜烂血栓组(B组)及活动性出血组(C组),对比分析各组病例一般资料、出院诊断、血常规、肝肾功能、凝血功能、腹水、肝性脑病、CTP评分、MELD评分、FIB-4、APRI、GPR及S-index值差异,建立多变量logistic回归判别模型。结果174例患者纳入研究,A、B、C组分别占37.36%、32.18%及30.46%;B组或C组同A组肝癌并门静脉癌栓、腹水构成比、白细胞计数(WBC)、凝血酶原(PT)、白蛋白(ALB)、CTP及MELD评分、CTP分级及MELD分度构成比差异有统计学意义(P<0.05或0.001),但B、C组间前述指标间无统计学意义(P>0.05);A组FIB-4、GPR及APRI同B组及C组比较均无统计学意义(P>0.05);C组S-index较A组及B组高,差异有统计学意义(P<0.05);logistic判别模型P(Y=1)=exp(0.144×WBC+0.856×CTP分级+0.857×腹水分度-3.53)1+exp(0.144×WBC+0.856×CTP分级+0.857×腹水分度-3.53),P≥0.5预测静脉糜烂血栓及活动性出血的正确率为86.2%;P<0.5预测静脉红色征的正确率为66.2%。结论37.36%的AEGVB急诊胃镜仅见红色征,多见于无腹水,WBC较低,ALB较高,PT较短,CTP A级及模型P值<0.5者,而62.64%的急诊胃镜可见静脉表面糜烂、血栓或活动性出血,多见于肝癌并门静脉癌栓、有中重度腹水、WBC较高、PT延长、CTP C级、MELD评分>18分及模型P≥0.5者,FIB、GPR及APRI与急诊内镜表现无关。内镜表现预估利于选择合适的内镜干预时机、人员及设备条件,减少并发症。

Objective To estimate emergency endoscopic manifestations based on clinical characteristics of acute esophageal and gastric variceal bleeding(AEGVB)in cirrhosis.Methods Retrospective analysis was carried out on the clinical data of AEGVB patients receiving emergency endoscopic treatment(within 12 hours of admission)from January 2019 to December 2021.All patients were divided into venous red color sign group(group A),venous and thrombus group(group B),and active bleeding group(group C)based on endoscopic manifestations.And then,differences in general information,discharge diagnosis,blood routine,liver and kidney function,coagulation function,ascites,hepatic encephalopathy,CTP score,MELD score,FIB-4,APRI,GPR,and S-index values among groups were compared and analyzed.In addition,multivariate logistic regression discrimination model was established.Results 174 patients were included in the study,and the group A,the group B,and the group C were accounted for 37.36%,32.18%,and 30.46%,respectively.The difference of the proportion of hepatocellular carcinoma with portal vein tumor thrombus and ascites,white blood cell count(WBC),prothrombin(PT),albumin(ALB),CTP and MELD scores,CTP grading and MELD scale division between the group A and the group B or the group C was statistically significant(P<0.05 or 0.001),but the difference of above-mentioned indicators between the group B and the group C was not statistically significant(P>0.05).There was no statistically significant difference in FIB-4,GPR,and APRI between the group A and the group B and the group C(P>0.05).The S-index of the group C was higher than that of the group A and the group B,and the difference was statistically significant(P<0.05).Logistic discriminant model P(Y=1)=exp(0.144×WBC+0.856×CTP score+0.857×ascites degree-3.53)1+exp(0.144×WBC+0.856×CTP score+0.857×ascites degree-3.53),P≥0.5 was used to predicted venous erosion thrombosis and active bleeding,and accuracy rate was 86.2%;P<0.5 was used to predicted venous red color sign,and accuracy rate was 66.2%.Conclusion 37.36%of AEGVB only show red color sign under emergency gastroscopy,which are more common in patients with no ascites,lower WBC,higher ALB,shorter PT,CTP grade A and model P value<0.5.While 62.64%show venous surface erosion,thrombosis or active bleeding under emergency gastroscopy,which are more common in patients with hepatocellular carcinoma with portal vein tumor thrombus,moderate to severe ascites,high WBC,prolonged PT,CTP grade C,MELD>18 points and model P value≥0.5.FIB,GPR and APRI are not related to emergency endoscopic performance.The prediction of endoscopic performance is beneficial to selecting the time of endoscopic intervention,personnel and equipment,and reducing complications.