首页|肝硬化患者急性静脉曲张出血的内镜干预时机

肝硬化患者急性静脉曲张出血的内镜干预时机

Timing of endoscopic intervention for acute variceal bleeding in patients with liver cirrhosis

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目的 探讨不同时机行内镜干预对肝硬化合并急性静脉曲张出血(AVB)患者预后的影响.方法 回顾性分析2013年2月至2020年5月来自以东南大学附属中大医院牵头的中国35所三级医院的2 678例肝硬化合并AVB患者的人口统计学和临床数据(包括实验室检查、临床和内镜检查数据).根据患者接受内镜检查时间分为入院后6 h内行急诊内镜检查(6 h)组(2 383例)和入院后6～12 h行急诊内镜检查(6～12 h)组(295例).为达到基线平衡(即最小混淆),对患者进行1∶1倾向评分匹配后,共纳入588例患者,其中6 h组和6～12 h组各294例.比较倾向评分匹配前后6 h组和6～12 h组患者的5 d内治疗失败发生率和住院病死率,并根据出血史与Child-Pugh分级分析倾向评分匹配后6 h组与6～12h组各因素亚组患者的5 d内治疗失败发生率.采用Kaplan-Meier法和log-rank检验进行组间比较,采用多因素分析探讨5 d内治疗失败的独立影响因素.结果 倾向评分匹配前,6 h组与6～12 h组5 d内治疗失败发生率比较[3.7％(89/2 383)比4.7％(14/295)],差异无统计学意义[HR(95％置信区间)1.19(0.67～2.13),P＞0.05];6 h 组与 6～12 h 组住院病死率比较[2.8％(67/2 383)比2.7％(8/295)],差异无统计学意义(P＞0.05).倾向评分匹配后,6 h组与6～12 h组5 d内治疗失败发生率比较[3.1％(9/294)比4.4％(13/294)],差异无统计学意义[HR(95％置信区间)1.48(0.63～3.45),P＞0.05];6 h组与6～12h组住院病死率比较[2.0％(6/294)比2.7％(8/294)],差异无统计学意义(P＞0.05).倾向评分匹配后亚组分析结果中,仅6 h组与6～12 h组中Child-Pugh分级C级患者5 d内治疗失败发生率比较[1.8％(1/55)比11.8％(6/51)],差异有统计学意义[HR(95％置信区间)6.89(0.83～57.20),P=0.041].多因素分析结果显示,Child-Pugh分级为C级是肝硬化合并AVB患者5 d内治疗失败的独立影响因素[HR(95％置信区间)2.13(1.12～4.03),P=0.021].结论 肝硬化患者在入院后6 h或6～12 h内进行内镜干预的短期预后相当.
Objective To explore the effects of endoscopic intervention at different times on the prognosis of patients with liver cirrhosis complicated with acute variceal bleeding(AVB).Methods From February 2013 to May 2020,the demographic and clinical data(including data from laboratory tests and clinical and endoscopic examinations)of 2 678 patients with liver cirrhosis complicated with AVB from 35 tertiary hospitals in China led by Zhongda Hospital Southeast University were retrospectively analyzed.According to the time of.endoscopic examination,the patients were divided into emergency endoscopy performed within 6 h after admission group(6 h group)(2 383 cases)and emergency endoscopy performed 6 to 12 h after admission group(6 to 12 h group)(295 cases).After 1 to 1 propensity score matching to achieve baseline balance(minimal confounding),a total of 588 patients were enrolled,with 294 patients each in the 6 h group and the 6 to 12 h group.Treatment failure rate and in-hospital mortality within 5 d were compared between the 6 h group and the 6 to 12 h group before and after propensity score matching.According to the history of bleeding and Child-Pugh classification,the treatment failure rate within 5 d was analyzed in the 6 h group and 6 to 12 h group after propensity score matching.The Kaplan-Meier method and log-rank test were performed for comparison between groups.Multivariate analysis was used to identify the independent influencing factors of treatment failure within 5 days.Results Before propensity score matching,there was no statistically significant difference in the treatment failure rate within 5 d between the 6 h group and the 6 to 12 h group(3.7％,89/2 383 vs.4.7％,14/295)(HR(95％confidence interval)1.19(0.67 to 2.13),P＞0.05).There was no statistically significant difference in in-hospital mortality between the 6 h group and the 6 to 12 h group(2.8％,67/2 383 vs.2.7％,8/295,P＞0.05).After propensity score matching,there was no statistically significant difference in the treatment failure rate within 5 d between the 6 h group and the 6 to 12 h group(3.1％,9/294 vs.4.4％,13/294)(HR(95％confidence interval)1.48(0.63 to 3.45),P＞0.05).There was no statistically significant difference in in-hospital mortality between the 6 h group and the 6 to 12 h group(2.0％,6/294vs.2.7％,8/294,P＞0.05).In the subgroup analysis after propensity score matching,there was only a statistically significant difference in the treatment failure rate within 5 d between the 6 h group and the 6 to 12 h group in patients of Child-Pugh grade C(1.8％,1/55 vs.11.8％,6/51)(HR(95％confidence interval)6.89(0.83 to 57.20),P=0.041).The results of the multivariate analysis revealed that Child-Pugh grade C was an independent influencing factor of treatment failure within 5 d in patients with liver cirrhosis complicated with AVB(HR(95％confidence interval)2.13(1.12 to 4.03),P=0.021).Conclusion The short-term prognosis of patients with cirrhosis who underwent endoscopic intervention within 6 h or 6 to 12 h after admission is similar.

Acute variceal bleedingLiver cirrhosisTiming of emergency endoscopic interventionTreatment failure rate within 5 daysIn-hospital mortality

陈卉卉、张文辉、向慧玲、张丽瑶、原丽莉、王省、吴斌、党彤、张国、呼圣娟、彭利军、高敏、夏冬丽、李嘉、宋瑛、周希乔、齐兴四、曾景、谭小燕、邓明明、方海明、綦盛麟、何松、贺永锋、叶斌、吴伟、邵江波、韦炜、胡建平、雍鑫、何朝晖、暴金伦、张月宁、姬瑞、卜阳、晏维、栗红江、黄义飞、祁小龙

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东南大学附属中大医院放射科超声科门静脉高压中心,南京 210009

北京市大兴区人民医院消化内科,北京 102699

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急性静脉曲张出血 肝硬化 急诊内镜干预时机 5d内治疗失败率 住院病死率

2024

10.3760/cma.j.cn311367-20230818-00045

中华消化杂志
中华医学会

中华消化杂志

CSTPCD北大核心
影响因子：1.726
ISSN：0254-1432
年,卷(期)：2024.44(3)
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