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

陈卉卉 ¹张文辉 ²向慧玲 ³张丽瑶 ⁴原丽莉 ⁵王省 ⁶吴斌 ⁶党彤 ⁷张国 ⁸呼圣娟 ⁹彭利军 ¹⁰高敏 ¹¹夏冬丽 ¹²李嘉 ¹³宋瑛 ¹⁴周希乔 ¹⁵齐兴四 ¹⁶曾景 ¹⁷谭小燕 ¹⁸邓明明 ¹⁹方海明 ²⁰綦盛麟 ²¹何松 ²²贺永锋 ²³叶斌 ²⁴吴伟 ²⁵邵江波 ²⁶韦炜 ²⁷胡建平 ²⁸雍鑫 ²⁹何朝晖 ³⁰暴金伦 ³¹张月宁 ³²姬瑞 ³³卜阳 ³⁴晏维 ³⁵栗红江 ³⁶黄义飞 ⁶祁小龙¹

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作者信息

1. 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
2. 北京市大兴区人民医院消化内科,北京 102699
3. 天津市第三中心医院消化(肝病)科天津市重症疾病体外生命支持重点实验室天津市肝胆疾病研究所,天津 300170
4. 沈阳市第六人民医院重症医学科,沈阳 110006
5. 山西白求恩医院消化内科,太原 030032
6. 中山大学附属第三医院消化内科,广州 510630
7. 内蒙古科技大学包头医学院第二附属医院消化科内蒙古消化病研究所,包头 014031
8. 中山大学附属第一医院广西医院消化内科,南宁 530025
9. 宁夏回族自治区人民医院消化内科,银川 750021
10. 临沂市人民医院消化内科,临沂 276034
11. 浙江大学医学院附属邵逸夫医院消化内科,杭州 310009
12. 重庆大学附属涪陵医院消化内科,重庆 408099
13. 天津市第二人民医院消化内科,天津 301799
14. 西安高新医院消化内科,西安 710075
15. 南京医科大学第一附属医院消化科,南京 210024
16. 青岛大学附属医院消化内科,青岛 264299
17. 广州医科大学附属惠州医院急诊科,惠州 516002
18. 茂名市人民医院消化内科,茂名 525099
19. 西南医科大学附属医院消化内科,泸州 646099
20. 安徽医科大学第二附属医院消化内科,合肥 230601
21. 大连市第六人民医院肝病科,大连 116113
22. 重庆医科大学附属第二医院消化内科,重庆 408599
23. 安康市中心医院消化内科内镜中心,安康 725099
24. 丽水市中心医院消化内科,丽水 323020
25. 温州医科大学附属第一医院消化内科,温州 325015
26. 镇江市第三人民医院肝病科,镇江 212009
27. 浙江大学医学院附属第二医院消化科,杭州 310009
28. 银川市第一人民医院消化内科,银川 750003
29. 解放军西部战区总医院消化内科,成都 610083
30. 遵义医科大学第五附属(珠海)医院消化内科与内镜科,珠海 519180
31. 山南市人民医院消化内科,山南 856099
32. 首都医科大学附属北京佑安医院肝病与胃肠病学中心,北京 100069
33. 兰州大学第一医院消化内科,兰州 730099
34. 宁夏回族自治区人民医院肝胆外科,银川 750021
35. 华中科技大学同济医学院附属同济医院消化内科,武汉 430101
36. 保定市人民医院肝病科,保定 071030
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摘要

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.

Abstract

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.

关键词

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

Key words

Acute variceal bleeding/Liver cirrhosis/Timing of emergency endoscopic intervention/Treatment failure rate within 5 days/In-hospital mortality

引用本文复制引用

出版年

2024

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

参考文献量22

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