内镜干预联合普萘洛尔治疗食管胃底静脉曲张破裂出血的临床研究

目的评价内镜套扎术和(或)硬化剂注射结合组织胶黏合剂联合普萘洛尔治疗食管胃底静脉曲张破裂出血患者的疗效。方法2017年10月—2019年10月同济大学附属第十人民医院崇明分院收治的食管胃静脉曲张破裂出血(esophagogastric variceal bleeding, EVB)患者共120例，将患者随机分为研究组和对照组，每组60例。两组患者在治疗前的年龄、性别、体质量指数、病因、Child-Pugh评分、静脉曲张严重程度、血液学检查(血红蛋白、C-反应蛋白(C-reactive protein, CRP)、肝酶水平、凝血酶原时间(prothrombin time, PT)、电解质）和影像学检查(静脉曲张直径、门静脉宽度、脾静脉宽度、门静脉流速)等基线资料均一致。研究组给予内镜下套扎术和(或)硬化剂注射结合组织胶黏合剂联合普奈洛尔治疗，而对照组长期口服普奈洛尔，根据最大耐受量调整剂量，术后随访24个月。评价患者的死亡率、再出血率以及实验室指标。结果研究组与对照组死亡率差异无统计学意义(P>0.05)；研究组输血量、止血时间和住院日与对照组相比明显减少，差异具有统计学意义(P<0.05)；研究组的Child-Pugh评分、PT、血钠水平、炎症指标CRP、静脉曲张直径、门静脉和脾静脉宽度改善较为明显，差异具有统计学意义(P<0.05)；血红蛋白、肝酶、血钾水平和门静脉流速在两组间无明显差异(P>0.05)；术后18个月和24个月，研究组再出血发生率显著低于对照组，差异具有统计学意义(P<0.05)；治疗前Child-Pugh评分、PT、丙氨酸氨基转移酶(alanine aminotransferase, ALT)、天冬氨酸氨基转移酶(aspartate aminotransferase, AST)、血钠水平、静脉曲径直径大小对预后具有重要意义，差异具有统计学意义(P<0.05)；Chlid-Pugh评分、PT、血钠水平、静脉曲径直径大小可能是肝硬化静脉曲张预后不良的独立影响因素(OR>1，P<0.05)。结论内镜干预联合普萘洛尔治疗方案用于防治食管胃底静脉曲张再出血的效果确切，安全性较高，值得广泛推广。

Efficacy of endoscopic intervention combined with propranolol in treatment of esophageal and gastric varices bleeding

ObjectiveTo evaluate the efficacy of endoscopic ligation and/or sclerotherapy combined with tissue adhesive combined with propranolol in the treatment of esophageal and gastric variceal bleeding(EGVB). MethodsOne hundred and twenty patients with EGVB admitted to our hospital from October 2017 to October 2019 were randomly divided into study group and control group, with 60 cases in each group. There were no significant differences between two groups in baseline data before treatment, including age, gender, body mass index, etiology, Child-Pugh score, severity of varicose veins, blood tests(hemoglobin, CRP, liver enzyme levels, PT, electrolytes) and imaging tests(varicose vein diameter, portal vein width, splenic vein width, portal vein flow rate). Both groups received oral propranolol 10mg, 2/d, and adjusted to the maximum tolerated dose; the study group received additional endoscopic ligation and/or sclerotherapy combined with tissue adhesive. Patients were followed up for 24 months and the mortality, rebleeding and laboratory indicators were documented. ResultsThere was no significant difference in mortality between the study group and the control group(P>0.05). The amount of blood transfusion, hemostatic time and length of hospital stay in the study group were significantly reduced compared with the control group(P<0.05). The Child-pugh score, PT, serum sodium levels, inflammatory index CRP, varicose vein diameter, portal vein and splenic vein width were significantly improved in the study group(P<0.05). There were no significant differences in hemoglobin, liver enzyme, blood potassium levels and portal vein flow rate between the two groups(P>0.05). After 18 and 24 months of follow up, the incidence of rebleeding in the study group was significantly lower than that in the control group(P<0.05). Univariate regression analysis showed that Child-Pugh score, PT, ALT, AST, serum sodium levels and varicose vein diameter before treatment were significantly associated with the prognosis of patients(P<0.05). Multivariate logistics regression analysis showed that Chlid-Pugh score, PT, serum sodium level and varicose vein diameter were independent risk factors for poor prognosis of cirrhotic varices(all OR>1, P<0.05). ConclusionEndoscopic intervention combined with propranolol is effective and safe in the treatment of esophageal and gastric varices.