肝硬化门静脉高压食管胃静脉曲张出血二级预防后再出血的临床特征

目的分析食管胃静脉曲张出血不同二级预防措施后再出血的临床表现、急诊内镜诊治情况及预后。方法回顾性分析2018年1月至2019年4月解放军总医院第五医学中心食管胃静脉曲张出血二级预防后(内镜、外科、介入预防)再出血行急诊内镜诊治的254例患者临床资料,对照同期单纯药物二级预防再出血的419例患者,观察临床特点,对比分析异同。正态分布的计量资料多组间比较采用方差分析;非正态分布的计量资料多组间比较采用Kruskal-Wallis H检验;进一步两两比较采用Bonferroni法。计数资料组间比较采用χ^2检验。结果254例二级预防后再出血的患者中,有144例(56.69%)曾行内镜预防,40例(15.75%)行手术预防,33例(12.99%)行介入预防,37例(14.57%)联合预防以内镜联合其他预防措施为主。分析出血距最近一次预防时间,手术预防组有57.50%再出血患者距预防时间在5年以上,介入预防组有69.70%发生在经颈静脉肝内门体分流术后的1年内。内镜和联合预防组的患者再出血,分别有40.28%和35.14%发生在预防结束的1年内。再出血时,介入预防组和联合预防组的肝性脑病发生率显著高于其他组(P值均<0.001),介入预防组的腹水情况较其他组控制显著(P值均<0.05)。各组再出血时多项临床指标均存在显著性差异(P值均<0.001),两两比较提示,内镜预防组的血红蛋白和白蛋白显著高于手术组(P值分别为<0.001、0.001)和药物预防组(P值分别为0.001、<0.001)。手术组的血小板水平显著高于介入组(P=0.037)、联合预防组(P<0.001)和药物预防组(P=0.012)。药物预防组的总胆红素水平显著高于内镜组(P=0.037)、介入组(P=0.025)和联合预防组(P<0.001);手术预防组的肌酐水平显著低于其他组(P值均<0.05);联合预防组的凝血功能(凝血酶原时间、国际标准化比值)显著优于药物组(P值均=0.002)。药物预防组的活动性出血比例(68.02%)显著高于内镜组(P<0.001)、介入组(P=0.004)和联合预防组(P=0.008)。手术预防组和药物预防组的食管胃静脉曲张破裂出血比例显著高于其他组(P值均<0.05)。介入预防组的消化性溃疡出血比例显著高于其他组(P值均<0.05)。药物预防组的内镜治疗不满意率和失败率显著高于内镜组(P<0.001)、介入组(P=0.007)和联合预防组(P<0.001)。药物预防组的42 d内再出血率和病死率均显著高于其他组(P值均<0.05)。结论介入、内镜或联合二级预防,较单纯的药物预防能显著减轻食管胃静脉曲张再出血的程度,提高急诊内镜止血率,显著降低42 d内再出血率和死亡率。需考虑不同二级预防后再出血的临床特点,对食管胃静脉曲张出血二级预防后再出血患者实施个体化治疗。

Clinical features of rebleeding after secondary prevention for esophagogastric variceal bleeding in cirrhotic portal hypertension

Objective To investigate the clinical manifestations,emergency endoscopic diagnosis and treatment,and prognosis of rebleeding after different secondary prevention measures for esophagogastric variceal bleeding in cirrhotic portal hypertension.Methods A retrospective analysis was performed for the clinical data of 254 patients with rebleeding after secondary prevention(endoscopic therapy,surgical treatment,or interventional prevention)for esophagogastric variceal bleeding who underwent emergency endoscopic diagnosis and treatment in The Fifth Medical Center of Chinese PLA General Hospital from January 2018 to April 2019,and 419 patients who received medication alone for the prevention of rebleeding during the same period of time were enrolled as controls.Clinical features were observed and compared between groups.An analysis of variance was used for comparison of normally distributed continuous data between groups,and the Kruskal-Wallis H test was used for comparison of continuous data with heterogeneity of variance between groups.The least significant difference Bonferroni test was used for further comparison between two groups.The chi-square test was used for comparison of categorical data between groups.Results Among the 254 patients with rebleeding after secondary prevention,144(56.69%)received endoscopic prevention,40(15.75%)received surgical prevention,33(12.99%)received interventional prevention,and 37(14.57%)received prevention with endoscopy combined with other prevention measures.As for the time from last prevention to bleeding,57.50%in the surgical prevention group had a time of more than 5 years,and 69.70%in the interventional prevention group experienced bleeding within 1 year after transjugular intrahepatic portosystemic shunt;40.28%in the endoscopic prevention group and 35.14%in the combined prevention group experienced rebleeding within 1 year after prevention ended.During rebleeding,the interventional prevention group and the combined prevention group had a significantly higher incidence rate of hepatic encephalopathy than the other groups(all P<0.001),and the interventional prevention group had significantly better controlled ascites than the other groups(all P<0.05).There were significant differences in various clinical indices between these groups during rebleeding(all P<0.001),and the endoscopic prevention group had significantly higher levels of hemoglobin and albumin than the surgical prevention group(P<0.001 and P=0.001)and the medication prevention group(P=0.001 and P<0.001).The surgical prevention group had a significantly higher platelet count than the interventional prevention group(P=0.037),the combined prevention group(P<0.001),and the medication prevention group(P=0.012).The medication prevention group had a significantly higher level of bilirubin than the endoscopic prevention group(P=0.037),the interventional prevention group(P=0.025),and the combined prevention group(P<0.001);the surgical prevention group had a significantly higher level of creatinine than the other four groups(all P<0.05);the combined prevention group had significantly better coagulation parameters prothrombin time and international normalized ratio than the medication prevention group(both P=0.002).The medication prevention group had a significantly higher proportion of patients with active bleeding than the endoscopic prevention group(P<0.001),the interventional prevention group(P=0.004),and the combined prevention group(P=0.008).The surgical prevention group and the medication prevention group had a significantly higher proportion of patients with esophageal variceal bleeding than the other groups(all P<0.05),and the interventional prevention group had a significantly higher proportion of patients with peptic ulcer and bleeding than the other four groups(all P<0.05).The medication prevention group had significantly higher dissatisfaction rate and failure rate of endoscopic treatment than the endoscopic prevention group(P<0.001),the interventional prevention group(P=0.007),and the combined prevention group(P<0.001).The medication prevention group had significantly higher rebleeding rate and mortality rate within 42 days than the other four groups(all P<0.05).Conclusion Compared with medication prevention alone,interventional prevention,endoscopic prevention,or combined secondary prevention can significantly alleviate the degree of esophagogastric variceal rebleeding,improve the hemostatic rate of emergency endoscopy,and significantly reduce rebleeding rate and mortality rate within 42 days.The clinical features of rebleeding after different secondary prevention measures should be considered to perform individualized treatment of patients with rebleeding after secondary prevention for esophagogastric variceal bleeding.