肝癌肝动脉化疗栓塞后急性上消化道出血的相关因素

背景与目的:原发性肝癌患者在施行肝动脉栓塞化疗后常并发急性上消化道出血。作者研究出血的相关因素,以帮助临床有效防治这一并发症。方法:208例中晚期原发性肝癌患者经影像学和AFP或病理检查确诊;采用Seldinger方法将动脉导管插入腹腔动脉、肝总动脉、肝固有动脉、肝左或右动脉,注入表阿霉素、顺铂、丝裂霉素、5-氟尿嘧啶(5-FU)以及碘化油或/和明胶海绵等;以呕血和/或黑便为依据诊断为上消化道出血,结合内镜检查和肝功能生化指标、血管选择情况、用药量等分析出血的相关因素。结果:208例中31例(14.9%)出现上消化道出血。内镜检查急性出血糜烂性胃炎18例、急性溃疡和Mallory-Weiss综合征各3例、食管静脉曲张破裂2例。肝功能Child-Pugh分级积分(B级)与并发出血呈正相关(r=0.59,P<0.005);导管插至腹腔动脉者或肝总动脉注射药物并发出血者(7/18,38.9%;18/38,47.4%),显著多于插至肝固有动脉或肝左、肝右动脉者(5/146,3.4%;P<0.005);化疗药物用量较大以及合用栓塞剂者出血发生率较高。结论:原发性肝癌患者动脉化疗栓塞后并发上消化道出血与患者肝功能分级、导管插入血管位置、化疗药物和栓塞剂用量大小等因素有关;认识这些因素,改进操作以及加强术后观察处理有助于减少上消化道出血的发生。

Factors related to acute upper gastrointestinal bleeding after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma

BACKGROUND & OBJECTIVE: Acute upper gastrointestinal bleeding (UGIB) often occurs after transcatheter arterial chemoembolization (TACE) in the patients with hepatocellular carcinoma (HCC). The authors studied the factors associated with UGIB for better prevention and management of the complication. METHODS: Epirubicin, cisplatin, mitomycin, 5-fluorouracil, lipidol and/or gelfoam were infused via catheters inserted in ciliac artery, common hepatic artery, arteria hepatica propria, or left or right hepatic artery by Seidinger method in 208 cases of advanced HCC confirmed by image techniques, alpha-fetoprotein (AFP) and/or pathology. Factors related to UGIB (vomiting of blood and/or melena, or positive fecal occult blood) were analyzed with reference to endoscopy, biochemical parameters of liver function, selection of blood vessels, and the amount of drugs. RESULTS: Of 208 patients, 31 cases were complicated with UGIB. Acute gastric mucosal lesion was confirmed in 18 cases; acute ulcer in 3 cases; Mallory-Weiss syndrome in 3 cases; and esophageal varices bleeding in 2 cases. Positive correlation was found between B grade of Child-Pugh hepatic functional reserve and bleeding (r = 0.59, P < 0.005). The incidence of UGIB in patients in whom drugs were infused via ciliac artery (7/18, 38.9%); or common hepatic artery (18/38, 47.4%) was significantly higher than in those via arteria hepatica propria, left, or right hepatic artery (5/146, 3.4%; P < 0.005). Patients with larger amount of chemotherapy drug and embolization agent had higher bleeding rate. CONCLUSION: Many factors may be associated with UGIB after TACE in patients with HCC, such as higher scores of hepatic functional reserve in Child-Pugh grading, selection of blood vessels, and amount of drugs. In order to reduce the incidence of UGIB, these factors should be necessarily considered in improvement of TACE procedure, in inspection and management after TACE.