【作者】 王敏；

【导师】 孔德润；

【作者基本信息】 安徽医科大学 ， 内科学， 2013， 硕士

【摘要】 目的：对肝硬化食管静脉曲张破裂出血（esophagealvaricesbleeding,EVB）内镜套扎疗法（endoscopicvaricealligation,EVL）和内镜硬化疗法（endoscopicinjectionsclerotherapy,EIS）治疗后为期两年的随访，比较套扎组和硬化组疗效，并探讨影响内镜治疗预后的相关因素和独立相关因素。方法：收集2005年1月至2010年12月安徽医科大学第一附属医院消化内科治疗的肝硬化食管静脉曲张出血患者106例，截止2012年12月，失访8例、3例因诊断为原发性肝癌被排除，最后纳入符合条件的肝硬化食管静脉曲张出血患者95例，其中行EVL47例、EIS48例，所有患者均采用统一设定的住院登记信息表，详细记录患者的临床信息和各项化验检查结果，每位患者均在首次内镜治疗后接受两年的随访，详细记录随访期间的病情变化情况。EIS组采用血管内注射硬化剂法，自贲门上方开始于曲张静脉内注射硬化剂，根据曲张静脉曲张程度决定每点注射量，一般5-10ml每点，每次2-6点，总量不超过40ml。EVL组从齿状线自下而上呈螺旋式套扎曲张静脉，套扎点数和次数依据静脉曲张程度而定，一般1-7点。两组均间隔3-4周后，依据患者病情需要及静脉曲张程度决定是否再次行内镜治疗。治疗后6周随访一次，然后每隔3月随访一次，共随访2年。从止血成功率、再出血率、并发症等方面比较EIS组和EVL组两组的疗效；同时把95例病例按照随访期间的转归分为死亡组（n=24）和存活组（n=71），从性别、年龄、病因、腹水程度、肝功能分级、生化指标、胃镜表现、影像学表现、治疗方法、术后再出血、术后感染等因素比较两组的差异性，探讨影响内镜治疗预后的相关因素和独立相关因素。结果：EIS组和EVL组疗效分析：EVL组止血成功率高于EIS组（97.5%VS87.5%），术后两年再出血EIS组高于EVL组（56.25%vs40.43%）,迟发性再出血EVL组高于EIS组（34.04%vs22.92%）,但差异均无统计学意义（P>0.05），EIS组早期再出血率（33.33%vs6.38%）、两年病死率(37.5%vs12.77%）高于EVL组，差异有统计学意义（P<0.05）。两组并发症比较，EIS组发热、发热天数、急诊止血失败率、术后肝性脑病均高于EVL组，EIS组有3例发生食管溃疡、4例发生胸膜炎,EVL组均未发生，差异均无统计学意义（P>0.05）,胸骨后疼痛或不适、腹胀EIS组显著高于EVL组（P<0.05）,进食哽咽感EVL组高于EIS组，差异显著（P<0.05）。影响预后的危险因素分析：单因素分析发现，年龄、肝功能Child-Pugh分级、出血程度、腹水程度、凝血酶原时间、治疗方法、早期再出血、再出血、再出血次数、合并胃底静脉曲张、术后感染、血浆白蛋白在死亡组和存活组之间存在差异显著性（P<0.05）；进一步将上述因素纳入多因素Logistic回归分析，结果显示肝功能Child-Pugh分级、出血程度、PT、治疗方法、合并胃底静脉曲张、血浆白蛋白、早期再出血逐一被剔除方程式，是影响内镜治疗预后的混杂因素；年龄、再出血、再出血次数及腹水程度被保留在回归方程，是影响内镜治疗预后的独立相关因素，其中以再出血影响最为显著。结论：1EVL和EIS都是治疗食管静脉曲张破裂出血的有效方法，EVL治疗食管静脉曲张出血总体疗效可能优于EIS组。2术后感染、凝血酶原时间、血浆白蛋白、年龄、肝功能分级、出血程度、腹水程度、治疗方法、早期再出血、再出血、再出血次数、合并胃底静脉曲张是影响内镜治疗预后的相关因素。3年龄、再出血、再出血次数和腹水程度是影响内镜治疗预后的独立危险因素，其中以再出血影响最为显著。更多还原

【Abstract】 Objective:Following-up for two years after endoscopic variceal ligation(EVL) or endoscopic injection sclerotherapy (EIS) in Liver cirrhosis patients with esophageal varices bleeding(EVB), to compare the effect of EVL group with EIS group, and to prospectively determine the risk factors of prognosis after endoscopic therapy.Methods:Collecting106cases of liver cirrhosis patients with esophageal varices bleeding In the first affiliated hospital of Anhui medical university digesting internal medicine from January2005to December2010,.8cases lost to following-up and3cases were excluded for the diagnosis of primary liver cancer by December2012. Finally95cases were qualified liver cirrhosis patients with esophageal varices bleeding,47cases in EVL and48cases in EIS. All the patients were set using the unified hospital registration information table, with a detailed record of the patient’s clinical information and the laboratory test results. Each of the patients was followed-up for two years after the first endoscopic therapy. To detailed record condition changes in the follow-up period. To inject hardener in varicose vein since the cardiac in EIS group, and to decide the injection quantity each point according to varicose vein varicose degree. Generally,5-10ml each point,2-6point every time, and the amount of all is not more than forty ml. To TaoZa varicose vein from dentate line with a screw, and to decide the points and frequency according to the degree of varicose veins in EVL group. Usually,1-7points every time. There is a3-4weeks interval to do endoscopic therapy again, according to patients’condition and varicose veins degree. There is a following-up six weeks later, then once every3months, until2years. To compare the treatment effect in two groups from hemostatic success rate, rebleeding rate, complications and so on. At the same time,95cases is divided into death group (n=24) and survival group (n=71) in accordance with the outcome during the follow-up period. To discuss the related factors and individual factors that influencing patients’prognosis after endoscopic therapy according to comparing with the difference between death group and survival group in the gender, age, etiology, ascites degree, liver function classification, biochemical index, gastroscope manifestation, imaging findings, treatment methods, postoperative rebleeding postoperative infection and so on.Results:The analysis of treatment effect between EIS group and EVL group: Hemostatic success rate and late-occurred rebleeding was higher in EVL group than EIS group (97.5%VS87.5%,34.04%VS22.92%), early rebleeding was higher in EIS group (56.25%VS40.43%), but the differences had no statistical significance (P>0.05). Early bleeding rate and fatality rate in EIS group was higher (33.33%vs6.38%,37.5%vs12.77%), and the difference was significant (P<0.05). Complications comparition:Fever, hot days, failure rate of Emergency hemostatic and hepatic encephalopathy were higher in EIS. There were3cases with esophageal ulcers and4cases with pleurisy after EIS, there was not in EVL group, but the differences had no statistical significance (P>0.05); Retrosternal pain or discomfort and abdominal distension were significantly higher in EIS group while eating choking was significantly higher in EVL group (P<0.05). The analysis of risk factors affecting the prognosis:Single factor analysis show the differences in age, liver function Child Pugh classification, bleeding degree, ascites degree, prothrombin time, treatment, early rebleeding, rebleeding, rebleeding times, merger fundic varices, postoperative infection and plasma albumin were significant between death group and live group (p<0.05); Many factors Logistic regression analysis show that liver Child-Pugh classification, bleeding degree, PT, treatment method, merger fundic varices, plasma albumin, early rebleeding eliminated out the equation, are confounding factors that affect the prognosis of endoscopic therapy; Age, rebleeding, rebleeding times and degree of ascites retained in the regression equation, are the independent factors. Eespecially, rebleeding influence is the most significant.Conclusion:1EVL and EIS are the effective methods to treat esophageal varicose vein rupture hemorrhage. The effect of EVL treatment may be superior to EIS for the patients of esophageal varices bleeding.2Infection, prothrombin time, plasma albumin, age, liver function classification, bleeding degree, ascites degree, treatment, early rebleeding, rebleeding, rebleeding times and merger fundic varices are the related factors that affect the prognosis of endoscopic therapy.3Rebleeding, rebleeding times and ascites degree are independent risk factors that affect the prognosis of endoscopic therapy, and rebleeding influence is the most significant.更多还原