【作者】 夏颖；

【导师】 朱强；

【作者基本信息】 山东大学 ， 内科学（消化内科）（专业学位）， 2016， 硕士

【摘要】 研究背景：肝硬化门脉高压行脾切除术后容易形成门静脉血栓(portal vein thrombosis,PVT),PVT是脾切除术后一种常见的并发症,可导致肝脏的血流供应减少,门静脉压力增高,如不能及时发现并处理可出现上消化道出血,甚至死亡等严重后果。目前肝硬化门静脉高压脾切除术后PVT的发病机制尚不完全明确,尽管对PVT形成的单因素分析较多,但对多因素分析研究较少。本研究通过比较凝血功能各项指标的变化、门静脉内径、门静脉血流速度、脾切除前后血小板变化率等因素,旨在探讨肝硬化门静脉高压脾切除术后PVT形成相关影响因素之间的关系,从而为PVT的早期预防和诊断提供理论依据。目的：分析肝硬化患者脾切除术后PVT发生与凝血功能、门静脉内径、门静脉血流速度、脾切除前后血小板变化率之间的关系,为PVT的早期预防和诊断提供理论依据。方法：选取2014年1月至2016年1月聊城市人民医院肝硬化门静脉高压行脾切除术患者100例,术前、术后行彩超,根据术后发生PVT的情况将患者分为血栓组(有PVT)及对照组(无PVT)。收集与PVT形成有关的数据包括性别、年龄、门静脉内径、门静脉血流速度、计算每位患者的Child-Pugh评分；收集患者术前及术后凝血功能各项指标包括肝硬化患者血小板计数、APTT、PT、TT、DD及FIB的变化情况,分析PVT与以上各项指标变化的关系。结果：1.肝硬化门静脉高压行脾切除术后PVT发生情况：100例患者手术前检查均证实无门静脉血栓,手术后行超声检查存在门静脉系统血栓者35例,PVT的发生率为35.0%。血栓通常发生在术后3.07±1.23天,主要分布在脾静脉及门静脉主干处。2.血栓组PVT形成与患者的性别、年龄等因素无关,而与门静脉内径、术后门静脉血流速度、脾切除前后血小板的变化率有关。血栓组与对照组相比,脾切除术后门静脉血流速度明显小于对照组,血流速度下降梯度大于对照组(P<0.05)；手术前后门静脉内径均大于对照组(P<0.05)。手术前后血小板(PLT)的变化比率越高,血栓的发生率就越高。(P<0.05)3.肝硬化门静脉高压行脾切除术后PVT发生与Child-Pugh分级无相关性(P>0.05)。4.血栓组与对照组相比,术后第一天DD值高于对照组(P<0.05)；血栓组术后第3天DD值达最高峰。结论：检测肝硬化门脉高压脾切除术前后门静脉内径、门静脉血流速度、血小板(PLT)的变化率及D-二聚体(DD)值有利于早期诊断和预防PVT,具有重要的临床意义。术前通过改善凝血功能,或早期抗凝治疗从而减少PVT的发生率。出院后,患者仍有可能发生PVT,需要定期随访。更多还原

【Abstract】 Background:Patients with liver cirrhosis and portal hypertension after splenectomy are prone to form portal vein thrombosis (PVT), which is very serious complication after surgery. The formation of PVT further leads to the reduce of blood supply to the liver and increase portal vein pressure, and may also leads to upper gastrointestinal bleeding. If PVT was not detected and treated timely, serious consequences such as liver function damage may occur.At present, the pathogenesis of PVT in patients with liver cirrhosis and portal hypertension after splenectomy is not clear. Although there is relatively more study on unilateral factors analysis of PVT formation, study on multivariate analysis is still insufficiency. In this study, we analyzed changes of coagulation function indexes, diameter of portal vein, velocity of portal vein blood flow, platelet rate before and after splenectomy, which aimed to explore relationship between portal vein thrombosis and coagulation function in patients with liver cirrhosis after splenectomy and to provide theoretical basis for the early prevention and diagnosis of PVT.Aim:To analyze the relationship between PVT, coagulation function, diameter of portal vein, velocity of portal vein blood flow, platelet rate before and after splenectomy and provide theoretical basis for the early prevention and diagnosis of PVT.Method:From January,2014 to January,2016,100 patients with liver cirrhosis after splenectomy were selected. Patients were divided into two groups, thrombosis group and non thrombosis group according to the presence of PVT performed by color Doppler ultrasonography. Data related formation of PVT were collected, such as sex, age, diameter of portal vein, velocity of portal vein blood flow and child Pugh grading. Data related preoperative and postoperative indexes of coagulation function were collected, such as platelet count, activated partial thromboplastin time (APTT), thrombin time (PT), thrombin time (TT), plasma D-poly (DD) and fibrin original quantitative (FIB) to analysis relationship between the changes of the above indicators.Results:1. PVT occurrence in patients with liver cirrhosis and portal hypertension after splenectomy:100 patients were confirmed absence of portal vein thrombosis among preoperative examination, and 35 patients had portal venous system thrombosis through color Doppler ultrasound after surgery, and occurrence rate of PVT was 35.0%. Thrombosis normally formed 3.07±1.23 day after operation, and mainly distribute in the main portal vein and splenic vein.2. There was no correlation between the formation of PVT and patients’sex and age. However, significant correlation were observed between formation of PVT and inner diameter of portal vein, velocity of portal vein blood flow and platelet rate before and after splenectomy. Compared with the control group, portal vein blood flow rate after operation was significantly lower than that of the control group, and gradient of blood flow velocity was greater than that of the control group (p<0.05); the diameter of the portal vein was larger than that of the control group before and after operation(p< 0.05). The higher the rate of platelet (PLT) before and after surgery, the higher the incidence of thrombosis (p<0.05).3. There is no correlation between the occurrence of PVT and Child-Pugh grading in patients with liver cirrhosis after splenectomy.4. Compared with the control group, the DD value of the first day after surgery was higher than that in the control group (p<0.05); The DD value reached the highest peak at third days after operation in the thrombosis group.Conclusion:It is conducive for the early diagnosis and prevention of PVT by detecting the diameter of portal vein, portal vein blood flow velocity, blood platelet (PLT) and the ratio of D dimer (DD) in patients with liver cirrhosis after splenectomy, which has important clinical significance. By improving the coagulation function before surgery or early anti coagulation therapy to reduce incidence of PVT. After discharge, PVT is still likely to occur in the patients, it’s also needed to follow-up.更多还原