【作者】 刘洋；

【导师】 姜慧卿；

【作者基本信息】 河北医科大学 ， 内科学（专业学位）， 2019， 硕士

【摘要】 目的:回顾性分析内镜下组织黏合剂治疗胃静脉曲张的疗效,并且了解此类患者内镜治疗后的再出血情况,进一步分析其危险因素。方法:1.选取2013年1月至2018年1月在河北医科大学第二医院消化内科住院的肝硬化患者,经胃镜检查存在胃重度静脉曲张并行内镜下组织黏合剂治疗的58例患者为观察对象。2.通过回顾性分析内镜治疗后胃静脉曲张消失率、总有效率、重复治疗率、复发率、再出血率、病死率及并发症等指标来评价治疗效果。3.根据内镜下治疗后再出血情况,分为出血组和非出血组。回顾性分析患者的临床资料,对有显著差异的临床指标,采用单因素、多因素Logistic回归分析法,得到相应的独立危险因素。对有统计学意义的指标,计算受试者工作特征曲线(ROC)的曲线下面积(AUC),评估各指标对判断内镜下食管胃静脉曲张治疗术后的再出血的诊断价值。结果:1.入选重度胃静脉曲张患者共58例,男性36人(62.0%),女性22人(37.9%),平均年龄53.6±13.3岁。2.纳入的58例患者中,经内科和内镜治疗,止血成功率100%。经内镜下组织黏合剂治疗后,总有效50例(86.2%),其中胃静脉曲张消失28例(48.2%),显效21例(36.3%),有效1例(1.7%),无效8例(13.8%),重复内镜下组织黏合剂治疗的10例(17.2%),复发1例(1.7%)。死亡3例,病死率为5.1%。3.本研究中,随访过程中16例患者发生出血,再出血率为27.58%,其中早期再出血的患者7例(12%)。出血组与非出血组患者在PLT(P=0.041)、ALB(P=0.012)、Cr(P=0.041)、Child-Pugh分级(P=0.034)等方面有统计学差异;单因素Logistic分析显示PLT、ALB、Child-Pugh A级是内镜下食管胃静脉曲张治疗术后再出血的潜在影响因素(P<0.05),且呈负相关。多因素Logistic回归分析示血小板是再出血的独立危险因素。血小板(PLT)曲线下面积(AUC)为85.3%,血小板的最佳值为73.5×10~9/L,敏感性为86%,特异性为73.5%。4.并发症:术后发热3例,恶心、呕吐1例,胸腹痛2例(系联合食管套扎治疗术后的患者),吞咽困难1例(系合并食管静脉曲张,并行EVL+EIS序贯治疗,已行食管扩张术),无异位栓塞。结论:1.内镜下组织黏合剂治疗止血成功率高,可作为急性胃静脉曲张破裂出血的首选治疗措施,并具有近期疗效好、复发率和病死率低之特点。2.内镜下食管胃静脉曲张治疗术后发生再出血的潜在影响因素是血小板、白蛋白、Child-Pugh A级,其中血小板减少是其独立危险因素。更多还原

【Abstract】 Objective:To retrospectively analyze the efficacy of endoscopic gastric varices obturation using tissue adhesive and follow up the rebleeding patients after endoscopic treatment.To analyze the risk factors of such patients.Methods:1.Collect 58 patients with liver cirrhosis from January 2013 to January2018 admitted to the Department of Gastroenterology of the Second Hospital of Hebei Medical University.These patients with severe gastric varices treated with endoscopic variceal obturation were observed.2.The therapeutic effects were evaluated by retrospective analysis of the disappearance rate,total effective rate,repeated treatment rate,recurrence rate,rebleeding rate,mortality and complications.3.According to the rebleeding of patients after endoscopic treatment,it was divided into bleeding group and non-bleeding group.Recording the patient’s general information and using single factor、multi-factor logistic regression analysis,to obtain the independent risk factors.For the statistically significant indicators,the area under the curve(AUC)of the receiver operating characteristic curve(ROC)was calculated to judge the diagnostic value of each index.Results:1.A total of 58 patients with gastric varices were enrolled,including 36males(62.0%)and 22 females(37.9%),with an mean age of 53.6+13.3 years.2.In this study,the success rate of hemostasis was 100%after internal medicine and endoscopic treatment.Among the 58 patients with endoscopic gastric varices obturation using tissue adhesive,50(86.2%)cases were effective,including 28(48.2%)cases with gastric varices disappeared,21(36.3%)cases with significant effects,1(1.7%)case with mild effect,8(13.8%)cases with ineffective effects,10(17.2%)cases with repeated endoscopic treatment with tissue adhesives,and 1 cases(1.7%)with recurrent effects.There were 3 deaths,the mortality rate was 5.1%.3.In this study,16 patients had rebleeding during the follow-up,and the rate of rebleeding was 27.58%,7 patients(12%)with early rebleeding.There were statistical differences in PLT(P=0.041),ALB(P=0.012),Cr(P=0.041)and child-pugh grading(P=0.034)between the two groups.Univariate Logistic analysis showed that PLT,ALB and child-pugh grade A were negatively correlated with re-bleeding after endoscopic tissue adhesion therapy for gastric varices(P<0.05).Multivariate Logistic regression analysis showed that platelets were independent risk factors for re-bleeding.The area(AUC)under the platelet(PLT)curve was 85.3%,the optimal platelet value was 73.5×10~9/L,the sensitivity was 86%,and the specificity was 73.5%.4.Complications:postoperative fever(3 cases),nausea and vomiting(1case),chest and abdominal pain(2 cases),1 patient with dysphagia who combined esophageal varices,was treated by EVL and EIS therapy,no ectopic embolism.Conclusions:1.Endoscopic variceal obturation which has high success rate of hemostasis,can be used as the preferred treatment of acute gastric varices bleeding and has the characteristics of good short-term efficacy,low recurrence rate and mortality.2.The potential influencing factors of rebleeding after endoscopic treatment are platelet,albumin and Child-Pugh A grade,of which platelet is independent risk factors.更多还原