肝硬化门静脉高压症内镜治疗围手术期门静脉血栓形成的危险因素分析

发布时间：2018-03-17 01:38

本文选题：肝硬化　切入点：门静脉高压症　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:门静脉血栓形成(portal vein thrombosis,PVT)是肝硬化(liver cirrhos is)合并门静脉高压症(portal hypertension)患者少见但严重的并发症之一,多隐匿发病,临床症状多为非特异性表现,如发热、腹痛等,甚至不少患者无任何前驱症状,因此不易早期诊断,待腹部超声或其他影像学检查发现时常已产生一定的不良后果。如今随着消化内镜技术的不断发展,内镜下曲张静脉硬化剂注射治疗(endoscopic injection sclerotherapy,EIS)、内镜下曲张静脉套扎治疗(endoscopic variceal ligation,EVL)、内镜下曲张静脉栓塞治疗(endosc opic variceal obturation,EVO)用于治疗失代偿期肝硬化导致的食管/胃底静脉曲张(esophageal/gastric varices,EV/GV)的效果已获得公认。然而在实际应用消化内镜治疗食管/胃底静脉曲张破裂出血及预防再出血时,单次镜下治疗一般无法取得令人满意的效果,需要多次并联合应用EIS、EVL及EVO来将后期出血发生率降至最低,因此我们将联合多次内镜下治疗静脉曲张的综合治疗过程称为内镜序贯治疗(endoscopic sequential therapy,EST)。在内镜治疗食管/胃底静脉曲张的序贯疗程中,不少患者于围手术期产生了门静脉血栓,针对此类患者,临床上往往需要给予抗凝或改善微循环药物治疗,待血栓溶解或机体脱离高凝风险后方可考虑下一步镜下治疗方案,然而抗凝治疗势必增加出血风险,这无疑增加了临床治疗难度,同时延长了患者住院天数及治疗区间,并增加了患方家庭的经济负担。因此,在联合多次应用EIS、EVO和EVL治疗肝硬化合并门静脉高压症的过程中,对患者在内镜治疗围手术期发生PVT的早期预测和早期干预显得尤为重要。目的:本研究通过分析接受内镜下序贯治疗肝硬化合并门静脉高压症(伴发食管/胃底静脉曲张)的患者围手术期的临床资料,期望发现可以预测内镜治疗围手术期PVT发生的危险因素,从而筛选出内镜下治疗围手术期或治疗间歇期的高危患者,以求为临床医生在针对肝硬化合并门静脉高压症的内镜下治疗后期行预防性抗凝处理提供指导。方法:回顾性分析从2011年9月至2016年9月于山东大学附属省立医院消化内二科住院治疗的肝硬化门静脉高压症出血患者的临床资料,筛选出其中符合入组条件的病例159例;其中48例在内镜序贯治疗的围手术期出现了 PVT,另111例于疗程中未发生PVT,基于临床经验,选择性收集患者的性别、年龄、脾切除术手术史、Child-Pugh评分、内镜治疗方式、注射硬化剂/组织胶总量及次数、肿瘤病史、外周血小板计数及D-二聚体浓度等可能影响PVT进程的数据资料,对这些可疑因素进行统计分析(包括单因素分析和二元非条件Logistic回归模型分析),筛选出高危因素。结果:通过对以上临床资料进行的单因素及多因素分析(通过建立二元非条件L ogistic回归模型分析),我们发现:Child-Pugh评分、D-二聚体浓度与内镜序贯疗程中出现PVT有显著性关联,差异有统计学意义(P0.05);脾切除术病史与内镜疗程中出现PVT可能有关(P=0.051、P=0.061),考虑可能受限于本次研究病例数量较少等因素在对照组与PVT组中未呈现出显著性差异;但患者性别、年龄、内镜治疗方式、注射硬化剂总量及次数、肿瘤病史、血小板数量与发生PVT无显著性关联,差异无统计学意义(P0.05)。结论:Child-Pugh分级(及评分)和外周血D-二聚体浓度是肝硬化合并门静脉高压症患者在内镜序贯治疗过程中出现门静脉血栓的独立危险因素,需引起临床医师高度关注,对Child-Pugh评分高(肝功能受损严重)或外周血D-二聚体高的患者在内镜治疗后期及时加用抗凝及改善微循环药物,以预防PVT。
[Abstract]:Background: portal vein thrombosis (portal vein, thrombosis, PVT) (liver cirrhos is) in liver cirrhosis with portal hypertension (portal hypertension) in patients with a rare but serious complication, occult onset, clinical symptoms were nonspecific manifestations, such as fever, abdominal pain, and even a lot of patients without any premonitory symptoms, so not easy to early diagnosis, abdominal ultrasound or other imaging findings often has produced some adverse consequences. Now the development of digestive endoscopy, endoscopic variceal sclerotherapy treatment (endoscopic injection sclerotherapy, EIS), endoscopic variceal ligation (endoscopic variceal, ligation, EVL), endoscopy varices embolization (Endosc opic variceal obturation, EVO) for the treatment of decompensated cirrhosis caused by esophageal / gastric varices (esophageal/gastric vari CES, EV/GV) the effect has been recognized. However, in the practical application of endoscopic treatment of esophageal and gastric variceal bleeding and prevent rebleeding, a single treatment under the microscope to obtain satisfactory results, and requires the combination of EIS, EVL and EVO to the late bleeding rate dropped to the lowest, comprehensive the treatment process so that we will be combined with multiple endoscopic treatment of varicose veins called endoscopic therapy (endoscopic sequential, therapy, EST). In the endoscopic treatment of esophageal and gastric varices / sequential treatment, many patients had portal vein thrombosis in perioperative period, for these patients, patients often need to give the microcirculation treatment of anticoagulant or thrombolytic or to be improved, the body from the high coagulation risk before the next step to consider endoscopic treatment, however, anticoagulation is bound to increase the risk of bleeding, it will increase the pro The bed also increases the difficulty of treatment, hospitalization and treatment interval of patients, and increase the patients' economic burden of the family. Therefore, many times in the United Application of EIS, EVO and EVL for the treatment of liver cirrhosis complicated with portal hypertension, is particularly important for early prediction and early intervention for patients in the endoscopic treatment of perioperative PVT look. Objective: This study received endoscopic sequential therapy in the treatment of liver cirrhosis complicated with portal hypertension through the analysis (associated with esophageal / gastric varices) clinical data of perioperative patients, expect to find risk factors can predict the endoscopic treatment of peri operation period of PVT, in order to find out the endoscopic treatment of high-risk patients in the perioperative period or the intermittent period of treatment, in order to provide guidance for clinicians late treatment of anticoagulant treatment in the prevention of endoscopy in view of liver cirrhosis complicated with portal hypertension. Methods: a retrospective analysis from 2 011 years from September to September 2016 in the digestive Provincial Hospital Affiliated to Shandong University hospital in two cirrhotic patients with portal hypertension treatment of bleeding in patients with clinical data, were selected including 159 cases were eligible cases; including 48 cases of endoscopic sequential therapy in the perioperative period of the emergence of PVT, the other 111 cases in the treatment without PVT, based on clinical experience, selective collection of patients with sex, age, Child-Pugh score, splenectomy surgery, endoscopic treatment, injection of sclerosing agent / tissue glue amount and times, tumor history, peripheral platelet count and D- two concentration may affect the process of PVT data, statistical analysis of these factors (suspicious including two yuan of single factor analysis and non conditional Logistic regression model analysis), selected risk factors. Results: the single factor on the above clinical data and multivariate analysis (through the establishment of Two yuan L non conditional ogistic regression model analysis), we found that: the scores of Child-Pugh, D- two concentration and endoscopic treatment in sequential PVT has a significant correlation, the difference was statistically significant (P0.05); splenectomy and endoscopic treatment history may be related to PVT (P= 0.051, P=0.061), consideration may be limited to cases this study number and other factors in the control group and PVT group did not show significant difference; but the gender, age, endoscopic treatment, and the total number of sclerosing agent injection, tumor history, no significant association of platelet count and the occurrence of PVT, the difference was not statistically significant (P0.05). Conclusion: Child-Pugh grade (and score) and peripheral blood D- two concentration is an independent risk factor in patients with cirrhosis and portal hypertension of portal vein thrombosis in endoscopic sequential therapy in the process, need to cause the attention of clinicians, Child-Pu Patients with high GH score (severe impairment of liver function) or high D- two polymer in peripheral blood were treated with anticoagulant and improved microcirculation drugs in a timely manner to prevent PVT. in the late stage of endoscopic treatment.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.34

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