非静脉曲张性上消化道出血预后的危险因素及四种评分系统的应用研究
发布时间：2018-07-13 21:19
【摘要】：背景:上消化道出血是临床常见的消化科急重症,虽然药物治疗的不断进步与内镜技术的不断提高,其死亡率未见明显下降。目前多种非静脉曲张性上消化道出血(non-variceal upper gastrointestinal bleeding,NVUGIB)评分系统先后报道,对于各评分系统的预测价值,不同研究差异较大,对于指南推荐应用的Full Rockall Score(FRS)和Glasgow-Blatchford Score(GBS)评分系统,以及近年新建立的AIMS65评分系统和Progetto Nazionale Emorragia Digestiva(PNED)评分系统的对比,国内研究较少。这些评分系统在中国人群NVUGIB患者中的临床预测能力与应用价值,以及不良结局的危险因素需要进一步研究。目的:1、分析NVUGIB患者的临床特征,利用GBS、AIMS65、FRS和PNED评分系统对NVUGIB患者进行评估,研究不同评分系统对再出血、死亡和临床干预的预测价值,寻找预测的最佳诊断界值;2、探讨NVUGIB患者不同临床结局下的危险因素,为进一步制定适用于我国NVUGIB患者的评分系统奠定基础。方法:1、通过对天津医科大学总医院消化科2015年1月1日至2016年12月31日入院的394例非静脉曲张性上消化道出血的患者进行回顾性分析,收集每位患者住院期间资料,分析其一般临床特征。分别按照GBS、AIMS65、FRS和PNED评分系统对每位患者进行上消化道出血累计评分,绘制受试者工作特征曲线(receiver-operating characteristic curve,ROC曲线),计算ROC曲线下面积(the area under the receiver-operating characteristic curve,AUROC),评价不同评分系统对再出血、死亡、临床干预的预测价值,并寻找最佳的诊断界值。2、采用logistic单因素与多因素回归分析,进而探讨与NVUGIB不同临床结局相关的危险因素。结果:1、消化性溃疡、恶性肿瘤、糜烂性病变是NVUGIB的主要病因,分别占60.6%、13.7%、11.2%,男女比例为3.2:1。NVUGIB平均住院天数9.6±5.1天,住院再出血发生率9.1%,死亡患者占4.1%,需要进行临床干预治疗的患者共189例,比例为48.0%,其中输血41.3%,内镜下止血9.1%,外科治疗6.6%,介入治疗占3.3%。2、各评分系统死亡患者评分较存活患者高,再出血患者评分较非再出血患者评分高,临床干预患者四种评分比非临床干预者均高,差异均有统计学意义。3.、PNED评分系统对死亡预测AUROC为0.933,高于GBS、AIMS65和FRS评分系统(p0.05),AUROC分别为0.809、0.813、0.809,后三者对死亡的预测能力相当。GBS和FRS对再出血具有预测价值,其AUROC分别为0.715和0.702,预测能力相当,均高于AIMS65(AUROC 0.597),AIMS65预测再出血能力欠佳。预测临床干预治疗方面,GBS、AIMS65、FRS评分系统三者的曲线下面积分别为0.656(95%CI,0.607-0.703;p0.001),0.613(95%CI,0.563-0.662;p0.001),0.620(95%CI,0.570-0.668;p0.001),无统计学差异。GBS对于再出血、死亡、临床干预判断的最佳界值7,9,7,PNED评分对死亡判断的最佳界值为3,而AIMS65和FRS评分对再出血、死亡、临床干预治疗的最佳诊断界值为:AIMS65是1,0,0,FRS是4,5,3。4、血红蛋白、白蛋白、PTINR、血尿素氮与再出血相关,其独立危险因素为PTINR、血红蛋白和白蛋白。上消化道再出血、输血、年龄超过65岁、血红蛋白、白蛋白、PTINR、血尿素氮与NVUGIB死亡相关,而预测死亡的独立危险因素为PTINR和血尿素氮。年龄超过65岁、血红蛋白、白蛋白、血尿素氮与临床干预治疗相关,多因素回归分析:血红蛋白和白蛋白水平是NVUGIB临床干预治疗的独立危险因素。结论:1、消化性溃疡、恶性肿瘤、黏膜糜烂性病变仍是非静脉曲张性上消化道出血的主要原因。2、PNED是对NVUGIB死亡预测的有效评分系统,临床预测价值高于GBS、AIMS65和FRS;GBS、FRS评分系统对于预测再出血具有较好的预测价值,优于AIMS65评分;但对于临床干预,GBS、AIMS65和FRS三种评分系统虽然具有一定的预测价值,但评分结果不佳,并非理想预测工具。3、PTINR、血红蛋白和白蛋白是预测再出血的独立危险因素。PTINR和血尿素氮是预测NVUGIB死亡的独立危险因素。血红蛋白和白蛋白是预测临床干预治疗的独立危险因素。
[Abstract]:Background: hemorrhage in the upper digestive tract is a common severe acute severe disease in the Department of digestive department. Although the continuous improvement of drug treatment and the continuous improvement of endoscopy, the mortality rate has not decreased significantly. At present, various non variceal upper gastrointestinal bleeding (non-variceal upper gastrointestinal bleeding, NVUGIB) scoring system has been reported for each score. The value of the system is very different from the different research. For the recommended application of the Full Rockall Score (FRS) and Glasgow-Blatchford Score (GBS) scoring system, as well as the newly established AIMS65 scoring system and Progetto Nazionale Emorragia Digestiva score system in recent years, the domestic research is less. These scoring systems are in China. The clinical predictive and applied value of NVUGIB patients and the risk factors for adverse outcomes need further study. Objective: 1. Analyze the clinical features of NVUGIB patients and evaluate the NVUGIB patients by using GBS, AIMS65, FRS and PNED scoring systems to study the predictive value of different scoring systems for rebleeding, death and clinical intervention. To find the best diagnostic value of prediction; 2, to explore the risk factors of NVUGIB patients with different clinical outcomes, and to lay the foundation for further formulating the scoring system for NVUGIB patients in China. Methods: 1, 394 cases of non variceal upper gastrointestinal tract were admitted to the Department of digestive department of General Hospital Affiliated to Tianjin Medical University from January 1, 2015 to December 31, 2016. The patients with bleeding were analyzed retrospectively, collected the data of each patient and analyzed their general clinical features. The cumulative score of upper gastrointestinal bleeding was performed on each patient according to the GBS, AIMS65, FRS and PNED scoring system respectively, and the subjects' work characteristic curve (receiver-operating characteristic curve, ROC curve) was drawn and the ROC curve was calculated. The lower area (the area under the receiver-operating characteristic curve, AUROC) was used to evaluate the predictive value of different scoring systems for rebleeding, death, and clinical intervention, and to find the best diagnostic value.2, using logistic single factor and multivariate regression analysis to explore the risk factors associated with NVUGIB clinical outcomes. Results: 1, Peptic ulcer, malignant tumor and erosive disease were the main causes of NVUGIB, which accounted for 60.6%, 13.7%, 11.2% respectively. The ratio of male and female to 3.2:1.NVUGIB was 9.6 + 5.1 days, the incidence of rebleeding in hospital was 9.1%, and the mortality was 4.1%. There were 189 patients needing clinical intervention, with the proportion of 48%, 41.3% of blood transfusions and endoscopy hemostasis. 9.1%, surgical treatment 6.6%, intervention therapy accounted for 3.3%.2, the score system death patients score higher than the survival patients, rebleeding score higher than non rebleeding score, four types of clinical intervention patients were higher than non clinical intervention, the difference was statistically significant.3., the PNED score system to death prediction AUROC was 0.933, higher than GBS, AIMS65 And the FRS scoring system (P0.05), AUROC was 0.809,0.813,0.809, and the latter three had a predictive value for death by.GBS and FRS. The AUROC was 0.715 and 0.702, respectively. The predictive ability was equal to AIMS65 (AUROC 0.597), and AIMS65 predicted a poor rebleeding ability. The area under the curve of the three sub system were 0.656 (95%CI, 0.607-0.703; p0.001), 0.613 (95%CI, 0.563-0.662; p0.001), 0.620 (95%CI, 0.570-0.668; p0.001), and there was no statistical difference in.GBS for rebleeding, death, and clinical intervention, the best boundary value was 3. The best diagnostic value of blood, death, and clinical intervention is that AIMS65 is 1,0,0, FRS is 4,5,3.4, hemoglobin, albumin, PTINR, blood urea nitrogen is associated with rebleeding, and its independent risk factors are PTINR, hemoglobin and albumin. The upper digestive tract rebleeding, blood transfusion, more than 65 years old, hemoglobin, albumin, PTINR, blood urea nitrogen and NVUGIB death The independent risk factors for predicting death are PTINR and blood urea nitrogen. Age over 65 years old. Hemoglobin, albumin, blood urea nitrogen are associated with clinical intervention. Multivariate regression analysis: hemoglobin and albumin levels are independent risk factors for NVUGIB clinical intervention. Conclusion: 1, peptic ulcer, malignant tumor, mucous chyle. Rotten disease is still the main cause of non variceal upper gastrointestinal bleeding.2, PNED is an effective scoring system for predicting NVUGIB death, and the clinical predictive value is higher than GBS, AIMS65 and FRS; GBS, FRS scoring system has better predictive value for predicting rebleeding than AIMS65 score, but three comments on clinical intervention, GBS, AIMS65, and FRS. Although the sub-system has a certain predictive value, the score is not good, it is not an ideal predictor.3, PTINR, hemoglobin and albumin are independent risk factors for predicting rebleeding,.PTINR and blood urea nitrogen are independent risk factors for predicting NVUGIB death. Hemoglobin and white egg white are independent risk factors for predicting clinical intervention.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R573.2
本文编号：2120775
[Abstract]:Background: hemorrhage in the upper digestive tract is a common severe acute severe disease in the Department of digestive department. Although the continuous improvement of drug treatment and the continuous improvement of endoscopy, the mortality rate has not decreased significantly. At present, various non variceal upper gastrointestinal bleeding (non-variceal upper gastrointestinal bleeding, NVUGIB) scoring system has been reported for each score. The value of the system is very different from the different research. For the recommended application of the Full Rockall Score (FRS) and Glasgow-Blatchford Score (GBS) scoring system, as well as the newly established AIMS65 scoring system and Progetto Nazionale Emorragia Digestiva score system in recent years, the domestic research is less. These scoring systems are in China. The clinical predictive and applied value of NVUGIB patients and the risk factors for adverse outcomes need further study. Objective: 1. Analyze the clinical features of NVUGIB patients and evaluate the NVUGIB patients by using GBS, AIMS65, FRS and PNED scoring systems to study the predictive value of different scoring systems for rebleeding, death and clinical intervention. To find the best diagnostic value of prediction; 2, to explore the risk factors of NVUGIB patients with different clinical outcomes, and to lay the foundation for further formulating the scoring system for NVUGIB patients in China. Methods: 1, 394 cases of non variceal upper gastrointestinal tract were admitted to the Department of digestive department of General Hospital Affiliated to Tianjin Medical University from January 1, 2015 to December 31, 2016. The patients with bleeding were analyzed retrospectively, collected the data of each patient and analyzed their general clinical features. The cumulative score of upper gastrointestinal bleeding was performed on each patient according to the GBS, AIMS65, FRS and PNED scoring system respectively, and the subjects' work characteristic curve (receiver-operating characteristic curve, ROC curve) was drawn and the ROC curve was calculated. The lower area (the area under the receiver-operating characteristic curve, AUROC) was used to evaluate the predictive value of different scoring systems for rebleeding, death, and clinical intervention, and to find the best diagnostic value.2, using logistic single factor and multivariate regression analysis to explore the risk factors associated with NVUGIB clinical outcomes. Results: 1, Peptic ulcer, malignant tumor and erosive disease were the main causes of NVUGIB, which accounted for 60.6%, 13.7%, 11.2% respectively. The ratio of male and female to 3.2:1.NVUGIB was 9.6 + 5.1 days, the incidence of rebleeding in hospital was 9.1%, and the mortality was 4.1%. There were 189 patients needing clinical intervention, with the proportion of 48%, 41.3% of blood transfusions and endoscopy hemostasis. 9.1%, surgical treatment 6.6%, intervention therapy accounted for 3.3%.2, the score system death patients score higher than the survival patients, rebleeding score higher than non rebleeding score, four types of clinical intervention patients were higher than non clinical intervention, the difference was statistically significant.3., the PNED score system to death prediction AUROC was 0.933, higher than GBS, AIMS65 And the FRS scoring system (P0.05), AUROC was 0.809,0.813,0.809, and the latter three had a predictive value for death by.GBS and FRS. The AUROC was 0.715 and 0.702, respectively. The predictive ability was equal to AIMS65 (AUROC 0.597), and AIMS65 predicted a poor rebleeding ability. The area under the curve of the three sub system were 0.656 (95%CI, 0.607-0.703; p0.001), 0.613 (95%CI, 0.563-0.662; p0.001), 0.620 (95%CI, 0.570-0.668; p0.001), and there was no statistical difference in.GBS for rebleeding, death, and clinical intervention, the best boundary value was 3. The best diagnostic value of blood, death, and clinical intervention is that AIMS65 is 1,0,0, FRS is 4,5,3.4, hemoglobin, albumin, PTINR, blood urea nitrogen is associated with rebleeding, and its independent risk factors are PTINR, hemoglobin and albumin. The upper digestive tract rebleeding, blood transfusion, more than 65 years old, hemoglobin, albumin, PTINR, blood urea nitrogen and NVUGIB death The independent risk factors for predicting death are PTINR and blood urea nitrogen. Age over 65 years old. Hemoglobin, albumin, blood urea nitrogen are associated with clinical intervention. Multivariate regression analysis: hemoglobin and albumin levels are independent risk factors for NVUGIB clinical intervention. Conclusion: 1, peptic ulcer, malignant tumor, mucous chyle. Rotten disease is still the main cause of non variceal upper gastrointestinal bleeding.2, PNED is an effective scoring system for predicting NVUGIB death, and the clinical predictive value is higher than GBS, AIMS65 and FRS; GBS, FRS scoring system has better predictive value for predicting rebleeding than AIMS65 score, but three comments on clinical intervention, GBS, AIMS65, and FRS. Although the sub-system has a certain predictive value, the score is not good, it is not an ideal predictor.3, PTINR, hemoglobin and albumin are independent risk factors for predicting rebleeding,.PTINR and blood urea nitrogen are independent risk factors for predicting NVUGIB death. Hemoglobin and white egg white are independent risk factors for predicting clinical intervention.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R573.2
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