门体压力梯度在门静脉高压症治疗中的临床意义研究

发布时间：2019-06-14 20:23

【摘要】：目的：门体压力梯度与门静脉侧支血管形成、食管静脉曲张形成及破裂、腹水形成、肝脏功能具有密切联系,同时其与内毒素、内皮素、多种细胞因子在形成和加重肝硬化门静脉高压血流动力学方面具有关键作用。方法：收集2013年1月至2015年12月入150例我院肝硬化门静脉高压症患者临床数据,包括门体压力梯度、CT门静脉成像、胃镜下食管静脉曲张程度、腹水量、既往病史、实验室检查。以既往是否出现食管静脉曲张破裂出血分为出血组100例和未出血组50例,比较以门体压力梯度为核心的多因素评分与其他评分对食管静脉曲张破裂出血的预测价值；同时把既往出血组以术前是否出现急性出血分为急性出血组25例和稳定组75例,比较其术前外周血液内毒素水平；对于2015年1月至10月间行经颈内静脉肝内分流术患者,术前及术后7天抽取外周静脉、下腔静脉、门静脉血液,比较术前术后门体压力梯度变化及各自内的内毒素、内皮素、IL-1,IL-6变化。结果：出血组和未出血组中的肝功能Child和MELDP评分、食管静脉曲张程度、胃左静脉直径、门体压力梯度的比较P0.05,均有统计学意义。门体压力梯度16mmHg、胃左静脉直径6.5mmm、食管重度静脉曲张程度的95%CI曲线下面积分别为0.796-0.917、0.691-0.865、0.528-0.717,而门体压力梯度为核心的多因素评分的95%CI曲线下面积为0.843-0.958,提示门体压力梯度为核心的多因素评分较食管静脉曲张程度、MELD和Child评分及胃左静脉直径在预测出血的敏感性和特异性好。顽固性腹水组(n=22,PSG=38±6.11mmHg)与无明显腹水组(n=128, PSG=32±5.2mmHg)(P0.05)存在脾肾分流患者HVPG明显小于无脾肾分流患者,但出血率较未出组高(54%VS.45%)(P0.05)；95%近期出血患者的内毒素水平大于125 ng/L,提示内毒素在慢性肝硬化肝功能失代偿期患者食管静脉曲张急性出血中的作用。所有行TIPS术的患者门体压力梯度平均降低10±3.2mmHg,门静脉内毒素为83±8.63 pg/L,而术后门静脉内毒素为51±7.32 pg/L,变化有显著性差异(P0.05),同样门静脉内皮素的变化有显著性改变(P0.05),IL-1、IL一6及TNF作为炎症因子结果显示术后门静脉内浓度较术前减少,变化有显著性差异(P0.05)。结论：以应用门体压力梯度为核心的多因素评分可能提高门静脉高压症患者食管静脉曲张破裂出血的出血风险准确性；对于既往存在出血病史的食管静脉曲张的患者,外周内毒素水平增高提示出现急性出血可能性增高；对于行经颈内静脉门体分流术患者,门体压力梯度下降可能是降低患者全身炎症因子水平的重要影响因素。
[Abstract]:Aim: portal pressure gradient is closely related to portal vein collateral formation, esophageal variceal formation and rupture, ascitic fluid formation and liver function. At the same time, it plays a key role in the formation and aggravation of portal hypertension hemodynamics in cirrhotic patients. Methods: the clinical data of 150 patients with cirrhotic portal hypertension from January 2013 to December 2015 were collected, including portal pressure gradient, CT portal vein imaging, degree of esophageal varices under gastroscopy, abdominal water volume, previous history and laboratory examination. According to whether esophageal variceal bleeding occurred in the past or not, 100 cases in bleeding group and 50 cases in non-bleeding group were divided into bleeding group (100 cases) and non-bleeding group (50 cases), and the prediction value of esophageal variceal bleeding was compared with other scores. At the same time, the former bleeding group was divided into acute bleeding group (25 cases) and stable group (75 cases) according to whether acute bleeding occurred before operation, and the levels of endotoxin in peripheral blood before operation were compared. From January to October 2015, peripheral vein, inferior vena cava and portal vein blood were extracted before and 7 days after operation, and the changes of portal pressure gradient and endotoxin, Endothelin and IL-1,IL-6 were compared before and 7 days after operation. Results: the Child and MELDP scores of liver function, the degree of esophageal varices, the diameter of left gastric vein and the pressure gradient of portal body in bleeding group and non-bleeding group were statistically significant. The area under the 95%CI curve of portal pressure gradient 16mm, left gastric vein diameter 6.5 mm, severe esophageal varicose degree was 0.796 0.917, 0.691 0.865, 0.528 0.717, respectively, while the area under 95%CI curve with portal pressure gradient as the core of multivariate score was 0.843 卤0.958, suggesting that the multivariate score with portal pressure gradient as the core was more serious than esophageal varicose vein. MELD and Child scores and left gastric vein diameter were sensitive and specific in predicting bleeding. The HVPG of patients with spleen and kidney shunt was significantly lower than that of patients without spleen and kidney shunt, but the bleeding rate was higher than that of patients without spleen and kidney shunt (54% vs 45%) (P 0.05). The endotoxin level of 95% of patients with recent bleeding was higher than 125 ng/L, suggesting the role of endotoxin in acute bleeding of esophageal varices in patients with chronic liver cirrhosis and liver function decompensation. The portal pressure gradient decreased by 10 卤3.2 mm pg/L, the portal vein endotoxin was 83 卤8.63 pg/L, and the portal vein endotoxin was 51 卤7.32 pg/L, after operation (P 0.05). The changes of portal vein Endothelin were also significant (P 0.05). The results of IL-1,IL-6 and TNF as inflammatory factors showed that the portal vein concentration after operation was lower than that before operation. There was significant difference in the change (P 0.05). Conclusion: the application of portal pressure gradient as the core of multivariate score may improve the accuracy of bleeding risk of esophageal variceal bleeding in patients with portal hypertension, and the increase of peripheral endotoxin level in patients with esophageal varicose veins with a history of bleeding in the past suggests an increased possibility of acute bleeding. The decrease of portal pressure gradient may be an important factor to reduce the level of systemic inflammatory factors in patients undergoing internal jugular vein portosystemic shunt.
【学位授予单位】：南京大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R575.2

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