Ben-Ari Z, Cardin F, McCormick A P, Wannamethee G, Burroughs A K
Liver Transplantation and Hepatobiliary Medicine, The Royal Free Hospital and School of Medicine, London, UK.
J Hepatol. 1999 Sep;31(3):443-50. doi: 10.1016/s0168-8278(99)80035-x.
BACKGROUND/AIMS: Variceal bleeding is a frequent complication of cirrhosis and is associated with a high risk of early rebleeding. In patients with peptic ulcers, continued bleeding or early rebleeding are risk factors for mortality and can be predicted by statistical models; however, no such models exist for acute variceal bleeding.
We prospectively evaluated failure to control bleeding in 695 consecutive patients with cirrhosis, admitted for haematemesis and/or melaena. Criteria were defined for failure to control bleeding, which comprised both continued bleeding or early rebleeding within 5 days of admission. There were 2 sequential groups of patients: (i) those with variceal bleeding initially treated with blood transfusion and vasoactive drugs, and if these failed followed by sclerotherapy (n = 385); (ii) those with variceal bleeding treated with injection sclerotherapy at diagnostic endoscopy (n = 144). The third group was those with bleeding from other sources related to portal hypertension (n = 166).
Failure to control bleeding was noted in 169 (44%) patients in group 1, 55 (38%) in group 2 and 44 (25%) in group 3. Twenty variables that were evaluable within 6 h of admission, pertaining to severity of bleeding, severity of type of liver disease, mode of admission, and time of diagnostic endoscopy, were entered into a multivariate Cox model. Independent predictors of early rebleeding in group 1 were: active bleeding at endoscopy (irrespective of interval from admission) (p<0.0001), encephalopathy (p = 0.007), platelet count (p = 0.002), history of alcoholism (p = 0.002), presentation with haematemesis (p = 0.02), log urea (p = 0.03) and (shorter) interval to admission (p = 0.007). The variables predictive of 30-day mortality were: early bleeding (p<0.0007), bilirubin (p = 0.0006), encephalopathy (p<0.0001), (shorter) interval to admission (p<0.0001), and log urea (p = 0.004); a model based on these variables was also a good predictor of mortality in the other 2 groups. However, the model derived from group 1 for failure to control variceal bleeding was different in group 2, despite similar patient characteristics and a similar failure rate (following a single injection). This could suggest that sclerotherapy may induce bleeding in some patients independently of the baseline risk for failure to control bleeding.
In cirrhotic patients who present with haematemesis or melaena, active variceal bleeding at diagnostic endoscopy is predictive of failure to control bleeding (continued bleeding or early rebleeding within 5 days of admission), and this failure is predictive of 30-day mortality.
背景/目的：静脉曲张出血是肝硬化常见的并发症，且早期再出血风险高。在消化性溃疡患者中，持续出血或早期再出血是死亡的危险因素，可通过统计模型预测；然而，急性静脉曲张出血尚无此类模型。
我们对695例因呕血和/或黑便入院的肝硬化患者进行前瞻性评估，以确定出血控制失败情况。定义了出血控制失败的标准，包括持续出血或入院5天内早期再出血。患者分为两组：（i）最初接受输血和血管活性药物治疗静脉曲张出血的患者，若治疗失败则接受硬化治疗（n = 385）；（ii）诊断性内镜检查时接受注射硬化治疗的静脉曲张出血患者（n = 144）。第三组是门静脉高压相关其他原因出血的患者（n = 166）。
第1组169例（44%）患者出血控制失败，第2组55例（38%），第3组44例（25%）。将入院6小时内可评估的20个变量，包括出血严重程度、肝病类型严重程度、入院方式和诊断性内镜检查时间，纳入多变量Cox模型。第1组早期再出血的独立预测因素为：内镜检查时活动性出血（无论距入院时间）（p<0.0001）、肝性脑病（p = 0.007）、血小板计数（p = 0.002）、酗酒史（p = 0.002）、呕血表现（p = 0.02）、血尿素对数（p = 0.03）和（较短的）入院间隔（p = 0.007）。预测30天死亡率的变量为：早期出血（p<0.0007）、胆红素（p = 0.0006）、肝性脑病（p<0.0001）、（较短的）入院间隔（p<0.0001）和血尿素对数（p = 0.004）；基于这些变量的模型对其他两组的死亡率也是良好的预测指标。然而，尽管第2组患者特征相似且失败率相近（单次注射后），但第1组得出的控制静脉曲张出血失败模型与第2组不同。这可能表明硬化治疗在某些患者中可能独立于出血控制失败的基线风险而导致出血。
在因呕血或黑便就诊的肝硬化患者中，诊断性内镜检查时活动性静脉曲张出血可预测出血控制失败（入院5天内持续出血或早期再出血），而这种失败可预测30天死亡率。
