D'Amico Gennaro, De Franchis Roberto
Department of Medicine, Ospedale V. Cervello, Palermo, Italy.
Hepatology. 2003 Sep;38(3):599-612. doi: 10.1053/jhep.2003.50385.
Several treatments have been proven to be effective for variceal bleeding in patients with cirrhosis. The aim of this multicenter, prospective, cohort study was to assess how these treatments are used in clinical practice and what are the posttherapeutic prognosis and prognostic indicators of upper digestive bleeding in patients with cirrhosis. A training set of 291 and a test set of 174 bleeding cirrhotic patients were included. Treatment was according to the preferences of each center and the follow-up period was 6 weeks. Predictive rules for 5-day failure (uncontrolled bleeding, rebleeding, or death) and 6-week mortality were developed by the logistic model in the training set and validated in the test set. Initial treatment controlled bleeding in 90% of patients, including vasoactive drugs in 27%, endoscopic therapy in 10%, combined (endoscopic and vasoactive) in 45%, balloon tamponade alone in 1%, and none in 17%. The 5-day failure rate was 13%, 6-week rebleeding was 17%, and mortality was 20%. Corresponding findings for variceal versus nonvariceal bleeding were 15% versus 7% (P =.034), 19% versus 10% (P =.019), and 20% versus 15% (P =.22). Active bleeding on endoscopy, hematocrit levels, aminotransferase levels, Child-Pugh class, and portal vein thrombosis were significant predictors of 5-day failure; alcohol-induced etiology, bilirubin, albumin, encephalopathy, and hepatocarcinoma were predictors of 6-week mortality. Prognostic reassessment including blood transfusions improved the predictive accuracy. All the developed prognostic models were superior to the Child-Pugh score. In conclusion, prognosis of digestive bleeding in cirrhosis has much improved over the past 2 decades. Initial treatment stops bleeding in 90% of patients. Accurate predictive rules are provided for early recognition of high-risk patients.
几种治疗方法已被证明对肝硬化患者的静脉曲张出血有效。这项多中心、前瞻性队列研究的目的是评估这些治疗方法在临床实践中的应用情况，以及肝硬化患者上消化道出血的治疗后预后和预后指标。纳入了291例出血性肝硬化患者的训练集和174例患者的测试集。治疗根据各中心的偏好进行，随访期为6周。通过逻辑模型在训练集中建立了5天失败（出血未控制、再出血或死亡）和6周死亡率的预测规则，并在测试集中进行了验证。初始治疗使90%的患者出血得到控制，其中27%使用血管活性药物，10%接受内镜治疗，45%采用联合（内镜和血管活性）治疗，1%仅行气囊压迫，17%未进行任何治疗。5天失败率为13%，6周再出血率为17%，死亡率为20%。静脉曲张出血与非静脉曲张出血的相应结果分别为15%对7%（P = 0.034）、19%对10%（P = 0.019）和20%对15%（P = 0.22）。内镜下活动性出血、血细胞比容水平、转氨酶水平、Child-Pugh分级和门静脉血栓形成是预测5天失败的重要指标；酒精性病因、胆红素、白蛋白、肝性脑病和肝癌是预测6周死亡率的指标。包括输血在内的预后重新评估提高了预测准确性。所有建立的预后模型均优于Child-Pugh评分。总之，在过去20年中，肝硬化患者消化性出血的预后有了很大改善。初始治疗使90%的患者出血停止。提供了准确的预测规则，以便早期识别高危患者。
