Liver Unit-Department of Internal Medicine, Universitat Autònoma de Barcelona, Spain.
Am J Gastroenterol. 2011 Oct;106(10):1787-95. doi: 10.1038/ajg.2011.173. Epub 2011 May 31.
After an acute variceal bleeding, early decision for aggressive management of patients with worse prognosis may improve outcomes. The effectiveness of currently recommended standard therapy (drugs plus endoscopic ligation) for different risk subgroups and the validity of available risk criteria in clinical practice are unknown.
We analyzed data of 301 consecutive cirrhotic patients admitted with esophageal variceal bleeding. All patients received antibiotics, somatostatin, and in 263 early endoscopic therapy. A stratified 6-week mortality assessment according to risk (low-risk: Child-Pugh B without active bleeding or Child-Pugh A; high-risk: Child-Pugh B with active bleeding or Child-Pugh C) was performed. A multivariate analysis was conducted to elaborate a new risk classification rule.
Among the 162 patients receiving emergency ligation, 14% rebled and 16% died. Standard therapy was very effective in all risk strata, even in high-risk patients, specially if eligible for therapeutic trials (child <14, age ≤75 years, creatinine ≤3.0 mg/dl, no hepatocellular carcinoma, or portal thrombosis), showing this stratum a 10% mortality. In patients receiving ligation, Child-Pugh C patients with baseline creatinine <1.0 mg/dl showed similar mortality to Child-Pugh A or B patients (8% vs. 7%, respectively). Only Child-Pugh C patients with creatinine ≥1.0 were at a significant higher risk (Child-Pugh C: 46% mortality if creatinine ≥1.0 vs. 8% if creatinine <1.0, P=0.006).
The combination of somatostatin, antibiotics, and endoscopic ligation after an acute variceal bleeding in a real-life situation is associated with very low mortality. Child-Pugh C patients with baseline creatinine ≥1.0 mg/dl should be considered high-risk patients in this setting.
急性静脉曲张出血后，对预后较差的患者进行积极治疗的早期决策可能会改善预后。目前推荐的标准治疗（药物联合内镜结扎）在不同风险亚组中的有效性以及现有风险标准在临床实践中的有效性尚不清楚。
我们分析了 301 例连续因食管静脉曲张出血入院的肝硬化患者的数据。所有患者均接受了抗生素、生长抑素治疗，并且 263 例患者在早期接受了内镜治疗。根据风险（低危：无活动性出血的 Child-Pugh B 级或 Child-Pugh A 级；高危：Child-Pugh B 级伴活动性出血或 Child-Pugh C 级）进行了分层 6 周死亡率评估。进行了多变量分析以阐述新的风险分类规则。
在接受紧急结扎的 162 例患者中，有 14%再次出血，16%死亡。标准治疗在所有风险分层中均非常有效，即使在高危患者中也是如此，特别是如果符合治疗试验条件（年龄＜14 岁、年龄≤75 岁、肌酐≤3.0mg/dl、无肝细胞癌或门静脉血栓形成），这一分层的死亡率为 10%。在接受结扎治疗的患者中，基线肌酐＜1.0mg/dl 的 Child-Pugh C 患者的死亡率与 Child-Pugh A 或 B 患者相似（分别为 8%和 7%）。只有肌酐≥1.0mg/dl 的 Child-Pugh C 患者风险显著增加（Child-Pugh C：肌酐≥1.0mg/dl 时的死亡率为 46%，肌酐＜1.0mg/dl 时的死亡率为 8%，P=0.006）。
在真实情况下，急性静脉曲张出血后联合使用生长抑素、抗生素和内镜结扎与非常低的死亡率相关。在此背景下，基线肌酐≥1.0mg/dl 的 Child-Pugh C 患者应被视为高危患者。
