Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan.
Hepatology. 2012 Aug;56(2):698-705. doi: 10.1002/hep.25684. Epub 2012 Jul 6.
Peptic ulcer bleeding leads to substantial morbidity and mortality in patients with liver cirrhosis, but their long-term risk of recurrent bleeding remains elusive. This nationwide cohort study aimed to elucidate the association between cirrhosis and recurrent peptic ulcer bleeding by analyzing the Taiwan National Health Insurance Research Database. We enrolled a total of 9,711 patients who had cirrhosis with clinical complications of portal hypertension from all patients (n = 271,030) hospitalized for peptic ulcer bleeding between January 1997 and December 2006, along with 38,844 controls who were matched at a 1:4 proportion for age, sex, and antisecretory agents. We accounted for death as the competing cause of risk when calculating the cumulative incidences and hazard ratios of recurrent bleeding during the 10-year study period. Overall, patients with cirrhosis had a significantly higher death-adjusted rebleeding rate compared with controls (1 year, 14.4% versus 11.3%; 5 years, 26.1% versus 22.5%; 10 years, 28.4% versus 27.1%; P < 0.001). The modified Cox proportional hazard model verified that cirrhosis was significantly associated with peptic ulcer rebleeding (adjusted hazard ratio, 3.19; 95% confidence interval, 2.62-3.88), but also uncovered a seemingly paradoxical interaction between cirrhosis and age. Multivariate stratified analysis further revealed that the rebleeding risk after adjustment for death diminished with age in patients with cirrhosis, whose risk of death far exceeded that of rebleeding when they grew old.
Liver cirrhosis is associated with long-term risk of recurrent peptic ulcer bleeding, although the risk declines with age because of death being the competing cause. Effective therapy should be sought to reduce this excessive risk in these critically ill patients, particularly for those at younger age with longer life expectancy.
本项全国性队列研究旨在通过分析台湾全民健康保险研究数据库，阐明肝硬化与复发性消化性溃疡出血之间的关系。
我们共纳入了 9711 例肝硬化伴有门静脉高压临床并发症的患者，这些患者均因消化性溃疡出血而住院（1997 年 1 月至 2006 年 12 月），并将其与 38844 例按年龄、性别和抗分泌药物 1:4 比例匹配的对照组进行比较。在计算 10 年研究期间复发性出血的累积发生率和风险比时，我们将死亡视为风险的竞争原因。
总体而言，与对照组相比，肝硬化患者的死亡校正再出血率明显较高（1 年时为 14.4%比 11.3%；5 年时为 26.1%比 22.5%；10 年时为 28.4%比 27.1%；P<0.001）。校正后的 Cox 比例风险模型验证了肝硬化与消化性溃疡再出血显著相关（调整后的危险比为 3.19；95%置信区间为 2.62-3.88），但也揭示了肝硬化和年龄之间存在一种看似矛盾的相互作用。多变量分层分析进一步表明，在调整死亡因素后，肝硬化患者的再出血风险随年龄的增长而降低，因为随着年龄的增长，他们的死亡风险远远超过再出血风险。
肝硬化与复发性消化性溃疡出血的长期风险相关，但由于死亡是竞争原因，风险会随着年龄的增长而降低。对于这些重病患者，特别是那些年龄较小、预期寿命较长的患者，应寻求有效的治疗方法来降低这种过高的风险。
