NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
MRC Clinical Trials Unit, London, UK.
Dig Liver Dis. 2014 May;46(5):419-26. doi: 10.1016/j.dld.2013.12.010. Epub 2014 Jan 14.
Despite advances in treatment, acute variceal haemorrhage remains life-threatening.
To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality.
Multi-centre clinical audit conducted in 212 UK hospitals.
In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01).
Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
尽管治疗方法有所进步，但急性静脉曲张出血仍然危及生命。
描述肝硬化和急性静脉曲张出血患者的当代特征、治疗方法和结局，以及再出血和死亡的危险因素。
在英国 212 家医院进行多中心临床审计。
在 526 例急性静脉曲张出血患者中，66%在 24 小时内进行了内镜检查，其中 64%（n=339）接受了内镜治疗。在进行内镜检查之前，57%（n=299）接受质子泵抑制剂治疗，44%（n=232）接受血管加压素治疗，27%（n=144）接受抗生素治疗。73%（n=386）接受红细胞输注，35%（n=184）接受新鲜冰冻血浆输注，14%（n=76）接受血小板输注，输注阈值差异很大。26%（n=135）出现再次出血，15%（n=80）在第 30 天死亡。终末期肝病模型评分是死亡率的最佳预测指标（受试者工作特征曲线下面积=0.74，P<0.001）。临床和完整的 Rockall 评分均不是结局的有用预测指标。凝血功能障碍与再出血（优势比 2.23，95%置信区间 1.22-4.07，P=0.01，直至第 30 天）和死亡率（优势比 3.06，95%置信区间 1.29-7.26，P=0.01）密切相关。
尽管急性静脉曲张出血后的死亡率有所改善，但再出血率仍然相当高。血管加压素和内镜治疗的应用存在明显不足。需要进一步研究以了解最佳输血策略。需要更好的风险分层工具来识别需要更强化支持的患者。
