肝硬化患者内镜逆行胰胆管造影术后不良事件和急性慢性肝衰竭：一项多中心匹配队列研究。
Adverse Events and Acute Chronic Liver Failure in Patients With Cirrhosis Undergoing Endoscopic Retrograde Cholangiopancreatography: A Multicenter Matched-Cohort Study.
机构信息
GI/Endoscopy Unit. Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.
Gastroenterology Department, Hospital Universitari de Vic, Barcelona, Spain.
出版信息
Am J Gastroenterol. 2019 Jan;114(1):89-97. doi: 10.1038/s41395-018-0218-1.
BACKGROUND
Data on the outcome of adverse events (AEs) and the risk of developing acute-on-chronic liver failure (ACLF) after ERCP in patients with cirrhosis are unknown. We examined the incidence and risk factors of post-ERCP AEs in patients with cirrhosis and the appearance of ACLF after ERCP.
METHODS
In this multicenter, retrospective, matched-cohort study, we evaluated ERCPs performed from January 2002 to 2015. A group of patients with cirrhosis with non-ERCP interventions and one without interventions was also analyzed for the development of ACLF.
RESULTS
A total of 441 ERCPs were analyzed; 158 in patients with cirrhosis (cases) and 283 in patients without cirrhosis (controls). The overall rate of AEs after all ERCPs was significantly higher in cases compared to controls (17% vs 9.5, p = 0.02). Cholangitis developed more in cases compared to controls (6.3% vs 1.8%; p = 0.01). In a subanalysis of those with sphincterotomy, the rate of bleeding was higher in those with cirrhosis (9.4% vs 3.4%; p = 0.03). Logistic regression identified cirrhosis (OR, 2.48; 95% CI, 1.36-4.53; p = 0.003) and sphincterotomy (OR, 2.66; 95% CI, 1.23-5.72; p = 0.01) as risk factors of AEs. A total of 18/158 (11.4%) cases developed ACLF after ERCP. ACLF occurred in 7/27 cases with post-ERCP AEs and in 11/131 without post-ERCP AEs (25.9% vs 8.3%; p = 0.01). A total of 3.2% (13/406) patients without interventions developed ACLF compared to 17.5% (102/580) who developed ACLF after non-ERCP interventions. Patients with decompensated cirrhosis at ERCP had a higher risk of developing ACLF (17% vs 6.8%; p = 0.04). Patients with a MELD score ≥ 15 were 3.1 times more likely (95% CI: 1.14-8.6; p = 0.027) to develop ACLF after ERCP.
CONCLUSIONS
The rate of AEs after ERCP is higher in patients with cirrhosis compared to the non-cirrhotic population. The incidence of ACLF is higher in those with AEs after ERCP compared to those without AEs, especially cholangitis. The development of ACLF is common after ERCP and other invasive procedures. ACLF can be precipitated by numerous factors which include preceding events before the procedure, including manipulation of the bile duct, and AEs after an ERCP.
背景
关于肝硬化患者内镜逆行胰胆管造影（ERCP）后不良事件（AE）的结局和发生慢加急性肝衰竭（ACLF）的风险的数据尚不清楚。我们研究了肝硬化患者 ERCP 后 AE 的发生率和风险因素以及 ERCP 后 ACLF 的出现情况。
方法
在这项多中心、回顾性、匹配队列研究中，我们评估了 2002 年 1 月至 2015 年进行的 ERCP。还分析了一组接受非 ERCP 干预的肝硬化患者和一组无干预的患者发生 ACLF 的情况。
结果
共分析了 441 例 ERCP；158 例为肝硬化患者（病例），283 例为无肝硬化患者（对照）。与对照组相比，所有 ERCP 后病例的 AE 发生率明显更高（17%比 9.5%，p = 0.02）。与对照组相比，病例中更易发生胆管炎（6.3%比 1.8%；p = 0.01）。在对行括约肌切开术患者的亚分析中，肝硬化患者的出血率更高（9.4%比 3.4%；p = 0.03）。逻辑回归确定肝硬化（OR，2.48；95%CI，1.36-4.53；p = 0.003）和括约肌切开术（OR，2.66；95%CI，1.23-5.72；p = 0.01）是 AE 的危险因素。共有 18/158（11.4%）例患者在 ERCP 后发生 ACLF。在 27 例发生 ERCP 后 AE 的病例中发生 ACLF，在 131 例无 ERCP 后 AE 的病例中发生 ACLF（25.9%比 8.3%；p = 0.01）。与接受非 ERCP 干预后发生 ACLF 的患者（17.5%）相比，无干预的患者中发生 ACLF 的比例为 3.2%（13/406）。在 ERCP 时失代偿性肝硬化的患者发生 ACLF 的风险更高（17%比 6.8%；p = 0.04）。MELD 评分≥15 的患者发生 ACLF 的可能性是 ERCP 后发生 ACLF 的患者的 3.1 倍（95%CI：1.14-8.6；p = 0.027）。
结论
与非肝硬化人群相比，肝硬化患者 ERCP 后 AE 的发生率更高。与无 AE 的患者相比，发生 ERCP 后发生 ACLF 的患者发生率更高，尤其是胆管炎。ACLF 在 ERCP 及其他有创操作后很常见。在操作前，包括胆管操作，以及 ERCP 后的 AE 等因素都可能引发 ACLF。
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