N Engl J Med. 1988 Oct 13;319(15):983-9. doi: 10.1056/NEJM198810133191505.
We conducted a prospective study of 321 patients with cirrhosis of the liver and esophageal varices with no history of bleeding to see whether a comprehensive analysis of their clinical features and of the endoscopic appearances of their varices could help to identify those at highest risk for bleeding. Varices were classified endoscopically as suggested by the Japanese Research Society for Portal Hypertension. Patients were followed for 1 to 38 months (median, 23), during which 85 patients (26.5 percent) bled. Multiple regression analysis (Cox's model) revealed that the risk of bleeding was significantly related to the patient's modified Child class (an index of liver dysfunction based on serum albumin concentration, bilirubin level, prothrombin time, and the presence of ascites and encephalopathy), the size of the varices, and the presence of red wale markings (longitudinal dilated venules resembling whip marks) on the varices. A prognostic index based on these variables was devised that enabled us to identify a subset of patients with a one-year incidence of bleeding exceeding 65 percent. The index was prospectively validated on an independent sample of 75 patients with varices and no history of bleeding. We conclude that our prognostic index, which identifies groups of patients with one-year probabilities of bleeding ranging from 6 to 76 percent, can be used to identify candidates for prophylactic treatment.
我们对321例无出血史的肝硬化和食管静脉曲张患者进行了一项前瞻性研究，以观察对其临床特征和静脉曲张内镜表现的综合分析是否有助于识别出血风险最高的患者。根据日本门静脉高压研究学会的建议，对静脉曲张进行内镜分类。对患者进行了1至38个月（中位数为23个月）的随访，在此期间，85例患者（26.5%）发生了出血。多元回归分析（Cox模型）显示，出血风险与患者改良的Child分级（基于血清白蛋白浓度、胆红素水平、凝血酶原时间以及腹水和肝性脑病情况的肝功能不全指标）、静脉曲张大小以及静脉曲张上红色条纹（类似鞭痕的纵向扩张小静脉）的存在显著相关。基于这些变量设计了一个预后指数，该指数使我们能够识别出一组一年出血发生率超过65%的患者。该指数在75例无出血史的静脉曲张患者独立样本中进行了前瞻性验证。我们得出结论，我们的预后指数可用于识别预防性治疗的候选对象，该指数能识别出一年出血概率在6%至76%之间的患者群体。
