Ingrand P, Rodriguez B, Silvain C, Beauchant M
Unité de Biostatistique, Faculté de Médecine, CHU, Poitiers.
Gastroenterol Clin Biol. 1998 May;22(5):519-24.
Acute bleeding from esophageal varices is a major complication of cirrhosis. Despite the large number of published studies no predictive factors of control of bleeding have been identified. We assessed the clinical and biological factors predictive of bleeding control within the first 2 weeks after a bleeding episode in a homogeneous group of patients enrolled in a large multicenter trial, who underwent a standardized emergency sclerotherapy session.
101 patients with cirrhosis were enrolled. All had endoscopy-proven variceal bleeding, and the interval between hematemesis or melena and emergency sclerotherapy was always less than 24 hours. A second sclerotherapy session and other methods for the prevention of rebleeding were allowed after 5 days.
Treatment failed in 16 patients after 24 hours and in a total of 33 patients after 15 days. Three of the 17 variables included in multivariate logistic analysis were associated with failure at 24 hours: encephalopathy (P = 0.006, OR = 4.0), blood transfusion prior to sclerotherapy (P = 0.012, OR = 6.2) and previous propranolol therapy (P = 0.022, OR = 4.6). Two variables were associated with failure between 24 hours and day 15 in patients successfully controlled after 24 hours: an interval between the onset of bleeding and sclerotherapy of less than 12 hours (P = 0.010) and blood transfusion (P = 0.018). After 15 days, three variables were associated with failure in a multivariate Cox model: encephalopathy (P = 0.0025, OR = 2.3), time to sclerotherapy (P = 0.022, OR 2.3) and blood transfusion before sclerotherapy (P = 0.0005, OR = 4.0).
Encephalopathy, the severity of bleeding, assessed in terms of transfusion requirements, and the time between clinically overt bleeding and sclerotherapy are the main predictive factors of failure of the control of bleeding after emergency sclerotherapy for acute bleeding from esophageal varices.
食管静脉曲张急性出血是肝硬化的主要并发症。尽管已发表大量研究，但尚未确定出血控制的预测因素。我们在一项大型多中心试验纳入的一组同质患者中，评估了出血发作后前2周内出血控制的临床和生物学预测因素，这些患者接受了标准化的紧急硬化治疗。
纳入101例肝硬化患者。所有患者均经内镜证实为静脉曲张出血，呕血或黑便与紧急硬化治疗之间的间隔时间均小于24小时。5天后允许进行第二次硬化治疗及其他预防再出血的方法。
24小时后16例患者治疗失败，15天后共有33例患者治疗失败。多因素逻辑分析纳入的17个变量中，有3个与24小时时的治疗失败相关：肝性脑病（P = 0.006，比值比[OR]=4.0）、硬化治疗前输血（P = 0.012，OR = 6.2）和既往普萘洛尔治疗（P = 0.022，OR = 4.6）。对于24小时后成功控制的患者，有2个变量与24小时至第15天期间的治疗失败相关：出血发作与硬化治疗之间的间隔时间小于12小时（P = 0.010）和输血（P = 0.018）。15天后，多因素Cox模型中有3个变量与治疗失败相关：肝性脑病（P = 0.0025，OR = 2.3）、硬化治疗时间（P = 0.022，OR = 2.3）和硬化治疗前输血（P = 0.0005，OR = 4.0）。
肝性脑病、根据输血需求评估的出血严重程度以及临床明显出血与硬化治疗之间的时间是食管静脉曲张急性出血紧急硬化治疗后出血控制失败的主要预测因素。
