不同时机急诊内镜干预急性食管胃底静脉曲张出血的临床研究

Emergent endoscopic intervention of acute esophageal and gastric fundal varices bleeding at different times

摘要:

目的 探讨不同时机急诊内镜干预对急性食管胃底静脉曲张出血的临床应用价值。方法 选择2020年7月至2022年12月浙江大学医学院附属第二医院74例、浙江大学医学院附属金华医院41例、兰溪市人民医院36例、永康市第一人民医院31例及浦江县人民医院25例总共207例通过胃镜确诊为肝硬化合并食管胃底静脉曲张出血的患者，对其临床资料进行回顾性分析，按照病例是否进行内镜干预以及内镜治疗的不同时机分为3组。在出血6 h内行内镜治疗的病例纳入A组（n=68）；出血超过6 h，在24 h内行内镜治疗的病例纳入B组（n=72）；选择药物保守治疗、未进行内镜治疗的病例纳入C组（n=67）。比较3组的预后转归（止血成功率、早期再出血率、病死率）以及治疗效益（开放饮食时间、输血量、住院时间、住院费用）。结果 A组、B组、C组止血成功率分别为100.00%（68/68）、97.22%（70/72）和86.57%（58/67），差异有统计学意义（χ2 = 13.51，P<0.001）。A组无患者死亡，B组和C组的死亡率分别为2.78%（2/72）和13.43%（9/67），3组死亡率比较差异有统计学意义（χ2 =15.61，P<0.001）。A组无早期再出血，B组和C组的早期再出血率分别为2.86%（2/70）和13.43%（5/58），3组比较差异无统计学意义（χ2 = 3.41，P=0.182）。3组患者开放饮食时间［A组（28.32±2.52）h、B组（37.25 ± 2.45）h、C组（66.62 ± 2.65）h，F=58.69，P<0.001］、输血量［A组（3.62 ± 0.30）U、B组（5.46 ± 0.37）U、C组（6.25 ± 0.39）U，F=11.35，P<0.001］、住院时间［A组（6.58 ± 0.23）d、B组（7.83 ± 0.34）d、C组（8.24 ± 0.45）d，F = 5.75，P=0.004］及费用［ A组（10 152 ± 821）元、B组（13 568 ± 1 017）元、C组（15 306 ± 1 186）元，F = 4.96，P=0.008］比较，差异有统计学意义。止血成功与未成功患者的肝功能Child?Pugh分级差异有统计学意义（χ2 = 15.63，P<0.001）。结论 急性食管胃底静脉曲张出血在早期24 h内行内镜下诊疗可改善预后转归，减轻患者经济负担，临床应用价值高。

Abstract:

Objective To investigate the clinical value of emergent endoscopic intervention at different times of acute esophageal and gastric fundal varices bleeding. Methods From July 2020 to December 2022, data of 207 cases of liver cirrhosis with esophageal and gastric fundal variceal bleeding diagnosed by gastroscopy were retrospectively analyzed, including 74 cases from the Second Affiliated Hospital, Zhejiang University School of Medicine, 41 cases from Affiliated Jinhua Hospital, Zhejiang University School of Medicine, 36 cases from Lanxi People''s Hospital, 31 cases from Yongkang First People''s Hospital and 25 cases from Pujiang People''s Hospital. Patients were divided into 3 groups according to the time of endoscopic intervention and treatment. Patients who received endoscopic treatment within 6 h of hemorrhage were included in group A (n=68); patients within 6?24 hours were in group B (n=72). A total of 67 patients selected for conservative drug treatment were included in group C, who did not undergo endoscopic therapy. The prognosis (success rate of hemostasis, early rebleeding rate, mortality rate) and treatment benefit (open diet time, blood transfusion volume, hospital stay, hospital cost) of the 3 groups were compared. Results The success rates of hemostasis were 100.00% (68/68), 97.22% (70/72), 86.57% (58/67) in group A, B and C respectively with significant difference (χ2=13.51, P<0.001). The mortalities of the three groups were 0.00% (0/68) in group A, 2.78% (2/72) in group B and 13.43% (9/67) in in group C respectively with significant difference (χ2 =15.61, P<0.001). The early rebleeding rates of the three groups were 0.00% (0/68) in group A, 2.86% (2/70) in group B, and 13.43% (5/58) in group C respectively with significant difference (χ2 =3.41, P=0.182). There were significant differences in open diet time (group A: 28.32 ±2.52 h, group B: 37.25±2.45 h, group C: 66.62±2.65 h, F=58.69, P<0.001), blood transfusion volume (group A: 3.62 ± 0.30 U, group B: 5.46 ± 0.37 U, group C: 6.25 ± 0.39 U, F=11.35, P<0.001), hospital stay (group A: 6.58 ± 0.23 d, group B: 7.83 ± 0.34 d, group C: 8.24 ± 0.45 d, F=5.75, P=0.004) and cost (group A: 10 152±821 yuan, group B: 13?568 ± 1 017 yuan, group C: 15 306 ± 1 186 yuan, F=4.96, P=0.008) among the three groups. There was significant difference in Child?Pugh grading among hemostasis?success patients and those who failed (χ2 =15.63, P<0.001). Conclusion Early endoscopic diagnosis and treatment in the early 24 hours of acute esophageal and gastric fundal variceal hemorrhage can improve the prognosis and reduce the economic burden of patients with high clinical application value.