門體壓力梯度在門靜脈高壓癥治療中的臨床意義研究
發(fā)布時間：2019-06-14 20:23
【摘要】：目的：門體壓力梯度與門靜脈側(cè)支血管形成、食管靜脈曲張形成及破裂、腹水形成、肝臟功能具有密切聯(lián)系,同時其與內(nèi)毒素、內(nèi)皮素、多種細(xì)胞因子在形成和加重肝硬化門靜脈高壓血流動力學(xué)方面具有關(guān)鍵作用。方法：收集2013年1月至2015年12月入150例我院肝硬化門靜脈高壓癥患者臨床數(shù)據(jù),包括門體壓力梯度、CT門靜脈成像、胃鏡下食管靜脈曲張程度、腹水量、既往病史、實(shí)驗(yàn)室檢查。以既往是否出現(xiàn)食管靜脈曲張破裂出血分為出血組100例和未出血組50例,比較以門體壓力梯度為核心的多因素評分與其他評分對食管靜脈曲張破裂出血的預(yù)測價值；同時把既往出血組以術(shù)前是否出現(xiàn)急性出血分為急性出血組25例和穩(wěn)定組75例,比較其術(shù)前外周血液內(nèi)毒素水平；對于2015年1月至10月間行經(jīng)頸內(nèi)靜脈肝內(nèi)分流術(shù)患者,術(shù)前及術(shù)后7天抽取外周靜脈、下腔靜脈、門靜脈血液,比較術(shù)前術(shù)后門體壓力梯度變化及各自內(nèi)的內(nèi)毒素、內(nèi)皮素、IL-1,IL-6變化。結(jié)果：出血組和未出血組中的肝功能Child和MELDP評分、食管靜脈曲張程度、胃左靜脈直徑、門體壓力梯度的比較P0.05,均有統(tǒng)計(jì)學(xué)意義。門體壓力梯度16mmHg、胃左靜脈直徑6.5mmm、食管重度靜脈曲張程度的95%CI曲線下面積分別為0.796-0.917、0.691-0.865、0.528-0.717,而門體壓力梯度為核心的多因素評分的95%CI曲線下面積為0.843-0.958,提示門體壓力梯度為核心的多因素評分較食管靜脈曲張程度、MELD和Child評分及胃左靜脈直徑在預(yù)測出血的敏感性和特異性好。頑固性腹水組(n=22,PSG=38±6.11mmHg)與無明顯腹水組(n=128, PSG=32±5.2mmHg)(P0.05)存在脾腎分流患者HVPG明顯小于無脾腎分流患者,但出血率較未出組高(54%VS.45%)(P0.05)；95%近期出血患者的內(nèi)毒素水平大于125 ng/L,提示內(nèi)毒素在慢性肝硬化肝功能失代償期患者食管靜脈曲張急性出血中的作用。所有行TIPS術(shù)的患者門體壓力梯度平均降低10±3.2mmHg,門靜脈內(nèi)毒素為83±8.63 pg/L,而術(shù)后門靜脈內(nèi)毒素為51±7.32 pg/L,變化有顯著性差異(P0.05),同樣門靜脈內(nèi)皮素的變化有顯著性改變(P0.05),IL-1、IL一6及TNF作為炎癥因子結(jié)果顯示術(shù)后門靜脈內(nèi)濃度較術(shù)前減少,變化有顯著性差異(P0.05)。結(jié)論：以應(yīng)用門體壓力梯度為核心的多因素評分可能提高門靜脈高壓癥患者食管靜脈曲張破裂出血的出血風(fēng)險準(zhǔn)確性；對于既往存在出血病史的食管靜脈曲張的患者,外周內(nèi)毒素水平增高提示出現(xiàn)急性出血可能性增高；對于行經(jīng)頸內(nèi)靜脈門體分流術(shù)患者,門體壓力梯度下降可能是降低患者全身炎癥因子水平的重要影響因素。
[Abstract]:Aim: portal pressure gradient is closely related to portal vein collateral formation, esophageal variceal formation and rupture, ascitic fluid formation and liver function. At the same time, it plays a key role in the formation and aggravation of portal hypertension hemodynamics in cirrhotic patients. Methods: the clinical data of 150 patients with cirrhotic portal hypertension from January 2013 to December 2015 were collected, including portal pressure gradient, CT portal vein imaging, degree of esophageal varices under gastroscopy, abdominal water volume, previous history and laboratory examination. According to whether esophageal variceal bleeding occurred in the past or not, 100 cases in bleeding group and 50 cases in non-bleeding group were divided into bleeding group (100 cases) and non-bleeding group (50 cases), and the prediction value of esophageal variceal bleeding was compared with other scores. At the same time, the former bleeding group was divided into acute bleeding group (25 cases) and stable group (75 cases) according to whether acute bleeding occurred before operation, and the levels of endotoxin in peripheral blood before operation were compared. From January to October 2015, peripheral vein, inferior vena cava and portal vein blood were extracted before and 7 days after operation, and the changes of portal pressure gradient and endotoxin, Endothelin and IL-1,IL-6 were compared before and 7 days after operation. Results: the Child and MELDP scores of liver function, the degree of esophageal varices, the diameter of left gastric vein and the pressure gradient of portal body in bleeding group and non-bleeding group were statistically significant. The area under the 95%CI curve of portal pressure gradient 16mm, left gastric vein diameter 6.5 mm, severe esophageal varicose degree was 0.796 0.917, 0.691 0.865, 0.528 0.717, respectively, while the area under 95%CI curve with portal pressure gradient as the core of multivariate score was 0.843 鹵0.958, suggesting that the multivariate score with portal pressure gradient as the core was more serious than esophageal varicose vein. MELD and Child scores and left gastric vein diameter were sensitive and specific in predicting bleeding. The HVPG of patients with spleen and kidney shunt was significantly lower than that of patients without spleen and kidney shunt, but the bleeding rate was higher than that of patients without spleen and kidney shunt (54% vs 45%) (P 0.05). The endotoxin level of 95% of patients with recent bleeding was higher than 125 ng/L, suggesting the role of endotoxin in acute bleeding of esophageal varices in patients with chronic liver cirrhosis and liver function decompensation. The portal pressure gradient decreased by 10 鹵3.2 mm pg/L, the portal vein endotoxin was 83 鹵8.63 pg/L, and the portal vein endotoxin was 51 鹵7.32 pg/L, after operation (P 0.05). The changes of portal vein Endothelin were also significant (P 0.05). The results of IL-1,IL-6 and TNF as inflammatory factors showed that the portal vein concentration after operation was lower than that before operation. There was significant difference in the change (P 0.05). Conclusion: the application of portal pressure gradient as the core of multivariate score may improve the accuracy of bleeding risk of esophageal variceal bleeding in patients with portal hypertension, and the increase of peripheral endotoxin level in patients with esophageal varicose veins with a history of bleeding in the past suggests an increased possibility of acute bleeding. The decrease of portal pressure gradient may be an important factor to reduce the level of systemic inflammatory factors in patients undergoing internal jugular vein portosystemic shunt.
【學(xué)位授予單位】：南京大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R575.2
本文編號：2499662
[Abstract]:Aim: portal pressure gradient is closely related to portal vein collateral formation, esophageal variceal formation and rupture, ascitic fluid formation and liver function. At the same time, it plays a key role in the formation and aggravation of portal hypertension hemodynamics in cirrhotic patients. Methods: the clinical data of 150 patients with cirrhotic portal hypertension from January 2013 to December 2015 were collected, including portal pressure gradient, CT portal vein imaging, degree of esophageal varices under gastroscopy, abdominal water volume, previous history and laboratory examination. According to whether esophageal variceal bleeding occurred in the past or not, 100 cases in bleeding group and 50 cases in non-bleeding group were divided into bleeding group (100 cases) and non-bleeding group (50 cases), and the prediction value of esophageal variceal bleeding was compared with other scores. At the same time, the former bleeding group was divided into acute bleeding group (25 cases) and stable group (75 cases) according to whether acute bleeding occurred before operation, and the levels of endotoxin in peripheral blood before operation were compared. From January to October 2015, peripheral vein, inferior vena cava and portal vein blood were extracted before and 7 days after operation, and the changes of portal pressure gradient and endotoxin, Endothelin and IL-1,IL-6 were compared before and 7 days after operation. Results: the Child and MELDP scores of liver function, the degree of esophageal varices, the diameter of left gastric vein and the pressure gradient of portal body in bleeding group and non-bleeding group were statistically significant. The area under the 95%CI curve of portal pressure gradient 16mm, left gastric vein diameter 6.5 mm, severe esophageal varicose degree was 0.796 0.917, 0.691 0.865, 0.528 0.717, respectively, while the area under 95%CI curve with portal pressure gradient as the core of multivariate score was 0.843 鹵0.958, suggesting that the multivariate score with portal pressure gradient as the core was more serious than esophageal varicose vein. MELD and Child scores and left gastric vein diameter were sensitive and specific in predicting bleeding. The HVPG of patients with spleen and kidney shunt was significantly lower than that of patients without spleen and kidney shunt, but the bleeding rate was higher than that of patients without spleen and kidney shunt (54% vs 45%) (P 0.05). The endotoxin level of 95% of patients with recent bleeding was higher than 125 ng/L, suggesting the role of endotoxin in acute bleeding of esophageal varices in patients with chronic liver cirrhosis and liver function decompensation. The portal pressure gradient decreased by 10 鹵3.2 mm pg/L, the portal vein endotoxin was 83 鹵8.63 pg/L, and the portal vein endotoxin was 51 鹵7.32 pg/L, after operation (P 0.05). The changes of portal vein Endothelin were also significant (P 0.05). The results of IL-1,IL-6 and TNF as inflammatory factors showed that the portal vein concentration after operation was lower than that before operation. There was significant difference in the change (P 0.05). Conclusion: the application of portal pressure gradient as the core of multivariate score may improve the accuracy of bleeding risk of esophageal variceal bleeding in patients with portal hypertension, and the increase of peripheral endotoxin level in patients with esophageal varicose veins with a history of bleeding in the past suggests an increased possibility of acute bleeding. The decrease of portal pressure gradient may be an important factor to reduce the level of systemic inflammatory factors in patients undergoing internal jugular vein portosystemic shunt.
【學(xué)位授予單位】：南京大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R575.2
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