本文選題：肝硬化　切入點(diǎn)：門靜脈高壓癥　出處：《山東大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景:門靜脈血栓形成(portal vein thrombosis,PVT)是肝硬化(liver cirrhos is)合并門靜脈高壓癥(portal hypertension)患者少見(jiàn)但嚴(yán)重的并發(fā)癥之一,多隱匿發(fā)病,臨床癥狀多為非特異性表現(xiàn),如發(fā)熱、腹痛等,甚至不少患者無(wú)任何前驅(qū)癥狀,因此不易早期診斷,待腹部超聲或其他影像學(xué)檢查發(fā)現(xiàn)時(shí)常已產(chǎn)生一定的不良后果。如今隨著消化內(nèi)鏡技術(shù)的不斷發(fā)展,內(nèi)鏡下曲張靜脈硬化劑注射治療(endoscopic injection sclerotherapy,EIS)、內(nèi)鏡下曲張靜脈套扎治療(endoscopic variceal ligation,EVL)、內(nèi)鏡下曲張靜脈栓塞治療(endosc opic variceal obturation,EVO)用于治療失代償期肝硬化導(dǎo)致的食管/胃底靜脈曲張(esophageal/gastric varices,EV/GV)的效果已獲得公認(rèn)。然而在實(shí)際應(yīng)用消化內(nèi)鏡治療食管/胃底靜脈曲張破裂出血及預(yù)防再出血時(shí),單次鏡下治療一般無(wú)法取得令人滿意的效果,需要多次并聯(lián)合應(yīng)用EIS、EVL及EVO來(lái)將后期出血發(fā)生率降至最低,因此我們將聯(lián)合多次內(nèi)鏡下治療靜脈曲張的綜合治療過(guò)程稱為內(nèi)鏡序貫治療(endoscopic sequential therapy,EST)。在內(nèi)鏡治療食管/胃底靜脈曲張的序貫療程中,不少患者于圍手術(shù)期產(chǎn)生了門靜脈血栓,針對(duì)此類患者,臨床上往往需要給予抗凝或改善微循環(huán)藥物治療,待血栓溶解或機(jī)體脫離高凝風(fēng)險(xiǎn)后方可考慮下一步鏡下治療方案,然而抗凝治療勢(shì)必增加出血風(fēng)險(xiǎn),這無(wú)疑增加了臨床治療難度,同時(shí)延長(zhǎng)了患者住院天數(shù)及治療區(qū)間,并增加了患方家庭的經(jīng)濟(jì)負(fù)擔(dān)。因此,在聯(lián)合多次應(yīng)用EIS、EVO和EVL治療肝硬化合并門靜脈高壓癥的過(guò)程中,對(duì)患者在內(nèi)鏡治療圍手術(shù)期發(fā)生PVT的早期預(yù)測(cè)和早期干預(yù)顯得尤為重要。目的:本研究通過(guò)分析接受內(nèi)鏡下序貫治療肝硬化合并門靜脈高壓癥(伴發(fā)食管/胃底靜脈曲張)的患者圍手術(shù)期的臨床資料,期望發(fā)現(xiàn)可以預(yù)測(cè)內(nèi)鏡治療圍手術(shù)期PVT發(fā)生的危險(xiǎn)因素,從而篩選出內(nèi)鏡下治療圍手術(shù)期或治療間歇期的高�；颊�,以求為臨床醫(yī)生在針對(duì)肝硬化合并門靜脈高壓癥的內(nèi)鏡下治療后期行預(yù)防性抗凝處理提供指導(dǎo)。方法:回顧性分析從2011年9月至2016年9月于山東大學(xué)附屬省立醫(yī)院消化內(nèi)二科住院治療的肝硬化門靜脈高壓癥出血患者的臨床資料,篩選出其中符合入組條件的病例159例;其中48例在內(nèi)鏡序貫治療的圍手術(shù)期出現(xiàn)了 PVT,另111例于療程中未發(fā)生PVT,基于臨床經(jīng)驗(yàn),選擇性收集患者的性別、年齡、脾切除術(shù)手術(shù)史、Child-Pugh評(píng)分、內(nèi)鏡治療方式、注射硬化劑/組織膠總量及次數(shù)、腫瘤病史、外周血小板計(jì)數(shù)及D-二聚體濃度等可能影響PVT進(jìn)程的數(shù)據(jù)資料,對(duì)這些可疑因素進(jìn)行統(tǒng)計(jì)分析(包括單因素分析和二元非條件Logistic回歸模型分析),篩選出高危因素。結(jié)果:通過(guò)對(duì)以上臨床資料進(jìn)行的單因素及多因素分析(通過(guò)建立二元非條件L ogistic回歸模型分析),我們發(fā)現(xiàn):Child-Pugh評(píng)分、D-二聚體濃度與內(nèi)鏡序貫療程中出現(xiàn)PVT有顯著性關(guān)聯(lián),差異有統(tǒng)計(jì)學(xué)意義(P0.05);脾切除術(shù)病史與內(nèi)鏡療程中出現(xiàn)PVT可能有關(guān)(P=0.051、P=0.061),考慮可能受限于本次研究病例數(shù)量較少等因素在對(duì)照組與PVT組中未呈現(xiàn)出顯著性差異;但患者性別、年齡、內(nèi)鏡治療方式、注射硬化劑總量及次數(shù)、腫瘤病史、血小板數(shù)量與發(fā)生PVT無(wú)顯著性關(guān)聯(lián),差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:Child-Pugh分級(jí)(及評(píng)分)和外周血D-二聚體濃度是肝硬化合并門靜脈高壓癥患者在內(nèi)鏡序貫治療過(guò)程中出現(xiàn)門靜脈血栓的獨(dú)立危險(xiǎn)因素,需引起臨床醫(yī)師高度關(guān)注,對(duì)Child-Pugh評(píng)分高(肝功能受損嚴(yán)重)或外周血D-二聚體高的患者在內(nèi)鏡治療后期及時(shí)加用抗凝及改善微循環(huán)藥物,以預(yù)防PVT。
[Abstract]:Background: portal vein thrombosis (portal vein, thrombosis, PVT) (liver cirrhos is) in liver cirrhosis with portal hypertension (portal hypertension) in patients with a rare but serious complication, occult onset, clinical symptoms were nonspecific manifestations, such as fever, abdominal pain, and even a lot of patients without any premonitory symptoms, so not easy to early diagnosis, abdominal ultrasound or other imaging findings often has produced some adverse consequences. Now the development of digestive endoscopy, endoscopic variceal sclerotherapy treatment (endoscopic injection sclerotherapy, EIS), endoscopic variceal ligation (endoscopic variceal, ligation, EVL), endoscopy varices embolization (Endosc opic variceal obturation, EVO) for the treatment of decompensated cirrhosis caused by esophageal / gastric varices (esophageal/gastric vari CES, EV/GV) the effect has been recognized. However, in the practical application of endoscopic treatment of esophageal and gastric variceal bleeding and prevent rebleeding, a single treatment under the microscope to obtain satisfactory results, and requires the combination of EIS, EVL and EVO to the late bleeding rate dropped to the lowest, comprehensive the treatment process so that we will be combined with multiple endoscopic treatment of varicose veins called endoscopic therapy (endoscopic sequential, therapy, EST). In the endoscopic treatment of esophageal and gastric varices / sequential treatment, many patients had portal vein thrombosis in perioperative period, for these patients, patients often need to give the microcirculation treatment of anticoagulant or thrombolytic or to be improved, the body from the high coagulation risk before the next step to consider endoscopic treatment, however, anticoagulation is bound to increase the risk of bleeding, it will increase the pro The bed also increases the difficulty of treatment, hospitalization and treatment interval of patients, and increase the patients' economic burden of the family. Therefore, many times in the United Application of EIS, EVO and EVL for the treatment of liver cirrhosis complicated with portal hypertension, is particularly important for early prediction and early intervention for patients in the endoscopic treatment of perioperative PVT look. Objective: This study received endoscopic sequential therapy in the treatment of liver cirrhosis complicated with portal hypertension through the analysis (associated with esophageal / gastric varices) clinical data of perioperative patients, expect to find risk factors can predict the endoscopic treatment of peri operation period of PVT, in order to find out the endoscopic treatment of high-risk patients in the perioperative period or the intermittent period of treatment, in order to provide guidance for clinicians late treatment of anticoagulant treatment in the prevention of endoscopy in view of liver cirrhosis complicated with portal hypertension. Methods: a retrospective analysis from 2 011 years from September to September 2016 in the digestive Provincial Hospital Affiliated to Shandong University hospital in two cirrhotic patients with portal hypertension treatment of bleeding in patients with clinical data, were selected including 159 cases were eligible cases; including 48 cases of endoscopic sequential therapy in the perioperative period of the emergence of PVT, the other 111 cases in the treatment without PVT, based on clinical experience, selective collection of patients with sex, age, Child-Pugh score, splenectomy surgery, endoscopic treatment, injection of sclerosing agent / tissue glue amount and times, tumor history, peripheral platelet count and D- two concentration may affect the process of PVT data, statistical analysis of these factors (suspicious including two yuan of single factor analysis and non conditional Logistic regression model analysis), selected risk factors. Results: the single factor on the above clinical data and multivariate analysis (through the establishment of Two yuan L non conditional ogistic regression model analysis), we found that: the scores of Child-Pugh, D- two concentration and endoscopic treatment in sequential PVT has a significant correlation, the difference was statistically significant (P0.05); splenectomy and endoscopic treatment history may be related to PVT (P= 0.051, P=0.061), consideration may be limited to cases this study number and other factors in the control group and PVT group did not show significant difference; but the gender, age, endoscopic treatment, and the total number of sclerosing agent injection, tumor history, no significant association of platelet count and the occurrence of PVT, the difference was not statistically significant (P0.05). Conclusion: Child-Pugh grade (and score) and peripheral blood D- two concentration is an independent risk factor in patients with cirrhosis and portal hypertension of portal vein thrombosis in endoscopic sequential therapy in the process, need to cause the attention of clinicians, Child-Pu Patients with high GH score (severe impairment of liver function) or high D- two polymer in peripheral blood were treated with anticoagulant and improved microcirculation drugs in a timely manner to prevent PVT. in the late stage of endoscopic treatment.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R657.34

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