| Objectives To analyze the risk factors for rebleeding after variceal hemorrhage in cirrhosis and establish the prediction model for rebleeding risk using relevant influencing factors;to explore the preventive effect of applying spironolactone and carvedilol combined with spironolactone on rebleeding in cirrhotic varices,and to provide a theoretical basis for secondary prevention and early intervention of this disease.Methods 1 A case-control study method was used to collect 1105 patients diagnosed with cirrhosis complicated by esophagogastric fundic variceal bleeding in Beijing Ditan Hospital from January 2008 to January 2018 as study subjects.They were divided into two groups according to the presence or absence of rebleeding,717 cases in the case group and388 cases in the control group.The patients’general basic information,causes of cirrhosis,treatment of variceal bleeding,degree of varices,abdominal water volume,portal vein diameter,spleen thickness,and laboratory blood chemistry indexes were analyzed,and the established model was evaluated with ROC curves and clinical decision curves,etc.2 A retrospective cohort study method was used to collect the results of the study from 01,2013 to 01,2018.From 01/2013 to 01/2018,420 patients diagnosed with cirrhosis complicated by esophagogastric variceal bleeding at Beijing Ditan Hospital,who participated in regular reviews,had complete follow-up records and were excluded from serious cardiac,cerebral and pulmonary diseases and malignant tumors,were used as study subjects.The non-exposed group and the non-exposed group were divided according to whether spironolactone was applied in their treatment or not..The occurrence of rebleeding,treatment effects and adverse effects were compared between the two groups.3 A clinical trial study was conducted using 100 patients with confirmed ruptured esophagogastric variceal bleeding from cirrhosis admitted to the Affiliated Hospital of North China University of Science and Technology from January 2016 to January 2018.The 100patients were randomly divided into observation group and control group based on the hospitalization number,with 50 cases in each group.The treatment effect and the incidence of rebleeding were observed in the two groups.Results 1 A case-control study method,the results of univariate analysis showed that differences in family history of variceal bleeding,history of diabetes mellitus,history of diuretic application,Child-Pugh classification,degree of varices,portal vein internal diameter,splenic thickness,hemoglobin,Na+,and prothrombin activity between the two groups were statistically significant(all P<0.05),which may be the influential factors for rebleeding in cirrhotic EGVB.The results of dichotomous logistic multifactor analysis showed that the risk of rebleeding was significantly higher in the age group of 50～compared with patients in the age<40 years group(OR=1.71,95%CI:1.06-2.75);history of alcohol consumption,family history of cirrhosis,and history of diabetes mellitus were risk factors for rebleeding;the degree of varices was moderate and high(vs.mild),and Child-Pugh classification of B and C(vs.A)were risk factors for rebleeding;history of spironolactone application was a protective factor for rebleeding(OR=0.59,95%CI:0.43-0.81);portal vein internal diameter and spleen thickness were positively associated with the risk of rebleeding,while hemoglobin concentration and serum sodium concentration were negatively associated with the risk of rebleeding.Logistic regression models were constructed using the optimal subset method,and 11 predictor variables were included in the training set to construct the prediction models,and the differentiation and calibration indices were used to test the models in the test set,respectively.(AUC,AUC,accuracy,F1score,etc.)in the test set.The results show that the accuracy of the model in the test set is0.70,sensitivity is 0.63,specificity is 0.83,AUC is 0.77,F1 score is 0.76,O/E ratio is 0.84,ICI is 0.05,and Brier score is 0.19.Using a grid search method to determine the parameters of the random-into-forest prediction model,the results showed that the random forest model had an accuracy of 0.90,a sensitivity of 0.73,a specificity of 0.77,an AUC of0.90,an F1 score of 0.83;an O/E ratio of 0.75,an ICI of 0.15,and a Brier score of 0.16 in the test set.2 A retrospective cohort study,a total of 342 patients in the exposed and non-exposed groups experienced esophagogastric fundic vein rebleeding,with an overall rebleeding rate of 81.43%.The rebleeding rate in the exposed group was 67.07%;the rebleeding rate in the non-exposed group was 90.91%,with a statistically significant difference compared with the exposed group(χ~2=37.82,P<0.05).A statistical analysis of rebleeding occurring within 1 month,1 month～,3 months～,6 months～,and 12-24 months respectively revealed that the rebleeding rate in the exposed group was 24.55%in the period of 3 months or more,which was lower than the rebleeding rate of 33.60%in the non-exposed group,and the comparison between the two groups was statistically significant(χ~2=3.92,P=0.048);the rebleeding rate in the exposed group was 7.19%in the period of 1 year or more.The rebleeding rate in the exposed group was 7.19%,which was significantly lower than that in the non-exposed group,which was 15.02%,and the comparison between the two groups was statistically significant(χ~2=5.89,P=0.015).The median time to rebleeding was 5 months in both the exposed and non-exposed groups,and the survival analysis function was plotted and the Log Rank test was performed to compare the difference in rebleeding rate between the two groups.χ~2=6.92,P=0.005,and the difference between the two groups was statistically significant.There was no significant difference in the incidence of adverse reactions between the two groups.3 A clinical trial study,the incidence of rebleeding at 24 months in the observation group was significantly lower than that in the control group,and the difference was statistically significant(P<0.05);there was no significant difference in the death rate of rebleeding during the follow-up time between the two groups(P>0.05);the overall effective rate in the observation group was higher than that in the control group,and the difference was statistically significant(P<0.05);the patients in the observation group had a significantly lower portal vein trunk after treatment The difference was statistically significant(P<0.05);there was no statistically significant difference in the incidence of adverse reactions between the two groups of patients during treatment(P>0.05).Conclusions 1 In this study,we analyzed the factors influencing the occurrence of rebleeding in varices of cirrhosis to establish a risk prediction model for rebleeding in esophagogastric veins of cirrhosis,and the final risk prediction model was constructed with fair performance,which can provide a basis for early clinical intervention for patients.2This study used a retrospective cohort study to analyze the effect of spironolactone application on variceal rebleeding.A between-group comparison and survival analysis revealed that spironolactone was effective in preventing variceal rebleeding,and the incidence of adverse effects did not increase,providing some assistance in the clinical work-up of cirrhotic decompensation.3 Carvedilol combined with low-dose spironolactone reduces the risk of long-term rebleeding in patients with cirrhotic bleeding after endoscopic variceal therapy.Figure 6;Table 30;Reference 206... |
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