Predictors Of Esophageal/Ggastric Varices Bleeding In Patients With HBV-related Cirrhosis

objective: patients with cirrhosis are often associated with complex coagulation changes.Coagulation disorder is not only an important part of liver cirrhosis,but also a key factor in most prognostic scores.For many years,liver cirrhosis complicated with bleeding has been a major problem faced by clinicians,bleeding in patients with liver disease can be roughly divided into two types:(1)portal vein pressure is too high,such as esophageal and gastric variceal bleeding,which has little correlation with the disorder of hemostatic mechanism;(2)mucosal or puncture wound bleeding,this kind of bleeding is usually caused by premature dissolution of blood clots or hyperfibrinolysis.In addition to the risk of bleeding,the increase of fibrinogenemia,coagulation factor VIII and von Willebrand factor and portal hypertension in patients with liver cirrhosis constitute unique risk factors for blood hypercoagulable state and even thrombosis in patients with liver cirrhosis.The main clinical manifestation is portal vein and mesenteric vein thrombosis,but also can be seen in peripheral limb deep vein thrombosis.In summary,clotting mechanisms in patients with liver cirrhosis are often rebalanced in an unstable way,which is easily affected by other factors,such as volume status,systemic infection and renal function,so the balance is very unstable.Bleeding is one of the main causes of death in patients with liver cirrhosis,and esophageal and gastric varices bleeding is the main cause of bleeding in patients with liver cirrhosis.therefore,the main purpose of this paper is to explore the predictive value of non-invasive markers in the first occurrence of esophagogastric variceal bleeding and rebleeding within 3 months in patients with hepatitis B cirrhosis complicated with moderate to severe esophagogastric varices.The secondary purpose is to discuss the effect of hypercoagulable state on disease progression in patients with liver cirrhosis.Methods: From January 2018 to January 2020,the patients with hepatitis B cirrhosis complicated with moderate to severe esophageal/gastric varices in the first Hospital of Lanzhou University were selected.According to the inclusion criteria,a total of 232 subjects were enrolled,and 79 patients were enrolled in the observational study cohort.These patients were followed up for 6 months,and the number of patients with EGVB was 39,with an incidence of 49%.Then 33 patients with the first bleeding were followed up for 3 months,during which 14 patients had rebleeding events,with an incidence of 42%.The medical history,clinical data and laboratory data of all patients were collected within 24 hours after admission,and the relevant scores were calculated.The area under ROC curve was used to determine the best index for predicting variceal bleeding for the first time and rebleeding at 3 months.Independent sample T test and multivariate analysis were used to determine the effect of treatment on rebleeding,the independent risk factors of red sign and CTP classification.Results: In 79 patients with hepatitis B cirrhosis complicated with moderate to severe esophageal/gastric varices,the incidence of EGVB was as high as 49%.Red blood cell count(OR=0.23,95%CI:0.10-0.56),portal vein flow rate(OR=2.14;95%CI:1.20-3.84),aspartate aminotransferase and platelet ratio index(OR=0.67;95%CI:0.46-0.96),portal vein width to red blood cell count ratio(OR=5.00).95%CI:1.78-14.07 is a significant and powerful predictor of esophageal variceal bleeding for the first time.In addition,the width of portal vein(AUC=0.85,95% CI:0.76-0.94,P < 0.001),the thickness of spleen(AUC=0.74,95% CI:0.74-0.93,P < 0.001)and the ratio of width to velocity of portal vein(AUC=0.81,95% CI:0.71-0.91,P < 0.001)were independent risk factors for red sign.In 33 hepatitis B cirrhosis patients with esophageal and gastric varices bleeding for the first time,8(24%)were treated with transjugular intrahepatic portosystemic shunt,19(58%)with gastroscopy and 6(18%)with conservative medical treatment.The incidence of recurrent EGVB was as high as 42% in 3 months,and there was no significant correlation between rebleeding and treatment.Except that hypocoagulant function and portal hypertension were more common in the rebleeding group,other baseline characteristics were similar between the two groups.ROC curve analysis showed that only portal vein flow velocity(AUC=0.86,95%CI:0.73-0.98)and model for end-stage liver disease score of end-stage liver disease model(AUC=0.76,95%CI:0.59-0.93)were significant and strong predictors of rebleeding in patients with first bleeding after 3 months.In addition,rebleeding has nothing to do with the patient’s CTP grade and only albumin can be used to distinguish the CTP grade of the bleeding patient.Conclusion: portal vein flow velocity,PW/RC,RBC and APRI are strong predictors of6-month bleeding in patients with hepatitis B cirrhosis complicated with moderate to severe esophageal varices.Portal vein width,spleen thickness and PW/PV are independent risk factors for red sign,which can be used as an early screening tool for hepatitis B cirrhosis complicated with moderate to severe esophageal variceal bleeding.In addition,among the patients with HBV-related cirrhosis and esophageal and gastric variceal bleeding for the first time,there may be little relationship between current treatment methods and short-term rebleeding,while portal vein flow velocity ≤19cm/s is the main predictor of short-term rebleeding.