| Background:Upper gastrointestinal bleeding(UGIB)refers to bleeding of digestive tract above Treitz’s ligaments,including the esophagus,stomach and duodenum or pancreatic biliary lesions.Its clinical manifestations are mainly hematemesis and/or melena,and acute peripheral circulatory failure in severe cases,with a fatality rate of 8%-13.7%.UGIB in patients with liver cirrhosis accounts for about 25%of all UGIB,while esophagogastric variceal rupture accounts for 50%-80%of UGIB in patients with liver cirrhosis.In addition,peptic ulcer,and portal hypertension(PH)gastroenteropathy can also cause bleeding.In cirrhosis with PH,blood in the lower esophagus and fundus of the stomach is blocked,which resulting the esophageal and gastric varices.UGIB in cirrhosis,which is usually rapid,large amount bleeding accompanied with acute peripheral circulatory failure,are the main causes of death in cirrhotic patients.Therefore,how to effectively control bleeding and save patients’lives is of particular importance.Currently the treatment recommended is to establish venous access to restore volume,administer hemostatic drugs,and administer endoscopic,interventional,or surgical treatment as soon as possible.However,due to the limitation of medical level and the choice of patients,drug therapy still occupies an important position.In order to guide clinical work,we analyzed the risk factors of drug treatment failure and rebleeding during admission for UGIB in cirrhosis.Objectives:To investigate the clinical characteristics and risk factors of upper gastrointestinal bleeding failure in cirrhotic patients;as well as the clinical features and risk factors of patients with rebleeding during hospitalization.Methods:A retrospective analysis was performed on cirrhotic patients with UGIB who were hospitalized in Jinan Infectious Disease Hospital from January 2010 to October 2019.Demographic data,medical history,clinical manifestations,drug treatment,intake and output volume,laboratory examination and imaging examination were collected.Drug treatment failure was defined in patients with progressive decline in hemoglobin or hematocrit and increased reticulocyte and unstable peripheral circulation after 5 days of medication;the others were defined as successful treatment.Patients in the successful hemostasis group were divided into rebleeding and non-rebleeding according to whether new active bleeding occurred after hemostasis.The investigation was approved by the hospital’s Medical Ethics Committee.The characteristics of patients with drug treatment failure and patients with rebleeding were analyzed using SPSS 23.0 software.T test was employed for measurement data conforming to normal distribution and nonparametric test was used for measurement data conforming to skewness distribution.The χ2 test was used to calculate the difference of mean or rate between the two groups and the 95%confidence interval(95%CI).Multivariate Logistic regression was applied to analyze the independent risk factors of hemostatic failure and rebleeding after hemostasis,and two side P<0.05 was considered statistically significant.Results:A total of 518 patients were involved in the study,including 187 drug treatment failure patients and 331 successful hemostasis patients,Rebleeding occurred in 98 patients after hemostasis.The mean age of the patients was 53.00± 10.90 years,of whom 425(82.05%)were male,and 281(54.3%)were from rural areas.133 patients(25.7%)had obvious bleeding inducements,including eating hard and rough food,taking drugs or drinking alcohol,or being tired,emotional and overexert,etc.Cirrhosis was caused by HBV infection in 83.7%of patients.The numbers of patients with Child-Pugh grade of A,B and C at admission were 107(20.7%),230(44.4%)and 181(34.9%),respectively,and the mean MELD score at admission was 12.85±9.70.Somatostatin and octreotide were the main drugs used to diminish portal vein pressure.Characteristics and risk factors of cirrhotic patients with UGIB who failed drug therapy1.There were no statistically significant differences in age,gender,smoking history,drinking history,underlying diseases,and Child-Pugh grading distribution between the two groups of patients with drug treatment failure and those with drug treatment success.MELD score(14.97±11.38vs.11.71 ±8.46,P<0.001),the proportion of patients with hepatic encephalopathy(25.1%vs.14.2%,P=0.003),the proportion of patients with no clear bleeding cause(82.4%vs.69.8%,P=0.002)were significantly higher than the other part.The proportions of TBIL and INR levels in failed patients,ALT>200U/L,AST>200U/L,TBIL>170μmol/L and INR>1.5 were significantly higher than those in successful patients(P<0.05).There were no significant differences in hemoglobin and platelet levels between the two groups at admission(P>0.05).The mortality of patients with treatment failure and drug success during hospitalization was 27.3%and 6.6%,respectively(P<0.001).2.Multivariate Logistic regression analysis found that the independent risk factors for drug treatment failure were:No bleeding inducement(OR=1.87,95%CI 1.20-2.93,P=0.006),MELD score>18 points(OR=1.71,95%CI 1.10-2.68,P=0.02),combined with hepatic encephalopathy(OR=1.67,95%CI 1.03-2.70,P<0.04).Characteristics and risk factors of rebleeding during hospitalization after hemostasis in cirrhotic patients with UGIB who used drug therapy1.There were no significant differences in age,gender,smoking history,drinking history,underlying diseases,Child-Pugh grading,MELD score,hemoglobin,and platelet levels between the two groups(P>0.05).It is significantly more common that spontaneous bacterial peritonitis in patients with rebleeding than those without(43.9%vs.31.8%,P=0.04).The first five days after hospitalization,mean plasma infusion volume(P=0.04),proportion of patients with red blood cell infusion(P=0.01),mean red blood cell infusion volume(P=0.02),the proportion of patients with average daily supplemental physiological salt volume(P=0.03),average daily fluid intake and output difference(P<0.001),and average daily fluid intake and output difference>500mL were significantly higher than those without rebleeding.Within 2 days after the withdrawal of drugs reducing portal venous pressure,the proportion of the difference between the cumulative amount of rebleeding patients and the amount of rebleeding patients(P<0.001)and the proportion of the difference between the amount of rebleeding patients and the amount of rebleeding patients>0mL(P<0.001)was significantly higher than that of the group without rebleeding.The mortality of patients with rebleeding and patients without rebleeding during hospitalization was 9.2%and 6.0%,respectively(P=0.48),2.Multivariate Logistic regression analysis found that the independent risk factors for rebleeding during admission were:With spontaneous bacterial peritonitis(OR= 1.7,95%CI 1.0-2.9,P=0.04),red blood cell infusion 5 days after hemorrhage(OR=2.2,95%CI 1.2-4.0,P=0.008),the difference between intakes and output within 5 days after hemorrhage>500mL(OR=2.1,95%CI 1.2-3.5,P=0.007),and intakes which outnumbered outtakes within 2 days after withdrawal of drugs(OR=2.2,95%CI 1.2-4.0,P=0.008).Conclusions:1.Failure of drug treatment for UGIB in liver cirrhosis was associated with the severity of liver disease,such as MELD score>18,encephalopathy,and spontaneous bleeding without inducement.For these patients,there is a high risk of failure of drug therapy,and emergency endoscopy or TIPS might be a suitable treatment.2.Rebleeding during hospitalization in cirrhotic patients with UGIB was associated with spontaneous bacterial peritonitis,inappropriate red blood cell infusion,and excessive fluid replenishment.Clinical fluid infusion should be well balanced between output and input,according to patients’ vital signs,appropriate fluid infusion,strict control of red blood cell infusion indications,restricted blood transfusion. |
