食道靜脈瘤出血預後及其影響因子探討

A study on prognostic factors of esophageal vericeal bleeding

劉育穎(Yu-Ying Liu)

指導教授 ： 葉錦瑩

臺北醫學大學/公共衛生暨營養學院/公共衛生學研究所/碩士(2007年)

摘要

食道靜脈瘤出血（Esophageal Vericeal Bleeding）為一種需要緊急處理，且死亡率、復發率高、預後不佳的疾病。已有文獻指出，食道靜脈瘤出血的發生，與靜脈瘤張力、門靜脈壓上升、肝病的惡化、細菌感染、酒精、生理運動有關。目前有關食道靜脈瘤出血的臨床資料雖然很多，但探討食道靜脈瘤出血危險因子的流行病學資料卻相對較少。其中多著重於臨床特徵、生化指標的分析，而有關生活習慣（如：喝酒、抽菸、檳榔…等）對食道靜脈瘤出血的影響卻探討不多。故本研究有別於其他相關研究，將著重於生活習慣的探討，以了解患病者是否有較差的生活習慣或是較正常人容易暴露於某些危險因子，進而增加他們患病的機會，並希望藉此探討食道靜脈瘤出血及其預後之危險因子，以提供未來流行病學相關研究之參考。
本研究以來自花蓮門諾醫院最近5年內(2001~2006)所有經醫師診斷為肝硬化之病人共約1600名為研究母群。在所有肝硬化病人中，排除居住在外縣市、病歷資料不全者後，找出所有經醫師診斷為門靜脈高血壓所引起之食道靜脈瘤出血患者共175名，以進行食道靜脈瘤出血患者之描述性資料調查及存活分析研究。並於同時期(2001~2006)所有肝硬化病人中，排除食道靜脈瘤出血之病人後，約1000名個案中以1:2之比例匹配性別、年齡(±5歲)，隨機選取350名為對照組，以探討食道靜脈瘤之出血危險因子。結果顯示，第一次肝硬化時肌酸酐（Creatinine）異常（HR=2.483,95％CI：1.363-4.526）及腹水（HR=2.672,95％CI：1.267-5.632），為食道靜脈瘤出血死亡的危險因子。而第一次食道靜脈瘤出血時出現紅斑或紅點（HR=1.993,95％CI：1.346-2.951）、腹水（HR=2.048,95％CI：1.171-3.582）、Creatinine異常（HR=2.733,95％CI：1.832-4.077）及總膽紅素（total Bilirubin）異常（HR=1.050,95％CI：1.017-1.083），亦為出血死亡的危險因子；但並無發現抽菸、喝酒、檳榔等暴露與食道靜脈瘤出血死亡呈顯著關係。而第一次食道靜脈瘤出血之危險因子包括：酒精性肝硬化（OR =5.228,95％CI=2.617-10.443）、檳榔（OR =0.443,95％CI=0.247-0.796）、肝硬化初診年度於90年以前（OR =3.135,95％CI=1.273-7.720）、凝血脢原時間(prothrombin time ,PT) （OR =22.523,95％CI=2.856-177.637）、麩氨酸丙酮酸轉胺（Alanine transaminase ,ALT/GPT）（OR =0.477,95％CI=0.256-0.889）等因素，而與抽菸、喝酒等暴露呈正向關係，但不達統計上之顯著性。為了釐清生活習慣對食道靜脈瘤出血與死亡的影響，未來應以5年內所有肝硬化病人資料進行進一步的分析，使研究結果更具代表性。

關鍵字

食道靜脈瘤出血 ； 門靜脈高血壓 ； 肝硬化 ； 抽菸 ； 喝酒

並列摘要

Esophageal vericeal bleeding (EVB) is a emergent and rebellious disease with a high recurrence and mortality rate. Previous studies were reported that EVB is related to variceal wall tension, portal pressure elevation, the severity of liver disease, infections, ethanol intake and physical exercise. The majority of those studies emphasized the clinical characteristics and biochemical parameters analysis, but few studies identified the relation between lifestyle（e.g., alcohol intake, smoking, betel nut ... and so on.）and EVB. The aim of this study is to explore the overall risk factors and the prognostic factors of EVB.

From January 2001 to December 2006, a total of 175 patients who have EVB caused by portal hypertension in Hua-Lien Mennonite Christian Hospital was collected as case group, excluding not live in Hua-Lien and medical records absence, and accomplished the descriptive statistics and the survival analysis .Moreover, in order to investigate the risk factors of the EVB, in all liver cirrhosis patients diagnosed from January 2001 to December 2006, excluding EVB patients, 350 patients were sampled as control group, matching sex, age (±5 years old) by 1:2 proportion. Results show that creatinine abnormality（HR=2.483, 95％CI：1.363-4.526）, ascites（HR=2.672, 95％CI：1.267-5.632）at first diagnosis cirrhosis are independent predictors of mortality in patients with EVB.Varices with red wheals or red spots（HR=1.993, 95％CI：1.346-2.951）, ascites（HR=2.048, 95％CI：1.171-3.582）, Creatinine abnormality（HR=2.733, 95％CI：1.832-4.077）, total Bilirubin abnormality（HR=1.050, 95％CI：1.017-1.083）at the first esophageal vericeal bleeding occurs are independent predictors of mortality in patients with EVB. The significant association between alcohol intake, smoking and betel nut with mortality in EVB patients are not found.Alcoholic cirrhosis （OR =5.228, 95％CI=2.617-10.443）, betel nut（OR =0.443, 95％CI=0.247-0.796）, first diagnosis cirrhosis before 2001（OR =3.135, 95％CI=1.273-7.720）, PT（OR =22.523, 95％CI=2.856-177.637）, GPT（OR =0.477, 95％CI=0.256-0.889）are independent predictors of first esophageal vericeal bleeding. The association between alcohol intake and smoking are found without statistically significant with first esophageal vericeal bleeding.For better understanding of risk factors in lifestyle of EVB patients, futher investigation in all liver cirrhosis patients showed be made.

並列關鍵字

Esophageal vericeal bleeding ； Portal hypertension ； Cirrhosis ； Alcohol

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