彩色多普勒超声肝门血流在肝硬化食管胃底静脉曲张患者出血风险的评估价值

doi:10.3877/cma.j.issn.2095-2015.2025.05.013

目的

探讨彩色多普勒超声肝门血流评估结合肝硬度及血小板等指标对肝硬化食管胃底静脉曲张患者出血风险的评估价值。

方法

回顾性分析2022年3月至2024年3月陕西省人民医院收治的110例肝硬化食管胃底静脉曲张患者的临床资料，以胃镜检查为金标准，根据患者是否破裂出血分为出血组46例、未出血组64例，所有患者均行彩色多普勒超声检查，记录并比较两组门静脉血流参数、脾静脉血流参数评估患者肝门血流情况，收集所有患者的肝脏剪切波速度（Vs）、肝脏弹性检测值（E）、肝硬度值（LSM）、脾脏直径（SD）及血清学指标白蛋白（ALB）、血红蛋白（Hb）、总胆红素（TBil）、血肌酐（SCr）、血尿素氮（SUN）、活化部分凝血活酶时间（APTT）、凝血酶原时间（PT）、血小板计数（PLT）等，根据LSM、PLT、SD比值计算LSPS评分，比较不同组别患者间的指标差异，并绘制受试者工作特征（ROC）曲线，计算曲线下面积（AUC）评估各相关影响因素对肝硬化食管胃底静脉曲张患者出血风险的评估价值。

结果

出血组DPV、QPV、DSV、QSV、LSM、SD、肝脏Vs、肝脏E高于未出血组，VPV、VSV低于未出血组，差异有统计学意义（P<0.05）。出血组LSPS评分显著高于未出血组，差异有统计学意义（P<0.05），但两组ALB、Hb、TBil、SCr、SUN、APTT、PT、PLT比较差异无统计学意义（P>0.05）。Logistic多因素回归分析显示，DPV≥1.5 cm、VPV<10 cm/s、QPV≥1390 mL/min、DSV≥1.4 cm、VSV<14 cm/s、QSV≥970 mL/min、LSPS≥3.9分、肝脏Vs≥2.5 m/s、肝脏E≥15.8 kPa均为影响肝硬化食管胃底静脉曲张患者出血的独立危险因素（P<0.05）。ROC曲线显示，联合DPV、VPV、QPV、DSV、VSV、QSV、LSPS、肝脏Vs、肝脏E评估肝硬化食管胃底静脉曲张患者出血的AUC为0.875（95% CI 0.860~0.902），特异度和敏感度分别为84.26%、83.86%。基于超声检查（包括彩色多普勒超声和超声弹性成像）的结果建立超声特征模型，基于LSPS评分构建临床模型，整合临床模型（LSPS）和超声特征模型，两模型联合诊断效能更高AUC为0.912（95% CI 0.905~0.952），显著高于单独临床模型（LSPS）和单独超声特征模型。

结论

彩色多普勒超声通过测量肝硬化食管胃底静脉曲张患者门静脉、脾静脉血流动力学，有助于预测其出血风险，联合肝硬度及血小板等指标具有更高的预测价值。

关键词: 食管胃底静脉曲张, 肝硬化, 彩色多普勒超声, 肝硬度, 血小板计数, 血流动力学

Objective

To explore the value of color Doppler ultrasound assessment of hepatic portal blood flow combined with liver hardness and platelet in evaluating the risk of hemorrhage in patients with esophageal and gastric varices in cirrhosis.

Methods

The clinical data of 110 cirrhotic patients with esophageal and gastric varices admitted to Shaanxi Provincial People's Hospital from March 2022 to March 2024 were retrospectively analyzed. Gastroscopy was used as the gold standard, and the patients were divided into the bleeding group (46 cases) and the non-bleeding group (64 cases) according to whether they had bleeding. All patients underwent color Doppler ultrasound. Portal vein blood flow parameters and splenic vein blood flow parameters of the two groups were recorded and compared to evaluate the hepatic portal blood flow of the patients. Liver shear wave velocity (Vs), liver elasticity test value (E), liver stiffness measurement (LSM), spleen diameter (SD) and serological indexes such as albumin (ALB), hemoglobin (Hb), total bilirubin (TBil), blood creatinine (SCr), blood urea nitrogen (SUN), activated partial thrombin time (APTT), and prothrombin time (PT) and platelet count (PLT) of all patients were collected. The LSPS score was calculated according to the ratio of LSM, PLT and SD, and the index differences between the two groups were compared. The receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was calculated to evaluate the evaluation value of relevant influencing factors on the risk of hemorrhage in cirrhotic patients with esophageal and gastric varices.

Results

DPV, QPV, DSV, QSV, LSM, SD, liver Vs and liver E in the bleeding group were higher than those in the non-bleeding group, and VPV and VSV were lower than those in the non-bleeding group, with statistically significant differences (P<0.05). The LSPS score of the bleeding group was significantly higher than that of the non-bleeding group, with statistically significant difference (P<0.05), but there were no statistically significant differences in ALB, Hb, TBil, SCr, SUN, APTT, PT and PLT between the two groups (P>0.05). Logistic multivariate regression analysis showed that DPV≥1.5 cm, VPV<10 cm/s, QPV≥1 390 mL/min, DSV≥1.4 cm, VSV<14 cm/s, QSV≥970 mL/min, LSPS≥3.9 points, liver Vs≥2.5 m/s, liver E≥15.8 kPa were independent risk factors for hemorrhage in cirrhotic patients with esophageal and gastric varices (P<0.05). ROC curve showed that the AUC in combination with DPV, VPV, QPV, DSV, VSV, QSV, LSPS, liver Vs, and liver E was 0.875 (95% CI: 0.860-0.902), and the specificity and sensitivity were 84.26% and 83.86%, respectively. The ultrasonic feature model was established based on the results of ultrasound examination (including color Doppler ultrasound and ultrasonic elastography), and the clinical model was constructed based on the LSPS score, the combined diagnostic efficiency of the two models was higher, with an AUC of 0.912 (95% CI: 0.905-0.952), which was significantly higher than that of single clinical model (LSPS) and single ultrasonic characteristic model.

Conclusion

Color Doppler ultrasound can help to predict the bleeding risk of patients with cirrhotic esophageal and gastric varices by measuring the blood flow dynamics of portal vein and splenic vein, and has higher prediction value in combination with liver hardness and platelet.

Key words: Esophageal and gastric varices, Liver cirrhosis, Color Doppler ultrasound, Liver hardness, Platelet count, Hemodynamics

图2 肝硬化食管胃底静脉曲张未出血超声。患者女，59岁，食欲减退，乏力、消瘦，体重减轻，超声表现：肝硬化、腹水、脾大，门静脉增宽，门静脉侧支循环形成；血流速度正常19 cm/s，搏动指数0.9

表1 不同组别肝硬化食管胃底静脉曲张患者的超声检查指标比较

指标	未出血组(n=46)	出血组(n=64)	t	P
年龄(岁,±s)	54.42±10.12	55.60±10.45	0.591	0.555
男性[例(%)]	24(52.17)	38(59.37)	0.564	0.452
DPV(cm,±s)	1.33±0.22	1.63±0.47	4.020	<0.001
VPV(cm/s,±s)	13.57±1.67	8.58±1.35	17.305	<0.001
QPV(mL/min,±s)	1327.14±190.57	1420.43±200.45	2.457	0.015
DSV(cm,±s)	1.17±0.14	1.58±0.36	7.328	<0.001
VSV(cm/s,±s)	15.25±1.23	14.63±0.48	3.667	<0.001
QSV(ml/min,±s)	940.77±120.22	997.58±143.36	2.189	0.030
LSM(kPa,±s)	18.65±3.23	27.23±3.35	13.448	<0.001
SD(cm,±s)	13.54±2.25	18.47±2.33	11.103	<0.001
肝脏Vs(m/s,±s)	2.16±0.56	2.97±0.65		<0.001
肝脏E(kPa,±s)	13.56±6.67	30.23±7.19		<0.001

表1 不同组别肝硬化食管胃底静脉曲张患者的超声检查指标比较

指标	未出血组(n=46)	出血组(n=64)	t	P
年龄(岁,±s)	54.42±10.12	55.60±10.45	0.591	0.555
男性[例(%)]	24(52.17)	38(59.37)	0.564	0.452
DPV(cm,±s)	1.33±0.22	1.63±0.47	4.020	<0.001
VPV(cm/s,±s)	13.57±1.67	8.58±1.35	17.305	<0.001
QPV(mL/min,±s)	1327.14±190.57	1420.43±200.45	2.457	0.015
DSV(cm,±s)	1.17±0.14	1.58±0.36	7.328	<0.001
VSV(cm/s,±s)	15.25±1.23	14.63±0.48	3.667	<0.001
QSV(ml/min,±s)	940.77±120.22	997.58±143.36	2.189	0.030
LSM(kPa,±s)	18.65±3.23	27.23±3.35	13.448	<0.001
SD(cm,±s)	13.54±2.25	18.47±2.33	11.103	<0.001
肝脏Vs(m/s,±s)	2.16±0.56	2.97±0.65		<0.001
肝脏E(kPa,±s)	13.56±6.67	30.23±7.19		<0.001

表2 不同组别肝硬化食管胃底静脉曲张患者的血清学指标及LSPS评分比较（

±s）

指标	未出血组(n=46)	出血组(n=64)	t	P
Alb(g/L)	27.57±5.52	26.23±4.43	1.410	0.161
Hb(g/L)	87.55±10.25	86.58±9.46	0.512	0.609
TBil(mmol/L)	37.34±4.32	36.23±4.47	1.302	0.195
SCr(mmol/L)	78.47±6.67	76.68±6.35	1.427	0.156
SUN(mmol/L)	9.60±1.53	9.53±1.45	0.244	0.807
APTT(s)	38.56±5.20	39.68±5.32	1.099	0.274
PT(s)	17.25±2.23	17.73±2.38	1.071	0.286
PLT(×10⁹ /L)	64.77±7.22	62.58±7.36	1.551	0.123
LSPS(分)	2.66±0.20	8.23±1.49	25.159	<0.001

表2 不同组别肝硬化食管胃底静脉曲张患者的血清学指标及LSPS评分比较（

±s）

指标	未出血组(n=46)	出血组(n=64)	t	P
Alb(g/L)	27.57±5.52	26.23±4.43	1.410	0.161
Hb(g/L)	87.55±10.25	86.58±9.46	0.512	0.609
TBil(mmol/L)	37.34±4.32	36.23±4.47	1.302	0.195
SCr(mmol/L)	78.47±6.67	76.68±6.35	1.427	0.156
SUN(mmol/L)	9.60±1.53	9.53±1.45	0.244	0.807
APTT(s)	38.56±5.20	39.68±5.32	1.099	0.274
PT(s)	17.25±2.23	17.73±2.38	1.071	0.286
PLT(×10⁹ /L)	64.77±7.22	62.58±7.36	1.551	0.123
LSPS(分)	2.66±0.20	8.23±1.49	25.159	<0.001

表3 多因素回归分析赋值表

变量		赋值
Y	出血	未发生=0，发生=1
X1	DPV	<1.5 cm=0，≥1.5 cm=1
X2	VPV	≥10 cm/s=0，<10 cm/s=1
X3	QPV	<1390 mL/min=0，≥1390 mL/min=1
X4	DSV	<1.4 cm=0，≥1.4 cm=1
X5	VSV	≥14 cm/s=0，<14 cm/s=1
X6	QSV	<970 mL/min=0，≥970 mL/min=1
X8	LSPS	<3.9分=0，≥3.9分=1
X9	肝脏Vs	<2.5 m/s=0，≥ 2.5 m/s=1
X10	肝脏E	<15.8 kPa=0，≥15.8 kPa=1

表3 多因素回归分析赋值表

变量		赋值
Y	出血	未发生=0，发生=1
X1	DPV	<1.5 cm=0，≥1.5 cm=1
X2	VPV	≥10 cm/s=0，<10 cm/s=1
X3	QPV	<1390 mL/min=0，≥1390 mL/min=1
X4	DSV	<1.4 cm=0，≥1.4 cm=1
X5	VSV	≥14 cm/s=0，<14 cm/s=1
X6	QSV	<970 mL/min=0，≥970 mL/min=1
X8	LSPS	<3.9分=0，≥3.9分=1
X9	肝脏Vs	<2.5 m/s=0，≥ 2.5 m/s=1
X10	肝脏E	<15.8 kPa=0，≥15.8 kPa=1

表4 影响肝硬化食管胃底静脉曲张患者出血的多因素回归分析结果

影响因素	β	SE(β)	Wald χ²值	P值	OR	95% CI
DPV≥1.5 cm	1.334	0.499	7.147	0.008	3.796	1.428~10.095
VPV<10 cm/s	1.483	0.462	10.304	0.001	4.406	1.782~10.897
QPV≥1390 mL/min	1.396	0.397	12.365	<0.001	4.039	1.855~8.794
DSV≥1.4 cm	1.089	0.475	5.256	0.022	2.971	1.171~7.538
VSV<14 cm/s	1.406	0.568	6.127	0.013	4.080	1.340~12.420
QSV≥970 mL/min	1.339	0.599	4.997	0.025	3.815	1.179~12.342
LSPS≥3.9分	1.427	0.338	17.824	<0.001	4.166	2.148~8.081
肝脏Vs≥2.5 m/s	1.548	0.407	14.466	<0.001	4.702	2.118~10.441
肝脏E≥15.8 kPa	1.654	0.411	16.195	<0.001	5.228	2.336~11.700

表4 影响肝硬化食管胃底静脉曲张患者出血的多因素回归分析结果

影响因素	β	SE(β)	Wald χ²值	P值	OR	95% CI
DPV≥1.5 cm	1.334	0.499	7.147	0.008	3.796	1.428~10.095
VPV<10 cm/s	1.483	0.462	10.304	0.001	4.406	1.782~10.897
QPV≥1390 mL/min	1.396	0.397	12.365	<0.001	4.039	1.855~8.794
DSV≥1.4 cm	1.089	0.475	5.256	0.022	2.971	1.171~7.538
VSV<14 cm/s	1.406	0.568	6.127	0.013	4.080	1.340~12.420
QSV≥970 mL/min	1.339	0.599	4.997	0.025	3.815	1.179~12.342
LSPS≥3.9分	1.427	0.338	17.824	<0.001	4.166	2.148~8.081
肝脏Vs≥2.5 m/s	1.548	0.407	14.466	<0.001	4.702	2.118~10.441
肝脏E≥15.8 kPa	1.654	0.411	16.195	<0.001	5.228	2.336~11.700

表5 多因素评估肝硬化食管胃底静脉曲张患者出血的效能分析

危险因素	截断值	AUC	95% CI	敏感度(%)	特异度(%)
DPV	1.5 cm	0.742	0.526~0.767	73.10	62.15
VPV	10 cm/s	0.583	0.491~0.603	52.62	49.20
QPV	1390 mL/min	0.603	0.512~0.654	58.16	50.24
DSV	1.4 cm	0.696	0.642~0.804	74.52	50.56
VSV	14 cm/s	0.550	0.506~0.594	62.99	55.37
QSV	970 mL/min	0.598	0.547~0.636	64.19	54.94
LSPS	3.9分	0.778	0.676~0.796	72.98	65.36
肝脏Vs	2.5 m/s	0.781	0.668~0.812	78.54	68.24
肝脏E	15.8 kPa	0.785	0.674~0.887	78.96	70.21
联合	-	0.875	0.860~0.902	83.86	84.26

表5 多因素评估肝硬化食管胃底静脉曲张患者出血的效能分析

危险因素	截断值	AUC	95% CI	敏感度(%)	特异度(%)
DPV	1.5 cm	0.742	0.526~0.767	73.10	62.15
VPV	10 cm/s	0.583	0.491~0.603	52.62	49.20
QPV	1390 mL/min	0.603	0.512~0.654	58.16	50.24
DSV	1.4 cm	0.696	0.642~0.804	74.52	50.56
VSV	14 cm/s	0.550	0.506~0.594	62.99	55.37
QSV	970 mL/min	0.598	0.547~0.636	64.19	54.94
LSPS	3.9分	0.778	0.676~0.796	72.98	65.36
肝脏Vs	2.5 m/s	0.781	0.668~0.812	78.54	68.24
肝脏E	15.8 kPa	0.785	0.674~0.887	78.96	70.21
联合	-	0.875	0.860~0.902	83.86	84.26

表6 不同模型评估肝硬化食管胃底静脉曲张患者出血的效能分析

模型	AUC	95% CI	敏感度(%)	特异度(%)
临床模型	0.782	0.756~0.857	83.70	72.45
超声特征模型	0.843	0.801~0.883	86.44	79.33
两者联合	0.912	0.905~0.952	90.43	92.40

表6 不同模型评估肝硬化食管胃底静脉曲张患者出血的效能分析

模型	AUC	95% CI	敏感度(%)	特异度(%)
临床模型	0.782	0.756~0.857	83.70	72.45
超声特征模型	0.843	0.801~0.883	86.44	79.33
两者联合	0.912	0.905~0.952	90.43	92.40

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Evaluation value of color Doppler ultrasound hepatic portal blood flow in the risk of bleeding in patients with cirrhosis and esophagogastric varices

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Evaluation value of color Doppler ultrasound hepatic portal blood flow in the risk of bleeding in patients with cirrhosis and esophagogastric varices