内镜下溃疡特征联合血清白蛋白水平对消化性溃疡出血患者预后的预测价值

doi:10.3877/cma.j.issn.2095-2015.2026.05.002

目的

探究内镜下溃疡特征联合血清白蛋白（ALB）水平检测对消化性溃疡出血（PUB）患者预后的预测价值。

方法

回顾性选取2023年5月至2025年5月邢台市中心医院收治的PUB患者210例为研究对象，均接受急诊内镜检查及内镜下止血治疗。根据患者30 d内的预后情况，将其分为预后不良组（n=54）和预后良好组（n=156）。比较两组的临床资料、内镜下溃疡特征（包括溃疡大小、位置、Forrest分级等）及血清ALB、尿素氮与肌酐比值（BUN/Cr）水平。采用logistic回归分析筛选出导致PUB患者预后不良的影响因素并构建相关模型，采用受试者工作特征（ROC）曲线分析各影响因素及联合预测模型对PUB患者预后不良的预测价值。

结果

预后不良组的SI、Forrest分级、最大溃疡直径、ALB、BUN/Cr差异有统计学意义（P<0.05）。SI高、Forrest分级为高危、溃疡最大直径>2 cm、ALB低、BUN/Cr高都是影响PUB患者预后不良的危险因素（P<0.05）。ROC曲线分析结果显示：SI、Forrest分级、溃疡最大直径、ALB、BUN/Cr、列线图预测模型的AUC分别为0.756、0.671、0.685、0.707、0.796、0.941，经过Delong分析，发现列线图预测模型的AUC最大，预测效能最佳（P<0.05），同时列线图预测模型的敏感度和特异度最高，分别为85.2%和87.8%。

结论

本研究构建整合了内镜下局部特征（Forrest高危分级、溃疡直径>2 cm）与全身性血清标志物（ALB），并纳入SI及BUN/Cr的列线图预测模型，能够有效甄别PUB后预后不良的高危患者。该模型实现了"局部－全身"风险维度的整合，其预测效能显著优于传统单一指标或仅依赖临床参数的评分系统，为临床早期分层干预提供了新思路。

关键词: 消化性溃疡出血, 消化内镜, 血清白蛋白, 预后评估

Objective

To explore the predictive value of endoscopic ulcer characteristics combined with serum albumin (ALB) levels for the prognosis of patients with peptic ulcer bleeding (PUB).

Methods

A retrospective study was conducted on 210 PUB patients admitted to Xingtai Central Hospital from May 2023 to May 2025, all of whom underwent emergency endoscopic examination and endoscopic hemostasis treatment. According to the patient's prognosis within 30 days, they were divided into a poor prognosis group (n=54) and a good prognosis group (n=156). Clinical data, endoscopic ulcer characteristics (including ulcer size, location, and Forrest classification), serum ALB, and blood urea nitrogen-to-creatinine ratio (BUN/Cr) were compared between the two groups. Logistic regression analysis was used to identify influencing factors for poor prognosis in PUB patients, and a predictive model was constructed. Receiver operating characteristic (ROC) curves were used to evaluate the predictive value of each independent factor and the combined prediction model.

Results

There were statistically significant differences in SI, Forrest grading, maximum ulcer diameter, ALB, and BUN/Cr between the two groups (P<0.05). High SI, Forrest classification as high-risk, ulcer diameter >2 cm, low ALB, and high BUN/Cr were all risk factors affecting poor prognosis in PUB patients (P<0.05). The ROC curve analysis results showed that the area under the curve (AUC) of SI, Forrest grading, maximum ulcer diameter, ALB, BUN/Cr, and the nomogram prediction model were 0.756, 0.671, 0.685, 0.707, 0.796, and 0.941, respectively. Delong analysis revealed that the nomogram prediction model had the highest AUC and the best prediction performance (P<0.05). At the same time, the sensitivity and specificity of nomogram prediction model were the highest, which were 85.2% and 87.8% respectively.

Conclusion

The nomogram prediction model constructed in this study, which integrates endoscopic local features (Forrest high-risk grading, ulcer diameter >2 cm) and systemic serum biomarker (ALB), and incorporates SI and BUN/Cr, can effectively identify high-risk patients with poor prognosis after PUB. This model integrates the "local-systemic" risk dimension, and its predictive performance is significantly better than traditional single-index or scoring systems that rely solely on clinical parameters, providing a new approach for early stratified intervention in clinical practice.

Key words: Peptic ulcer bleeding, Endoscopy, Serum albumin, Prognostic assessment

表1 两组消化性溃疡出血患者的临床资料比较

临床资料		预后不良组(n=54)	预后良好组(n=156)	t/χ²值	P值
年龄(岁,±s)		45.59±6.71	45.78±7.09	-0.171	0.864
性别[例(%)]	男	28(51.85)	80(51.28)	0.005	0.942
	女	26(48.15)	76(48.72)	0.005	0.942
体重指数(kg/m²,±s)		23.31±1.58	23.54±1.38	-1.026	0.306
高血压[例(%)]	有	16(29.63)	44(28.21)	0.040	0.842
	无	38(70.37)	112(71.79)	0.040	0.842
糖尿病[例(%)]	有	10(18.52)	32(20.51)	0.100	0.752
	无	44(81.48)	124(79.49)	0.100	0.752
肝硬化[例(%)]	有	6(11.11)	14(8.97)	0.213	0.645
	无	48(88.89)	142(91.03)	0.213	0.645
抗凝/抗血小板药物使用史[例(%)]	有	8(14.81)	20(12.82)	0.138	0.710
	无	46(85.19)	136(87.18)	0.138	0.710
非甾体抗炎药使用史[例(%)]	有	15(27.78)	38(24.36)	0.248	0.618
	无	39(72.22)	118(75.64)	0.248	0.618
幽门螺杆菌感染[例(%)]	有	22(40.74)	68(43.59)	0.133	0.715
	无	32(59.26)	88(56.41)	0.133	0.715
内镜下止血方式[例(%)]	钛夹	20(37.04)	64(41.03)	0.431	0.934
	注射	18(33.33)	52(33.33)
	电凝	10(18.52)	24(15.38)
	联合	6(11.11)	16(10.26)
收缩压(mmHg,±s)		108.30±12.50	110.36±11.85	-1.087	0.278
舒张压(mmHg,±s)		66.81±8.55	68.21±8.24	-1.058	0.291
心率(次/min,±s)		96.39±10.30	95.14±9.53	0.812	0.418
休克指数(±s)		1.16±0.37	0.83±0.30	6.389	<0.001
Forrest分级[例(%)]	高危	42(77.78)	68(43.59)	18.797	<0.001
	低危	12(22.22)	88(56.41)	18.797	<0.001
溃疡最大直径[例(%)]	>2 cm	38(70.37)	52(33.33)	22.469	<0.001
	≤2 cm	16(29.63)	104(66.67)	22.469	<0.001
溃疡位置[例(%)]	胃溃疡	30(55.56)	92(58.97)	0.207	0.902
	十二指肠球部溃疡	20(37.04)	54(34.62)
	复合型溃疡	4(7.40)	10(6.41)
白蛋白(g/L,±s)		28.50±4.47	32.11±4.99	-4.692	<0.001
血红蛋白(g/L,±s)		85.43±12.54	86.76±11.31	-0.729	0.467
尿素氮/肌酐(±s)		23.38±6.10	16.26±5.99	7.495	<0.001

表1 两组消化性溃疡出血患者的临床资料比较

临床资料		预后不良组(n=54)	预后良好组(n=156)	t/χ²值	P值
年龄(岁,±s)		45.59±6.71	45.78±7.09	-0.171	0.864
性别[例(%)]	男	28(51.85)	80(51.28)	0.005	0.942
	女	26(48.15)	76(48.72)	0.005	0.942
体重指数(kg/m²,±s)		23.31±1.58	23.54±1.38	-1.026	0.306
高血压[例(%)]	有	16(29.63)	44(28.21)	0.040	0.842
	无	38(70.37)	112(71.79)	0.040	0.842
糖尿病[例(%)]	有	10(18.52)	32(20.51)	0.100	0.752
	无	44(81.48)	124(79.49)	0.100	0.752
肝硬化[例(%)]	有	6(11.11)	14(8.97)	0.213	0.645
	无	48(88.89)	142(91.03)	0.213	0.645
抗凝/抗血小板药物使用史[例(%)]	有	8(14.81)	20(12.82)	0.138	0.710
	无	46(85.19)	136(87.18)	0.138	0.710
非甾体抗炎药使用史[例(%)]	有	15(27.78)	38(24.36)	0.248	0.618
	无	39(72.22)	118(75.64)	0.248	0.618
幽门螺杆菌感染[例(%)]	有	22(40.74)	68(43.59)	0.133	0.715
	无	32(59.26)	88(56.41)	0.133	0.715
内镜下止血方式[例(%)]	钛夹	20(37.04)	64(41.03)	0.431	0.934
	注射	18(33.33)	52(33.33)
	电凝	10(18.52)	24(15.38)
	联合	6(11.11)	16(10.26)
收缩压(mmHg,±s)		108.30±12.50	110.36±11.85	-1.087	0.278
舒张压(mmHg,±s)		66.81±8.55	68.21±8.24	-1.058	0.291
心率(次/min,±s)		96.39±10.30	95.14±9.53	0.812	0.418
休克指数(±s)		1.16±0.37	0.83±0.30	6.389	<0.001
Forrest分级[例(%)]	高危	42(77.78)	68(43.59)	18.797	<0.001
	低危	12(22.22)	88(56.41)	18.797	<0.001
溃疡最大直径[例(%)]	>2 cm	38(70.37)	52(33.33)	22.469	<0.001
	≤2 cm	16(29.63)	104(66.67)	22.469	<0.001
溃疡位置[例(%)]	胃溃疡	30(55.56)	92(58.97)	0.207	0.902
	十二指肠球部溃疡	20(37.04)	54(34.62)
	复合型溃疡	4(7.40)	10(6.41)
白蛋白(g/L,±s)		28.50±4.47	32.11±4.99	-4.692	<0.001
血红蛋白(g/L,±s)		85.43±12.54	86.76±11.31	-0.729	0.467
尿素氮/肌酐(±s)		23.38±6.10	16.26±5.99	7.495	<0.001

表2 纳入自变量共线性诊断分析

可疑影响因素	共线性统计
可疑影响因素	容许	VIF
SI	0.948	1.055
Forrest分级	0.925	1.082
溃疡最大直径	0.943	1.061
ALB	0.956	1.046
BUN/Cr	0.954	1.049

表2 纳入自变量共线性诊断分析

可疑影响因素	共线性统计
可疑影响因素	容许	VIF
SI	0.948	1.055
Forrest分级	0.925	1.082
溃疡最大直径	0.943	1.061
ALB	0.956	1.046
BUN/Cr	0.954	1.049

表3 Logistic回归模型中自变量的赋值方式

可疑影响因素	赋值
SI	连续变量，直接纳入
Forrest分级	高危=1，低危=0
溃疡最大直径	>2 cm=1，≤2 cm=0
ALB	连续变量，直接纳入
BUN/Cr	连续变量，直接纳入

表3 Logistic回归模型中自变量的赋值方式

可疑影响因素	赋值
SI	连续变量，直接纳入
Forrest分级	高危=1，低危=0
溃疡最大直径	>2 cm=1，≤2 cm=0
ALB	连续变量，直接纳入
BUN/Cr	连续变量，直接纳入

表4 影响消化性溃疡出血患者预后不良的二元logistic回归分析

变量	B	SE	Wald	P	OR(95% CI)
SI	3.817	0.855	19.921	<0.001	45.486(8.509~243.158)
Forrest分级	1.630	0.559	8.510	0.004	5.103(1.707~15.256)
溃疡最大直径	2.221	0.548	16.411	<0.001	9.200(3.148~27.008)
ALB	-0.170	0.051	11.057	0.001	0.844(0.763~0.933)
BUN/Cr	0.241	0.045	28.891	<0.001	1.273(1.166~1.390)
常量	-6.729	2.100	10.267	0.001	-

表4 影响消化性溃疡出血患者预后不良的二元logistic回归分析

变量	B	SE	Wald	P	OR(95% CI)
SI	3.817	0.855	19.921	<0.001	45.486(8.509~243.158)
Forrest分级	1.630	0.559	8.510	0.004	5.103(1.707~15.256)
溃疡最大直径	2.221	0.548	16.411	<0.001	9.200(3.148~27.008)
ALB	-0.170	0.051	11.057	0.001	0.844(0.763~0.933)
BUN/Cr	0.241	0.045	28.891	<0.001	1.273(1.166~1.390)
常量	-6.729	2.100	10.267	0.001	-

图1 影响消化性溃疡出血患者预后不良的独立危险因素列线图模型注：SI为休克指数；ALB为血清白蛋白；BUN/Cr为血尿素氮与肌酐比值

图2 列线图预测模型预测消化性溃疡出血患者预后不良的受试者工作特征曲线

图3 列线图预测模型预测消化性溃疡出血患者预后不良的校准曲线

图4 列线图预测模型预测消化性溃疡出血患者预后不良的决策曲线

表5 ROC分析多指标对消化性溃疡出血患者预后的预测效能

检验结果变量	AUC	SE	P	95% CI	cut-off值	约登指数	敏感度(%)	特异度(%)
SI	0.756	0.039	<0.001	0.679~0.833	0.98次/min:mmHg	0.416	70.4	71.2
Forrest分级	0.671	0.041	<0.001	0.590~0.752	高危	0.342	77.8	56.4
溃疡最大直径	0.685	0.042	<0.001	0.603~0.768	>2 cm	0.371	70.4	66.7
ALB	0.707	0.040	<0.001	0.630~0.785	29.31 g/L	0.317	72.4	59.3
BUN/Cr	0.796	0.035	<0.001	0.727~0.865	18.78	0.501	81.5	68.6
列线图预测模型	0.941	0.017	<0.001	0.907~0.974	-	0.730	85.2	87.8

表5 ROC分析多指标对消化性溃疡出血患者预后的预测效能

检验结果变量	AUC	SE	P	95% CI	cut-off值	约登指数	敏感度(%)	特异度(%)
SI	0.756	0.039	<0.001	0.679~0.833	0.98次/min:mmHg	0.416	70.4	71.2
Forrest分级	0.671	0.041	<0.001	0.590~0.752	高危	0.342	77.8	56.4
溃疡最大直径	0.685	0.042	<0.001	0.603~0.768	>2 cm	0.371	70.4	66.7
ALB	0.707	0.040	<0.001	0.630~0.785	29.31 g/L	0.317	72.4	59.3
BUN/Cr	0.796	0.035	<0.001	0.727~0.865	18.78	0.501	81.5	68.6
列线图预测模型	0.941	0.017	<0.001	0.907~0.974	-	0.730	85.2	87.8

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Predictive value of endoscopic ulcer characteristics combined with serum albumin for prognosis in peptic ulcer bleeding

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Predictive value of endoscopic ulcer characteristics combined with serum albumin for prognosis in peptic ulcer bleeding