摘要： 目的·分析急性非静脉曲张性上消化道出血（acute nonvariceal upper gastrointestinal bleeding，ANVUGIB）患者再出血的独立危险因素，构建再出血预测模型及风险评分系统。方法·收集2016年1月1日至2019年12月31日苏州大学附属第一医院收治的686例ANVUGIB患者的病例资料，记录患者的一般情况、临床表现、实验室检查结果、内镜下表现、病情转归等，并计算所有患者的内镜前Baylor、内镜后Baylor、Rockall、GBS（Glasgow Blatchford Score）、CSMCPI（Cedars-Sinai Medical Center Predictive Index）、AIMS65、MAP（ASH）评分。将所收集的病例按7∶3随机分成建模组（
n=481）和验证组（
n=205），使用建模组数据建立模型。将单因素分析中有意义的变量（
P<0.1）纳入Logistic回归分析，探究再出血的独立危险因素，构建再出血风险预测模型并进行内部验证，分别评价建模组及验证组的区分度及校准度，最终将模型转换为风险评分系统。受试者操作特征（receiver operating characteristic，ROC）曲线效能的比较采用Delong统计法。结果·低收缩压，低血红蛋白水平，美国麻醉医师协会（American Society of Anesthesiologists，ASA）分级>3级，内镜下呈现为血凝块、血管裸露、活动性出血是再出血的独立危险因素。预测模型的ROC曲线下面积（area under the curve，AUC）为0.892（95%
CI 0.838~0.946，
P=0.001），Hosmer-Lemeshow检验
P=0.934；内部验证AUC=0.915（95%
CI 0.851~0.980，
P=0.001）；Hosmer-Lemeshow检验
P=0.871。该风险评分系统的AUC=0.882（95%
CI 0.823~0.942），对再出血的预测能力优于除MAP（ASH）评分以外的其余各项评分（均
P<0.05）。结论·该研究建立的评分系统对ANVUGIB再出血具有良好的预测能力，具有一定的临床应用价值。
关键词: 急性非静脉曲张性上消化道出血, 预测模型, 评分系统, 再出血 Abstract: Objective·To explore independent risk factors of rebleeding and construct a prediction model and risk scoring system of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB).
Methods·A total of 686 patients with ANVUGIB admitted to the First Affiliated Hospital of Soochow University from January 1, 2016 to December 31, 2019 were collected. The general conditions, clinical characteristics, laboratory results, endoscopic findings and prognosis were recorded. The Baylor score, Rockall score, Glasgow Blatchford Score (GBS), Cedars-Sinai Medical Center Predictive Index(CSMCPI), AIMS65 and MAP (ASH) for each patient were calculated. The collected data were randomly divided into a training set (n=481) and a validation set (n=205). A new prediction model for rebleeding was established by binary Logistic regression based on the training set data. The discrimination and calibration of the training and validation set were evaluated respectively, and then the model was transformed into a risk scoring system. The comparisons between the receiver operating characteristics (ROC) curves were based on the Delong test.
Results·Binary Logistic regression analysis showed that low systolic blood pressure, low hemoglobin level, American Society of Anesthesiologists (ASA) grade>3, and endoscopic findings of clots, visible vessels and active bleeding were independent risk factors for rebleeding. The area under the curve (AUC) of the prediction model was 0.892 (95% CI 0.838?0.946, P=0.001), Hosmer-Lemeshow test P=0.934. The validation set AUC=0.915 (95% CI 0.851?0.980, P=0.001), Hosmer-Lemeshow test P=0.871. The scoring system (AUC=0.882, 95% CI 0.823?0.942) was better at predicting rebleeding than all other scores mentioned except MAP (ASH) score (P<0.05).
Conclusion·The scoring system could predict rebleeding after ANVUGIB, which could be an option in clinical practice.
Key words: acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), prediction model, scoring system, rebleeding PDF全文下载地址:
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