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摘要：
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摘要：目的 分析乙型肝炎病毒（hepatitis B virus，HBV）相关肝细胞癌患者并发上消
化道出血的影响因素。方法 选取2014年1月至2017年12月于深圳市第三人民医院确诊
的135例HBV相关肝细胞癌患者进行回顾性分析，根据患者是否发生上消化道出血分
为出血组（45例）和对照组（90例），比较两组患者的临床特征和转归。具体指标包
括年龄、性别、是否抗病毒治疗、HBV DNA、血小板（blood platelet，PLT）、白蛋
白（albumin，ALB）、凝血酶原时间（prothrombin time，PT）、脾脏厚度、门静脉
癌栓、食管胃底静脉曲张、红色征、门脉高压性胃病、腹水、腹膜炎、肝性脑病和肝
肾综合征。采用Logistic多因素回归分析HBV相关肝细胞癌并发上消化道出血的影响因
素。结果 出血组与对照组患者HBV DNA阳性率（77.8% vs 66.7%）和PLT计数（中位
数：147.87 × 109
/L vs 148.51× 109
/L）差异无统计学意义（χ
2
= 1.776，P = 0.183；U =
2009.500，P = 0.942）。出血组患者ALB水平显著低于对照组 [（31.47 ± 6.64）g/L vs
（36.24 ± 7.04）g/L]，PT显著长于对照组（中位数：17.85 s vs 16.91 s），脾脏厚度较
对照组增厚 [（47.98 ± 10.93）mm vs（43.71 ± 11.45）mm]，差异均有统计学意义
（t = -3.787，P ＜ 0.001；U = 221.500，P ＜ 0.001；t = 2.072，P = 0.040）。出血组患
者门静脉癌栓（73.3% vs 40.0%）、食管胃底静脉曲张（71.1% vs 46.7%）、红色征阳
性（42.2% vs 6.7%）、门脉高压性胃病（48.9% vs 12.2%）、腹水（77.8% vs 44.4%）、
腹膜炎（55.6% vs 22.2%）、肝性脑病（17.8% vs 3.3%）和肝肾综合征（17.8% vs
2.2%）发生率均显著高于对照组，差异有统计学意义（P均＜ 0.05）。Logistic多因
素回归分析表明，ALB（OR = 0.912，95% CI：0.852～0.977，P = 0.008）、红色征
（OR = 8.551，95% CI：2.808～26.036，P ＜ 0.001）、门静脉癌栓（OR = 4.368，
95% CI：1.761～10.834，P = 0.001）、腹膜炎（OR = 4.135，95% CI：1.877～9.109，
P ＜ 0.001）和肝性脑病（OR = 5.466，95% CI：1.282～23.313，P = 0.022）是HBV相
关肝细胞癌并发上消化道出血的独立影响因素，其中ALB为保护性因素，红色征为最
主要的独立危险因素。出血组患者病死率显著高于对照组（51.5% vs 11.1%），差异有
统计学意义（χ2 = 25.989，P ＜ 0.001）。出血组中病死者和生存者ALB水平差异无统
计学意义 [（31.11 ± 5.73）g/L vs（31.84 ± 7.59）g/L；t = -0.366，P = 0.716]，对照组
中病死者和生存者ALB水平差异也无统计学意义（中位数：32.56 g/L vs 36.70 g/L；U =
256.500，P = 0.065）。出血组和对照组患者仅合并红色征（0% vs 0%）、门静脉癌栓
（3.0% vs 11.1%）、腹膜炎（8.0% vs 5.0%）及肝性脑病（12.5% vs 0%）的病死率差异
无统计学意义（P均＞ 0.05）。结论 红色征、门静脉癌栓、腹膜炎和肝性脑病是HBV
相关肝细胞癌并发上消化道出血的独立危险因素，ALB为保护性因素。临床工作中应
尽早采取干预措施减少上消化道出血的发生，降低病死率，提高生存率。
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Abstract: Objective To analyze the influencing factors of patients with hepatitis B virus
(HBV)-related hepatocellular carcinoma complicated with upper gastrointestinal bleeding.
Methods A total of 135 cases with HBV-related hepatocellular carcinoma in Shenzhen Third
People’s Hospital from January 2014 to December 2017 were retrospectively analyzed and
divided into bleeding group (45 cases) and control group (90 cases) according to whether
complicated with upper gastrointestinal bleeding. The clinical features and outcomes of
patients in both groups were compared. The indexes included age, gender, antiviral therapy,
HBV DNA, blood platelet (PLT), albumin (ALB), prothrombin time (PT), spleen thickness,
portal vein tumor thrombus, esophageal and gastric varices, red sign, portal hypertensive
gastropathy, ascites, peritonitis, hepatic encephalopathy and hepatorenal syndrome. The
independent influencing factors of HBV-related hepatocellular carcinoma complicated with
upper gastrointestinal bleeding were analyzed by Logistic multivariate regression analysis.
Results There were no statistically significant differences of HBV DNA positive rate
(77.8% vs 66.7%) and PLT count (median: 147.87 × 109
/L vs 148.51 × 109
/L) of patients in
bleeding group and control group (χ
2
= 1.776, P = 0.183; U = 2009.500, P = 0.942). ALB
level of patients in bleeding group was lower than that in control group [(31.47 ± 6.64) g/L vs (36.24 ±
7.04) g/L], the level of PT was longer than that of control group (median: 17.85 s vs 16.91 s) and
the spleen was thicker than that of control group [(47.98 ± 10.93) mm vs (43.71 ± 11.45)
mm], the differences were statistically significant (t = -3.787, P ＜ 0.001; U = 221.500, P ＜
0.001; t = 2.072, P = 0.040). The incidence of portal vein tumor thrombus (73.3% vs 40.0%),
esophageal and gastric varices (71.1% vs 46.7%), red sign positive (42.2% vs 6.7%), portal
hypertensive gastropathy (48.9% vs 12.2%), ascites rate (77.8% vs 44.4%), peritonitis (55.6%
vs 22.2%), hepatic encephalopathy (17.8% vs 3.3%) and hepatorenal syndrome (17.8% vs
2.2%) of patients in bleeding group were significantly higher than those in control group,
the differences were statistically significant (all P ＜ 0.05). Logistic multivariate regression
analysis showed that ALB (OR = 0.912, 95% CI: 0.852～0.977, P = 0.008), red sign (OR = 8.551,
95% CI: 2.808～26.036, P ＜ 0.001), portal vein tumor thrombus (OR = 4.368, 95% CI:
1.761～10.834, P = 0.001), peritonitis (OR = 4.135, 95% CI: 1.877～9.109, P ＜ 0.001) and
hepatic encephalopathy (OR = 5.466, 95% CI: 1.282～23.313, P = 0.022) were independent
influencing factors of HBV-related hepatocellular carcinoma complicated with upper
gastrointestinal bleeding. ALB was a protective factor and red sign was the most important
independent influencing factor. The mortality of the bleeding group was higher than that
of the control group (51.5% vs 11.1%), and the difference was statistically significant (χ2 =
25.989, P ＜ 0.001). There was no significant difference in ALB level between dead patients
and survivors in bleeding group [(31.11 ± 5.73) g/L vs (31.84 ± 7.59) g/L; t = -0.366, P =
0.716]. There was no significant difference in ALB level between dead patients and survivors
in control group (median: 32.56 g/L vs 36.70 g/L; U = 256.500, P = 0.065). There were no
significant differences in the fatality rate of patients with red sign (0% vs 0%), portal vein
tumor thrombus (3.0% vs 11.1%), peritonitis (8.0% vs 5.0%), and hepatic encephalopathy
(12.5% vs 0%) in bleeding group and control group (all P ＞ 0.05). Conclusions Red sign,
portal vein tumor thrombus, peritonitis and hepatic encephalopathy were independent risk
factors of HBV-related hepatocellular carcinoma complicated with upper gastrointestinal
bleeding, while ALB was a protective factor. Clinical interventions should be taken as soon
as possible to reduce the occurrence of upper gastrointestinal bleeding, thereby reducing
mortality and improving survival rate.
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