鼻胆管造影对经内镜逆行胰胆管造影取石术后结石残留的诊断价值及结石残留相关因素分析
DOI: 10.3969/j.issn.1001-5256.2021.04.028
Value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography and related factors of residual common bile duct stones
-
摘要:
目的 评价经鼻胆管造影对经内镜逆行胰胆管造影(ERCP)术后残留胆总管结石的诊断价值,分析残留结石的相关危险因素。 方法 回顾性分析2018年1月1日—2019年12月31日在北京大学第一医院完成ERCP取石及内镜下鼻胆管引流术后鼻胆管造影的病例资料。计数资料组间比较采用χ2检验。运用logistic回归分析结石残留的独立危险因素。 结果 366例患者完成ERCP取石及鼻胆管造影,27例可疑残留结石,再次ERCP证实其中25例为结石残留(残留组),另341例无残留(无残留组)。ERCP胆管取石后结石残留率为6.8%(25/366),鼻胆管造影对胆总管残留结石的阳性预测值为92.6%(25/27)。单因素分析结果显示:多发结石、胆总管直径≥1.5cm、机械碎石在两组间的差异有统计学意义(χ2值分别为5.014、7.651、9.670,P值均 < 0.05)。多因素logistic回归分析显示,多发结石(OR=2.713, 95%CI: 1.002~7.345, P=0.049)、机械碎石(OR=9.183, 95%CI: 2.347~35.925, P=0.001)是结石残留的独立危险因素。 结论 术后鼻胆管造影是发现胆总管残留结石的有效手段。多发结石和术中使用机械碎石是结石残留的独立危险因素。 -
关键词:
- 胆石 /
- 胰胆管造影术, 内窥镜逆行 /
- 引流术
Abstract:Objective To investigate the value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography (ERCP) and the risk factors for residual stones. Methods A retrospective analysis was performed for the clinical data of the patients who underwent ERCP and nasobiliary cholangiography after endoscopic nasobiliary drainage in Peking University First Hospital from January 1, 2018 to December 31, 2019. The chi-square test was used for comparison of categorical data between groups, and a logistic regression analysis was used to investigate independent risk factors for residual stones. Results A total of 366 patients underwent ERCP and nasobiliary cholangiography and 27 patients were suspected to have residual stones, among whom 25 had residual stones confirmed by ERCP. The rate of residual stones after ERCP was 6.8% (25/366), and nasobiliary cholangiography had a positive predictive value of 92.6% (25/27) in predicting residual common bile duct stones. The univariate analysis showed that there were significant differences between the two groups in multiple stones, common bile duct diameter ≥1.5 cm, and mechanical lithotripsy (χ2=5.014, 7.651, and 9.670, all P < 0.05). The multivariate logistic regression analysis showed that multiple stones (odds ratio [OR]=2.713, 95% confidence interval [CI]: 1.002-7.345, P=0.049) and mechanical lithotripsy (OR=9.183, 95% CI: 2.347-35.925, P=0.001) were independent risk factors for residual stones. Conclusion Post-ERCP nasobiliary cholangiography is an effective method to detect residual common bile duct stones. Multiple stones and mechanical lithotripsy during ERCP are independent risk factors for residual stones. -
Key words:
- Gallstones /
- Cholangiopancreatography, Endoscopic Retrograde /
- Drainage
-
表 1 ERCP取石后结石残留的单因素分析
因素 无残留组(n=341) 残留组(n=25) χ2值 P值 性别(例) 0.111 0.739 男 189 13 女 152 12 年龄(例) 0.615 0.433 < 60岁 85 8 ≥60岁 256 17 首次ERCP(例) 0.465 0.495 是 282 22 否 59 3 结石数目(例) 5.014 0.045 单发 180 8 多发 161 17 胆囊结石(例) 0.015 0.903 无 168 12 有 173 13 胆总管直径(例) 7.651 0.006 < 1.5 cm 299 17 ≥1.5 cm 42 8 乳头打开方式(例) 0.105 0.746 单纯切开 112 9 切开+扩张 229 16 机械碎石(例) 9.670 0.002 是 11 4 否 330 21 表 2 ERCP术后发生结石残留的多因素logistic回归分析
因素 B值 SE Wald P值 OR 95%CI 多发结石 -0.998 0.508 3.860 0.049 2.713 1.002~7.345 胆总管直径≥1.5 cm 0.281 0.527 0.285 0.593 1.325 0.472~3.722 机械碎石 2.217 0.696 10.149 0.001 9.183 2.347~35.925 -
[1] FREEMAN ML, NELSON DB, SHERMAN S, et al. Complications of endoscopic biliary sphincterotomy[J]. N Engl J Med, 1996, 335(13): 909-918. DOI: 10.1056/NEJM199609263351301. [2] PRAT F, MALAK NA, PELLETIER G, et al. Biliary symptoms and complications more than 8 years after endoscopic sphincterotomy for choledocholithiasis[J]. Gastroenterology, 1996, 110(3): 894-899. DOI: 10.1053/gast.1996.v110.pm8608900. [3] HAWES RH, COTTON PB, VALLON AG. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy[J]. Gastroenterology, 1990, 98(4): 1008-1012. DOI: 10.1016/0016-5085(90)90026-w. [4] ANDO T, TSUYUGUCHI T, OKUGAWA T, et al. Risk factors for recurrent bile duct stones after endoscopic papillotomy[J]. Gut, 2003, 52(1): 116-121. DOI: 10.1136/gut.52.1.116. [5] PASPATIS GA, PARASKEVA K, VARDAS E, et al. Long-term recurrence of bile duct stones after endoscopic papillary large balloon dilation with sphincterotomy: 4-year extended follow-up of a randomized trial[J]. Surg Endosc, 2017, 31(2): 650-655. DOI: 10.1007/s00464-016-5012-9. [6] KONSTANTAKIS C, TRIANTOS C, THEOPISTOS V, et al. Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones[J]. World J Gastrointest Endosc, 2017, 9(1): 26-33. DOI: 10.4253/wjge.v9.i1.26. [7] TSUCHIYA S, TSUYUGUCHI T, SAKAI Y, et al. Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy[J]. J Gastroenterol Hepatol, 2008, 23(10): 1590-1595. DOI: 10.1111/j.1440-1746.2008.05458.x. [8] YANG JJ, LIU XC, CHEN XQ, et al. Clinical value of DPOC for detecting and removing residual common bile duct stones (video)[J]. BMC Gastroenterol, 2019, 19(1): 135. DOI: 10.1186/s12876-019-1045-6. [9] SEJPAL DV, TRINDADE AJ, LEE C, et al. Digital cholangioscopy can detect residual biliary stones missed by occlusion cholangiogram in ERCP: A prospective tandem study[J]. Endosc Int Open, 2019, 7(4): e608-e614. DOI: 10.1055/a-0842-6450. [10] PIERCE RA, JONNALAGADDA S, SPITLER JA, et al. Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP[J]. Surg Endosc, 2008, 22(11): 2365-2372. DOI: 10.1007/s00464-008-9785-3. [11] YU JF, HAO JY, WU DF, et al. Comparison between endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage in treatment of acute cholangitis[J]. Chin J Dig Endosc, 2019, 36(3): 169-175. DOI: 10.3760/cma.j.issn.1007-5232.2019.03.004.于剑锋, 郝建宇, 吴东方, 等. 经内镜胆道内支架放置术和鼻胆管引流术治疗各级急性胆管炎的效果比较[J]. 中华消化内镜杂志, 2019, 36(3): 169-175. DOI: 10.3760/cma.j.issn.1007-5232.2019.03.004. [12] MA M, ZHOU ZY. A comparative analysis of acute pancreatitis and hyperamylasemia after endoscopic retrograde cholangiopancreatography[J]. J Clin Hepatol, 2020, 36(2): 395-398. DOI: 10.3969/j.issn.1001-5256.2020.02.033.马敏, 周中银. 经内镜逆行胰胆管造影术后急性胰腺炎与高淀粉酶血症对比观察[J]. 临床肝胆病杂志, 2020, 36(2): 395-398. DOI: 10.3969/j.issn.1001-5256.2020.02.033. [13] ZHANG C, YANG YL, LI JY, et al. Application of X-ray assisted nasal catheter extractor to nose biliary oronasal conversion[J]. Chin J Dig Endosc, 2018, 35(3): 167-170. DOI: 10.3760/cma.j.issn.1007-5232.2018.03.004.张诚, 杨玉龙, 李婧伊, 等. X线辅助鼻导管取出器在鼻胆管口鼻转换中的应用研究[J]. 中华消化内镜杂志, 2018, 35(3): 167-170. DOI: 10.3760/cma.j.issn.1007-5232.2018.03.004. [14] AHN DW, LEE SH, PAIK WH, et al. Effects of saline irrigation of the bile duct to reduce the rate of residual common bile duct stones: A multicenter, prospective, randomized study[J]. Am J Gastroenterol, 2018, 113(4): 548-555. DOI: 10.1038/ajg.2018.21. [15] CAIRNS SR, DIAS L, COTTON PB, et al. Additional endoscopic procedures instead of urgent surgery for retained common bile duct stones[J]. Gut, 1989, 30(4): 535-540. DOI: 10.1136/gut.30.4.535. [16] LIU YB, WU SD, TANG SS. Clinical study on observing common bile duct residual stones by saline injection through ENBD under the guidance of ultrasound[J]. Chin J Min Inv Surg, 2017, 17(11): 990-994. DOI: 10.3969/j.issn.1009-6604.2017.11.008.刘彦伯, 吴硕东, 唐少珊. 超声下经ENBD注入生理盐水辅助观察胆总管残余结石的临床研究[J]. 中国微创外科杂志, 2017, 17(11): 990-994. DOI: 10.3969/j.issn.1009-6604.2017.11.008. 期刊类型引用(37)
1. 李容容,苟悦,刘宁宁,陈日润,孙鑫,刘成海. 基于临床数据挖掘的中药对抗肿瘤药物相关肝损伤的影响及用药规律探讨. 时珍国医国药. 2024(01): 243-247 . 百度学术
2. 张倩茹,卢颖,张婉婷,杨艳. 某院急性白血病患者药源性肝损伤临床治疗的回顾性分析. 遵义医科大学学报. 2024(04): 401-407 . 百度学术
3. 中华医学会,中华医学会杂志社,中华医学会肝病分会药物性肝病学组,中华医学会全科医学分会,中华医学会《中华全科医师杂志》编辑委员会,中国医药生物技术协会药物性肝损伤防治技术专业委员会,中国初级卫生保健基金会药物肝脏安全性专业委员会,中国药物性肝损伤基层诊疗与管理指南制定专家组. 中国药物性肝损伤基层诊疗与管理指南(2024年). 中华全科医师杂志. 2024(08): 813-830 . 百度学术
4. 郑晖,孙蓉. 药物联合应用对中草药相关肝损伤的影响. 临床肝胆病杂志. 2024(08): 1519-1524 . 本站查看
5. 李容容,李盟,苟悦,罗琼,吕桦,孙鑫,刘成海. 113例抗肿瘤药物相关肝损伤的临床特点及危险因素分析. 中国药物警戒. 2023(05): 505-510 . 百度学术
6. 中国医药生物技术协会药物性肝损伤防治技术专业委员会,中华医学会肝病学分会药物性肝病学组. 中国药物性肝损伤诊治指南(2023年版). 中华肝脏病杂志. 2023(04): 355-384 . 百度学术
7. 程诗思,杨成明,曾安津. 荆州地区结核病专科医院抗结核药物不良反应分析. 临床合理用药. 2023(22): 147-150 . 百度学术
8. 江程,李春晓,杨玉晴,郭静. 热毒宁注射液上市后临床安全性文献研究. 中国药事. 2023(11): 1252-1265 . 百度学术
9. 王双双,熊清芳,胡一帆,陈妙洋,杨永峰. 药物性肝损伤的临床与病理特点分析. 肝脏. 2023(11): 1280-1284 . 百度学术
10. 孟尧,张萌萌,郭甜甜,赵新颜. 《中国药物性肝损伤诊治指南(2023年版)》更新要点解读. 中国肝脏病杂志(电子版). 2023(04): 1-5 . 百度学术
11. 马世武,刘成海,刘晓琰,苏明华,李东良,李异玲,陈公英,陈军,陈金军,茅益民,赵景民,郭晓燕,唐洁婷,诸葛宇征,谢青,谢雯,赖荣陶,蔡大川,蔡庆贤. 中国药物性肝损伤诊治指南(2023年版). 胃肠病学. 2023(07): 397-431 . 百度学术
12. 孙晓楠,吕萌,程国亭. 药物性肝损伤139例回顾性分析. 中南医学科学杂志. 2022(03): 391-394 . 百度学术
13. 李娜. 肺癌患者化疗后药物性肝损伤的临床特点. 中国医药指南. 2022(16): 22-25 . 百度学术
14. 劳明珠. 异甘草酸镁治疗抗肿瘤药物引起的急性药物性肝损伤临床效果和安全性. 临床合理用药杂志. 2022(17): 84-87 . 百度学术
15. 马万龙,焦运,张旭,丁向春,张平,欧阳花,王梦甜,张乐,徐灵博,杨安宁,姜怡邓. 血清IL-6在人工肝治疗药物性肝损伤预后评估中的价值. 宁夏医科大学学报. 2022(06): 622-629 . 百度学术
16. 沈婷婷,李光耀,罗琼,李盟,孙鑫,陶艳艳,周祖山,刘成海. 类风湿性关节炎患者应用雷公藤制剂及合并用药所致药物性肝损伤的临床特征分析. 临床肝胆病杂志. 2022(09): 2067-2072 . 本站查看
17. 马世武,刘成海,刘晓琰,苏明华,李东良,李异玲,陈公英,陈军,陈金军,茅益民,赵景民,郭晓燕,唐洁婷,诸葛宇征,谢青,谢雯,赖荣陶,蔡大川,蔡庆贤. 中国药物性肝损伤诊治指南(2023年版). 胃肠病学. 2022(06): 341-375 . 百度学术
18. 汪涛,王学伟,蒋元烨,曹勤,季光. 162例药物性肝损伤患者分析. 肝脏. 2021(03): 243-246 . 百度学术
19. 王艳,王昱,王岚,田秋菊,杨瑞园,李柯鑫,刘立伟,王晓明,王宇,欧晓娟,贾继东,赵新颜. 中草药与西药致药物性肝损伤的临床特征及其预后的对比研究. 肝脏. 2021(04): 364-369 . 百度学术
20. 杨焕芝,李兴德,陈学平,张仲安,钱彦华,蒋潇,徐艳琼,宋沧桑. 93例药物性肝损伤患者临床特征分析. 中国药业. 2021(15): 122-125 . 百度学术
21. 何婷婷,王丽苹,任璐彤,崔延飞,柏兆方,郭玉明,宫嫚,王睿林. 中西药肝损伤临床及病理特征分析. 肝脏. 2021(09): 962-967 . 百度学术
22. 刘秀兰,李为,郭敏,杜金凤,刘东,李娟. 药物性肝损伤相关医疗损害案例分析. 药物流行病学杂志. 2021(11): 729-734 . 百度学术
23. 陈凯霞,赵广玉,印登阳,陈宏俊,黄继勋. 三种保肝药治疗化疗引起的DILI的药物经济学评价. 中国实用医药. 2021(35): 188-191 . 百度学术
24. 罗琼,朱哿瑞,顾宏图,刘坤,陈高峰,邢枫,陶艳艳,刘成海. 50例中草药与西药致药物性肝损伤患者的肝组织病理学特点比较. 临床肝胆病杂志. 2020(03): 596-601 . 本站查看
25. 蔡春梅. 妊娠早期肝功能异常60例的病因分析及干预. 中国城乡企业卫生. 2020(06): 100-102 . 百度学术
26. 周力. 中西药所致药物性肝损伤临床及病理特点研究. 临床医药文献电子杂志. 2020(39): 56 . 百度学术
27. 纪童童,陆海英,谭宁,于岩岩,徐小元. 急、慢性药物性肝损伤临床特征的对比分析. 临床肝胆病杂志. 2020(07): 1556-1561 . 本站查看
28. 何文昌,张克恭,赵凡惠,郭芮杉,高禄化,黄长形,王临旭. 290例药物性肝损伤患者临床特征分析. 实用肝脏病杂志. 2020(04): 540-543 . 百度学术
29. 李梁,陶应敏,张学敏,谢娟,陈园. 药物性肝损伤患者外周血清HIF1α和COX-2定量检测的临床价值. 肝脏. 2020(08): 848-852 . 百度学术
30. 李卉,张宏亮,杨天燕,黄振光,刘滔滔,韦芳. 我院125例抗结核药物不良反应报告分析. 中国医药导报. 2020(29): 151-154 . 百度学术
31. 姜正艳,郑亮. 异甘草酸镁治疗药物性肝损伤临床疗效观察. 世界最新医学信息文摘. 2019(07): 123 . 百度学术
32. 张惠娟,史祖宣,赵兰芳,高天慧,李健. 56例抗肿瘤药物致肝损伤临床特点分析. 临床肝胆病杂志. 2019(03): 574-578 . 本站查看
33. 梁栋,董晓锋,张燕,朱晓红,王建斌,刘妲妲,柳伟伟,方圆,王全楚. 98例药物性肝损伤的临床特点及诊疗体会. 肝脏. 2019(04): 389-391 . 百度学术
34. 黄波,张炜. 喜炎平注射液联合还原型谷胱甘肽治疗重症烧伤后急性肝功能损伤临床研究. 创伤与急危重病医学. 2019(03): 156-159 . 百度学术
35. 郭立杰,张海丛,叶立红,王超,杜婧,伍彦辉. 中西药所致药物性肝损伤临床及病理特点分析. 临床误诊误治. 2019(08): 28-33 . 百度学术
36. 吴宇宇,袁苏榆,孙四珍,王岁晶,丁洋. 药物性肝损伤诊断治疗进展概述. 药物流行病学杂志. 2018(08): 550-555 . 百度学术
37. 王建青,叶珺,郜玉峰,杨利琦. 106例药物性肝损伤患者用药回顾性调查. 中国医院药学杂志. 2018(18): 1967-1970 . 百度学术
其他类型引用(11)
-