超声引导下经皮肝穿刺活检在肝病诊断中的意义

杨文霞; 张静怡; 杨娴; 唐映梅

doi:10.3969/j.issn.1001-5256.2022.07.024

超声引导下经皮肝穿刺活检在肝病诊断中的意义

DOI: 10.3969/j.issn.1001-5256.2022.07.024

昆明医科大学第二附属医院消化内科，昆明 650032

基金项目:

国家自然科学基金项目 (81660102);

云南省科技厅科技计划项目 (2018FE001[-051]);

昆明医科大学研究生创新基金项目 (2021S050)

伦理学声明：本研究方案于2021年8月13日经由昆明医科大学第二附属医院医学伦理委员会审批，批号：审-PJ-2021-128。

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：杨文霞负责课题设计，资料分析，撰写论文；张静怡、杨娴参与收集数据，修改论文；唐映梅负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
唐映梅，tangyingmei_med@kmmu.edu.cn

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出版历程
- 收稿日期: 2021-12-06
- 录用日期: 2022-01-06
- 出版日期: 2022-07-20

Clinical significance of ultrasound-guided percutaneous liver biopsy in the diagnosis of liver diseases

Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming 650032, China

Research funding:

National Natural Science Foundation of China (81660102);

Science and Technology Project of Science and Technology Department of Yunnan Province (2018FE001[-051]);

Postgraduate Innovation Foundation of Kunming Medical University (2021S050)

More Information

Corresponding author: TANG Yingmei, tangyingmei_med@kmmu.edu.cn(ORCID: 0000-0002-0731-4198)

摘要

摘要: 目的了解超声引导下经皮肝穿刺活检的疾病构成，以及肝穿刺在不同肝病中的诊断效能。方法收集2015年5月—2020年7月于昆明医科大学第二附属医院病理科行肝穿刺活检患者共918例，收集患者病理诊断和临床诊断资料，以临床诊断为标准，分析疾病构成比以及不同性别、年龄(＜60岁、≥60岁)的疾病构成差异，统计肝穿刺诊断各型常见肝病的灵敏度、特异度、准确度、阳性预测值、阴性预测值、假阳性率和假阴性率。计数资料采用χ²检验或Fisher确切概率法进行组间比较。结果 918例肝穿刺活检患者中，最常见的疾病依次为：恶性肿瘤(282例，30.72%)，自身免疫性肝病(AILD)(139例，15.14%)，慢性乙型肝炎(CHB)(118例，12.85%)，药物性肝损伤(DILI)(49例，5.34%)、代谢相关性脂肪性肝病(MAFLD)(34例，3.70%)，肝脓肿(26例，2.83%)，良性肿瘤(18例，1.96%)，寄生虫感染(18例，1.96%)，酒精性肝病(ALD)(9例，0.98%)等；恶性肿瘤、CHB、ALD、肝脓肿比例男性高于女性(χ²值分别为31.67、19.61、4.68，P值均＜0.05)，AILD、DILI、寄生虫感染比例女性高于男性(χ²值分别为58.60、7.91、6.60，P值均＜0.05)；＜60岁的患者恶性肿瘤、CHB、AILD、MAFLD比例高于≥60岁的患者(χ²值分别为105.90、7.58、20.03、6.97，P值均＜0.01)。肝穿刺诊断各型肝病的准确度、特异度、阳性预测值和阴性预测值均接近100%，但灵敏度及假阴性率存在差异，恶性肿瘤、良性肿瘤、寄生虫感染灵敏度分别为93.26%、100%、94.40%，CHB、AILD、DILI灵敏度分别为87.29%、77.70%、76.60%，假阴性率分别为12.71%、22.30%、23.40%；MAFLD、ALD灵敏度分别为42.31%、44.44%，其假阴性率分别达57.69%、55.56%。结论肝穿刺主要疾病构成为肝脏恶性肿瘤、AILD、CHB、DILI、MAFLD等，肝穿刺对各型肝病均具有重要诊断价值，对恶性肿瘤、良性肿瘤、寄生虫感染具有较高诊断效能，CHB、AILD、DILI存在一定假阴性率，MAFLD、ALD诊断效能一般，临床应结合病史、临床特征、有无其他肝损伤等综合判断。
- 肝疾病 /
- 活组织检查, 针吸 /
- 超声检查 /
- 病理学 /
- 诊断
Abstract: Objective To investigate the disease constitution of ultrasound-guided percutaneous liver biopsy and its diagnostic efficacy in different liver diseases. Methods A total of 918 patients who underwent liver biopsy in Department of Pathology, The Second Affiliated Hospital of Kunming Medical University, from May 2015 to July 2020 were enrolled, and the data on pathological diagnosis and clinical diagnosis were collected. With clinical diagnosis as the criteria, the constitution ratio of liver diseases and the difference in disease constitution between sexes and ages (< 60 or ≥60 years) were analyzed, and a statistical analysis was performed for liver biopsy in the diagnosis of common liver diseases in terms of sensitivity, specificity, accuracy, positive predictive value, negative predictive value, false positive rate, and false negative rate. The chi-square test or the Fisher's exact test was used for comparison of categorical data between groups. Results In the 918 patients undergoing liver biopsy, the most common diseases included malignant tumor in 282 patients (30.72%), autoimmune liver disease (AILD) in 139 patients (15.14%), chronic hepatitis B (CHB) in 118 patients (12.85%), drug-induced liver injury (DILI) in 49 patients (5.34%), metabolic associated fatty liver disease (MAFLD) in 34 patients (3.70%), liver abscess in 26 patients (2.83%), benign tumor in 18 patients (1.96%), parasitic infection in 18 patients (1.96%), and alcoholic liver disease (ALD) in 9 patients (0.98%). For malignant tumor, CHB, ALD, and liver abscess, the proportion of male patients was significantly higher than that of female patients (χ²=31.67, 19.61, and 4.68, all P < 0.05), and for AILD, DILI, and parasitic infection, the proportion of female patients was significantly higher than that of male patients (χ²=58.60, 7.91, and 6.60, all P < 0.05). Compared with the patients aged ≥60 years, the patients aged < 60 years had significantly higher proportions of patients with malignant tumor, CHB, AILD, and MAFLD (χ²=105.90, 7.58, 20.03, and 6.97, all P < 0.01). The accuracy, specificity, positive predictive value, and negative predictive value of liver biopsy were all close to 100% in the diagnosis of various liver diseases, but with differences in sensitivity and false negative rate; liver biopsy had a sensitivity of 93.26%, 100%, and 94.40%, respectively, in the diagnosis of malignant tumor, benign tumor, and parasitic infection, while it had a sensitivity of 87.29%, 77.70%, and 76.60%, respectively, in the diagnosis of CHB, AILD, and DILI, with a false negative rate of 12.71%, 22.30%, and 23.40%, respectively; liver biopsy had a sensitivity of 42.31% and 44.44%, respectively, in the diagnosis of MAFLD and ALD, with a false negative rate of 57.69% and 55.56%. Conclusion The main disease constitution of liver biopsy includes malignant liver tumor, AILD, CHB, DILI, and MAFLD. Liver biopsy has an important diagnostic value in various types of liver diseases, with a relatively high diagnostic efficacy in malignant tumor, benign tumor, and parasitic infection, while it also has a certain false negative rate in CHB, AILD, and DILI and a fair diagnostic efficacy in MAFLD and ALD. Therefore, a comprehensive judgment should be given with reference to medical history, clinical features, and the presence or absence of other types of liver injury.
- Liver Diseases /
- Biopsy, Needle /
- Ultrasonography /
- Pathology /
- Diagnosis

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图 1 肝淀粉样变性组织学表现

注：男，42岁，肝穿刺确诊为肝淀粉样变性。a, 肝组织胞外大量淀粉样物质沉积，呈均质粉红色，伴肝细胞萎缩(HE染色，×100)；b, 刚果红染色阳性，呈橘红色(×100)。

Figure 1. Histology of hepatic amyloidosis

下载: 全尺寸图片幻灯片

图 2 SLE累及肝脏组织学表现

注：男，46岁，SLE累及肝脏。a, 肝细胞大泡性和小泡性脂肪变性(HE染色，×100)；b, 汇管区肉芽肿形成(HE染色，×100)；c, CK-7免疫组化染色示细胆管反应(×100)。

Figure 2. Histologic features of liver involvement in SLE

下载: 全尺寸图片幻灯片

图 3 PEcoma病理学表现

注：女，66岁，经肝穿刺诊断为PEcoma。a, 肿瘤细胞呈巢状排列(HE染色，×40)；b, 肿瘤细胞由上皮样细胞构成，胞质稀薄、嗜酸性(HE染色，×100)；c, 免疫组化表达黑素细胞标志物HMB45(×40)；d, CD34免疫组化染色示肿瘤内部血管丰富(×40)。

Figure 3. Pathology of PEcoma

下载: 全尺寸图片幻灯片

图 4 硬化性血管瘤病理学表现

注：女，60岁，肝穿刺提示硬化性血管瘤。a, 显著纤维化、玻变的结节样背景中，见残存的狭窄及闭塞血管(HE染色，×100)；b, CD34免疫组化示血管间隙(×40)。

Figure 4. Pathology of sclerosing hemangioma

下载: 全尺寸图片幻灯片

表 1 918例肝穿刺活检患者肝病构成及性别、年龄分布

Table 1. Composition, sex and age distribution of liver diseases in 918 patients with liver biopsy

临床诊断	例数(%)	男/女(例)	年龄范围(岁)	平均年龄(岁)
恶性肿瘤	282(30.72)	186/96	26~85	58.97±11.25
AILD	139(15.14)	31/108	15~69	48.83±10.66
CHB	118(12.85)	84/34	17~67	41.27±11.52
DILI	49(5.34)	16/33	13~76	45.27±15.42
MAFLD	34(3.70)	13/21	12~65	39.00±13.96
肝脓肿	26(2.83)	19/7	20~67	49.04±12.40
寄生虫感染	18(1.96)	4/14	16~65	41.50±15.31
良性肿瘤	18(1.96)	7/11	23~60	40.22±14.06
ALD	9(0.98)	9/0	23~68	43.56±12.28
慢性丙型肝炎	7(0.76)	7/0	42~62	46.71±6.90
结核	5(0.54)	1/4	22~55	35.60±13.63
系统性疾病累及肝脏	6(0.65)	5/1	14~72	44.67±20.23
血管性肝病	4(0.44)	2/2	25~64	47.25±16.24
遗传代谢性肝病	3(0.33)	3/0	18~64	41.67±23.03
慢性肝炎(隐源性)	48(5.23)	15/33	12~80	47.46±15.48
肝硬化(隐源性)	19(2.07)	9/10	18~65	47.00±12.04
其他肝病(胆囊结石、胆囊炎等)	26(2.83)	14/12	16~76	47.52±17.20
不明肝病(非特异性诊断、提示性诊断未明)	107(11.66)	54/53	10~81	45.53±14.41
注：AILD, 自身免疫性肝病; CHB, 慢性乙型肝炎; DILI, 药物性肝损伤; MAFLD, 代谢相关性脂肪性肝病; ALD, 酒精性肝病。

下载: 导出CSV

表 2 各型肝病肝穿刺活检与临床诊断结果比较

Table 2. Comparison of liver biopsy and clinical diagnosis of liver diseases

疾病	灵敏度(%)	特异度(%)	准确度(%)	阳性预测值(%)	阴性预测值(%)	假阳性率(%)	假阴性率(%)
恶性肿瘤	93.26	100	97.93	100	97.10	0	6.74
良性肿瘤	100	100	100	100	100	0	0
寄生虫感染	94.40	100	99.89	100	99.89	0	5.56
CHB	87.29	100	98.37	100	98.16	0	12.71
AILD	77.70	100	96.62	100	96.17	0	22.30
DILI	76.60	99.77	98.58	94.74	98.98	0.23	23.40
MAFLD	42.31	100	98.37	100	98.35	0	57.69
ALD	44.44	100	99.46	100	99.45	0	55.56

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