PDF下载 ( 1784 KB)
恶性肿瘤相关肝脓肿患者的临床特征分析
DOI: 10.3969/j.issn.1001-5256.2023.04.016
伦理学声明：本研究方案经由空军军医大学第二附属医院伦理委员会审批，批号为TDLL-第202210-01号。
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：张谷芬负责撰写论文；王临旭、毕铭辕、康文参与收集数据；张野、姚娜修改论文；汪春付、连建奇负责课题设计，资料分析，指导撰写文章并最后定稿。
-
摘要:
目的 对恶性肿瘤相关肝脓肿的临床特点进行分析和总结，早期判断病情进展，及时有效治疗。 方法 回顾性分析2005年3月—2018年7月空军军医大学第二附属医院收治的371例肝脓肿患者的临床资料。其中34例恶性肿瘤相关肝脓肿患者作为肿瘤组，按照约1∶2比例、时间匹配的原则，随机选择非恶性肿瘤相关肝脓肿患者(n=70)作为非肿瘤组，将两组的临床特点进行比较。正态分布的计量资料两组间比较采用成组t检验；非正态分布的计量资料两组间比较采用Mann-Whitney U检验；计数资料两组间比较采用χ2检验或Fisher检验。 结果 肿瘤组中肝胆系统肿瘤22例(64.7%)，胃肠道肿瘤7例(20.6%)，非消化道肿瘤5例(14.7%)。肿瘤组合并腹部手术史及肝硬化比例(44.1%、26.5%)高于较非肿瘤组(7.1%、7.1%)(χ2值分别为20.142、7.338，P值均＜0.05)；入院急性生理与慢性健康评分＞16分患者比例高于非肿瘤组(44.1% vs 15.7%, χ2=9.846，P=0.002)。肿瘤组白蛋白低于非肿瘤组[(27.2±5.2) g/L vs (30.8±2.6) g/L， t=-3.131，P=0.002]，而总胆红素显著高于非肿瘤组[54(13~313) μmol/L vs 33(7~96) μmol/L, U=1 816.0，P＜0.001]。肿瘤组以大肠埃希菌为主(23.5%)，非肿瘤组以肺炎克雷伯菌为主(27.1%)，前者两种以上细菌感染更为多见(11.8% vs 2.8%)。影像学提示肿瘤组多发脓肿更为多见(47.1% vs 24.3%，χ2=5.479，P=0.019)。与非肿瘤组相比，肿瘤组平均住院天数长(U=1 728.5，P＜0.001)、治疗失败率高(P=0.005)。 结论 恶性肿瘤相关肝脓肿多合并肝胆肿瘤，致病菌以大肠埃希菌为主，多部位脓肿较常见，预后较差。临床应选择合适抗生素，联合穿刺引流，针对高危人群，必要时可降低手术干预门槛，降低病死率。 Abstract:Objective To investigate the clinical features of malignant tumor-related pyogenic liver abscess (PLA), and to provide a basis for early judgment of disease progression and timely and effective treatment. Methods A retrospective analysis was performed for the clinical data of 371 patients with PLA who were admitted to the Second Affiliated of Air Force Medical University, from March 2005 to July 2018, among whom 34 patients with malignant tumor-related PLA were enrolled as tumor group, and after matching for time and at a ratio of 1∶2, 70 patients without malignant tumor-related PLA were enrolled as non-tumor group. Clinical features were compared between the two groups. The group t-test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between groups. Results In the tumor group, there were 22 patients with hepatobiliary tumor (64.7%), 7 patients with gastrointestinal tumor (20.6%), and 5 patients with non-gastrointestinal tumor (14.7%). Compared with the non-tumor group, the tumor group had a significantly higher proportion of patients with a history of abdominal surgery (44.1% vs 7.1%, χ2=20.142, P < 0.05), liver cirrhosis (26.5% vs 7.1%, χ2=7.338, P < 0.05), or an Acute Physiology and Chronic Health Evaluation Ⅱ score of > 16 (44.1% vs 15.7%, χ2=9.846, P=0.002). Compared with the non-tumor group in terms of laboratory examination, the tumor group had a significantly lower level of albumin [(27.2±5.2) g/L vs (30.8±2.6) g/L, t=-3.131, P=0.002] and a significantly higher level of total bilirubin [54(13~313) μmol/L vs 33(7~96) μmol/L, U=1 816.0, P < 0.001]. Escherichia coli was the main pathogen in the tumor group (23.5%), while Klebsiella pneumonia was the main pathogen in the non-tumor group (23.5%), and compared with the non-tumor group, the tumor group had a significantly higher proportion of patients infected with more than two types of bacteria (11.8% vs 2.8%). Radiological examination showed that the tumor group had a significantly higher proportion of patients with multiple abscesses than the non-tumor group (47.1% vs 24.3%, χ2=5.479, P=0.019). Compared with the non-tumor group, the tumor group had a significantly longer mean length of hospital stay (U=1 728.5, P < 0.001) and a significantly higher treatment failure rate (P=0.005). Conclusion Patients with malignant tumor-related PLA often have hepatobiliary tumor, with Escherichia coli as the main pathogen. Abscesses at multiple sites are common, and patients tend to have a poor prognosis. Appropriate antibiotics combined with percutaneous drainage should be used in clinical practice, and for the high-risk population, the threshold for surgical intervention can be lowered to reduce mortality. -
Key words:
- Liver Abscess /
- Neoplasms /
- Prognosis
-
表 1 两组患者临床资料比较
Table 1. Comparison of clinical data between PLA patients with or without tumor
项目 肿瘤组(n=34) 非肿瘤组(n=70) 统计值 P值 性别[例(%)] χ2=0.156 0.625 男 23 50 女 11 20 年龄(岁) 59.3±11.3 56.9±14.9 t=0.830 0.409 合并疾病[例(%)] 糖尿病 2(5.8) 16(22.8) 0.025 胆道疾病 8(23.5) 8(11.4) χ2=2.574 0.169 肝硬化 9(26.5) 5(7.1) χ2=7.338 0.007 心血管疾病 1(2.9) 12(17.1) 0.033 临床表现[例(%)] 发热 30(88.2) 65(92.8) 0.329 腹痛或背痛 3(8.9) 16(22.8) 0.107 消化道症状 2(5.9) 10(14.3) 0.177 腹部手术史[例(%)] 15(44.1) 5(7.1) χ2=20.142 ＜0.001 APACHEⅡ评分[例(%)] χ2=9.846 0.002 ≤16分 19(55.9) 59(84.3) ＞16分 15(44.1) 11(15.7) 复发型[例(%)] 10(29.4) 4(5.7) 0.002 脓肿数量[例(%)] χ2=5.479 0.019 单个 18(52.9) 53(75.7) 多个 16(47.1) 17(24.3) 气腔形成[例(%)] 6(17.6) 12(17.1) χ2=0.004 0.949 分隔形成[例(%)] 18(23.5) 29(41.4) χ2=1.225 0.268 直径＞5 cm[例(%)] 22(64.7) 32(45.7) χ2=1.635 0.201 微生物学特征[例(%)] 大肠杆菌感染 8(23.5) 4(5.7) 0.018 肺炎克雷伯菌感染 1(2.9) 19(27.1) 0.003 两种细菌感染 4(11.8) 2(2.8) 0.088 
下载: 导出CSV
表 2 两组患者实验室检查指标对比
Table 2. Comparison of laboratory tests between PLA patients with or without tumor
指标 肿瘤组(n=34) 非肿瘤组(n=70) 统计值 P值 白细胞计数(×109/L) 13.7±7.0 14.7±5.9 t=-0.772 0.442 中性粒细胞(%) 84.6±11.2 84.0±8.3 t=0.305 0.761 血红蛋白(g/L) 105±19 108±13 t=-0.052 0.958 ALT(U/L) 66(9~509) 67(11~724) U=1 217.5 0.849 ALP(U/L) 167(23~1 189) 156(56~678) U=1 110.5 0.582 GGT(U/L) 204(23~634) 161(45~564) U=1 388.0 0.170 总胆红素(μmol/L) 54(13~313) 33(7~96) U=1 816.0 ＜0.001 白蛋白(g/L) 27.2±5.2 30.8±2.6 t=-3.131 0.002
下载: 导出CSV
表 3 两组患者并发症发生情况的比较
Table 3. Comparison of complication between PLA patients with or without tumor
并发症 肿瘤组(n=34) 非肿瘤组(n=70) χ2值 P值 肺部感染(例) 5 18 1.610 0.204 败血症(例) 5 4 0.149 腹膜炎(例) 3 2 0.327 胸腔积液(例) 4 8 1.000 其他部位合并脓肿(例) 7 2 0.005
下载: 导出CSV
表 4 两组治疗方法及疗效转归比较
Table 4. Comparison of therapies and outcome between PLA patients with or without tumor
项目 肿瘤组(n=34) 非肿瘤组(n=70) U值 P值 治疗方法[例(%)] 0.340 单纯抗生素 2(5.8) 9(12.8) 抗生素+穿刺引流 28(82.3) 61(87.2) 抗生素+手术 4(11.9) 0 住院天数(d) 21(12~47) 16(7~32) 1 728.5 ＜0.001 无效[例(%)] 6(17.6) 1(1.4) 0.005
下载: 导出CSV
-
[1] RAHIMIAN J, WILSON T, ORAM V, et al. Pyogenic liver abscess: recent trends in etiology and mortality[J]. Clin Infect Dis, 2004, 39(11): 1654-1659. DOI: 10.1086/425616. [2] SEETO RK, ROCKEY DC. Pyogenic liver abscess. Changes in etiology, management, and outcome[J]. Medicine (Baltimore), 1996, 75(2): 99-113. DOI: 10.1097/00005792-199603000-00006. [3] YEH TS, JAN YY, JENG LB, et al. Pyogenic liver abscesses in patients with malignant disease: a report of 52 cases treated at a single institution[J]. Arch Surg, 1998, 133(3): 242-245. DOI: 10.1001/archsurg.133.3.242. [4] MAVILIA MG, MOLINA M, WU GY. The evolving nature of hepatic abscess: A review[J]. J Clin Transl Hepatol, 2016, 4(2): 158-168. DOI: 10.14218/JCTH.2016.00004. [5] XIAO J, XIN XJ. Analysis of clinical characteristics of pyogenic liver abscess patients with diabetes mellitus[J]. China Med Herald, 2021, 18(14): 128-131. https://www.cnki.com.cn/Article/CJFDTOTAL-YYCY202114032.htm肖娟, 辛小娟. 细菌性肝脓肿合并糖尿病患者的临床特征分析[J]. 中国医药导报, 2021, 18(14): 128-131. https://www.cnki.com.cn/Article/CJFDTOTAL-YYCY202114032.htm [6] LV WF, LU D, HE YS, et al. Liver abscess formation following transarterial chemoembolization: Clinical features, risk factors, bacteria spectrum, and percutaneous catheter drainage[J]. Medicine (Baltimore), 2016, 95(17): e3503. DOI: 10.1097/MD.0000000000003503. [7] de BAÈRE T, ROCHE A, AMENABAR JM, et al. Liver abscess formation after local treatment of liver tumors[J]. Hepatology, 1996, 23(6): 1436-1440. DOI: 10.1002/hep.510230620. [8] FACCIORUSSO A, DI MASO M, MUSCATIELLO N. Drug-eluting beads versus conventional chemoembolization for the treatment of unresectable hepatocellular carcinoma: A meta-analysis[J]. Dig Liver Dis, 2016, 48(6): 571-577. DOI: 10.1016/j.dld.2016.02.005. [9] LARDIÈRE-DEGUELTE S, RAGOT E, AMROUN K, et al. Hepatic abscess: Diagnosis and management[J]. J Visc Surg, 2015, 152(4): 231-243. DOI: 10.1016/j.jviscsurg.2015.01.013. [10] MUKTHINUTHALAPATI V, ATTAR BM, PARRA-RODRIGUEZ L, et al. Risk factors, management, and outcomes of pyogenic liver abscess in a us safety net hospital[J]. Dig Dis Sci, 2020, 65(5): 1529-1538. DOI: 10.1007/s10620-019-05851-9. [11] YU SL, WENG XH. Antimicrobial therapy in adult patients with bacterial liver abscess[J]. J Prac Hepatol, 2015, 18(4): 337-339. DOI: 10.3969/j.issn.1672-5069.2015.04.001.虞胜镭, 翁心华. 成人细菌性肝脓肿的抗感染治疗要点与进展[J]. 实用肝脏病杂志, 2015, 18(4): 337-339. DOI: 10.3969/j.issn.1672-5069.2015.04.001. [12] ROSSI G, NGUYEN Y, LAFONT E, et al. Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses[J]. Infection, 2022, 50(5): 1205-1215. DOI: 10.1007/s15010-022-01793-z. [13] LI W, WU C, QIN M, et al. The aura of malignant tumor: Clinical analysis of malignant tumor-related pyogenic liver abscess[J]. Medicine (Baltimore), 2020, 99(9): e19282. DOI: 10.1097/MD.0000000000019282. [14] WANG Y, WANG Y, LIU K, et al. Pyogenic liver abscess as initial presentation of colon cancer: a case report[J]. Gastroenterol Nurs, 2020, 43(6): 470-473. DOI: 10.1097/SGA.0000000000000558. [15] CHONG VH, LIM KS. Pyogenic liver abscess as the first manifestation of hepatobiliary malignancy[J]. Hepatobiliary Pancreat Dis Int, 2009, 8(5): 547-550. [16] DESALEGN H, TESFAYE A, SHUME P. Pyogenic liver abscess presenting as an initial manifestation of underlying hepatocellular cancer: A case report in ethiopia[J]. Ethiop J Health Sci, 2022, 32(3): 665-668. DOI: 10.4314/ejhs.v32i3.24. [17] ZHANG CL, GUO JJ, JIA TY, et al. Clinical and pathogenic characteristics in 75 patients with pyogenic liver abscess[J]. Infect Dis Info, 2014, 27(3): 157-159. DOI: 1007-8134(2014)03-0157-04 .[18] WANG Y, LI WK, SU JY, et al. Clinical characteristics of bacterial liver abscess and its risk factors in ICU[J]. J Clin Exp Med, 2022, 21(20): 2233-2238. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLC202220029.htm王芸, 李文坤, 苏珈仪, 等. 细菌性肝脓肿临床特征及其入住重症监护室危险因素分析[J]. 临床和实验医学杂志, 2022, 21(20): 2233-2238. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLC202220029.htm [19] XU J, ZHOU X, ZHENG C. The geriatric nutritional risk index independently predicts adverse outcomes in patients with pyogenic liver abscess[J]. BMC Geriatr, 2019, 19(1): 14. DOI: 10.1186/s12877-019-1030-5. [20] CHOK KS, CHEUNG TT, CHAN AC, et al. Liver resection for de novo hepatocellular carcinoma complicated by pyogenic liver abscess: A clinical challenge[J]. World J Surg, 2016, 40(2): 412-418. DOI: 10.1007/s00268-015-3239-6. [21] ZHUANG HX, HUANG WP. Analysis of pyogenic liver abscesses of biliary and cryptogenic origin[J]. Mod Med J China, 2017, 19(9): 23-26. DOI: 10.3969/j.issn.1672-9463.2017.09.007.庄涵虚, 黄伟平. 胆源性肝脓肿和隐源性肝脓肿临床特征分析[J]. 中国现代医药杂志, 2017, 19(9): 23-26. DOI: 10.3969/j.issn.1672-9463.2017.09.007. [22] RUIZ-HERNÁNDEZ JJ, CONDE-MARTEL A, SERRANO-FUENTES M, et al. Pyogenic liver abscesses due to Escherichia coli are still related to worse outcomes[J]. Ir J Med Sci, 2020, 189(1): 155-161. DOI: 10.1007/s11845-019-02041-4. [23] CHEN SC, TSAI SJ, CHEN CH, et al. Predictors of mortality in patients with pyogenic liver abscess[J]. Neth J Med, 2008, 66(5): 196-203. [24] YAO N, KANG W, LIAN JQ, et al. Clinical features of liver abscess versus[J]. J Clin Hepatol, 2020, 36(9): 2010-2014. DOI: 10.3969/j.issn.1001-5256.2020.09.020.姚娜, 康文, 连建奇, 等. 肺炎克雷伯菌肝脓肿与大肠埃希菌肝脓肿临床特点对比分析[J]. 临床肝胆病杂志, 2020, 36(9): 2010-2014. DOI: 10.3969/j.issn.1001-5256.2020.09.020. [25] TAN YM, CHUNG AY, CHOW PK, et al. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm[J]. Ann Surg, 2005, 241(3): 485-490. DOI: 10.1097/01.sla.0000154265.14006.47. [26] CHEN CH, WU SS, CHANG HC, et al. Initial presentations and final outcomes of primary pyogenic liver abscess: a cross-sectional study[J]. BMC Gastroenterol, 2014, 14: 133. DOI: 10.1186/1471-230X-14-133. 期刊类型引用(20)
1. 秦鹏，李树森，刘皓，吴广迎. 胃冠状静脉栓塞术在门脉高压性上消化道出血经颈静脉肝内门腔静脉分流术患者中的临床疗效. 血管与腔内血管外科杂志. 2022(09): 1130-1134 . 
百度学术2. 高绍，王宏亮，聂春晖，张岳林，周坦洋，余子牛，杨月，孙军辉. 对比TIPS联合胃冠状静脉栓塞术与单独TIPS治疗肝硬化门静脉高压伴上消化道出血的中远期疗效：Meta分析. 中国介入影像与治疗学. 2022(11): 673-677 . 百度学术3. 张大维，吴东辉，孙兴安. TIPS对肝硬化并发上消化道出血患者近期肝肾功能和远期疗效的影响. 当代医学. 2021(35): 129-130 . 百度学术4. 林纲毅，马洺远，蔡宗洋. 超声引导下门静脉穿刺导引经颈静脉肝内门体分流术联合曲张静脉栓塞治疗食管胃底静脉曲张破裂出血的临床效果. 中国当代医药. 2020(07): 113-116 . 百度学术5. 王宁，林芳明，吕明. TIPS联合GCVE用于门静脉高压并发上消化道大出血的应用价值. 肝脏. 2020(09): 952-954 . 百度学术6. 韩志强. 肝硬化上消化道出血37例外科临床治疗效果观察. 世界最新医学信息文摘. 2019(05): 95+102 . 百度学术7. 张明礼. PTVE联合PSE治疗肝硬化门脉高压并上消化道出血的观察. 实用中西医结合临床. 2019(05): 24-26 . 百度学术8. 孙允涛. 肝硬化门静脉高压并发上消化道出血的相关危险因素分析. 中国民康医学. 2019(10): 81-83 . 百度学术9. 孙巧玉，赖雪珍，河源媛. 门脉高压合并上消化道出血采用PTVE联合PSE手术的效果分析. 现代消化及介入诊疗. 2019(08): 837-841+846 . 百度学术10. 杨荣焕. TIPS和PTVE介入方法治疗肝硬化门静脉高压引起的上消化道出血的优劣差异. 黑龙江医学. 2019(09): 1012-1013+1016 . 百度学术11. 武和平. 不同介入途径胃冠状静脉栓塞术治疗肝硬化门静脉高压出血的临床疗效观察. 现代消化及介入诊疗. 2018(02): 208-210 . 百度学术12. 李广忠. 分析肝硬化门脉高压症下食管静脉曲张破裂出血的危险因素. 智慧健康. 2018(07): 91-92+126 . 百度学术13. 李贤圣，董勤勇，张乐，夏侨，贺军. 经颈静脉门静脉分流术介入治疗门静脉高压引起上消化道出血的疗效分析. 浙江创伤外科. 2018(02): 272-273 . 百度学术14. 赵晓飞，林栋栋，李宁，臧运金，郭庆良，武聚山. 门静脉高压患者脾切断流术后曲张静脉再出血的危险因素分析. 临床肝胆病杂志. 2018(10): 2182-2185 . 
本站查看15. 吴笋. 经颈静脉肝内门体静脉分流术加胃冠状静脉栓塞术治疗门脉高压症初探. 现代医用影像学. 2018(05): 1522-1523+1528 . 百度学术16. 田广俊，池晓玲，常钢，孟凡喆，曹敏玲，黎英贤，徐浩祥，梁宏才，赵朋涛，吴晓菊，萧焕明. 中药灌肠防治TIPS治疗肝硬化门静脉高压伴上消化道出血术后肝性脑病临床观察. 新中医. 2018(12): 87-91 . 百度学术17. 樊春燕，叶晓丽，戴晓婷，吴宇清. 肝硬化门静脉高压并发上消化道出血的相关性分析研究. 血管与腔内血管外科杂志. 2018(05): 381-385 . 百度学术18. 彭虹. 肝硬化门静脉高压并发上消化道出血的相关危险因素分析. 中国继续医学教育. 2017(31): 58-59 . 百度学术19. 张志勇. 不同手术方案治疗肝硬化门脉高压症的临床对比. 临床医药文献电子杂志. 2017(46): 8924-8925 . 百度学术20. 向平，张川，张亮科，唐瑞强，叶继彬. 1例上消化道出血病人护理体会. 世界最新医学信息文摘. 2016(14): 247 . 百度学术其他类型引用(3)
-
百度学术
