急性胰腺炎合并脂肪肝患者脂肪肝严重程度动态变化的影响因素分析

陈强; 蒋明宽; 张苗; 罗琳; 张利荣

doi:10.3969/j.issn.1001-5256.2023.06.018

急性胰腺炎合并脂肪肝患者脂肪肝严重程度动态变化的影响因素分析

DOI: 10.3969/j.issn.1001-5256.2023.06.018

陈强¹,
蒋明宽²,
张苗¹,
罗琳¹,
张利荣^1, , ,

1.
内蒙古科技大学包头医学院第一附属医院医学影像科，内蒙古包头 014010
2.
蚌埠医学院第一附属医院放射科，安徽蚌埠 233004

基金项目:

包头医学院青苗计划项目 (BYJJ-QM-201753)

伦理学声明：本研究方案于2021年11月24日经由包头医学院第一附属医院伦理委员会审批，批号：20200011。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：张利荣、陈强负责课题设计；蒋明宽、张苗负责资料收集整理；陈强、蒋明宽负责数据分析；陈强、罗琳负责撰写论文；罗琳、张利荣参与修改论文；张利荣负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
张利荣，yfyz_1466@163.com (ORCID: 0000-0002-6295-0605)

计量
- 文章访问数: 305
- HTML全文浏览量: 51
- PDF下载量: 25
- 被引次数: 0
出版历程
- 收稿日期: 2022-10-23
- 录用日期: 2022-11-29
- 出版日期: 2023-06-20

Influencing factors for dynamic changes in the severity of fatty liver in patients with acute pancreatitis and fatty liver

1.
Department of Medical Imaging, The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, Inner Mongolia Autonomous Region 014010, China
2.
Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China

Research funding:

Seedling Project of Baotou Medical College (BYJJ-QM-201753)

More Information

Corresponding author: ZHANG Lirong, yfyz_1466@163.com (ORCID: 0000-0002-6295-0605)

摘要

摘要: 目的探讨急性胰腺炎(AP)合并脂肪肝(FLAP)患者脂肪肝(FL)动态变化规律及其影响因素。方法选取内蒙古科技大学包头医学院第一附属医院2017年12月—2021年12月收治的136例FLAP患者为研究对象。以入院后首次CT检查为研究起点，出院前最后一次CT检查为研究终点，根据患者FL的变化程度将研究对象分为FL加重组、FL轻度缓解组和FL明显缓解组。比较各组患者一般资料及临床资料的差异。一般资料包括：年龄、性别、住院时间、AP病因以及患者的体质量变化和体温变化等；临床资料包括治疗方式以及实验室指标和AP严重程度的变化。计数资料组间比较采用χ²检验或Fisher精确概率法。符合正态分布的计量资料多组间比较采用单因素方差分析，进一步两两比较采用LSD-t检验；不符合正态分布的计量资料多组间比较采用Kruskal-Wallis H检验，并以Bonferroni校正的Mann-Whitney U检验进行组间两两比较。数据的动态变化以其在研究终点与研究起点的差值表示，采用协方差分析进行动态变化数据的比较。采用Spearman相关检验进行差异指标与FL变化程度的相关性分析。结果 136例FLAP患者中61例在研究终点表现为FL轻度缓解，59例表现为明显缓解，16例表现为FL加重。3组患者的住院时间(χ²=16.215，P＜0.001)以及体质量的变化(F=3.908，P=0.023)差异均有统计学意义；FL明显缓解组患者体质量降低幅度更大，住院时间更长。3组患者的禁食水天数(χ²=11.020，P=0.004)以及C反应蛋白(F=8.589，P＜0.001)、白细胞计数(F=5.448，P=0.005)和CT严重程度指数(F=7.544，P=0.001)的变化幅度差异亦均有统计学意义；FL明显缓解组患者C反应蛋白、白细胞计数和CT严重程度指数降低幅度更大且禁食水时间更长。患者的住院时间(r=0.352，P＜0.001)、禁食水天数(r=0.372，P＜0.001)以及C反应蛋白(r=-0.365，P＜0.001)和CT严重程度指数(r=-0.350，P＜0.001)的变化与FL的变化存在显著相关性。结论 FLAP患者的FL大多呈缓解趋势，其动态变化与患者C反应蛋白和CT严重程度指数的变化密切相关。
- 胰腺炎 /
- 脂肪肝 /
- 体重 /
- C反应蛋白质 /
- CT严重程度指数
Abstract: Objective To investigate the dynamic change of fatty liver (FL) in patients with fatty liver-related acute pancreatitis (FLAP) and related influencing factors. Methods A total of 136 FLAP patients who were admitted to The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, from December 2017 to December 2021 were enrolled as subjects. With the first CT examination after admission as the starting point and the last CT examination before discharge as the ending point, the subjects were divided into FL aggravation group (FLAG group), FL mild mitigation group (FLMMG group), and FL significant mitigation group (FLSMG group) according to the degree of change in FL. General information and clinical data were compared between groups. General information included age, sex, length of hospital stay, etiology of acute pancreatitis (AP), and changes in body weight and temperature, and clinical data included treatment modality and the changes in laboratory markers and AP severity. The chi-square test or the Fisher's exact test was used for comparison of categorical data between groups. A one-way analysis of variance was used for comparison of normally distributed continuous data between multiple groups, and the least significant difference t-test was used for further comparison between two groups; the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between multiple groups, and the Mann-Whitney U test with Bonferroni correction was used for further comparison between two groups. Dynamic changes of data were expressed as the difference from the starting point to the ending point, and a covariance analysis was used for comparison of data with dynamic changes. The Spearman correlation analysis was used to investigate the correlation of indices with significant changes with the degree of change in FL. Results Among the 136 FLAP patients, 61 achieved mild mitigation of FL, 59 achieved significant mitigation of FL, and 16 experienced aggravation of FL at the ending point of the study. There were significant differences between the three groups in the length of hospital stay (χ²=16.215, P < 0.001) and the change in body weight (F=3.908, P < 0.05), and the FLSMG group had a greater reduction in body weight and a longer length of hospital stay. There were also significant differences between the three groups in the number of fasting days (χ²=11.020, P=0.004) and the degree of changes in C-reactive protein (CRP) (F=8.589, P < 0.001), white blood cell count (WBC) (F=5.448, P=0.005), and CT severity index (CTSI) (F=7.544, P=0.001), and the FLSMG group had greater reductions in CRP, WBC, and CTSI and a longer duration of fasting. Length of hospital stay, number of fasting days, and changes in CRP and CTSI were significantly correlated with the change in FL (r=0.352, 0.372, -0.365, and -0.350, all P < 0.001). Conclusion Most FLAP patients tend to have mitigation of FL, and its dynamic changes are closely associated with the changes in CRP and CTSI.
- Pancreatitis /
- Fatty Liver /
- Body Weight /
- C-Reactive Protein /
- CT Severity Index

HTML全文

表 1 3组患者一般资料的比较

Table 1. Comparison of general information among three groups

项目	FL加重组 (n=16)	FL轻度缓解组 (n=61)	FL明显缓解组 (n=59)	统计值	P值
年龄(岁)	42.13±10.03	42.64±13.59	42.17±9.94	F=0.028	0.972
男性患者[例(%)]	11(68.8)	47(77.0)	40(67.8)	χ²=1.374	0.503
代谢综合征[例(%)]	10(62.5)	39(63.9)	37(62.7)	χ²=0.023	0.988
体温变化(℃)	-0.1(-0.5~0.2)	0.0(-0.3~0.2)	-0.2(-0.7~0.1)	F=2.460	0.089
住院时间(d)	13.0(10.0~30.0)¹⁾	14.0(10.0~20.0)¹⁾	20.0(14.0~29.0)	χ²=16.215	＜0.001
死亡[例(%)]	0(0.0)	2(3.3)	0(0.0)		0.608
AP病因[例(%)]
高脂血症	9(56.3)	42(68.9)	46(78.0)	χ²=3.232	0.199
胆石症	1(6.3)	4(6.6)	5(8.5)		0.907
酒精性	2(12.5)	7(11.5)	4(6.8)		0.623
其他	4(25.0)	9(14.8)	7(11.9)	χ²=1.732	0.421
既往慢性疾病[例(%)]
高血压	4(25.0)	7(11.5)	10(16.9)	χ²=1.957	0.376
糖尿病	4(25.0)	17(27.9)	18(30.5)	χ²=0.222	0.895
高脂血症	0(0.0)	5(8.2)	3(5.1)		0.672
心脑血管病	0(0.0)	2(3.3)	2(3.4)		＞0.05
注：与FL明显缓解组比较，1)P＜0.05。AP病因中有2例患者同时以胆石症和高脂血症为病因，另有2例患者同时以酒精性和高脂血症为病因；其他病因包括肿瘤诱发、术后及不明原因。既往慢性疾病泛指高血压、糖尿病、高脂血症和心脑血管病中的一种或多种。

下载: 导出CSV

表 2 3组患者实验室指标动态变化的比较

Table 2. Comparison of dynamic changes of laboratory test among three groups

实验室指标	FL加重组 (n=16)	FL轻度缓解组 (n=61)	FL明显缓解组 (n=59)	F值	P值
血淀粉酶(U/L)	-0.82(-1.00~-0.17)	-0.43(-1.04~-0.17)	-0.54(-1.06~-0.32)	0.115	0.891
血脂肪酶(U/L)	-0.73(-1.24~-0.59)	-0.63(-1.29~-0.18)	-0.74(-1.07~-0.33)	1.454	0.239
TG(mmol/L)	-0.29(-28.82~0.95)	-2.40(-8.99~0.15)	-3.10(-5.35~0.00)	0.039	0.962
TC(mmol/L)	-1.54(-6.24~-0.53)	-0.68(-4.69~0.20)	-1.46(-2.90~-0.02)	0.888	0.416
HDL(mmol/L)	-0.24(-0.43~0.12)	-0.01(-2.22~0.09)	-0.16(-0.33~0.02)	0.459	0.634
LDL(mmol/L)	-0.42(-2.12~3.23)	0.48(-0.04~1.41)	0.08(-0.88~1.71)	0.793	0.457
ALT(U/L)	-0.20(-0.41~0.46)	-0.11(-0.29~0.24)	-0.13(-0.38~0.10)	0.545	0.581
AST(U/L)	0.00(-0.24~0.25)	-0.09(-0.30~0.13)	-0.17(-0.33~-0.02)	0.120	0.887
Cr(μmol/L)	-0.04(-0.06~0.09)	0.02(-0.03~0.11)	0.00(-0.08~0.08)	0.791	0.456
WBC计数(×10⁹/L)	-2.59(-8.03~-1.06)¹⁾	-5.17(-10.68~-2.52)¹⁾	-6.75(-10.35~-1.79)	5.448	0.005
NEUT(%)	-10.60(-15.65~-7.70)	-19.35(-32.53~-8.90)	-22.15(-31.05~-12.85)	2.915	0.058
CRP(mg/L)	1.18(1.05~1.88)¹⁾²⁾	-0.49(-0.97~0.00)¹⁾	-1.10(-1.79~-0.41)	8.589	＜0.001
空腹血糖(mmol/L)	-5.70(-25.25~-1.80)	-0.95(-4.03~1.10)	-1.95(-4.40~-0.25)	0.809	0.449
注：与FL明显缓解组比较，1)P＜0.05；与FL轻度缓解组比较，2)P＜0.05。血淀粉酶、血脂肪酶、ALT、AST、Cr、CRP水平已进行了对数转换。

下载: 导出CSV

表 3 3组患者治疗方式的比较

Table 3. Comparison of treatment modalities among three groups

治疗方式	FL加重组 (n=16)	FL轻度缓解组 (n=61)	FL明显缓解组 (n=59)	χ²值	P值
禁食水(d)	7.0(5.0~12.8)¹⁾	8.0(6.0~12.0)¹⁾	13.0(9.0~20.0)	11.020	0.004
胃肠减压(d)	4.0(0~7.0)	5.0(0~9.5)	8.0(0~12.0)	5.154	0.076
流质饮食[例(%)]	3(18.8)	17(27.9)	15(25.4)	0.557	0.757
灌肠[例(%)]	2(12.5)	9(14.8)	11(18.6)	0.515	0.773
抗炎治疗[例(%)]	15(93.8)	55(90.2)	58(98.3)		0.159
A类	6(37.5)	11(18.0)	8(13.6)	4.817	0.090
B类	7(43.8)	47(77.0)²⁾	49(83.1)²⁾	10.683	0.005
C类	5(31.3)	21(34.4)	30(50.8)	4.077	0.130
B类+C类	1(6.3)¹⁾	11(18.0)¹⁾²⁾	21(35.6)	8.235	0.016
联合	3(18.8)	19(31.1)	27(45.8)	5.129	0.077
蛋白酶抑制剂[例(%)]	7(43.8)	43(70.5)	43(72.9)	5.168	0.075
胰液抑制剂[例(%)]	14(87.5)	56(91.8)	56(94.9)		0.419
保肝药[例(%)]	7(43.8)	41(67.2)	40(67.8)	3.491	0.175
注：与FL明显缓解组比较，1)P＜0.05；与FL加重组比较，2)P＜0.05。抗炎治疗联合泛指A、B、C三类药物中的任意两种或三类药物同时使用。

下载: 导出CSV

表 4 3组患者胰腺炎严重程度动态变化的比较

Table 4. Comparison of dynamic changes of severity of AP among three groups

组别	例数	炎症评分	坏死评分	CTSI评分
FL加重组	16
研究起点		3.25±0.86	0.25±0.21	3.50±1.26
研究终点		3.43±0.81	0.63±0.36	4.06±1.69
FL轻度缓解组	61
研究起点		3.52±0.81	0.33±0.15	3.85±1.21
研究终点		3.11±1.27	0.23±0.10	3.34±1.56
FL明显缓解组	59
研究起点		3.75±0.54	0.51±0.29	4.25±1.27
研究终点		2.86±1.15	0.31±0.17	3.17±1.58
F值		4.402	3.620	7.544
P值		0.014	0.029	0.001

下载: 导出CSV

参考文献(25)

[1]	LI CL, JIANG M, PAN CQ, et al. The global, regional, and national burden of acute pancreatitis in 204 countries and territories, 1990-2019[J]. BMC Gastroenterol, 2021, 21(1): 332. DOI: 10.1186/s12876-021-01906-2.
[2]	WU D, ZHANG M, XU S, et al. Nonalcoholic fatty liver disease aggravated the severity of acute pancreatitis in patients[J]. Biomed Res Int, 2019, 2019: 9583790. DOI: 10.1155/2019/9583790.
[3]	SONG Y, ZHANG P, XU SW, et al. Predictive value of CT evaluation of fatty liver for the severity of acute pancreatitis[J]. Chin J Postgrad Med, 2018, 41(8): 701-705. DOI: 10.3760/cma.j.issn.1673-4904.2018.08.008. 宋宇, 张鹏, 许尚文, 等. CT评估脂肪肝对急性胰腺炎严重程度的预测价值[J]. 中国医师进修杂志, 2018, 41(8): 701-705. DOI: 10.3760/cma.j.issn.1673-4904.2018.08.008.
[4]	MIKOLASEVIC I, ORLIC L, POROPAT G, et al. Nonalcoholic fatty liver and the severity of acute pancreatitis[J]. Eur J Intern Med, 2017, 38: 73-78. DOI: 10.1016/j.ejim.2016.10.019.
[5]	YOON SB, LEE IS, CHOI MH, et al. Impact of fatty liver on acute pancreatitis severity[J]. Gastroenterol Res Pract, 2017, 2017: 4532320. DOI: 10.1155/2017/4532320.
[6]	JIANG MK, ZHANG M, ZHANG LR, et al. Impact of fatty liver on acute pancreatitis severity and prognosis: A meta-analysis of English and Chinese studies[J]. Radiol Infect Dis, 2021, 8(4): 140-149. DOI: 10.4103/RID.RID_10_22.
[7]	VÁNCSA S, NÉMETH D, HEGYI P, et al. Fatty liver disease and non-alcoholic fatty liver disease worsen the outcome in acute pancreatitis: A systematic review and Meta-analysis[J]. J Clin Med, 2020, 9(9): 2698. DOI: 10.3390/jcm9092698.
[8]	ZHANG M, ZHANG LR, LUO L, et al. Influence of fatty liver on the severity of acute pancreatitis[J]. J Clin Hepatol, 2022, 38(7): 1595-1601. DOI: 10.3969/j.issn.1001-5256.2022.07.025. 张苗, 张利荣, 罗琳, 等. 合并脂肪肝对急性胰腺炎严重程度的影响[J]. 临床肝胆病杂志, 2022, 38(7): 1595-1601. DOI: 10.3969/j.issn.1001-5256.2022.07.025.
[9]	Chinese Pancreatic Surgery Association, Chinese Society of Surgery, Chinese Medical Association. Guidelines for diagnosis and treatment of acute pancreatitis in China (2021)[J]. Chin J Surg, 2021, 59(7): 578-587. DOI: 10.3760/cma.j.cn112139-20210416-00172. 中华医学会外科学分会胰腺外科学组. 中国急性胰腺炎诊治指南(2021)[J]. 中华外科杂志, 2021, 59(7): 578-587. DOI: 10.3760/cma.j.cn112139-20210416-00172.
[10]	SUREKA B, BANSAL K, PATIDAR Y, et al. Imaging lexicon for acute pancreatitis: 2012 Atlanta Classification revisited[J]. Gastroenterol Rep (Oxf), 2016, 4(1): 16-23. DOI: 10.1093/gastro/gov036.
[11]	ZENG MD, FAN JG, LU LG, et al. Guidelines for the diagnosis and treatment of nonalcoholic fatty liver diseases[J]. J Dig Dis, 2008, 9(2): 108-112. DOI: 10.1111/j.1751-2980.2008.00331.x.
[12]	Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel Ⅲ)[J]. JAMA, 2001, 285(19): 2486-2497. DOI: 10.1001/jama.285.19.2486.
[13]	SU L, LI Y. Antimicrobial therapy in patients with acute pancreatitis complicated with infection[J]. J Med Postgra, 2017, 30(7): 684-692. DOI: 10.16571/j.cnki.1008-8199.2017.07.003. 苏磊, 李悦. 急性胰腺炎合并感染的抗生素应用[J]. 医学研究生学报, 2017, 30(7): 684-692. DOI: 10.16571/j.cnki.1008-8199.2017.07.003.
[14]	WU D, SONG LL, ZHAO YH. Study on the relationship between fatty liver and classification of acute pancreatitis[J]. Chin J Lab Diag, 2018, 22(9): 1557-1559. DOI: 10.3969/j.issn.1007-4287.2018.09.023. 吴迪, 宋玲玲, 赵艳辉. 脂肪肝与急性胰腺炎分级的关系研究[J]. 中国实验诊断学, 2018, 22(9): 1557-1559. DOI: 10.3969/j.issn.1007-4287.2018.09.023.
[15]	HOU S, TANG X, CUI H, et al. Fatty liver disease is associated with the severity of acute pancreatitis: A systematic review and meta-analysis[J]. Int J Surg, 2019, 65: 147-153. DOI: 10.1016/j.ijsu.2019.04.003.
[16]	LI J, TIAN T, HU WW, et al. Concomitant nonalcoholic fatty liver disease affects the severity and clinical outcome of acute pancreatitis[J]. Chin J Clinicians, 2021, 49(4): 456-459. DOI: 10.3969/j.issn.2095-8552.2021.04.024. 李吉, 田甜, 胡文炜, 等. 合并非酒精性脂肪性肝病影响急性胰腺炎严重程度和临床结局[J]. 中国临床医生杂志, 2021, 49(4): 456-459. DOI: 10.3969/j.issn.2095-8552.2021.04.024.
[17]	YAN YF, JIANG X, ZHONG R, et al. Clinical features and prognosis of acute pancreatitis with nonalcoholic fatty liver disease[J]. J Clin Hepatol, 2020, 36(5): 1091-1096. DOI: 10.3969/j.issn.1001-5256.2020.05.028. 严永峰, 蒋鑫, 钟瑞, 等. 急性胰腺炎合并非酒精性脂肪性肝病的临床特征及预后分析[J]. 临床肝胆病杂志, 2020, 36(5): 1091-1096. DOI: 10.3969/j.issn.1001-5256.2020.05.028.
[18]	FISIC E, POROPAT G, BILIC-ZULLE L, et al. The role of IL-6, 8, and 10, sTNFr, CRP, and pancreatic elastase in the prediction of systemic complications in patients with acute pancreatitis[J]. Gastroenterol Res Pract, 2013, 2013: 282645. DOI: 10.1155/2013/282645.
[19]	ZHANG M, ZHANG LR, LUO L, et al. Analysis of influence factors of serum CRP level in early onset of acute pancreatitis[J]. J Baotou Med Coll, 2021, 37(10): 71-76. DOI: 10.16833/j.cnki.jbmc.2021.10.017. 张苗, 张利荣, 罗琳, 等. 急性胰腺炎发病早期血清C-反应蛋白水平影响因素分析[J]. 包头医学院学报, 2021, 37(10): 71-76. DOI: 10.16833/j.cnki.jbmc.2021.10.017.
[20]	LI X, KE L, DONG J, et al. Significantly different clinical features between hypertriglyceridemia and biliary acute pancreatitis: a retrospective study of 730 patients from a tertiary center[J]. BMC Gastroenterol, 2018, 18(1): 89. DOI: 10.1186/s12876-018-0821-z.
[21]	SZATMARY P, GRAMMATIKOPOULOS T, CAI W, et al. Acute pancreatitis: diagnosis and treatment[J]. Drugs, 2022, 82(12): 1251-1276. DOI: 10.1007/s40265-022-01766-4.
[22]	PÁRNICZKY A, LANTOS T, TÓTH EM, et al. Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations[J]. Pancreatology, 2019, 19(4): 488-499. DOI: 10.1016/j.pan.2019.04.003.
[23]	LUO YY, LIU X. Research progress of probiotics in adjuvant treatment of severe acute pancreatitis[J]. Trauma Crit Care Med, 2021, 9(2): 161-164. DOI: 10.16048/j.issn.2095-5561.2021.02.22. 罗娅媛, 刘旭. 益生菌辅助治疗重症急性胰腺炎研究进展[J]. 创伤与急危重病医学, 2021, 9(2): 161-164. DOI: 10.16048/j.issn.2095-5561.2021.02.22.
[24]	MORAN RA, HALLORAN C, GUO Q, et al. Early infection is an independent risk factor for increased mortality in patients with culture-confirmed infected pancreatic necrosis[J]. Pancreatology, 2022, 22(1): 67-73. DOI: 10.1016/j.pan.2021.11.003.
[25]	Professional Committee of Pancreatic Disease, Chinese Medical Doctor Association. Chinese consensus on the multidisciplinary treatment (MDT) of acute pancreatitis[J]. J Clin Hepatol, 2015, 31(11): 1770-1775. DOI: 10.3969/j.issn.1001-5256.2015.11.003. 中国医师协会胰腺病学专业委员会. 中国急性胰腺炎多学科诊治共识意见[J]. 临床肝胆病杂志, 2015, 31(11): 1770-1775. DOI: 10.3969/j.issn.1001-5256.2015.11.003.