小儿肝囊型包虫病的诊断与治疗

发布时间：2018-05-27 07:41

  本文选题：囊型包虫病 + 诊断　； 参考：《新疆医科大学》2016年博士论文

【摘要】：目的:总结小儿肝囊型包虫病包虫囊肿特点并对不同术式在小儿肝囊型包虫病中的应用疗效进行评价,通过对小儿肝囊型包虫病术后并发症与临床资料进行相关性分析,寻找发生并发症的危险因素;通过影像学及血清学诊断在小儿肝囊型包虫病中的应用,探索术前正确诊断小儿单囊型肝包虫病的最佳方法;通过基因工程技术获得细粒棘球蚴抗原B1重组蛋白(rEgAgB1),探讨其对小儿肝囊型包虫病的血清学诊断价值,并将表达结果与临床资料进行相关性分析,寻找影响rEgAgB1在小儿囊型包虫病血清中表达相关因素。方法:1回顾性分析总结新疆医科大学第一附属医院2002年1月至2014年12月期间收治的191例14岁以下(包含14岁)肝囊型包虫病患儿,对患者性别、就诊时年龄、症状、囊肿特征(位置、大小、数量)、手术方案、住院时间、术后并发症等临床数据进行统计分析。治疗方案包括:改良内囊摘除组、外囊次全切除术与外囊完整剥离术。分别对患者性别、体征、有无胆漏、肝包虫囊肿个数、肝包虫囊肿破裂、有无合并其他脏器包虫、包虫大小、术式与术后并发症相关性进行探讨;2收集新疆医科大学第一附属医院自2012年1月至2014年12月经病理证实的小儿肝囊型包虫及肝囊肿的肝脏病变共100例,其中单囊型肝包虫50例,单纯性肝囊肿50例,分别进行影像学超声、CT检查及实验室包虫四项检查,计算其灵敏度和特异度,将超声与包虫试验、CT与包虫试验相结合,评估联合诊断价值;3将构建的rEgAgB1原核表达质粒(pET28a-EgAgB1)转化至E coli中,经亲和层析纯化获得高纯度rEgAgB1,用纯化的重组蛋白及HCF分别对25例小儿包虫病血清及25例正常儿童血清进行ELISA和Immunoblotting方法检测,并回顾性分析25例小儿肝囊型包虫病临床资料,探讨患者年龄、族别、症状、分型、有无合并其他脏器、包虫数量、包虫大小与rEgAgB1在血清中表达关系。结果:1)共有191例患儿纳入研究,其中行改良内囊摘除术(A组)63例,外囊次全切除术组(B组)89例,外囊完整剥离术式(C组)39例。通过对三组数据进行统计学分析,①手术时间,外囊次全切除术组(B组)占时显著低于外囊完整剥离术式(C组),而与改良内囊摘除术(A组)无显著性差异;②术中出血量,外囊次全切除术组(B组)术中出血量显著低于外囊完整剥离术式(C组),而与改良内囊摘除术(A组)无显著性差异;③术后带管时间,改良内囊摘除术(A组)术后带管时间显著长于外囊次全切除术组(B组)和外囊完整剥离术式(C组);④住院天数,改良内囊摘除术(A组)住院天数显著长于外囊次全切除术组(B组)和外囊完整剥离术式(C组);⑤术后残腔并发症(残腔积液、残腔感染、残腔胆漏),外囊次全切除术组(B组)显著低于改良内囊摘除术(A组),而与外囊完整剥离术式(C组)无显著性差异;术后共有26例患儿发生并发症。单因素统计分析显示术后发生并发症与腹痛、包虫囊肿与胆道相通、术前包虫囊肿破裂相关,P0.05;其他指标差异均无统计学意义。进行单因素分析时未控制其他因素干扰,将P小于0.1的变量纳入到多因素回归模型,进行二分类logistic回归,结果腹痛、包虫囊肿与胆道相通、包虫囊肿破裂变量有统计学意义,并且是危险因素。2超声在诊断单囊型肝包虫病中灵敏度为96.00%,特异度为98.00%,CT在诊断单囊型肝包虫病的灵敏度为80.00%,特异度为62.00%,包虫四项诊断单囊型肝包虫病灵敏度为86.00%,其检测特异度为72.00%。超声与包虫试验联合诊断灵敏度为82%,特异度为100%。CT与包虫试验联合诊断灵敏度为70%,特异度为82%。3用rEgAgB1为抗原对25例小儿肝囊型包虫病患者血清进行IgG1特异性抗体检测,结果显示19例为阳性,血清诊断阳性率为76%。对25例正常小儿血清检测,血清诊断无阳性结果,检测特异度为100%;用rEgAgB1为抗原对25例小儿肝囊型包虫病患者血清进行IgG4特异性抗体检测,结果显示9例为阳性,血清诊断阳性率为36%,对25例正常小儿血清检测,血清诊断无阳性结果,检测特异度为100%。分析25例小儿包虫囊肿病人临床资料,通过单因素独立样本t检验及卡方检验得出:年龄、族别、症状、包虫大小与rEgAgB1在小儿肝囊型包虫病患者中表达阳性无相关性(P0.05)。肝内多发及有无合并其他脏器这两个因素与rEgAgB1在小儿肝囊型包虫病患者中表达阳性有相关性(P0.05)。结论:⑴小儿肝囊型包虫病相比成人,其包虫囊肿具有独特的特点。其生长速度快,包虫囊壁薄,合并其他脏器包虫囊肿发生率高,而且包虫囊肿中CE1型居多,包虫囊肿张力大,较成人易破裂,包虫囊肿合并胆漏发生率小。影像学及实验室检查相结合可明确术前诊断。外囊次全切除术为首选术式,如病灶大部分位于肝脏实质内,可行改良的内囊摘除术,如术中包虫残腔合并胆瘘,术中胆道造影可有效降低术后残腔并发症。腹痛、术中包虫囊肿与胆道相通和包虫术前破裂的患者术后发生并发症发生率显著高于其他患者,可能为术后并发症的影响因素;⑵在鉴别诊断小儿肝囊型包虫病与单纯性肝囊肿中,超声具有高灵敏度和特异度,应为首选。如仅为诊断,CT因其放射性不应作为常规检查,但如需手术,可行CT明确囊肿大小位置与血管胆道关系,为手术入路提供佐证。免疫学检查是对影像学检查的重要补充,尤其在鉴别诊断囊性占位有困难时,可提高诊断品质;⑶rEgAgB1在小儿包虫血清学诊断中具有高特异性表达,能够有效提高特异度,但灵敏度较低,IgG1亚型抗体的检测显著高于IgG4亚型抗体,其临床诊断和随访价值有待今后大样本验证。
[Abstract]:Objective: To summarize the characteristics of echinococcosis cyst of hepatic cystic echinococcosis in children and evaluate the therapeutic effect of different surgical procedures in children with hepatic cystic echinococcosis. Through the correlation analysis of postoperative complications and clinical data of hepatic cystic echinococcosis in children, to find out the risk factors of complications and diagnosis in children's liver through imaging and serological diagnosis. The best method of diagnosis of single cystic echinococcosis in children was explored before the operation of cystic echinococcosis. The recombinant protein (rEgAgB1) of echinococcosis antigen B1 (rEgAgB1) was obtained by genetic engineering technology, and the value of its serological diagnosis for hepatic cystic echinococcosis in children was discussed, and the correlation analysis between the expression results and clinical data was carried out to find the influence of R. EgAgB1 in children with cystic echinococcosis serum related factors. Methods: 1 retrospective analysis and summary of the First Affiliated Hospital of Xinjiang Medical University from January 2002 to December 2014, 191 cases of children under 14 years of age (14 years old) with hepatic cystic echinococcosis, the sex, age, symptoms, cyst characteristics (position, size, quantity), operation of the patients, surgery The clinical data of the plan, the time of hospitalization and the postoperative complications were analyzed. The treatment scheme included the improved internal capsule extirpation group, the outer capsule subtotal excision and the complete exfoliation of the outer capsule. The patients' sex, signs, the bile leakage, the number of hepatic echinococcosis, the rupture of the hepatic echinococcosis, the size of the hydatid, the operation and the operation of the hydatid cyst, and the size of the hydatid cyst in the liver The correlation of postoperative complications was discussed. 2 a total of 100 cases of liver cystic echinococcosis and hepatic cysts confirmed by pathology of the First Affiliated Hospital of Xinjiang Medical University from January 2012 to 12 2014 were collected, including 50 cases of single cystic echinococcosis and 50 cases of simple hepatic cysts, including imaging ultrasound, CT examination and laboratory echinococcosis four items respectively. The sensitivity and specificity were calculated and combined with hydatid test, hydatid test, CT and echinococcosis test. 3 the rEgAgB1 prokaryotic expression plasmid (pET28a-EgAgB1) was transformed into E coli, high purity rEgAgB1 was purified by affinity chromatography, and 25 children with echinococcosis were purified by purified recombinant protein and HCF, respectively. The serum of normal children was detected by ELISA and Immunoblotting methods, and the clinical data of 25 children with hepatic cystic echinococcosis were analyzed. The age, family, symptoms and classification of the patients were analyzed. The relationship between the number of other organs, the number of hydatid, the size of echinococcosis and the rEgAgB1 in the serum. Results: 1) a total of 191 children were included in the study. There were 63 cases of benign internal capsule excision (group A), 89 cases (group B) and 39 cases of outer capsule complete dissection (group C). Through statistical analysis of the data of three groups, the time of operation and external capsule total excision group (group B) was significantly lower than that of the complete exfoliation of outer capsule (group C), but there was no significant difference with the modified internal capsule extirpation (group A); The amount of hemorrhage in the operation group (group B) was significantly lower than that of complete exfoliation (group C), but there was no significant difference from the improved internal capsule extirpation (group A). (group A) after operation, the time of improved internal capsule extirpation (group A) was significantly longer than that of the external capsule total excision group (group B) and the complete exfoliation of external capsule (group C); The number of days of hospitalization, improved internal capsule extirpation (group A) was significantly longer than that of the outer capsule subtotal excision group (group B) and the complete exfoliation of outer capsule (group C); (5) the postoperative residual cavity complications (residual cavity effusion, residual cavity infection, residual cavity bile leakage), the external capsule subtotal excision group (group B) was significantly lower than the modified internal capsule extirpation (group A), and the external capsule complete dissection (group C) There were no significant differences in 26 cases of postoperative complications. Single factor statistical analysis showed that postoperative complications and abdominal pain, hydatid cyst and biliary tract interlinked, pre operation hydatid cyst rupture, P0.05, and other indicators were not statistically significant. Single factor analysis did not control other factors interference, the P less than 0.1 variables Na In the multi factor regression model, two classification logistic regression was carried out. The results of abdominal pain, echinococcosis and biliary tract were interlinked, and the variable of echinococcosis was statistically significant, and the sensitivity of.2 ultrasound in the diagnosis of single cystic hydatid disease was 96%, the specificity was 98%, and the sensitivity of CT in the diagnosis of single cystic hydatid disease was 80%. The sensitivity of four diagnosis of echinococcosis with echinococcosis was 86%. The sensitivity of 72.00%. ultrasound and hydatid test was 82%, the specificity of specificity was 100%.CT and hydatid test, the sensitivity was 70%, and the specificity was 82%.3 rEgAgB1 as antiprimitive to the serum of 25 cases of children with hepatic cystic echinococcosis. The results of IgG1 specific antibody test showed that 19 cases were positive, and the positive rate of serum diagnosis was 76%. for 25 normal children. The serum diagnosis was not positive and the specificity was 100%. The serum specific antibody of 25 children with hepatic cystic echinococcosis was detected with rEgAgB1 as antigen. The results showed that 9 cases were positive and serum diagnosis was diagnosed. The positive rate was 36%, 25 cases of normal children serum test, serum diagnosis no positive results, detection specificity of 100%. analysis of 25 cases of pediatric echinococcosis patients clinical data, through single factor independent sample t test and chi square test concluded: age, family, symptoms, the size of echinococcosis and rEgAgB1 in children with hepatic cystic echinococcosis positive no expression. Correlation (P0.05). The two factors in the liver and the other organs were associated with the positive expression of rEgAgB1 in the patients with hepatic cystic echinococcosis (P0.05). Conclusion: (1) the hydatid cyst of the liver cystic echinococcosis in children has unique characteristics. The growth rate is fast, the cyst wall of the hydatid is thin, and the cyst of the hydatid cyst is combined with the cyst of other organs. The incidence of hydatid cyst is high, and hydatid cyst most CE1, hydatid cyst tension, adult prone to rupture, hydatid cyst combined with bile leakage rate is small. Imaging and laboratory examination can clear preoperative diagnosis. External capsule subtotal resection is the first choice, such as most of the lesion in the liver parenchyma, feasible improved internal capsule extirpation, such as surgery, such as surgery. The intraoperative cholangiography can effectively reduce the postoperative residual cavity complications. Abdominal pain, the incidence of postoperative complications in patients with hydatid cyst with biliary tract and pre operation of echinococcosis is significantly higher than that of other patients and may be the influencing factors of postoperative complications; 2. In the differential diagnosis of children's hepatic cystic echinococcosis and simplex In sexual hepatic cysts, ultrasound has high sensitivity and specificity, and should be the first choice. If only for diagnosis, CT should not be used as a routine examination because of its radioactivity. But if surgery is required, it is feasible that CT can identify the relationship between the size and location of the cyst and the vascular biliary tract, and provide evidence for the surgical approach. Immunological examination is an important supplement to the imaging examination, especially in the differential diagnosis capsule. When sexual occupancy is difficult, it can improve the quality of diagnosis; (3) rEgAgB1 is highly specific in the diagnosis of echinococcosis, and can effectively improve the specificity, but the sensitivity is low. The detection of IgG1 subtype antibody is significantly higher than that of the IgG4 subtype antibody. The clinical diagnosis and follow-up value of its clinical diagnosis and follow-up need to be verified in the future.
【学位授予单位】：新疆医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R726.5
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本文编号：1941114