原发性胆总管结石ERCP取石术后复发的高危因素及病原学特点

发布时间：2018-03-19 21:14

  本文选题：原发性胆总管结石　切入点：ERCP　出处：《第二军医大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究目的:通过分析对比原发性胆总管结石经内镜逆行胰胆管造影术(endoscopic retrograde cholangio-pancreatography,ERCP)取石后复发与未复发患者的临床资料及相关指标,筛选出原发性胆总管结石ERCP取石术后复发的相关危险因素,并分析胆总管结石伴胆道感染患者胆汁中主要致病菌的分布特点及药物耐药性情况,为临床抗生素的合理使用提供依据。研究方法:回顾性分析、总结2008年1月至2015年10月期间,在第二军医大学附属长征医院因原发性胆总管结石经ERCP治疗的162例患者的病例资料,并通过电话咨询及查阅门诊、住院复诊记录的方式进行。主要包括以下两个部分:1.根据胆总管结石复发的诊断标准将上述患者分为两组,即未复发组和复发组。用非条件Logistic回归单因素分析两组患者的一般情况(年龄、性别)、个人史(吸烟史、饮酒史)、既往史(胆囊切除史、ERCP手术史)、实验室检查(血常规、肝功能、肾功能、凝血功能、电解质、血脂)、胆道情况(十二指肠乳头旁憩室、胆道感染)、胆管结石情况(结石性状、结石数量、结石大小)等指标,将具有统计学意义的变量再进行多因素分析,确定胆总管结石取石术后复发的危险因素。2.按照胆道感染的诊断标准,统计分析胆总管结石患者胆汁细菌培养及药敏试验的结果。研究结果:针对157例有确切随访资料的原发性胆总管结石患者,中位观察时间42个月(最长观察时间87个月,最短12个月),其中105例未复发,52例复发的这一情况研究如下:1.单因素分析显示:(1)胆囊切除史(P=0.029)、ERCP手术史(P0.001)、胆道感染(P=0.018)、结石性状(混合样,P0.001)、结石大小(P=0.030),有统计学差异,说明上述因素是胆总管结石复发的危险因素。(2)年龄(50~70岁,P=0.189;70岁,P=0.435)、性别(P=0.214)、吸烟史(P=0.736)、饮酒史(P=0.665)、十二指肠乳头旁憩室(juxtapapillary duodenal diverticulum,JPDD)(P=0.413)、结石数量及实验室各项指标:WBC、N%、PLT、RBC、HB、TB、DB、Alb、ALT、AST、GGT、AKP、BUN、Cr、PT、INR、Na+、K+、Cl-、甘油三酯(triacylglyceride,TRIG)、总胆固醇(total cholesterol,TC)、HBV,P值均大于0.05,无统计学差异,说明上述因素不是胆总管结石复发的危险因素。(3)多因素分析显示:ERCP手术史(P0.001;AOR=535.44,95%CI:49.66-5773.66)、胆道感染(P=0.047;AOR=2.534,95%CI:1.010-5.037)、混合样结石(P=0.036;AOR=4.221,95%CI:1.099-16.207),有统计学差异,说明这三种因素在胆总管结石复发过程中的作用尤为突出。2.在112例行胆汁细菌培养的标本中有70例检出致病菌,阳性率为62.50%;共培养细菌100株,其中革兰氏阴性菌75株,革兰氏阳性菌18株,真菌7株;含量最多的细菌为大肠埃希菌25株和肺炎克雷伯杆菌13株,药敏结果显示,两者对头孢唑啉耐药率最高,对头孢西丁、阿米卡星较为敏感。研究结论:1.ERCP手术史、胆道感染和混合样结石为原发性胆总管结石ERCP取石术后结石复发的独立危险因素。2.胆总管结石并发胆道感染的患者,胆汁细菌培养以革兰氏阴性菌为主,治疗一般首先选用对革兰氏阴性菌耐药率低的抗生素。
[Abstract]:Objective: through the comparative analysis of primary choledocholithiasis by endoscopic retrograde cholangiopancreatography (endoscopic retrograde, cholangio-pancreatography, ERCP) clinical data of recurrence after stone and without recurrence and related indicators, screened the risk of primary common bile duct stones ERCP recurrence after nephrolithotomy factors, and analysis of common bile duct stone with the distribution characteristics and drug resistance of the main pathogenic bacteria in the bile of patients with biliary tract infection, provide the basis for clinical rational use of antibiotics. Methods: a retrospective analysis from January 2008 to October 2015, during the summary, at the Second Military Medical University because of primary common bile duct stones treated by ERCP Changzheng Hospital 162 cases of patients with clinical data, and through the telephone consultation and access to outpatient, hospital referral records. It mainly includes the following two parts: 1. according to the recurrence of bile duct stones The diagnostic criteria of the patients were divided into two groups, namely non recurrence group and recurrence group. Analysis of the general situation of the two groups of patients with single factor non conditional Logistic regression (age, gender), personal history (smoking history, drinking history), history (history of cholecystectomy, surgery, ERCP (Laboratory) blood routine, liver function, renal function, blood coagulation function, electrolyte, blood), biliary tract (cases of juxtapapillary duodenal diverticulum and biliary infection, biliary calculi (stones) of characters, number of stones, stone size) and other indicators, and then will have the statistically significant variables in multivariate analysis, to identify common bile duct stones lithotomy risk factors of recurrence after.2. according to the diagnostic criteria of biliary tract infection and analysis of common bile duct stones of bile bacteria culture and drug susceptibility in patients with test results and statistics. Results: in 157 cases with exact follow-up data of primary choledocholithiasis patients, median observation time 闂，

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