胆总管结石复发高危因素的探索研究

发布时间：2018-06-10 16:23

  本文选题：胆总管结石 + ERCP　； 参考：《第四军医大学》2015年硕士论文

【摘要】：研究背景:胆总管结石是较为常见的消化系统疾病之一。目前ERCP(经内镜逆行性胰胆管造影术)是治疗胆总管结石的一线方法,但4-24%的患者在成功取石后出现胆总管结石复发。与EPBD(内镜下乳头柱状球囊扩张术)相比EST(十二指肠乳头括约肌切开术)术后患者胆总管结石复发率高(5.7-26.7%vs.1.6-8.1%),可能原因为EST术后Oddi括约肌功能破坏会继发十二指肠内容物反流入胆道,导致胆道反复感染,增加结石复发风险。虽然众多学者认为,胆总管结石复发与十二指肠-胆道反流(DBR)有关,但一直缺乏直接证据。如何利用简单有效的方法证明两者之间的关系是需要解决的临床问题。胃食管反流和便秘是最常见的临床症状,食管下端括约肌松弛导致的胃食管反流与十二指肠-胆道反流的机制有相似之处,高危因素也十分相似,例如肠道内压力增高、胃肠道动力减弱、体位变化、解剖结构异常等。便秘也会增加肠腔内压力从而加重胃-食管反流问题。我们推测,临床常见症状如胃食管反流、便秘与十二指肠-胆道反流之间存在一定关系,可能会影响胆总管结石的复发,可用于胆总管结石复发高危人群的筛选。研究目的:1)通过前瞻性病例对照研究来探索十二指肠-胆道反流与胆总管结石复发之间的关系;2)通过回顾性病例对照研究来探索胃食管反流、便秘症状与胆总管结石复发之间的关系。研究对象:本研究共纳入在西京医院接受ERCP胆总管取石的患者264例。其中第一部分研究64例(结石复发组32例,对照组32例),第二部分研究200例(结石复发组100例,对照100例)。研究方法:第一部分研究所有患者接受标准上消化道钡餐、腹部CT、腹部磁共振检查;第二部分研究所有患者接受问卷调查。统计方法包括T检验、Fisher检验、卡方检验、回归分析。研究结果:1)两组患者的首次ERCP参数和基线资料特征具有可比性。结石复发组患者的DBR显著高于对照组(68.8%vs.15.6%,p0.001)。多因素回归分析显示DBR(OR=9.59;95%CI,2.65-34.76)和胆总管末段角度≤135°(OR=5.48;95%CI,1.52-19.78)是胆总管结石复发的高危因素。胆总管结石无复发、单次复发和多次复发患者的DBR分别是15.6%,60.9%和88.9%(p0.001)。多次复发患者的肝内胆管反流率更高(66.7%vs.10.9%,p0.001)。2)两组患者的胃食管反流及便秘症状的发生率无统计学差异。结石复发组及对照组中胃食管反流及便秘的发生率为21%vs.17%及15%vs.16%(p值均0.05)。多因素回归分析显示仅胆总管末段角度≤135°(OR=3.07;95%CI,1.22-7.72)是胆总管结石复发的高危因素。研究结论:1)本研究提供了十二指肠-胆道反流与ERCP术后胆总管结石复发相关的直接证据。DBR和较锐的胆总管末段角度是胆总管结石复发的高危因素。2)本研究结果显示胃食管反流及便秘症状与胆总管结石复发不相关。较锐的胆总管末段角度是胆总管结石复发的高危因素。
[Abstract]:Background: choledocholithiasis is one of the most common diseases of digestive system. ERCP (endoscopic retrograde cholangiopancreatography) is a first line method for the treatment of choledocholithiasis, but 4-24% of the patients have recurrence of choledocholithiasis after successful lithotomy. Compared with EPBD (endoscopic papillary sphincterotomy), the recurrence rate of choledocholithiasis in EST patients was 5.7-26.7vs.1.6-8.1.The possible reason was that the sphincter dysfunction of oddi after EST might cause secondary duodenal contents to flow back into the bile duct. Lead to recurrent biliary tract infection, increase the risk of recurrence of stones. Although many scholars believe that the recurrence of choledocholithiasis is associated with duodenal-biliary reflux (DBR), direct evidence has been lacking. How to use simple and effective methods to prove the relationship between the two is a clinical problem to be solved. Gastroesophageal reflux and constipation are the most common clinical symptoms. The mechanism of gastroesophageal reflux caused by lower esophageal sphincter relaxation is similar to that of duodenal-biliary reflux. Gastrointestinal motility decreased, posture changes, anatomic structure abnormal, and so on. Constipation also increases pressure in the lumen and exacerbates gastroesophageal reflux. We speculate that common clinical symptoms such as gastroesophageal reflux constipation and duodeno-biliary reflux may affect the recurrence of choledocholithiasis and can be used for screening high risk population for choledocholithiasis recurrence. Objective: to explore the relationship between duodenal-biliary reflux and the recurrence of choledocholithiasis in a prospective case-control study 2) to explore gastroesophageal reflux through a retrospective case-control study. Relationship between constipation symptoms and recurrence of choledocholithiasis. Participants: a total of 264 patients received ERCP choledocholithiasis in Xijing Hospital. In the first part, 64 cases (32 cases of stone recurrence group, 32 cases of control group) and 200 cases (100 cases of stone recurrence group and 100 cases of control group) were studied in the first part. Methods: in the first part, patients received barium meal of upper digestive tract, abdominal CT and abdominal magnetic resonance examination, and in the second part, patients were investigated by questionnaire. Statistical methods include T-test Fisher test, chi-square test and regression analysis. Results: 1) the first ERCP parameters and baseline data were comparable between the two groups. The DBR of the patients with recurrent stones was significantly higher than that of the control group (68.8vs.15.6B, P 0.001). Multivariate regression analysis showed that DBR OR9.5995 CI 2.65-34.76) and the end of common bile duct angle 鈮，

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