自身免疫性胰腺炎临床特点及其与胰腺癌的鉴别诊断研究

发布时间：2018-02-06 00:34

本文关键词： 自身免疫性胰腺炎胰腺癌鉴别诊断血清学　出处：《浙江大学》2014年博士论文　论文类型：学位论文

【摘要】：目的自身免疫性胰腺炎(autoimmune pancreatitis,AIP)是一种特殊类型的慢性胰腺炎,在临床上易被误诊为胰腺癌。本研究旨在总结AIP的临床特点,并探索其与胰腺癌基于临床表现、血清学、影像学和病理学等的鉴别诊断策略。方法回顾性分析浙江大学附属第一医院2009年11月至2014年4月间诊治的AIP与胰腺癌患者资料,收集包括一般情况、临床症状、血清学指标、影像学、组织病理学、治疗等在内的数据进行统计分析。AIP的诊断依据2010年国际胰腺病协会的国际共识,而胰腺癌均通过病理学检查确诊。结果 (1)AIP与胰腺癌均以老年男性多发,两组性别差异不显著,年龄以AIP组更年长。AIP患者最常见症状为腹痛、梗阻性黄疸和体重减轻,而胰腺癌为腹痛、腹胀和体重减轻,两者临床表现易混淆,AIP在门诊误诊为胰腺占位者高达56%。 (2)胰腺外器官受累是AIP的特征性表现,50%的AIP患者合并有胰腺外器官受累。 (3)AIP组以血清免疫球蛋白IgG、IgG4水平升高为特征表现,其血清球蛋白、嗜酸性粒细胞、胆红素、肝酶和胆酶显著高于胰腺癌组(P0.05),而肿瘤标志物Ca19-9、血红蛋白水平显著低于胰腺癌组(P0.05)。使用Ca19-9、球蛋白、血红蛋白和嗜酸性粒细胞四项指标联合以区别诊断AIP和胰腺癌,灵敏度为84%,特异度为88%,诊断价值较高。 (4)B超和CT是AIP和胰腺癌最为常用影像学手段,MRCP及ERCP对胰胆管病变有较好的显像效果。胰腺弥漫性肿大强烈提示AIP,但40%的AIP患者也表现为局灶性肿大,易与胰腺癌混淆。AIP的胆管近端狭窄及远端扩张较胰腺癌常见,而主胰管近端狭窄和远端扩张常提示胰腺癌。部分AIP病例可见胰腺周围渗出或包膜样改变。血管受累、淋巴结转移及其他脏器的肿瘤转移是胰腺癌的特征性表现。 (5)组织病理是诊断AIP和胰腺癌的有力证据。AIP的病理表现特征为淋巴浆细胞广泛浸润,席纹状纤维化,并可见IgG4阳性浆细胞。病理学诊断胰腺癌则以找到肿瘤细胞为依据。 (6)糖皮质激素治疗对AIP效果良好,合并胆道狭窄以致黄疸的患者则在糖皮质激素治疗前行ERCP下胆道支架植入术和或经内镜鼻胆管引流术减轻患者症状。12%的患者在1-2年内因AIP复发而重新住院。胰腺癌患者则根据病情行手术根除或姑息治疗。结论 AIP和胰腺癌作为两种独立的疾病,其治疗和预后完全不同。两者流行病学及临床表现相似,较易混淆。胰腺外器官受累、血清学、影像学及病理等特征有助于两种疾病的鉴别诊断。
[Abstract]:Purpose Autoimmune pancreatitis (AIP) is a special type of chronic pancreatitis. The purpose of this study was to summarize the clinical features of AIP and to explore the differential diagnosis strategies between AIP and pancreatic cancer based on clinical manifestations, serology, imaging and pathology. Method The data of AIP and pancreatic cancer patients from November 2009 to April 2014 in the first affiliated Hospital of Zhejiang University were analyzed retrospectively. The data were collected including general situation, clinical symptoms and serological indexes. Imaging, histopathology, treatment and other data were statistically analyzed. The diagnosis of AIP was based on the international consensus of the International Pancreatic Association in 2010, while pancreatic cancer was diagnosed by pathological examination. Results There was no significant difference between the two groups. The most common symptoms of age were abdominal pain, obstructive jaundice and weight loss in the older. AIP patients in the AIP group. The clinical manifestations of pancreatic cancer were abdominal pain, abdominal distension and weight loss. AIP was misdiagnosed as pancreatic occupying in outpatient department as high as 56%. (2) Extrapancreatic organ involvement is a characteristic feature of AIP. 50% of AIP patients have extrapancreatic organ involvement. The serum immunoglobulin (IgG) IgG4 level was elevated in the AIP group with serum globulin, eosinophilic granulocyte and bilirubin. The levels of liver enzyme and bile enzyme were significantly higher than that of pancreatic carcinoma group (P 0.05), but the tumor marker Ca 19-9 and hemoglobin level were significantly lower than that of pancreatic cancer group (P 0.05). Hemoglobin and eosinophilic granulocyte were combined to distinguish AIP from pancreatic cancer. The sensitivity and specificity of hemoglobin and eosinophilic granulocyte were 84 and 88 respectively. B ultrasound and CT are the most commonly used imaging methods for AIP and pancreatic cancer. MRCP and ERCP have better imaging effect for pancreaticocholangiopathy. Diffuse pancreatic enlargement strongly suggests AIP. However, 40% of AIP patients also presented with focal enlargement, and the proximal stricture and distal dilatation of bile duct were more common than pancreatic cancer. The proximal stenosis and distal dilatation of the main pancreatic duct often suggest pancreatic cancer. In some cases of AIP, peripancreatic effusion or capsular changes can be seen. Lymph node metastasis and other organ metastasis are characteristic manifestations of pancreatic cancer. Histopathology is a powerful evidence for the diagnosis of AIP and pancreatic cancer. The pathological features of AIP are extensive infiltration of lymphoplasmacytes and siliform fibrosis. IgG4 positive plasma cells can be seen. Pathological diagnosis of pancreatic cancer is based on finding tumor cells. The effect of glucocorticoid therapy on AIP was good. Before glucocorticoid therapy, biliary stenting under ERCP and / or endoscopic nasobiliary drainage alleviated symptoms in patients with biliary stricture and jaundice. 12% of patients had AIP within 1-2 years before glucocorticoid therapy. Recurrence and readmission. Patients with pancreatic cancer receive surgical eradication or palliative treatment depending on their condition. Conclusion AIP and pancreatic cancer are two independent diseases, their treatment and prognosis are completely different. The epidemiology and clinical manifestations of the two diseases are similar and easy to be confused. The imaging and pathological features are helpful to the differential diagnosis of the two diseases.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R576;R735.9

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