声触诊组织量化技术在预测肝硬化食管静脉曲张发生风险中的价值

发布时间：2018-08-09 15:19

【摘要】：研究背景食管静脉曲张(Esophageal varices,EV)是肝硬化门脉高压引起的重要并发症,也是临床上最常见的消化道静脉曲张。临床上常因出现急性消化道静脉曲张破裂出血才得以确诊。内镜检查仍是目前诊断上消化道静脉曲张及其出血的金标准。2007年美国肝病学会“肝硬化胃食管静脉曲张及出血诊治指南”及2009年中华医学会消化内镜学分会“消化道静脉曲张及出血的内镜诊断和治疗规范试行方案”中均提出:对于所有来诊肝硬化患者需尽早进行消化道内镜检查,以便筛查和确认需要预防性治疗的患者。然而,其中高风险食管静脉曲张患者只占15-25%,大多数患者未见静脉曲张或只有轻度静脉曲张但无需预防性治疗。因此,能够应用非侵入性方法早期诊断和评估肝硬化患者的EV及其程度,可使大部分患者有效地避免不必要的侵入性上消化道内镜检查,特别是针对于低风险的肝硬化患者群。此领域研究是目前国内外的研究热点。声脉冲辐射力成像(Acoustic Radiation Force Impulse,ARFI)是无创评估组织硬度的超声弹性成像技术,其借助声触诊组织量化(Virtual touch tissue quantification,VTQ)功能,测量声速经过组织的剪切波速度(Shear wave velocity,SWV),进而定量评估组织弹性及硬度变化。近年来,VTQ技术作为评估肝纤维化的无创性超声弹性成像方法备受国内外关注,2016年的美国肝病学会“肝硬化门脉高压出血的风险分层、诊断和管理实践指导”上把肝硬度(liver stiffness,LS)作为无创性监测临床显著性门静脉高压(clinically significant portal hypertension,CSPH)的重要指标之一。另一方面,国内外学者通过分别测定LS、脾硬度(spleen stiffness,SS)及脾脏长径等参数研究VTQ技术在预测和评估EV及出血(Esophageal variceal bleeding,EVB)的诊断价值,具有一定的临床应用前景,但大多数研究结果不能同时获得满意的灵敏度和特异度。本研究利用VTQ等多种超声诊断新技术,通过多种客观参数的系统检测试图探寻影响肝硬化EV发生的独立危险因素,并评估经ROC曲线分析获得的最佳临界值在预测肝硬化EV中的临床诊断价值,目前国内未见系统的研究报道。目的本研究应用二维超声及VTQ技术无创检测肝硬化患者的肝脏和脾脏的SWV值、肝门静脉及脾静脉的内径和血流速度,分析影响肝硬化EV发生的独立危险因素;探讨两种超声技术手段在肝硬化EV发生风险中的诊断效能及临床价值;并利用受试者工作特征曲线(Receiver operator characteristic curve,ROC)曲线为临床提供无创监测肝硬化EV的最佳临界值。方法本研究中的患者均符合《慢性乙型肝炎防治指南》(2015版)中肝硬化的诊断标准,共154例,男95例,女59例,年龄29-80岁,平均年龄55±10岁。所有入选患者均行上消化道内镜检查,并根据其结果进行分组:其中52例未发生EV归为无静脉曲张组(No esophageal varices,NEV组,n=52),102例存在EV归为静脉曲张组(EV组,n=102)。记录每位被检者的性别、年龄、身高及体重,并计算BMI。所有被检者严格空腹8小时以上,取静脉血用于检测肝功能及凝血常规。采用Siemens Acuson S2000型超声诊断仪(配备VTQ软件)行超声检查。所有被检者严格空腹8小时以上,平卧于检查床上,充分暴露腹部。首先对每一个被检者行常规超声检查,观察肝脏和脾脏的轮廓及实质回声,测量右肝斜径、脾脏厚径、脾脏长径、肝门静脉和脾静脉的内径及血流速度。然后,启动ARFI技术中VTQ模式,测量所有实验对象的肝脏和脾脏的SWV值。采用SPSS22.0统计学软件对实验数据进行独立样本t检验或卡方检验;应用Logistic回归分析筛选影响EV发生的独立危险因素;绘制ROC曲线并计算最佳临界值。采用Med Calc医学统计软件中的De Long检验进行曲线下面积(Area under the curve,AUC)之间的比较。结果1、EV组与NEV组各参数的比较(1)临床资料及肝功能分级的比较EV组的肝功能Child Pugh分级明显高于NEV组,具有统计学差异(P0.05);两组患者的年龄、性别和BMI未见明显统计学差异(P0.05)。(2)二维及频谱多普勒超声参数的比较EV组的肝门静脉和脾静脉内径明显大于NEV组,具有统计学差异(P0.05);EV组的肝门静脉及脾静脉的血流速度明显低于NEV组,具有统计学差异(P0.05)。(3)SWV值的比较EV组的肝脏和脾脏的SWV值明显高于NEV组,具有统计学差异(P0.05)。2、Logistic回归分析筛查影响EV的独立危险因素Logistic回归分析结果显示肝门静脉内径、肝脏及脾脏SWV值为预测EV发生的独立危险因素,其OR值分别为2.396、1.007和1.005(P0.05)。3、二维超声和VTQ技术在无创评估肝硬化EV发生风险中的诊断效能及临床价值绘制影响肝硬化EV的独立危险因素即肝门静脉内径、肝脏及脾脏SWV值的ROC曲线,其AUC分别为0.88(95%CI:0.824-0.936)、0.911(95%CI:0.866-0.957)和0.908(95%CI:0.863-0.953);采用Youden指数最大切点为临界点确定其最佳临界值,分别为14.05mm、2.013m/s和2.937m/s;灵敏度分别为73.6%、82.4%和79.6%;特异度分别为87.1%、90.3%和87.6%;阳性预测值分别为75%、80.8%和75%;阴性预测值分别为86.3%、91.2%和90.2%;准确度分别为82.5%、87.7%和85.1%。结论1、肝功能分级、肝门静脉和脾静脉的内径及血流速度以及肝脏和脾脏的SWV值在判断EV是否发生中起到一定的辅助作用。2、肝门静脉内径、肝脏和脾脏SWV值为预测EV发生的独立危险因素。3、经ROC曲线分析,肝门静脉内径、肝脏和脾脏SWV值在评估肝硬化EV发生风险中具有较好的诊断效能,尤其是肝脏SWV值具有一定的优势。提示二维超声和VTQ技术有望成为无创、简便、动态、客观评价肝硬化EV发生风险的有效指标。
[Abstract]:Background Esophageal varices (EV) is an important complication caused by portal hypertension in liver cirrhosis and the most common digestive tract varicose in the clinic. The diagnosis of acute gastrointestinal variceal bleeding is often found. Endoscopy is still the gold diagnosis of upper gastrointestinal varicosity and bleeding. Standard.2007 guidelines for the diagnosis and treatment of gastroesophageal varices and bleeding in cirrhosis of the liver disease society of the United States of America and the "trial plan for endoscopic diagnosis and treatment of digestive tract varices and bleeding" at the Chinese Medical Association's digestive endoscopy branch, 2009, all require early gastrointestinal endoscopy for all patients with cirrhosis of the liver, Screening and identifying patients requiring prophylactic treatment. However, only 15-25% of patients with high risk esophageal varices, most patients have no varicose or only mild varicosity but no preventive treatment. Therefore, the early diagnosis and evaluation of EV and its degree in patients with liver cirrhosis can be made by non invasive methods. Patients can effectively avoid unnecessary invasive upper gastrointestinal endoscopy, especially for patients with low risk of cirrhosis. Research in this field is a hot spot at home and abroad. Acoustic Radiation Force Impulse (ARFI) is a noninvasive ultrasonic elastic imaging technique for evaluating the hardness of the group fabric with the aid of sound contact. Virtual touch tissue quantification (VTQ) function, measuring sound velocity through tissue shear wave velocity (Shear wave velocity, SWV), and then quantifying the changes of tissue elasticity and hardness. In recent years, VTQ technology as a noninvasive hyper elastic imaging method for evaluating liver fibrosis has attracted much attention at home and abroad, in 2016, American Liver Liver stiffness (LS) is regarded as one of the important indicators of clinically significant portal hypertension (CSPH) for noninvasive monitoring of clinical significant portal hypertension (CSPH). On the other hand, domestic and foreign scholars have measured LS and splenic hard, on the other hand. Spleen stiffness (SS) and spleen length diameter and other parameters study VTQ technology to predict and evaluate the value of EV and hemorrhage (Esophageal variceal bleeding, EVB), and has a certain clinical application prospects, but most of the results can not obtain satisfactory sensitivity and specificity at the same time. This study uses a variety of new ultrasonic diagnostic techniques such as VTQ, etc., In order to explore the independent risk factors affecting the occurrence of cirrhosis EV by systematic detection of various objective parameters, and evaluate the clinical diagnostic value of the best critical value obtained by ROC curve analysis in predicting the EV of liver cirrhosis, there is no systematic study in China at present. The purpose of this study should be non-invasive detection of cirrhosis by two-dimensional ultrasound and VTQ technique. The SWV value of the liver and spleen, the internal diameter of the hepatic portal vein and the splenic vein, the internal diameter and blood flow velocity of the hepatic portal and splenic vein, analyzed the independent risk factors affecting the occurrence of EV in the liver cirrhosis, and discussed the diagnostic efficiency and clinical value of the two kinds of ultrasonic techniques in the risk of EV in the liver cirrhosis; and the Receiver operator characteristic curve was used. The ROC) curve provides the best critical value for non invasive monitoring of liver cirrhosis for clinical EV. Methods the patients in this study were in accordance with the diagnostic criteria for cirrhosis in the 2015 edition of the guide to chronic hepatitis B prevention and control. A total of 154 cases, 95 men, 59 women, 29-80 years of age, and the average age of 55 + 10 years. All the selected patients underwent upper gastrointestinal endoscopy and were based on them The results were divided into groups: 52 cases without EV were classified as no varicose group (No esophageal varices, NEV group, n=52), and 102 cases were classified as varicose vein group (EV group, n=102). The sex, age, height and weight of each person were recorded, and BMI. all subjects were strictly fasting for more than 8 hours, and venous blood was used to detect liver function and coagulation. Blood routine. The Siemens Acuson S2000 ultrasonic diagnostic instrument (with VTQ software) was used for ultrasound examination. All the subjects were strictly empty stomach for more than 8 hours, lying on the check bed, exposing the abdomen fully. First of all, the routine ultrasound examination of each person was performed to observe the liver and spleen profile and the essence echo, the right liver oblique diameter, splenic thickness, spleen were measured. The internal diameter and blood velocity of the hepatic portal vein and the splenic vein. Then, the VTQ model of the ARFI technique was started to measure the SWV value of the liver and spleen of all the subjects. The independent sample t test or chi square test of the experimental data was carried out by the SPSS22.0 statistics software, and the independent risk factors affecting the occurrence of EV were screened by the Logistic regression analysis. Draw the ROC curve and calculate the best critical value. Using the De Long test in the Med Calc medical statistics software, the comparison between the area under the curve (Area under the curve, AUC). Results 1, the comparison of the parameters between the EV group and the NEV group (1) the comparison of the clinical data and the classification of liver function is significantly higher than that of the group. The age, sex and BMI of the two groups were not significantly different (P0.05). (2) the comparison of the two dimensional and spectral Doppler ultrasound parameters in the EV group was significantly greater than that in the NEV group (P0.05), and the blood flow velocity of the hepatic portal vein and the splenic vein in the EV group was significantly lower than that of the NEV group, and the blood flow rate of the hepatic portal and splenic veins in the EV group was significantly lower than that of the NEV group. Study difference (P0.05). (3) SWV values compared with the EV group, the SWV value of the liver and spleen was significantly higher than that of the NEV group, with statistical difference (P0.05).2, Logistic regression analysis was used to screen the independent risk factors of EV. Logistic regression analysis showed the internal diameter of the hepatic portal vein, the liver and spleen SWV were the independent risk factors to predict the occurrence of EV. The diagnostic efficacy and clinical value of 2.396,1.007 and 1.005 (P0.05).3, two-dimensional ultrasound and VTQ in the noninvasive assessment of the risk of EV in liver cirrhosis, and to draw independent risk factors affecting the EV of liver cirrhosis, namely the hepatic portal diameter, the ROC curve of the liver and spleen SWV values of 0.88 (95%CI:0.824-0.936), 0.911 (95%CI:0.866-0.957) and 0.9, respectively. 08 (95%CI:0.863-0.953); the best critical points of the Youden index are determined as the critical point, 14.05mm, 2.013m/s and 2.937m/s respectively; the sensitivity is 73.6%, 82.4% and 79.6%, the specificity is 87.1%, 90.3% and 87.6%, respectively, and the positive predictive values are 75%, 80.8% and 75%, respectively, and the negative predictive values are respectively, 91.2% and 90.2%; accuracy points respectively. Do not be 82.5%, 87.7%, and 85.1%. conclusion 1, liver function classification, the internal diameter of the hepatic portal vein and the splenic vein and the SWV value of the liver and spleen play a certain auxiliary role in judging the occurrence of EV, the internal diameter of the hepatic portal vein, the liver and spleen SWV value as an independent risk factor for predicting the occurrence of EV, the ROC curve analysis, the hepatic portal vein. The SWV value of the liver and spleen has a good diagnostic efficiency in assessing the risk of EV in liver cirrhosis, especially the liver SWV value. It is suggested that two-dimensional ultrasound and VTQ may be an effective indicator of non invasive, simple, dynamic and objective evaluation of the risk of EV in liver cirrhosis.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R575.2

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