内镜超声对特发性急性胰腺炎病因诊断的临床应用价值

Clinical application value of endoscopic ultrasound in the etiological diagnosis of idiopathic acute pancreatitis

目的评估内镜超声(EUS)对初始诊断为特发性急性胰腺炎(IAP)患者病因学诊断的临床应用价值。方法收集2015年1月至2022年2月间海军军医大学第一附属医院消化内镜中心128例初次诊断为IAP后进一步行EUS和磁共振胰胆管造影(MRCP)检查患者的临床资料,依据AP发作次数分为单次发作组(单发组,51例)和多次发作组(复发组,77例),分析两组患者资料及EUS对两组IAP病因的诊断,并与MRCP的病因诊断结果进行比较。结果单发组与复发组IAP患者的性别、年龄、吸烟史、饮酒史、胰腺疾病家族史、胆囊切除史、肝功能是否异常、胰腺炎严重程度等基本资料的差异均无统计学意义。经EUS检查后79例(62%)IAP患者明确了病因,其中55例(43%)为胆道疾病(胆结石、胆道微结石和胆泥淤积),24例(19%)有胰腺疾病(慢性胰腺炎、胰腺分裂、胰腺间质或胰腺导管改变)。单发组IAP患者病因为胆道疾病的占比显著高于复发组患者(59%比32%),而复发组IAP患者病因为胰腺疾病的占比高于单发组(25%比10%),差异均有统计学意义(P值分别为0.004、0.035)。EUS诊断IAP病因的性能显著高于MRCP(62%比19%,P=0.032),其中EUS能更准确地检出胆道微结石或胆汁淤积(43%比9%,P<0.01),诊断慢性胰腺炎病变的一些微小变化(胰腺小结节、斑片状高回声等)和胰腺导管内乳头状黏液性肿瘤也优于MRCP(17%比7%,P<0.05),但识别胰腺分裂不及MRCP(2例比4例)。结论EUS诊断胆道疾病精确度高,基于我国大多数IAP病因为胆道疾病,应考虑将EUS作为IAP的初始诊断方法,MRCP可以作为EUS的补充,以确定有争议的病因。

Objective To evaluate the clinical application value of endoscopic ultrasonography(EUS)in the etiological diagnosis of patients initially diagnosed with idiopathic acute pancreatitis(IAP).Methods Clinical data of 128 patients who underwent further EUS and magnetic resonance cholangiopancreatography(MRCP)after initial diagnosis of IAP at the Gastrointestinal Endoscopy Center of the First Affiliated Hospital of Naval Medical University between January 2015 and February 2022 were collected and divided into a single-episode group(single-episode group,51 cases)and a multiple-episode group(recurrent group,77 cases)based on the number of AP episodes.The data and the diagnosis of the etiology of IAP in the two groups by EUS were analyzed and compared with the etiological diagnosis results of MRCP.Results The differences on basic information such as gender,age,history of smoking,history of alcohol consumption,family history of pancreatic disease,history of cholecystectomy,abnormality of liver function,and severity of pancreatitis between the single-episode group and recurrent group of IAP patients were not statistically significant.The etiology was clarified in 79(62%)IAP patients after EUS examination,of which 55(43%)cases had biliary disease(gallstones,microlithiasis,biliary sludge)and 24(19%)cases had pancreatic disease(chronic pancreatitis,pancreatic divisum,pancreatic interstitial or pancreatic ductal changes).The percentage of patients with biliary disease as the cause of IAP was significantly higher in the single-episode group than in the recurrent group(59%vs 32%),while the percentage of patients with pancreatic disease as the cause of IAP was higher in the recurrent group than in the single-episode group(25%vs 10%),with statistically significant differences(P values=0.004 and 0.035,respectively).The performance of EUS in diagnosing the etiology of IAP was significantly higher than that of MRCP(62%vs 19%,P=0.032),where EUS was more accurate in detecting biliary microlithiasis or biliary sludge(43%vs 9%,P<0.01).EUS was also superior to MRCP in identifying subtle changes in chronic pancreatitis lesions(small pancreatic nodules,patchy hyperechogenicity,etc.)and intraductal papillary mucinous neoplasms(17%vs 7%,P<0.05),but was inferior to MRCP in identifying pancreatic divisum(2 cases vs 4 cases).Conclusions In view of high diagnostic accuracy and safety of EUS in diagnosing biliary diseases,and based on the fact that most IAPs in China are due to biliary diseases,EUS based management strategy can be considered to be a reasonable approach for evaluation of IAP patients.The MRCP can be used as a supplement to the EUS to identify a controversial etiology.