合并胆胰系统疾病的壶腹周围憩室临床漏诊分析

Missed diagnosis of periampullary diverticulum complicated with pancreatobiliary diseases

目的总结合并胆胰系统疾病的壶腹周围憩室（PAD）的漏诊情况并分析其原因。方法回顾性分析2006年1月至2011年12月收治的194例合并胆胰系统疾病的PAD患者的临床资料，并对PAD的漏诊率及其原因进行分析。结果胆胰系统疾病首次至第四次发作时，PAD的漏诊率分别为75．3％、37．7％、21．8％和0。比较胆胰系统疾病首次发作时48例PAD确诊病例（确诊组）和146例漏诊病例（漏诊组）的临床资料，见两组在年龄、性别以及合并的胆胰系统疾病类别三个方面差异均无统计学意义（P〉0．05）；而在诊疗组别、诊疗时间、CT、磁共振（MRI）和磁共振胰胆管成像（MRCP）、上消化道造影、十二指肠镜／逆行胰胆管造影（ERcP）的应用频度方面，确诊组明显高于漏诊组（P〈0．05）。CT、MRI、MRCP、上消化道造影和十二指肠镜／ERCP对PAD的诊断率分别为30．0％、31．5％、36．3％、64．5％和100．0％。本组病例中，首次、第二次、第三次和第四次胆胰疾病发作时十二指肠镜／ERCP检查的应用率分别为18．0％、33．6％、70．9％和91．7％。与漏诊组比较，确诊组1年、2年、3年症状复发率均明显降低（P〈0．05）。结论合并胆胰系统疾病的PAD的临床漏诊较为普遍，其主要原因是对PAD的认识不够和重视不足，导致在胆胰系统疾病的临床处理中，CT、MRI、MRCP和上消化道造影对PAD的诊断率较低，十二指肠镜／ERCP检查应用不足。

Objective To summarize the occurrence of missed diagnosis of periampullary diver- ticulum （PAD） with pancreatobiliary diseases and analyze its underlying reasons. Methods We con- ducted a retrospective analysis of 194 patients with PAD complicated with pancreatobiliary diseases from January 2006 to December 2011 in our hospital. Results At the first onset of pancreatobiliary diseases, the diagnosis of PAD was made in 48 patients （correct diagnosis group） and missed in 146 patients （missed diagnosis group）, with a rate of missed diagnosis of 75.3%. At the second, third and fourth onsets of pancreatobiliary diseases in the missed diagnosis group patients, the rates of missed diagnosis were 37.7%, 21.8%, and 0% respectively. There were no significant differences between the correct diagnosis group and the missed diagnosis group with respect to sex, age or the kinds of pa.ncreatobiliary diseases （P〉0.05）. But there were significant differences in the two groups with respect to different medical groups, period of admission, the frequency of application of CT, magnetic resonance （MRI） and magnetic resonance cholangiopancreatography （MRCP）, duodenal en- doscopy/endoscopic retrograde cholangiopancreatography （ERCP） and upper gastrointestinal contrast radiography （P〈0.05）. The accuracy rates of CT, MRI, MRCP, upper gastrointestinal contrast ra- diography and duodenal endoscopy/ERCP for the diagnosis of PAD were 30.0%, 31.5%, 36.3%, 64.5% and 100.0% respectively. At the first, second, third and fourth onset of pancreatobiliary dis- eases, the application rates of duodenal endoscopy/ERCP were 18.0%, 33.6%, 70.9% and 91.7%, respectively. Compared with the missed diagnosis group, recurrence rate of symptom were lower significant- ly in the diagnosis group 1, 2, and 3 years post-treatmnet. Conclusions The missed diagnosis of PAD com- plicated with pancreatobiliary diseases is rather common, mainly due to insufficient understanding for PAD. As a result, for PAD patients with pancreatobiliary diseases, the correct diagnosis rates of CT, MRI, MRCP and upper gastrointestinal contrast are low and the use of duodenal endoscopy/ERCP is insufficient.