孤立性胰腺结核国内文献的荟萃分析

Solitary pancreatic tuberculosis:A case report and literature review

目的:探讨孤立性胰腺结核的临床特征和诊断方式.方法:报告1例孤立性胰腺结核,并结合国内34篇文献共49例孤立性胰腺结核病例进行荟萃分析.结果:49例病例中男25例,女24例,男女之比1∶1.08.平均年龄36.65岁±12.73岁.平均病程4.06mo±3.15mo.临床主要表现为腹痛(63.27%)、体质量下降(59.18%)、发热(36.73%)、黄疸(34.69%)等,其他表现有腹胀、恶心呕吐、盗汗、乏力等.实验室检查呈血沉增快(85.71%)、PPD阳性(5/9)、CA19-9升高(2/8).在CT检查中75.61%的病例显示有胰腺多发低密度结节样病灶,多伴有胰腺周围淋巴结增大(34.15%),少数表现有钙化影像、肝内外胆管及胰管扩张和胰腺假性囊肿等.在B超检查中51.06%的病例显示有胰腺肿大和胰腺不规则低回声区,少数病例伴有胰管扩张、肝内外胆管扩张等.确诊前55.1%的病例被误诊为胰腺肿瘤,其他误诊为胰腺假性囊肿、胰腺炎、胆总管癌等.全部病例均经病理组织学检查确诊,其中CT或B超引导下活体组织检查各2例,45例经剖腹探查术后经病理学确诊,病理组织学可见干酪样坏死或干酪样肉芽肿形成,82.22%的病例伴有胰腺周围淋巴结结核.正规的抗结核药物治疗有效者占95.92%,其中剖腹探查病例除抗结核药物治疗外,选择病灶引流(15.56%)、局部病变切除(8.89%)和胰十二指肠切除(8.89%)的手术方式.结论:孤立性胰腺结核极为少见,确诊前多被误诊.临床上缺乏典型的结核中毒症状,多表现有腹痛、体质量下降和血沉增快,少数表现有发热、黄疸和乏力等.易被误诊为胰腺肿瘤、胰腺炎等.腹部CT等影像学检查是重要的诊断手段,确诊主要依据病理组织学检查.抗结核药物对孤立性胰腺结核治疗有效,必要时可选择手术治疗.

RESULTS： Predominant symptoms consisted of abdominal pain （63.27%）, weight loss （59.18%）, fever （36.73%）, jaundice （34.69%）, and abdomi- nal distention/bloating, without night sweats. Most patients were misdiagnosed with pan- creatic tumors, and other misdiagnoses were pseudo-pancreatic cysts, chronic cholecysti- tis with pancreatitis, and cholecystic tumors. Erythrocyte sedimentation rate was elevated in 85.71% （12/14） of cases; PPD test was strongly positive in 55.56% （5/9）; and CA19-9 was mildly elevated in 25% （2/8）. CT scans showed a pan- creatic mass （31/41） with heterogeneous hy- podensity focus （9/41）, calcification （6/41）, or peripancreatic nodal enlargement （14/41）. Ultra- sound or CT-guided biopsies were performed in 8.16% （4/49） of cases, including one undergoing EUS-guided fine needle aspiration for cytologic diagnosis. Laparotomy was performed in 45 of 49 cases, and most received combined antituber- culosis therapy. Anti-tuberculosis therapy was successful in 42 of 49 cases.CONCLUSION： Solitary pancreatic tuberculosis is a rare condition with no specific clinical mani- festations. The possibility of solitary pancreatic tuberculosis should be considered in patients presenting with a pancreatic mass and irregu- lar pancreas enlargement. Diagnosis should be made cytologically, and laparotomy can be avoided if a definitive diagnosis was established before surgery. Solitary pancreatic tuberculo- sis can be effectively cured by antituberculosis therapy.