ERCP术前胆总管结石诊断238例

Diagnosis of common bile duct stones before ERCP:An analysis of 238 cases

目的:优化内镜下逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)术前胆总管结石诊断方法的选择.方法:回顾性分析238例拟诊胆总管结石患者的临床资料,分单一检查组和联合检查组.单一检查组:B超16例,电子计算机X射线断层扫描技术(electronic computer X-ray tomography technique,CT)12例,核磁共振胰胆管成像(magnetic resonance cholangiopancre atography,MRCP)12例;联合检查组:B超+CT100例,B超+MRCP80例,CT+MRCP6例,B超+CT+MRCP12例.计算B超、CT、MRCP的敏感度、特异度、阳性预测值、阴性预测值和准确度.比较胆总管结石≥1.0cm和≤0.5cm时各种检查方法的准确度.结果:敏感度、特异度、阳性预测值、阴性预测值和准确度B超分别为56.2%、66.7%、86.9%、28.0%、58.3%;CT分别为86.5%、57.1%、87.4%、55.2%、79.8%;MRCP分别为97.5%、82.1%、94.0%、92.0%、93.6%.MRCP对胆总管结石诊断的准确度明显高于CT和B超(P<0.01).胆总管结石≥1.0cm选择B超或CT较≤0.5cm准确率高(均P<0.01),选择MRCP无差异(P>0.05);胆总管结石≤0.5cm选择MRCP较CT更准确(P<0.01);联合检查占83.2%,以B超+MRCP和B超+CT为主,两者的准确率无差异(P>0.05).结论:B超是ERCP术前病因诊断的首选检查方法,MRCP是最佳选择.当胆总管结石≥1.0cm时,B超诊断的准确度较高,在条件限制或急诊情况下可单选;当结石≤0.5cm时,选择MRCP较CT的准确度高.总体来说,MRCP的检出率最好,CT次之,B超最差.临床绝大多数选择联合检查:B超+CT或B超+MRCP,以B超+MRCP的联合检查的准确度更高,但两者无统计学差异.而B超+CT+MRCP联合检查的选择不可取,除非前两项检查方法的诊断有出入或不能明确.

AIM： To optimize the choice of the diagnostic methods for common bile duct stones before en- doscopic retrograde cholangiopancreatography （ERCP）. METHODS： A retrospective analysis of clinical data for 238 patients who were suspected with common bile duct stones （CBDS） was performed. CBDS was graded using a single modality or com- bined modalities. In the single modality group, 16 patients were diagnosed by B ultrasound, 12 by CT, and 12 by magnetic resonance cholangiopan- creatography （MRCP）. In the combined modality group, 100 patients were diagnosed by B ultra- sound and CT, 80 by B ultrasound and MRCP, 6 by CT and MRCP, and 12 by B ultrasound, CT and MRCP. The sensitivity, specificity, positive predic- tive value, negative predictive value and accuracy of B ultrasound, CT, and MRCP were calculated.The accuracy of each method in diagnosis of CBDS /〉 1.0 cm or ~ 0.5 cm was compared. RESULTS： The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of B ultrasound were 56.2%, 66.7%, 86.9%, 28.0%, and 58.3%, those of CT were 86.5%, 57.1%, 87.4%, 55.2%, 79.8%, and those of MRCP were 97.5%, 82.1%, 94.0%, 92.0%, and 93.6%, respectively. The accuracy of MRCP to diagnose CBDS was significantly higher than that of CT and B ultrasound （both P 〈 0.01）. The accuracy of B ultrasound or CT in diagnosis of CBDS ≥1.0 cm was higher than that in diagno- sis of CBDS ≤ 0.5 cm （both P 〈 0.01）, while no significant difference was observed for MRCP （P 〉 0.05）. MRCP was more accurate than CT in diagnosis of CBDS ≤ 0.5 cm （P 〈 0.01）. Com- bined modalifies were adopted in 83.2% of cases, mainly B ultrasound ＋ MRCP or B ultrasound ＋ CT, whose accuracy had no significant differ- ence （P 〉 0.05）. CONCLUSION： B ultrasound is the preferred method for the dianosis of CBDS before ERCP, and MRCP is the best choice. The accuracy of B ultrasound in diagnosis of CBDS ≥ 1.0 cm is higher, and B ultrasound can be alone used under restrictions conditions or in emergency situation. In cases of stones ≤0.5 cm, MRCP has a higher accuracy than CT. Overall, the detec- tion rate of CBDS was best by MRCP, followed by CT and B ultrasound. Combined modalities （B ultrasound ＋ CT or B ultrasound ＋ MRCP） are adopted in the vast majority of clinical cases. The choice of B ultrasound ＋ CT ＋ MRCP is not desirable, unless diagnosis can not be estab- lished using the first two modalities.