胆管结石并积气患者内镜下十二指肠乳头及胆管病变的特点

Endoscopic characteristics of bile duct lesions and duodenal papilla in patients with bile duct stones and pneumatosis

目的探讨胆管结石并积气患者的胆汁病原学、胆道镜下胆管改变、乳头特征及临床意义.方法分析53例胆管结石并积气患者的胆汁病原学、胆道镜下胆管改变和乳头特征,并比较各亚型乳头的胆管直径、肠内容物返流及胆管反复炎症发生率,应用SPSS22.0进行统计分析.结果胆管结石并积气患者胆汁病原菌培养结果显示革兰阳性菌、革兰阴性菌和真菌分别占42.1%、57.9%和1.8%,其中细菌类以肠球菌属(36.6%)、大肠埃希菌(19.3%)、肺炎克雷伯菌(15.8%)为主.十二指肠乳头黏膜炎症、乳头关闭不全、Oddi括约肌松弛及胆管慢性炎症为其特征.16例患者胆管壁呈肠道绒毛样、黏膜小凹样、网状裂隙样改变,7例患者胆管局部形成肿物.12例患者胆管内出现十二指肠内容物返流.不同亚型乳头患者其胆总管直径不全相同(P<0.001),Ⅱb和Ⅱc组胆总管直径显著大于Ⅱa和Ⅱd组(P<0.05),其中Ⅱb、Ⅱc组间差异不显著(P>0.05),Ⅱa、Ⅱd组间差异不显著(P>0.05).不同亚型乳头组间肠内容物返流发生率存在差异(P<0.05),Ⅱa组肠液返流发生率高于Ⅱb、Ⅱc、Ⅱd组;但4个亚型乳头组间胆管反复炎症发生率无显著差异(P>0.05).结论胆管结石并积气型患者感染以细菌为主,其中革兰氏阳性菌比例有所升高.胆道镜下以乳头黏膜炎、乳头关闭不全、Oddi括约肌松弛及胆管慢性炎症为特征.不同亚型乳头间胆总管直径、肠内容物返流发生率存在差异,但4组间胆管反复炎症发生率无显著差异.

AIM To investigate the characteristics of biliary pathogenic bacteria, pathological changes of bile ducts, and changes of duodenal papilla in patients with bile duct stones and pneumatosis. METHODS We analyzed biliary pathogenic bacteria, pathological changes of bile ducts, and characteristics of duodenal papilla in 53 patients with bile duct stones and pneumatosis. The incidence of intestinal juice reflux and recurrent biliary infection and bile duct diameter were compared in each subtype of duodenal papilla. RESULTS The results of bacterial culture showed that the percentages of Gram positive bacteria, Gram negative bacteria, and fungi were 42.1%, 57.9%, and 1.8%, respectively. The main bacteria were Enterococcus （36.6%）, Escherichia coli （19.3%）, and Klebsiella pneumoniae （15.8%）.Chronic bile duct inflammation, duodenal papillary inflammation, incomplete closure of duodenal papilla, and Oddi sphincter relaxation were common features in patients with bile duct stones and pneumatosis. Chronic inflammation and abnormal hyperplasia of the bile duct mucosa were found in 16 patients, which manifested as intestinal villous change, mucous pits, and reticular pattern. Seven patients had local mass in the bile duct. There was a significant difference in bile duct diameter among each subtype of papilla （P 〈 0.001）. Common bile duct diameter was significantly bigger in lib and IIc subtypes than in IIa and IId subtypes （P 〈 0.05）, but there was no significant difference between IIb and IIc and between IIa and lid （P 〉 0.05）. The rate of intestinal juice reflux differed significantly among each subtype of papilla （P 〈 0.05）, and the rate of intestinal juice reflux was significantly higher in IIa subtype than in other subtypes. However, the rate of recurrent biliary infection showed no significant difference among each subtype of papilla （P 〉 0.05）. CONCLUSION Bacterial infection is the main etiology in patients with bile duct stones and pneumatosis, and the percentage of Gram positive bacteria is higher. Chronic bile duct inflammation, duodenal papillary inflammation, incomplete closure of duodenal papilla, and Oddi sphincter relaxation are common features in patients with bile duct stones and pneumatosis. There is a significant difference in bile duct diameter and the rate of intestinal juice reflux among each subtype of duodenal papilla, while there is no significant difference in the rate of recurrent biliary infection.