急诊科胆道梗阻患者的病因分析和病因鉴别

Etyology and identification of biliary obstruction in emergency department patients

目的研究急诊科胆道梗阻患者的病因构成,并探讨相关临床指标的病因鉴别能力。方法回顾性地收集2014年9月至2015年1月以"黄疸伴腹痛或发热"等症状就诊于首都医科大学附属北京友谊医院急诊科、诊疗过程中最终诊断为胆道梗阻的患者。收集患者的性别、年龄、主要症状(发热、腹痛、黄疸、恶心或呕吐)、白细胞(WBC)、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、直接胆红素(DBIL)及血清淀粉酶(AMY)等数据。结果研究共纳入47例胆道梗阻患者。结合影像学检查结果诊断如下:单纯胆总管结石所致胆道梗阻患者27例(57.45%)、其他原因所致胆道梗阻患者20例(42.55%,胆胰系统恶性肿瘤9例、胆管黏液腺瘤1例、重症胰腺炎1例、诊断不清9例)。其他原因所致胆道梗阻患者的TBIL水平及DBIL水平较单纯胆总管结石所致胆道梗阻患者高,两组间TBIL(P=0.045)及DBIL(P=0.043)水平均具有统计学差异。TBIL和DBIL在诊断其他原因所致胆道梗阻患者受试者工作特征曲线(ROC)下面积分别为0.672和0.674。结论单纯胆总管结石仍是急诊科胆道梗阻患者发病的主要原因。胆红素水平的升高幅度对于鉴别单纯胆总管结石所致胆道梗阻有一定的提示作用,但单一的胆红素指标并不能有效地将单纯胆总管结石所致胆道梗阻与其他原因所致胆道梗阻鉴别开来。

Objective To analyze the etiology of biliary obstruction in emergency department patients, and to explore the diagnostic efficacy of associated indicators. Methods Patients who were diagnosed with biliary obstruction in emergency department of Beijing Friendship Hospital affiliated to Capital Medical University from September 2014 to January 2015 with symptoms such as ＂jaundice with abdominal pain or fever＂ were retrospectively enrolled. Their medical records, including gender, age, cardinal symptom （such as fever, abdominal pain, jaundice, nausea or vomiting）, white blood cell （WBC）, alanine aminotransferase （ALT）, aspartate transaminase （AST）, total bilirubin （TBIL）, direct bilirubin （DBIL） and serum amylase （AMY） were collected. Results This study included 47 patients with biliary obstruction. The diagnosis combining imaging examinations were as follows： 27 cases （57.45%） of biliary obstruction were caused by simple choledocholithiasis, whereas 20 cases （42.55%） were of other causes, including 9 of malignant biliopancreatic tumors, 1 of myxadenoma, 1 of severe pancreatitis and 9 of ambiguous diagnosis. The patients in the other causes group had higher levels of TBIL （ P =0.045） and DBIL （ P =0.043） compared with the patients in choledocholithiasis group. The areas under the receiver operating characteristic （ROC） curve of TBIL and DBIL for distinguishing biliary obstruction of other causes from all biliary obstruction cases were 0.672 and 0.674, respectively. Conclusion Simple choledocholithiasis is still the major cause of biliary obstruction in emergency department patients. The bilirubin level has certain suggestive effect on the identification of biliary obstruction caused by simple choledocholithiasis, but it alone is without sufficient efficacy in exclusion of other obstructive causes.