胆总管结石内镜逆行胰胆管造影术后并发十二指肠乳头出血的危险因素分析

Risk factors of duodenal papilla hemorrhage after ERCP for choledocholithiasis

目的探讨胆总管结石内镜逆行胰胆管造影(ERCP)术后并发十二指肠乳头出血的危险因素,为临床防治提供理论基础。方法回顾性分析该院收治的672例胆总管结石行ERCP术患者的临床资料。根据是否出现术后十二指肠乳头出血,分为出血组和非出血组,采用单因素分析及Logistic回归分析对其危险因素进行分析。结果 672例行ERCP治疗性手术患者,其中44例发生十二指肠乳头出血,发生率为6.55%。单因素分析显示患者合并胆道感染、结石直径>1 cm、结石嵌顿、十二指肠乳头憩室及术中行内镜下乳头括约肌切开术(EST)存在明显差别,差异有统计学意义(P<0.05)。亚组分析显示:出血组女性患者术后3 d内月经来潮、术后血压异常、合并十二指肠乳头内憩室发生率明显高于非出血组,差异有统计学意义(P<0.05)。出血组行EST术预切开、切口偏斜、切口至后1/3及切割电流所占比例高于非出血组,差异有统计学意义(P<0.05)。多因素Logistic回归分析显示胆道感染(OR=3.905,P=0.002,95%CI:1.660~9.187)、结石直径>1 cm(OR=5.183,P=0.003,95%CI:1.742~11.421)、结石嵌顿(OR=2.953,P=0.017,95%CI:1.343~7.893)、术中行EST术(OR^=11.873,P=0.000,95%CI:3.838~36.729)、十二指肠乳头憩室(OR^=5.445,P=0.011,95%CI:1.783~8.679)是ERCP术后并发十二指肠乳头出血的独立危险因素。结论胆总管结石患者术后3 d内月经来潮、术后血压异常变化、合并胆道感染、结石直径>1 cm、结石嵌顿及十二指肠乳头憩室及行EST术是ERCP术后十二指肠乳头出血的危险因素,对上述危险因素临床应予重视,进而降低十二指肠乳头出血的风险。

Objective To investigate the risk factors of duodenal papilla hemorrhage after ERCP for choledocholithiasis,and to provide a theoretical basis for clinical prevention and treatment.Methods The clinical data of 672 cases of choledocholithiasis were treated by ERCP was analyzed retrospectively.According to whether the patients with duodenal papilla hemorrhage after ERCP,they were divided into the hemorrhage group and non-hemorrhage group.Then the risk factors were analyzed by single factor analysis and Logistic regression analysis.Results In 672 cases of duodenal papilla hemorrhage after ERCP,including 44 cases duodenal papilla hemorrhage,the incidence rate was 6.55%.Univariate analysis showed that there was a significant difference between the bleeding group and non bleeding group in terms of biliary tract infection,stone diameter>1 cm,stone incarceration,duodenal papilla diverticulum and intraoperative EST(P<0.05).Subgroup analysis showed that female patients with bleeding group after 3 days of menstruation,abnormal blood pressure,postoperative duodenal nipple diverticulum was obviously higher than that in non bleeding group,the difference was statistically significant(P<0.05).The proportion of EST pre-incision,incision skew,incision to post 1/3 and cutting current was higher than that in non bleeding group,and the difference was statistically significant(P<0.05).Logistic regression analysis showed that the infection of biliary tract(OR^^=3.905,P=0.002,95%CI:1.660~9.187),stone diameter>1 cm(OR^^=5.183,P=0.003,95%CI:1.742~11.421),stone incarceration(OR^^=2.953,P=0.017,95%CI:1.343~7.893),intraoperative EST(OR^=11.873,P=0.000,95%CI:3.838~36.729),duodenal papilla into diverticulum(OR^^=5.445,P=0.011,95%CI:1.783~8.679)was the independent risk factor associated with duodenal bleeding after ERCP for choledocholithiasis.Conclusion Choledocholithiasis with the after 3 days of menstruation,abnormal blood pressure after operation,biliary tract infection,stone diameter>1 cm,stone incarceration and duodenal papilla into diverticulum and EST was the independent risk factor associated with duodenal papilla hemorrhage after ERCP,and we should pay attention to the above risk factors and reduce the risk of duodenal papilla hemorrhage.