食管裂孔疝33例内镜下漏诊原因分析

Analysis of Causes of Missed Diagnosis in Endoscopic Examination of 33 Cases of Hiatal Hernia

目的探讨食管裂孔疝(hiatal hernia,HH)内镜下特点及漏诊原因,以提高内镜检出率。方法2017年1—12月在海军军医大学附属上海公利医院行胃镜检查共7204例,从中随机抽取513例首次胃镜检查未诊断HH者,结合Hill分级,重新阅胃镜电子影像记录评定有无HH漏诊。进一步对HH抽检阳性检出率、普通胃镜与无痛胃镜HH抽检阳性检出率、不同资历操作者HH抽检阳性检出率进行分析,寻找HH胃镜漏诊原因。结果 513例复核阅片发现33例HH,检出率6.43%。33例中Hill分级Ⅲ级30例,Ⅳ级3例。漏诊原因分析显示:无痛胃镜检查漏诊率为2.20%低于普通胃镜的11.25%,差异有统计学意义(χ~2=17.757,P<0.001);从事内镜工作≤5年医师的复核检出率为11.27%高于从事内镜工作> 5年医师的3.24%,差异有统计学意义(χ~2=13.191,P<0.001)。结论 HH胃镜检查容易漏诊,重视镜下表现尤其是Hill分级,尽可能开展无痛胃镜检查,同时加强内镜检查医师技术能力培训,有助于减少HH胃镜下漏误诊。

Objective To investigate the endoscopic characteristics and causes of missed diagnosis of hiatal hernia(HH),in order to improve the detection rate of HH.Methods A total of 7204 patients were examined by gastroscopy in our hospital(Gongli Hospital of Pudong New Area,Shanghai)from January 2017 to December 2017.We randomly selected 513 from 7204 patients who were not diagnosed with HH on endoscopy initially.Based on Hill grading,we reviewed their endoscopic image records to assess the presence or absence of missed diagnosis of HH.The positive detection rate of HH sampling,the positive rate by common or anaesthetized endoscopy and positive rate detected by different operators with different qualifications were analyzed,to pinpoint the causes of missed diagnosis of HH endoscopy.Results Of 513 cases,33 cases of HH were found in the review,and the detection rate was 6.43%.Of the 33 cases,30 had gradeⅢand 3 had grade IV based on Hill grading.Analysis of causes of missed diagnosis revealed that the missed diagnosis rate by anaesthetized endoscopy was 2.20%,lower than that(11.25%)by common endoscopy(χ^2=17.757,P<0.001).The review rate of physicians who had performed endoscopy for less than 5 years was 11.27%higher than that of physicians who had performed the procedure for more than 5 years(χ^2=13.191,P<0.001).Conclusion HH is an easily missed disease by endoscopic examination.Therefore,physicians should pay attention to the endoscopic characteristics of patients with HH,especially Hill grading,carrying out anaesthetized endoscopy as much as possible,and strengthening the training of physicians who perform endoscopy in technical ability.This may help to reduce the missed diagnosis and misdiagnosis of HH.