胃低级别上皮内瘤变临床和内镜特征及其进展相关危险因素分析

Analysis of clinical and endoscopic characteristics and progress-related risk factors of gastric low-grade intraepithelial neoplasia

目的分析胃低级别上皮内瘤变(LGIN)的临床和内镜特征,并探究LGIN进展相关危险因素。方法回顾性分析2012年1月1日至2020年12月30日于宜昌市第一人民医院(三峡大学人民医院)消化内科初次病理活体组织检查确诊的411例LGIN患者的临床、内镜和病理资料,每间隔3~6个月进行1次随访,并进行内镜和病理活体组织检查。收集患者的临床资料,包括年龄、性别,病灶部位、大小、形态、颜色、外观,有无胃癌家族史、吸烟史、饮酒史、腌制品饮食史,以及是否合并肠化生或萎缩及其程度、是否存在幽门螺杆菌感染等。依据末次随访结果,分析进展与非进展患者以上各因素的差异,以及LGIN患者进展的危险因素。采用独立样本t检验、卡方检验、单因素分析和多因素logistic回归进行统计学分析。结果411例LGIN患者中,男261例,女150例,男女比例为1.74∶1;年龄(范围)为(57.5±10.3)岁(30~86岁);临床症状以腹痛、腹部不适、腹胀为主,分别占30.7%(126/411)、25.8%(106/411)、20.9%(86/411);245例(59.6%)病灶发生在胃窦部,344例(83.7%)病灶最大径为0.5~<2.0 cm,隆起型、平坦型、凹陷型病灶分别有232例(56.4%)、104例(25.3%)、75例(18.2%);发红病灶298例(72.5%),正常或发白病灶113例(27.5%);病灶表面糜烂171例(41.6%),表面溃疡61例(14.8%);272例(66.2%)LGIN合并肠化生,其中轻、中、重度肠化生分别占50.4%(137/272)、33.8%(92/272)、15.8%(43/272);196例(47.7%)LGIN合并萎缩,其中轻、中、重度萎缩分别占58.2%(114/196)、29.1%(57/196)、12.7%(25/196);368例(89.5%)进行快速尿素酶试验或14C尿素呼气试验,幽门螺杆菌感染阳性率为45.1%(166/368),其中男性占比高于女性[59.6%(99/166)比40.4%(67/166)],差异有统计学意义(χ^(2)=4.537,P<0.05)。174例LGIN患者成功随访,其中11.5%(20/174)的患者LGIN病灶进展。单因素分析结果显示,进展(20例)与非进展患者(154例)在病灶部位构成、大小、形态和外观,是否合并萎缩,以及有无胃癌家族史、饮酒史和腌制品饮食史方面比较差异均有统计学意义(χ^(2)=11.950、22.370、8.964、8.552、10.362、7.139、5.913、4.668,P均<0.05)。多因素logistic回归分析结果显示,胃体病灶、病灶最大径≥2.0 cm、凹陷型病灶、溃疡病灶、合并萎缩、有胃癌家族史、有饮酒史、有腌制品饮食史是LGIN进展的危险因素(比值比=4.796、5.457、4.431、3.521、1.380、21.405、3.294、1.832,95%可信区间2.028~6.431、3.256~8.943、1.356~6.410、1.305~5.706、1.013~2.805、5.062~25.391、2.012~5.826、1.072~3.790,P均<0.05)。结论病灶发生于胃体、病灶最大径≥2.0 cm、凹陷型病灶、溃疡病灶、合并萎缩、有饮酒史、有腌制品饮食史、有胃癌家族史是LGIN进展的独立危险因素,当LGIN患者有此类特征时,可考虑内镜下治疗。

Objective To analyze the clinical and endoscopic characteristics of gastric low-grade intraepithelial neoplasia(LGIN),and to explore the risk factors related to the progression of LGIN.Methods The clinical,endoscopic and pathological data of 411 patients with LGIN diagnosed by initial pathological biopsy in the Department of Gastroenterology,the First People′s Hospital of Yichang(the People′s Hospital of China Three Gorges University)from January 1,2012 to December 30,2020 were retrospectively analyzed,and were followed up every three to six months and endoscopy and pathological biopsy were performed.The clinical data of patients were collected,which included age,gender,lesion location,lesion size,lesion type,lesion color,lesion appearance,family history of gastric cancer,history of smoking and alcohol intake,history of pickled food,whether complicated with intestinal metaplasia or gastric atrophy and the degree,whether there was Helicobacter pylori infection.According to the results of last follow up,the differences in above factors between progressive and non-progressive patients,and the risk factors for the progression of LGIN were analyzed.Indenpendent sample t test,chi square test,and univariate and multivariate logistic regression were used for statistical analysis.Results Among the 411 patients with LGIN,there were 261 males and 150 females,the ratio of male to female was 1.74∶1;the mean age was(57.5±10.3)years old(30 to 86 years old).The most common clinical symptoms were abdominal pain,abdominal discomfort and abdominal distension,which accounted for 30.7%(126/411),25.8%(106/411)and 20.9%(86/411),respectively.The lesions of 245 cases(59.6%)located in gastric antrum;the maximum diameter of lesions of 344 cases(83.7%)was 0.5 to less than 2.0 cm;the lesion types of 232 cases(56.4%),104 cases(25.3%)and 75 cases(18.2%)were prominent type,flat type and depressed type,respectively.The lesion color of 298 cases(72.5%)was red,and that of 113 cases(27.5%)was normal or white.One hundred and seventy-one cases(41.6%)had surface erosion and 61 cases(14.8%)had surface ulcer.Two hundred and seventy-two cases(66.2%)of LGIN were complicated with intestinal metaplasia,and the proportions of mild,moderate and severe intestinal metaplasia were 50.4%(137/272),33.8%(92/272)and 15.8%(43/272),respectively;196 cases(47.7%)of LGIN were with gastric atrophy,and the proportions of mild,moderate and severe degree of gastric atrophy were 58.2%(114/196),29.1%(57/196)and 12.7%(25/196),respectively.Rapid urease test or 14C urea breath test were carried out in 368 cases(89.5%),the positive rate of Helicobacter pylori infection was 45.1%(166/368),and the proportion of male was higher than that of female(59.6%,99/166 vs.40.4%,67/166),and the difference was statistically significant(χ^(2)=4.537,P<0.05).All 174 patients with LGIN were successfully followed up,and the LGIN lesion of 11.5%(20/174)patients was progressive.The results of univariate analysis indicated that there were statistically significant differences in the lesion location,lesion size,lesion type,lesion appearance,atrophy,family gastric cancer history,history of alcohol intake,and history of pickled food between the patients with progressive lesions(20 cases)and the patients with non-progressive lesions(154 cases)(χ^(2)=11.950,22.370,8.964,8.552,10.362,7.139,5.913 and 4.668,all P<0.05).The results of multivariate logistic regression analysis showed that lesions in gastric corpus,maximum diameter of the lesion≥2.0 cm,depressed lesions,ulcer lesions,atrophy,family gastric cancer,history of alcohol intake,history of pickled foods were independent risk factors of the progression of LGIN(odds ratio=4.796,5.457,4.431,3.521,1.380,21.405,3.294 and 1.832,95%confidence interval 2.028 to 6.431,3.256 to 8.943,1.356 to 6.410,1.305 to 5.706,1.013 to 2.805,5.062 to 25.391,2.012 to 5.826,1.072 to 3.790,all P<0.05).Conclusions The lesions located in gastric corpus,maximum diameter of the lesion≥2.0 cm,depressed lesions,ulcer lesions,atrophy,family gastric cancer history,history of alcohol intake,history of pickled foods are independent risk factors of the progression of LGIN.When the patients with LGIN have these characteristics,endoscopic resection should be considered.