超声引导下经皮肝穿刺活检在肝病诊断中的意义

Clinical significance of ultrasound-guided percutaneous liver biopsy in the diagnosis of liver diseases

目的了解超声引导下经皮肝穿刺活检的疾病构成,以及肝穿刺在不同肝病中的诊断效能。方法收集2015年5月—2020年7月于昆明医科大学第二附属医院病理科行肝穿刺活检患者共918例,收集患者病理诊断和临床诊断资料,以临床诊断为标准,分析疾病构成比以及不同性别、年龄(<60岁、≥60岁)的疾病构成差异,统计肝穿刺诊断各型常见肝病的灵敏度、特异度、准确度、阳性预测值、阴性预测值、假阳性率和假阴性率。计数资料采用χ^(2)检验或Fisher确切概率法进行组间比较。结果918例肝穿刺活检患者中,最常见的疾病依次为:恶性肿瘤(282例,30.72%),自身免疫性肝病(AILD)(139例,15.14%),慢性乙型肝炎(CHB)(118例,12.85%),药物性肝损伤(DILI)(49例,5.34%)、代谢相关性脂肪性肝病(MAFLD)(34例,3.70%),肝脓肿(26例,2.83%),良性肿瘤(18例,1.96%),寄生虫感染(18例,1.96%),酒精性肝病(ALD)(9例,0.98%)等;恶性肿瘤、CHB、ALD、肝脓肿比例男性高于女性(χ^(2)值分别为31.67、19.61、4.68,P值均<0.05),AILD、DILI、寄生虫感染比例女性高于男性(χ^(2)值分别为58.60、7.91、6.60,P值均<0.05);<60岁的患者恶性肿瘤、CHB、AILD、MAFLD比例高于≥60岁的患者(χ^(2)值分别为105.90、7.58、20.03、6.97,P值均<0.01)。肝穿刺诊断各型肝病的准确度、特异度、阳性预测值和阴性预测值均接近100%,但灵敏度及假阴性率存在差异,恶性肿瘤、良性肿瘤、寄生虫感染灵敏度分别为93.26%、100%、94.40%,CHB、AILD、DILI灵敏度分别为87.29%、77.70%、76.60%,假阴性率分别为12.71%、22.30%、23.40%;MAFLD、ALD灵敏度分别为42.31%、44.44%,其假阴性率分别达57.69%、55.56%。结论肝穿刺主要疾病构成为肝脏恶性肿瘤、AILD、CHB、DILI、MAFLD等,肝穿刺对各型肝病均具有重要诊断价值,对恶性肿瘤、良性肿瘤、寄生虫感染具有较高诊断效能,CHB、AILD、DILI存在一定假阴性率,MAFLD、ALD诊断效能一般,临床应结合病史、临床特征、有无其他肝损伤等综合判断。

Objective To investigate the disease constitution of ultrasound-guided percutaneous liver biopsy and its diagnostic efficacy in different liver diseases.Methods A total of 918 patients who underwent liver biopsy in Department of Pathology,The Second Affiliated Hospital of Kunming Medical University,from May 2015 to July 2020 were enrolled,and the data on pathological diagnosis and clinical diagnosis were collected.With clinical diagnosis as the criteria,the constitution ratio of liver diseases and the difference in disease constitution between sexes and ages(<60 or≥60 years)were analyzed,and a statistical analysis was performed for liver biopsy in the diagnosis of common liver diseases in terms of sensitivity,specificity,accuracy,positive predictive value,negative predictive value,false positive rate,and false negative rate.The chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups.Results In the 918 patients undergoing liver biopsy,the most common diseases included malignant tumor in 282 patients(30.72%),autoimmune liver disease(AILD)in 139 patients(15.14%),chronic hepatitis B(CHB)in 118 patients(12.85%),drug-induced liver injury(DILI)in 49 patients(5.34%),metabolic associated fatty liver disease(MAFLD)in 34 patients(3.70%),liver abscess in 26 patients(2.83%),benign tumor in 18 patients(1.96%),parasitic infection in 18 patients(1.96%),and alcoholic liver disease(ALD)in 9 patients(0.98%).For malignant tumor,CHB,ALD,and liver abscess,the proportion of male patients was significantly higher than that of female patients(χ^(2)=31.67,19.61,and 4.68,all P<0.05),and for AILD,DILI,and parasitic infection,the proportion of female patients was significantly higher than that of male patients(χ^(2)=58.60,7.91,and 6.60,all P<0.05).Compared with the patients aged≥60 years,the patients aged<60 years had significantly higher proportions of patients with malignant tumor,CHB,AILD,and MAFLD(χ^(2)=105.90,7.58,20.03,and 6.97,all P<0.01).The accuracy,specificity,positive predictive value,and negative predictive value of liver biopsy were all close to 100%in the diagnosis of various liver diseases,but with differences in sensitivity and false negative rate;liver biopsy had a sensitivity of 93.26%,100%,and 94.40%,respectively,in the diagnosis of malignant tumor,benign tumor,and parasitic infection,while it had a sensitivity of 87.29%,77.70%,and 76.60%,respectively,in the diagnosis of CHB,AILD,and DILI,with a false negative rate of 12.71%,22.30%,and 23.40%,respectively;liver biopsy had a sensitivity of 42.31%and 44.44%,respectively,in the diagnosis of MAFLD and ALD,with a false negative rate of 57.69%and 55.56%.Conclusion The main disease constitution of liver biopsy includes malignant liver tumor,AILD,CHB,DILI,and MAFLD.Liver biopsy has an important diagnostic value in various types of liver diseases,with a relatively high diagnostic efficacy in malignant tumor,benign tumor,and parasitic infection,while it also has a certain false negative rate in CHB,AILD,and DILI and a fair diagnostic efficacy in MAFLD and ALD.Therefore,a comprehensive judgment should be given with reference to medical history,clinical features,and the presence or absence of other types of liver injury.