经内镜逆行胰胆管造影术治疗Child C级肝硬化合并梗阻性黄疸的效果观察

Efficacy of endoscopic retrograde cholangiopancreatography in the treatment of Child-Pugh C cirrhosis complicated by obstructive jaundice

目的:观察经内镜逆行胰胆管造影术(ERCP)治疗Child C级肝硬化合并梗阻性黄疸的效果及对肝功能、感染指标的影响。方法:回顾性分析浙江大学医学院附属杭州市西溪医院2017年6月至2022年6月收治的Child C级肝硬化合并梗阻性黄疸患者86例的临床资料,根据治疗方式的不同分为两组,观察组(56例)采用ERCP治疗,对照组(30例)采用药物保守治疗。治疗14 d后比较两组临床疗效,分别记录并比较治疗前后两组患者的肝功能[丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、谷氨酰转肽酶(GGT)]、感染指标[白细胞计数(WBC),降钙素原(PCT)、C反应蛋白(CRP)]变化情况;比较两组患者术后并发症发生情况;随访6个月,观察两组患者预后情况。结果:观察组总有效率[98.21%(55/56)]高于对照组[60.00%(18/30)],差异有统计学意义(Z=23.43,P<0.001);对照组治疗前ALT、AST、GGT分别为(294.53±45.19)U/L、(286.62±17.15)U/L、(304.53±12.34)U/L,治疗14 d后分别为(96.25±16.70)U/L、(113.25±8.56)U/L、(122.25±9.24)U/L;观察组治疗前ALT、AST、GGT分别为(352.36±70.23)U/L、(303.31±12.12)U/L、(368.36±10.23)U/L,治疗14 d后分别为(108.65±12.38)U/L、(95.65±6.54)U/L、(85.66±7.28)U/L,治疗后两组ALT、AST、GGT等指标较治疗前均明显降低,差异均有统计学意义(观察组t=22.54、49.54、64.76,对照组t=25.57、112.83、168.48,均P<0.05),且观察组治疗后三者下降幅度均大于对照组(t=2.27、3.18、4.61,均P<0.05);治疗后两组PCT、CRP、WBC较治疗前均降低,组内比较差异均有统计学意义(观察组t=11.68、11.46、5.42,对照组t=20.39、18.69、19.02,均P<0.05),且观察组PCT、CRP、WBC下降幅度均明显高于对照组,差异均有统计学意义(t=5.14、1.67、2.11,均P<0.05);观察组术后14 d内,发生急性胰腺炎2例,高淀粉酶血症1例,胆道短暂性出血1例;对照组急性胰腺炎1例;观察组并发症发生率高于对照组,但两组差异无统计学意义(P>0.05);对照组治疗后有12例患者(40.00%)黄疸反而加重,追加ERCP补救治疗,术后总胆红素降低幅度均>50%,达到显效标准。观察组术后6个月随访,发生支架阻塞2例(及时处理并更换支架)。两组随访期间均无死亡病例。结论:ERCP置入鼻胆管或胆道内支架治疗Child C级肝硬化合并梗阻性黄疸比药物治疗退黄效果更显著,能够有效解除梗阻性黄疸,引流顺畅,改善患者肝功能和感染状态,具有一定的安全性。

Objective To investigate the efficacy of endoscopic retrograde cholangiopancreatography in the treatment of Child-Pugh C cirrhosis complicated by obstructive jaundice and its effects on liver function and infection indexes.Methods The clinical data of 86 patients with Child-Pugh C cirrhosis complicated by obstructive jaundice who received treatment in the Affiliated Hangzhou Xixi Hospital,Zhejiang University School of Medicine,from June 2017 to June 2022 were retrospectively analyzed.These patients were divided into an observation group(n=56)and a control group(n=30)according to different treatment methods.Patients in the observation group underwent endoscopic retrograde cholangiopancreatography and those in the control group received conservative drug treatment.After 14 days of treatment,clinical efficacy was compared between the two groups.The changes in liver function[alanine aminotransferase(ALT),aspartate aminotransferase(AST),glutamyl transpeptide(GGT)]and infection indicators[white blood cell count(WBC),procalcitonin(PCT),and C-reactive protein(CRP)]were compared between the two groups before and after treatment.The incidence of postoperative complications was compared between the two groups.At 6 months after treatment,the prognosis was compared between the two groups.Results The total response rate in the observation group was 98.21%(55/56),which was significantly higher than 60.00%(18/30)in the control group(Z=23.43,P<0.001).Before treatment,serum ALT,AST,GGT levels in the control group were(294.53±45.19)U/L,(286.62±17.15)U/L,and(304.53±12.34)U/L,respectively,and they were(96.25±16.7)U/L,(113.25±8.56)U/L,(122.25±9.24)U/L after 14 days of treatment.Before treatment,serum ALT,AST,and GGT levels in the observation group were(352.36±70.23)U/L,(303.31±12.12)U/L,and(368.36±10.23)U/L,respectively,and they were(108.65±12.38)U/L,(95.65±6.54)U/L,and(85.66±7.28)U/L,respectively,after 14 days of treatment.After treatment,serum ALT,AST,and GGT levels in each group were significantly decreased compared with those before treatment(observation group t=22.54,49.54,64.76;control group t=25.57,112.83,168.48,all P<0.05).After treatment,the amplitude of decrease in serum ALT,AST,and GGT levels in the observation group were significantly greater than those in the control group(t=2.27,3.18,4.61,all P<0.05).After treatment,PCT,CRP,and WBC in each group were significantly decreased compared with those before treatment(observation group:t=11.68,11.46,5.42,control group:t=20.39,18.69,19.02,all P<0.05).After treatment,the amplitude of decrease in serum PCT,CRP,and WBC in the observation group were significantly greater than those in the control group(t=5.14,1.67,and 2.11,all P<0.05).Within 14 days after treatment,there were two cases of acute pancreatitis,one case of hyperamylasemia,and one case of transient biliary bleeding in the observation group.There was one case of acute pancreatitis in the control group.The incidence of complications in the observation group was slightly,but not significantly,higher than that in the control group(P>0.05).After treatment,12 patients(40.00%)in the control group experienced worsening jaundice,and additional endoscopic retrograde cholangiopancreatography salvage treatment was given.After treatment,total bilirubin level decreased by>50%,reaching the standard of significant efficacy.At 6 months after treatment,stent obstruction occurred in two patients,which was effectively treated by replacement.There were no deaths in each group during the follow-up period.Conclusion Implantation of a nasobiliary duct or a biliary duct stent during endoscopic retrograde cholangiopancreatography is more effective at treating yelloxemia in patients with Child-Pugh C cirrhosis complicated by obstructive jaundice than medication.The former method can effectively relieve obstructive jaundice,smooth drainage,improve liver function,reduce infection,and be relatively safe.