【作者】 石爱忠；

【导师】 卢再鸣；

【作者基本信息】 中国医科大学 ， 影像医学与核医学， 2010， 硕士

【摘要】 目的恶性梗阻性黄疸(malignant biliary obstruction, MOJ)主要由胰头癌、胆囊癌、胆管癌以及转移性肿瘤如胃癌胆道转移压迫或侵蚀胆管所致,主要表现为皮肤黏膜及巩膜黄染,可以造成机体一系列病理生理紊乱,如免疫功能下降,凝血功能障碍、心功能降低、营养不良等,随着病情逐渐加重可引起肝肾功能衰竭,甚至死亡。自1974年Molnar和Stocknm创立经皮经肝胆道引流术(Percutaneous transhepatic cholangial drainage, PTCD)缓解恶性梗阻性黄疸以来,PTCD及胆道支架置入术作为微创技术已经成为姑息性治疗恶性梗阻性黄疸最常用的方法。不宜手术患者采用PTCD或／和胆道支架置入术进行治疗,可有效缓解恶性梗阻性黄疸症状、延长患者的生存期及提高患者的生活质量。但是以往研究显示,实施PTCD或／和胆道支架置入术后合并的并发症会影响治疗效果,甚至会导致患者死亡。其中,术后合并胰腺炎是较为严重的并发症之一。在经皮经肝胆管造影术中,当造影了解治疗(胆道引流和／或内支架置入)后胆道通畅情况时,有时可见到胆管、胰管同时显影；而正常情况下由于胆胰管均受Oddi括约肌控制,彼此不相交通,且胆管内压力高于十二指肠内压力,胰管内压力又高于胆管,胰管并不显影。本研究通过对2008年9月-2009年9月中国医科大学附属盛京医院经介入治疗的梗阻性黄疸患者的临床资料进行回顾性分析,旨在初步分析经皮经肝胆管造影术中胰管显影与术后胰腺炎相关性的关系。资料与方法收集2008年9月至2009年9月间连续82例因梗阻性黄疸于我科经PTC行介入治疗的病人的临床及影像学资料。确立病例纳入标准及排除标准,从中筛选出符合标准的病例70例。其中,男44例,女26例,年龄28-88岁,平均67.6±12.6岁。临床表现主要有无痛性不同程度皮肤粘膜及巩膜黄染伴皮肤瘙痒、食欲减退、小便黄、大便陶土色。所有患者均经CT和／或MR检查诊断为恶性胆道梗阻。化验室检查主要为肝功能测定,包括总胆红素(total bilirubin, TBIL)、直接胆红素(direct bilirubin, DBIL)、间接胆红素(indirect bilirubin, IBIL)、谷草转氨酶(aspartate aminotransferase, AST)、谷丙转氨酶(alanine aminotransferase, ALT)及白蛋白(albumin, ALB)。所有患者均先行经皮经肝胆道穿刺,随后置入引流管行胆道引流或胆道内支架。术后密切观察患者的皮肤粘膜颜色、尿色便色、腹部体征及体征的变化,1周后行化验复查。所有检查数据输入SPSS 13.0软件完成统计学处理。结果1、全部70例患者成功穿刺并置入引流管,其中仅行PTCD18例,胆管支架置入52例,成功率100%。总胆红素、直接胆红素及间接胆红素水平均有不同程度的下降；白蛋白水平亦有明显下降。2、全部70例患者中,术后合并胰腺炎患者9例,发病率为12.9%。术中胆管造影过程中,胰管显影病例与胰管未显影病例组胰腺炎发病差异具有统计学意义,术中胰管显影组胰腺炎发病率高于胰管未显影组；Spearman相关分析得,术中胰管显影与术后合并胰腺炎呈正相关。结论经皮经肝胆管造影中胰管显影组与未显影组,术后胰腺炎的发生率存在差异,具有统计学意义,术中胰管显影组术后胰腺炎的发生率高于胰管未显影组；术中胰管显影与术后合并胰腺炎呈正相关。更多还原

【Abstract】 ObjectiveMalignant obstructive jaundice is caused mainly by pancreatic cancer, gallbladder cancer, cholangiocarcinoma,and metastatic tumors such as biliary duct metastasis of gastric cancer. The main clinical manifestations of malignant obstructive jaundice are stained yellow skin and mucosa and sclera, which can cause the body a series of physiological and pathological disorders such as decreased immune function, blood coagulation dysfunction, decreased cardiac function, malnutrition, etc. As the disease gradually worsened, malignant obstructive jaundice can cause liver and kidney failure and even death. Since founded in 1974, Molnar and Stocknm percutaneous biliary drainage for malignant obstructive jaundice remission since, PTCD and biliary stent placement as a minimally invasive technique has become the palliative treatment of malignant obstructive jaundice the most common method. PTCD or/and biliary stent placement can effectively relieve malignant obstructive jaundice symptoms, prolong survival and improve quality of life of patients who should not be treated with surgery. However, previous studies showed that the complications of PTCD and/or biliary stent placement can affect the treatment, and even lead to death. Which, the pancreatitis after PTCD or/and biliary stent placement is one of the more serious complications. In percutaneous transhepatic cholangiography, when imaging to understand the case of biliary patency after the treatment(biliary drainage and/or stent), sometimes we can see bile duct and pancreatic duct develop at the same time. Normally, bile duct and pancreatic duct do not connect with each other,which are subject to control of Oddi sphincter.The pressure in bile duct is higher than the pressure in the duodenum, and the pressure in pancreatic duct is higher than the pressure in the bile duct, so when cholangiography, the pancreatic duct does not develop. This study aims at retrospectively analyzing the clinical data of the patients with obstructive jaundice who were treated by intervention in Shengjing Hospital of China Medical University between September 2008 and September 2009 to analysis the relationship between the visualization of pancreatic duct in percutaneous transhepatic cholangiography and the pancreatitis preliminarily.Materials and MethodsCollecting the clinical data of consecutive 82 Patients with obstructive jaundice(OJ) are receiving the Interventional therapy in our hospital from September 2008 to September 2009. Clinical findings and cholangiopancreatographic results were analyzed. Meanwhile the standard to be selected for cases and the criteria for exclusion were established,70 patients selected. Among them,44 males and 26 females, aged 28 to 88 years,the average age of whom was 67.6±12.6 years. The main clinical manifestations of malignant obstructive jaundice are different degrees of painless stained yellow skin and mucosa and sclera, loss of appetite, yellow urine, clay colored stools. All patients was diagnosed with malignant biliary obstruction by CT and/or MR. Laboratory examination of liver function is mainly determined, including TBIL,DBIL,IBIL,AST,ALT andAlb.All patients were underwent percutaneous transhepatic puncture befor PTCD and biliary stent placement. After interventional therapy, the skin color, urine color, stool color, abdominal signs and changes of symptoms are the major observation,the test review after 1 weeks. All of the data are analyzed by SPSS 13.0 statistical package.Results1、PTCD or/and biliary stent placement were performed successful for all patients.Among them,only 18 cases received PTCD, meanwhile,52 cases accepted biliary stent placement,100% success rate.The levels of TBIL,DBIL,IBIL,AST,ALT were in decline,and the levels of albumin also decreased significantly.2、Among all 70 patients,9 patients with pancreatitis occurred.The incidence rate was 12.9%. The incidence rate of pancreatitis of two cases were significant. The incidence of pancreatitis of the patients whose pancreatic duct intraoperative visualization was higher than that of pancreatic duct don’t develop. Spearman analysis of correlation show that there is positive correlation between the visualization of pancreatic duct in the operation of Cholescintigraphy and the pancreatitis after the operation of Cholescintigraphy.ConclusionThe incidence of pancreatitis of the patients whose pancreatic duct intraoperative visualization was higher than that of pancreatic duct don’t develop.There is positive correlation between the visualization of pancreatic duct in the operation of Cholescintigraphy and the pancreatitis after the operation of Cholescintigraphy.更多还原