本文選題：囊型包蟲病 + 診斷　； 參考：《新疆醫(yī)科大學》2016年博士論文

【摘要】：目的:總結小兒肝囊型包蟲病包蟲囊腫特點并對不同術式在小兒肝囊型包蟲病中的應用療效進行評價,通過對小兒肝囊型包蟲病術后并發(fā)癥與臨床資料進行相關性分析,尋找發(fā)生并發(fā)癥的危險因素;通過影像學及血清學診斷在小兒肝囊型包蟲病中的應用,探索術前正確診斷小兒單囊型肝包蟲病的最佳方法;通過基因工程技術獲得細粒棘球蚴抗原B1重組蛋白(rEgAgB1),探討其對小兒肝囊型包蟲病的血清學診斷價值,并將表達結果與臨床資料進行相關性分析,尋找影響rEgAgB1在小兒囊型包蟲病血清中表達相關因素。方法:1回顧性分析總結新疆醫(yī)科大學第一附屬醫(yī)院2002年1月至2014年12月期間收治的191例14歲以下(包含14歲)肝囊型包蟲病患兒,對患者性別、就診時年齡、癥狀、囊腫特征(位置、大小、數量)、手術方案、住院時間、術后并發(fā)癥等臨床數據進行統計分析。治療方案包括:改良內囊摘除組、外囊次全切除術與外囊完整剝離術。分別對患者性別、體征、有無膽漏、肝包蟲囊腫個數、肝包蟲囊腫破裂、有無合并其他臟器包蟲、包蟲大小、術式與術后并發(fā)癥相關性進行探討;2收集新疆醫(yī)科大學第一附屬醫(yī)院自2012年1月至2014年12月經病理證實的小兒肝囊型包蟲及肝囊腫的肝臟病變共100例,其中單囊型肝包蟲50例,單純性肝囊腫50例,分別進行影像學超聲、CT檢查及實驗室包蟲四項檢查,計算其靈敏度和特異度,將超聲與包蟲試驗、CT與包蟲試驗相結合,評估聯合診斷價值;3將構建的rEgAgB1原核表達質粒(pET28a-EgAgB1)轉化至E coli中,經親和層析純化獲得高純度rEgAgB1,用純化的重組蛋白及HCF分別對25例小兒包蟲病血清及25例正常兒童血清進行ELISA和Immunoblotting方法檢測,并回顧性分析25例小兒肝囊型包蟲病臨床資料,探討患者年齡、族別、癥狀、分型、有無合并其他臟器、包蟲數量、包蟲大小與rEgAgB1在血清中表達關系。結果:1)共有191例患兒納入研究,其中行改良內囊摘除術(A組)63例,外囊次全切除術組(B組)89例,外囊完整剝離術式(C組)39例。通過對三組數據進行統計學分析,①手術時間,外囊次全切除術組(B組)占時顯著低于外囊完整剝離術式(C組),而與改良內囊摘除術(A組)無顯著性差異;②術中出血量,外囊次全切除術組(B組)術中出血量顯著低于外囊完整剝離術式(C組),而與改良內囊摘除術(A組)無顯著性差異;③術后帶管時間,改良內囊摘除術(A組)術后帶管時間顯著長于外囊次全切除術組(B組)和外囊完整剝離術式(C組);④住院天數,改良內囊摘除術(A組)住院天數顯著長于外囊次全切除術組(B組)和外囊完整剝離術式(C組);⑤術后殘腔并發(fā)癥(殘腔積液、殘腔感染、殘腔膽漏),外囊次全切除術組(B組)顯著低于改良內囊摘除術(A組),而與外囊完整剝離術式(C組)無顯著性差異;術后共有26例患兒發(fā)生并發(fā)癥。單因素統計分析顯示術后發(fā)生并發(fā)癥與腹痛、包蟲囊腫與膽道相通、術前包蟲囊腫破裂相關,P0.05;其他指標差異均無統計學意義。進行單因素分析時未控制其他因素干擾,將P小于0.1的變量納入到多因素回歸模型,進行二分類logistic回歸,結果腹痛、包蟲囊腫與膽道相通、包蟲囊腫破裂變量有統計學意義,并且是危險因素。2超聲在診斷單囊型肝包蟲病中靈敏度為96.00%,特異度為98.00%,CT在診斷單囊型肝包蟲病的靈敏度為80.00%,特異度為62.00%,包蟲四項診斷單囊型肝包蟲病靈敏度為86.00%,其檢測特異度為72.00%。超聲與包蟲試驗聯合診斷靈敏度為82%,特異度為100%。CT與包蟲試驗聯合診斷靈敏度為70%,特異度為82%。3用rEgAgB1為抗原對25例小兒肝囊型包蟲病患者血清進行IgG1特異性抗體檢測,結果顯示19例為陽性,血清診斷陽性率為76%。對25例正常小兒血清檢測,血清診斷無陽性結果,檢測特異度為100%;用rEgAgB1為抗原對25例小兒肝囊型包蟲病患者血清進行IgG4特異性抗體檢測,結果顯示9例為陽性,血清診斷陽性率為36%,對25例正常小兒血清檢測,血清診斷無陽性結果,檢測特異度為100%。分析25例小兒包蟲囊腫病人臨床資料,通過單因素獨立樣本t檢驗及卡方檢驗得出:年齡、族別、癥狀、包蟲大小與rEgAgB1在小兒肝囊型包蟲病患者中表達陽性無相關性(P0.05)。肝內多發(fā)及有無合并其他臟器這兩個因素與rEgAgB1在小兒肝囊型包蟲病患者中表達陽性有相關性(P0.05)。結論:⑴小兒肝囊型包蟲病相比成人,其包蟲囊腫具有獨特的特點。其生長速度快,包蟲囊壁薄,合并其他臟器包蟲囊腫發(fā)生率高,而且包蟲囊腫中CE1型居多,包蟲囊腫張力大,較成人易破裂,包蟲囊腫合并膽漏發(fā)生率小。影像學及實驗室檢查相結合可明確術前診斷。外囊次全切除術為首選術式,如病灶大部分位于肝臟實質內,可行改良的內囊摘除術,如術中包蟲殘腔合并膽瘺,術中膽道造影可有效降低術后殘腔并發(fā)癥。腹痛、術中包蟲囊腫與膽道相通和包蟲術前破裂的患者術后發(fā)生并發(fā)癥發(fā)生率顯著高于其他患者,可能為術后并發(fā)癥的影響因素;⑵在鑒別診斷小兒肝囊型包蟲病與單純性肝囊腫中,超聲具有高靈敏度和特異度,應為首選。如僅為診斷,CT因其放射性不應作為常規(guī)檢查,但如需手術,可行CT明確囊腫大小位置與血管膽道關系,為手術入路提供佐證。免疫學檢查是對影像學檢查的重要補充,尤其在鑒別診斷囊性占位有困難時,可提高診斷品質;⑶rEgAgB1在小兒包蟲血清學診斷中具有高特異性表達,能夠有效提高特異度,但靈敏度較低,IgG1亞型抗體的檢測顯著高于IgG4亞型抗體,其臨床診斷和隨訪價值有待今后大樣本驗證。
[Abstract]:Objective: To summarize the characteristics of echinococcosis cyst of hepatic cystic echinococcosis in children and evaluate the therapeutic effect of different surgical procedures in children with hepatic cystic echinococcosis. Through the correlation analysis of postoperative complications and clinical data of hepatic cystic echinococcosis in children, to find out the risk factors of complications and diagnosis in children's liver through imaging and serological diagnosis. The best method of diagnosis of single cystic echinococcosis in children was explored before the operation of cystic echinococcosis. The recombinant protein (rEgAgB1) of echinococcosis antigen B1 (rEgAgB1) was obtained by genetic engineering technology, and the value of its serological diagnosis for hepatic cystic echinococcosis in children was discussed, and the correlation analysis between the expression results and clinical data was carried out to find the influence of R. EgAgB1 in children with cystic echinococcosis serum related factors. Methods: 1 retrospective analysis and summary of the First Affiliated Hospital of Xinjiang Medical University from January 2002 to December 2014, 191 cases of children under 14 years of age (14 years old) with hepatic cystic echinococcosis, the sex, age, symptoms, cyst characteristics (position, size, quantity), operation of the patients, surgery The clinical data of the plan, the time of hospitalization and the postoperative complications were analyzed. The treatment scheme included the improved internal capsule extirpation group, the outer capsule subtotal excision and the complete exfoliation of the outer capsule. The patients' sex, signs, the bile leakage, the number of hepatic echinococcosis, the rupture of the hepatic echinococcosis, the size of the hydatid, the operation and the operation of the hydatid cyst, and the size of the hydatid cyst in the liver The correlation of postoperative complications was discussed. 2 a total of 100 cases of liver cystic echinococcosis and hepatic cysts confirmed by pathology of the First Affiliated Hospital of Xinjiang Medical University from January 2012 to 12 2014 were collected, including 50 cases of single cystic echinococcosis and 50 cases of simple hepatic cysts, including imaging ultrasound, CT examination and laboratory echinococcosis four items respectively. The sensitivity and specificity were calculated and combined with hydatid test, hydatid test, CT and echinococcosis test. 3 the rEgAgB1 prokaryotic expression plasmid (pET28a-EgAgB1) was transformed into E coli, high purity rEgAgB1 was purified by affinity chromatography, and 25 children with echinococcosis were purified by purified recombinant protein and HCF, respectively. The serum of normal children was detected by ELISA and Immunoblotting methods, and the clinical data of 25 children with hepatic cystic echinococcosis were analyzed. The age, family, symptoms and classification of the patients were analyzed. The relationship between the number of other organs, the number of hydatid, the size of echinococcosis and the rEgAgB1 in the serum. Results: 1) a total of 191 children were included in the study. There were 63 cases of benign internal capsule excision (group A), 89 cases (group B) and 39 cases of outer capsule complete dissection (group C). Through statistical analysis of the data of three groups, the time of operation and external capsule total excision group (group B) was significantly lower than that of the complete exfoliation of outer capsule (group C), but there was no significant difference with the modified internal capsule extirpation (group A); The amount of hemorrhage in the operation group (group B) was significantly lower than that of complete exfoliation (group C), but there was no significant difference from the improved internal capsule extirpation (group A). (group A) after operation, the time of improved internal capsule extirpation (group A) was significantly longer than that of the external capsule total excision group (group B) and the complete exfoliation of external capsule (group C); The number of days of hospitalization, improved internal capsule extirpation (group A) was significantly longer than that of the outer capsule subtotal excision group (group B) and the complete exfoliation of outer capsule (group C); (5) the postoperative residual cavity complications (residual cavity effusion, residual cavity infection, residual cavity bile leakage), the external capsule subtotal excision group (group B) was significantly lower than the modified internal capsule extirpation (group A), and the external capsule complete dissection (group C) There were no significant differences in 26 cases of postoperative complications. Single factor statistical analysis showed that postoperative complications and abdominal pain, hydatid cyst and biliary tract interlinked, pre operation hydatid cyst rupture, P0.05, and other indicators were not statistically significant. Single factor analysis did not control other factors interference, the P less than 0.1 variables Na In the multi factor regression model, two classification logistic regression was carried out. The results of abdominal pain, echinococcosis and biliary tract were interlinked, and the variable of echinococcosis was statistically significant, and the sensitivity of.2 ultrasound in the diagnosis of single cystic hydatid disease was 96%, the specificity was 98%, and the sensitivity of CT in the diagnosis of single cystic hydatid disease was 80%. The sensitivity of four diagnosis of echinococcosis with echinococcosis was 86%. The sensitivity of 72.00%. ultrasound and hydatid test was 82%, the specificity of specificity was 100%.CT and hydatid test, the sensitivity was 70%, and the specificity was 82%.3 rEgAgB1 as antiprimitive to the serum of 25 cases of children with hepatic cystic echinococcosis. The results of IgG1 specific antibody test showed that 19 cases were positive, and the positive rate of serum diagnosis was 76%. for 25 normal children. The serum diagnosis was not positive and the specificity was 100%. The serum specific antibody of 25 children with hepatic cystic echinococcosis was detected with rEgAgB1 as antigen. The results showed that 9 cases were positive and serum diagnosis was diagnosed. The positive rate was 36%, 25 cases of normal children serum test, serum diagnosis no positive results, detection specificity of 100%. analysis of 25 cases of pediatric echinococcosis patients clinical data, through single factor independent sample t test and chi square test concluded: age, family, symptoms, the size of echinococcosis and rEgAgB1 in children with hepatic cystic echinococcosis positive no expression. Correlation (P0.05). The two factors in the liver and the other organs were associated with the positive expression of rEgAgB1 in the patients with hepatic cystic echinococcosis (P0.05). Conclusion: (1) the hydatid cyst of the liver cystic echinococcosis in children has unique characteristics. The growth rate is fast, the cyst wall of the hydatid is thin, and the cyst of the hydatid cyst is combined with the cyst of other organs. The incidence of hydatid cyst is high, and hydatid cyst most CE1, hydatid cyst tension, adult prone to rupture, hydatid cyst combined with bile leakage rate is small. Imaging and laboratory examination can clear preoperative diagnosis. External capsule subtotal resection is the first choice, such as most of the lesion in the liver parenchyma, feasible improved internal capsule extirpation, such as surgery, such as surgery. The intraoperative cholangiography can effectively reduce the postoperative residual cavity complications. Abdominal pain, the incidence of postoperative complications in patients with hydatid cyst with biliary tract and pre operation of echinococcosis is significantly higher than that of other patients and may be the influencing factors of postoperative complications; 2. In the differential diagnosis of children's hepatic cystic echinococcosis and simplex In sexual hepatic cysts, ultrasound has high sensitivity and specificity, and should be the first choice. If only for diagnosis, CT should not be used as a routine examination because of its radioactivity. But if surgery is required, it is feasible that CT can identify the relationship between the size and location of the cyst and the vascular biliary tract, and provide evidence for the surgical approach. Immunological examination is an important supplement to the imaging examination, especially in the differential diagnosis capsule. When sexual occupancy is difficult, it can improve the quality of diagnosis; (3) rEgAgB1 is highly specific in the diagnosis of echinococcosis, and can effectively improve the specificity, but the sensitivity is low. The detection of IgG1 subtype antibody is significantly higher than that of the IgG4 subtype antibody. The clinical diagnosis and follow-up value of its clinical diagnosis and follow-up need to be verified in the future.
【學位授予單位】：新疆醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R726.5
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本文編號：1941114