發(fā)布時(shí)間：2018-03-19 21:14

  本文選題：原發(fā)性膽總管結(jié)石　切入點(diǎn)：ERCP　出處：《第二軍醫(yī)大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究目的:通過(guò)分析對(duì)比原發(fā)性膽總管結(jié)石經(jīng)內(nèi)鏡逆行胰膽管造影術(shù)(endoscopic retrograde cholangio-pancreatography,ERCP)取石后復(fù)發(fā)與未復(fù)發(fā)患者的臨床資料及相關(guān)指標(biāo),篩選出原發(fā)性膽總管結(jié)石ERCP取石術(shù)后復(fù)發(fā)的相關(guān)危險(xiǎn)因素,并分析膽總管結(jié)石伴膽道感染患者膽汁中主要致病菌的分布特點(diǎn)及藥物耐藥性情況,為臨床抗生素的合理使用提供依據(jù)。研究方法:回顧性分析、總結(jié)2008年1月至2015年10月期間,在第二軍醫(yī)大學(xué)附屬長(zhǎng)征醫(yī)院因原發(fā)性膽總管結(jié)石經(jīng)ERCP治療的162例患者的病例資料,并通過(guò)電話咨詢及查閱門診、住院復(fù)診記錄的方式進(jìn)行。主要包括以下兩個(gè)部分:1.根據(jù)膽總管結(jié)石復(fù)發(fā)的診斷標(biāo)準(zhǔn)將上述患者分為兩組,即未復(fù)發(fā)組和復(fù)發(fā)組。用非條件Logistic回歸單因素分析兩組患者的一般情況(年齡、性別)、個(gè)人史(吸煙史、飲酒史)、既往史(膽囊切除史、ERCP手術(shù)史)、實(shí)驗(yàn)室檢查(血常規(guī)、肝功能、腎功能、凝血功能、電解質(zhì)、血脂)、膽道情況(十二指腸乳頭旁憩室、膽道感染)、膽管結(jié)石情況(結(jié)石性狀、結(jié)石數(shù)量、結(jié)石大小)等指標(biāo),將具有統(tǒng)計(jì)學(xué)意義的變量再進(jìn)行多因素分析,確定膽總管結(jié)石取石術(shù)后復(fù)發(fā)的危險(xiǎn)因素。2.按照膽道感染的診斷標(biāo)準(zhǔn),統(tǒng)計(jì)分析膽總管結(jié)石患者膽汁細(xì)菌培養(yǎng)及藥敏試驗(yàn)的結(jié)果。研究結(jié)果:針對(duì)157例有確切隨訪資料的原發(fā)性膽總管結(jié)石患者,中位觀察時(shí)間42個(gè)月(最長(zhǎng)觀察時(shí)間87個(gè)月,最短12個(gè)月),其中105例未復(fù)發(fā),52例復(fù)發(fā)的這一情況研究如下:1.單因素分析顯示:(1)膽囊切除史(P=0.029)、ERCP手術(shù)史(P0.001)、膽道感染(P=0.018)、結(jié)石性狀(混合樣,P0.001)、結(jié)石大小(P=0.030),有統(tǒng)計(jì)學(xué)差異,說(shuō)明上述因素是膽總管結(jié)石復(fù)發(fā)的危險(xiǎn)因素。(2)年齡(50~70歲,P=0.189;70歲,P=0.435)、性別(P=0.214)、吸煙史(P=0.736)、飲酒史(P=0.665)、十二指腸乳頭旁憩室(juxtapapillary duodenal diverticulum,JPDD)(P=0.413)、結(jié)石數(shù)量及實(shí)驗(yàn)室各項(xiàng)指標(biāo):WBC、N%、PLT、RBC、HB、TB、DB、Alb、ALT、AST、GGT、AKP、BUN、Cr、PT、INR、Na+、K+、Cl-、甘油三酯(triacylglyceride,TRIG)、總膽固醇(total cholesterol,TC)、HBV,P值均大于0.05,無(wú)統(tǒng)計(jì)學(xué)差異,說(shuō)明上述因素不是膽總管結(jié)石復(fù)發(fā)的危險(xiǎn)因素。(3)多因素分析顯示:ERCP手術(shù)史(P0.001;AOR=535.44,95%CI:49.66-5773.66)、膽道感染(P=0.047;AOR=2.534,95%CI:1.010-5.037)、混合樣結(jié)石(P=0.036;AOR=4.221,95%CI:1.099-16.207),有統(tǒng)計(jì)學(xué)差異,說(shuō)明這三種因素在膽總管結(jié)石復(fù)發(fā)過(guò)程中的作用尤為突出。2.在112例行膽汁細(xì)菌培養(yǎng)的標(biāo)本中有70例檢出致病菌,陽(yáng)性率為62.50%;共培養(yǎng)細(xì)菌100株,其中革蘭氏陰性菌75株,革蘭氏陽(yáng)性菌18株,真菌7株;含量最多的細(xì)菌為大腸埃希菌25株和肺炎克雷伯桿菌13株,藥敏結(jié)果顯示,兩者對(duì)頭孢唑啉耐藥率最高,對(duì)頭孢西丁、阿米卡星較為敏感。研究結(jié)論:1.ERCP手術(shù)史、膽道感染和混合樣結(jié)石為原發(fā)性膽總管結(jié)石ERCP取石術(shù)后結(jié)石復(fù)發(fā)的獨(dú)立危險(xiǎn)因素。2.膽總管結(jié)石并發(fā)膽道感染的患者,膽汁細(xì)菌培養(yǎng)以革蘭氏陰性菌為主,治療一般首先選用對(duì)革蘭氏陰性菌耐藥率低的抗生素。
[Abstract]:Objective: through the comparative analysis of primary choledocholithiasis by endoscopic retrograde cholangiopancreatography (endoscopic retrograde, cholangio-pancreatography, ERCP) clinical data of recurrence after stone and without recurrence and related indicators, screened the risk of primary common bile duct stones ERCP recurrence after nephrolithotomy factors, and analysis of common bile duct stone with the distribution characteristics and drug resistance of the main pathogenic bacteria in the bile of patients with biliary tract infection, provide the basis for clinical rational use of antibiotics. Methods: a retrospective analysis from January 2008 to October 2015, during the summary, at the Second Military Medical University because of primary common bile duct stones treated by ERCP Changzheng Hospital 162 cases of patients with clinical data, and through the telephone consultation and access to outpatient, hospital referral records. It mainly includes the following two parts: 1. according to the recurrence of bile duct stones The diagnostic criteria of the patients were divided into two groups, namely non recurrence group and recurrence group. Analysis of the general situation of the two groups of patients with single factor non conditional Logistic regression (age, gender), personal history (smoking history, drinking history), history (history of cholecystectomy, surgery, ERCP (Laboratory) blood routine, liver function, renal function, blood coagulation function, electrolyte, blood), biliary tract (cases of juxtapapillary duodenal diverticulum and biliary infection, biliary calculi (stones) of characters, number of stones, stone size) and other indicators, and then will have the statistically significant variables in multivariate analysis, to identify common bile duct stones lithotomy risk factors of recurrence after.2. according to the diagnostic criteria of biliary tract infection and analysis of common bile duct stones of bile bacteria culture and drug susceptibility in patients with test results and statistics. Results: in 157 cases with exact follow-up data of primary choledocholithiasis patients, median observation time 闂，

本文編號(hào)：1636025