本文選題：膽總管結(jié)石 + ERCP��； 參考：《第四軍醫(yī)大學(xué)》2015年碩士論文

【摘要】：研究背景:膽總管結(jié)石是較為常見的消化系統(tǒng)疾病之一。目前ERCP(經(jīng)內(nèi)鏡逆行性胰膽管造影術(shù))是治療膽總管結(jié)石的一線方法,但4-24%的患者在成功取石后出現(xiàn)膽總管結(jié)石復(fù)發(fā)。與EPBD(內(nèi)鏡下乳頭柱狀球囊擴(kuò)張術(shù))相比EST(十二指腸乳頭括約肌切開術(shù))術(shù)后患者膽總管結(jié)石復(fù)發(fā)率高(5.7-26.7%vs.1.6-8.1%),可能原因?yàn)镋ST術(shù)后Oddi括約肌功能破壞會(huì)繼發(fā)十二指腸內(nèi)容物反流入膽道,導(dǎo)致膽道反復(fù)感染,增加結(jié)石復(fù)發(fā)風(fēng)險(xiǎn)。雖然眾多學(xué)者認(rèn)為,膽總管結(jié)石復(fù)發(fā)與十二指腸-膽道反流(DBR)有關(guān),但一直缺乏直接證據(jù)。如何利用簡(jiǎn)單有效的方法證明兩者之間的關(guān)系是需要解決的臨床問題。胃食管反流和便秘是最常見的臨床癥狀,食管下端括約肌松弛導(dǎo)致的胃食管反流與十二指腸-膽道反流的機(jī)制有相似之處,高危因素也十分相似,例如腸道內(nèi)壓力增高、胃腸道動(dòng)力減弱、體位變化、解剖結(jié)構(gòu)異常等。便秘也會(huì)增加腸腔內(nèi)壓力從而加重胃-食管反流問題。我們推測(cè),臨床常見癥狀如胃食管反流、便秘與十二指腸-膽道反流之間存在一定關(guān)系,可能會(huì)影響膽總管結(jié)石的復(fù)發(fā),可用于膽總管結(jié)石復(fù)發(fā)高危人群的篩選。研究目的:1)通過前瞻性病例對(duì)照研究來探索十二指腸-膽道反流與膽總管結(jié)石復(fù)發(fā)之間的關(guān)系;2)通過回顧性病例對(duì)照研究來探索胃食管反流、便秘癥狀與膽總管結(jié)石復(fù)發(fā)之間的關(guān)系。研究對(duì)象:本研究共納入在西京醫(yī)院接受ERCP膽總管取石的患者264例。其中第一部分研究64例(結(jié)石復(fù)發(fā)組32例,對(duì)照組32例),第二部分研究200例(結(jié)石復(fù)發(fā)組100例,對(duì)照100例)。研究方法:第一部分研究所有患者接受標(biāo)準(zhǔn)上消化道鋇餐、腹部CT、腹部磁共振檢查;第二部分研究所有患者接受問卷調(diào)查。統(tǒng)計(jì)方法包括T檢驗(yàn)、Fisher檢驗(yàn)、卡方檢驗(yàn)、回歸分析。研究結(jié)果:1)兩組患者的首次ERCP參數(shù)和基線資料特征具有可比性。結(jié)石復(fù)發(fā)組患者的DBR顯著高于對(duì)照組(68.8%vs.15.6%,p0.001)。多因素回歸分析顯示DBR(OR=9.59;95%CI,2.65-34.76)和膽總管末段角度≤135°(OR=5.48;95%CI,1.52-19.78)是膽總管結(jié)石復(fù)發(fā)的高危因素。膽總管結(jié)石無復(fù)發(fā)、單次復(fù)發(fā)和多次復(fù)發(fā)患者的DBR分別是15.6%,60.9%和88.9%(p0.001)。多次復(fù)發(fā)患者的肝內(nèi)膽管反流率更高(66.7%vs.10.9%,p0.001)。2)兩組患者的胃食管反流及便秘癥狀的發(fā)生率無統(tǒng)計(jì)學(xué)差異。結(jié)石復(fù)發(fā)組及對(duì)照組中胃食管反流及便秘的發(fā)生率為21%vs.17%及15%vs.16%(p值均0.05)。多因素回歸分析顯示僅膽總管末段角度≤135°(OR=3.07;95%CI,1.22-7.72)是膽總管結(jié)石復(fù)發(fā)的高危因素。研究結(jié)論:1)本研究提供了十二指腸-膽道反流與ERCP術(shù)后膽總管結(jié)石復(fù)發(fā)相關(guān)的直接證據(jù)。DBR和較銳的膽總管末段角度是膽總管結(jié)石復(fù)發(fā)的高危因素。2)本研究結(jié)果顯示胃食管反流及便秘癥狀與膽總管結(jié)石復(fù)發(fā)不相關(guān)。較銳的膽總管末段角度是膽總管結(jié)石復(fù)發(fā)的高危因素。
[Abstract]:Background: choledocholithiasis is one of the most common diseases of digestive system. ERCP (endoscopic retrograde cholangiopancreatography) is a first line method for the treatment of choledocholithiasis, but 4-24% of the patients have recurrence of choledocholithiasis after successful lithotomy. Compared with EPBD (endoscopic papillary sphincterotomy), the recurrence rate of choledocholithiasis in EST patients was 5.7-26.7vs.1.6-8.1.The possible reason was that the sphincter dysfunction of oddi after EST might cause secondary duodenal contents to flow back into the bile duct. Lead to recurrent biliary tract infection, increase the risk of recurrence of stones. Although many scholars believe that the recurrence of choledocholithiasis is associated with duodenal-biliary reflux (DBR), direct evidence has been lacking. How to use simple and effective methods to prove the relationship between the two is a clinical problem to be solved. Gastroesophageal reflux and constipation are the most common clinical symptoms. The mechanism of gastroesophageal reflux caused by lower esophageal sphincter relaxation is similar to that of duodenal-biliary reflux. Gastrointestinal motility decreased, posture changes, anatomic structure abnormal, and so on. Constipation also increases pressure in the lumen and exacerbates gastroesophageal reflux. We speculate that common clinical symptoms such as gastroesophageal reflux constipation and duodeno-biliary reflux may affect the recurrence of choledocholithiasis and can be used for screening high risk population for choledocholithiasis recurrence. Objective: to explore the relationship between duodenal-biliary reflux and the recurrence of choledocholithiasis in a prospective case-control study 2) to explore gastroesophageal reflux through a retrospective case-control study. Relationship between constipation symptoms and recurrence of choledocholithiasis. Participants: a total of 264 patients received ERCP choledocholithiasis in Xijing Hospital. In the first part, 64 cases (32 cases of stone recurrence group, 32 cases of control group) and 200 cases (100 cases of stone recurrence group and 100 cases of control group) were studied in the first part. Methods: in the first part, patients received barium meal of upper digestive tract, abdominal CT and abdominal magnetic resonance examination, and in the second part, patients were investigated by questionnaire. Statistical methods include T-test Fisher test, chi-square test and regression analysis. Results: 1) the first ERCP parameters and baseline data were comparable between the two groups. The DBR of the patients with recurrent stones was significantly higher than that of the control group (68.8vs.15.6B, P 0.001). Multivariate regression analysis showed that DBR OR9.5995 CI 2.65-34.76) and the end of common bile duct angle 鈮，

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