嬰兒期稽延性滯留性疸之鑑別診斷－前瞻式研究

本文是對37例罹患稽延性滯留性黃疸之嬰兒作前瞻式之研究，其目的在分析作者等所提出之3天快速檢查計劃中，各單項檢查之診斷正確率，特異性及敏感性。37例病童之最後診斷爲25例新生兒肝炎及12例膽道閉鎖。各單項檢查之診斷正確率依序爲活體肝穿刺病理檢查(94.4%)，十二指腸液顔色分析(91.9%)，持續性典型灰白便(91.9%)，超音波檢視肝門附近膽管狀況(89.2%)及十二指腸液鎝同位素單位活性(78.4%)。各種檢查中以Tc-99m HIDA(H-substituted imino-diacetic acid)（1982年8月前使用）或Tc-99m DISIDA(2.6 diisopropyl phenyl-carbamoymethyl imino-diacetic acid)（1982年8月後使用）之十二指腸液同位素單位活性檢查最具客觀性，然若以大於30×10^4cpm/ml以上診斷爲新生兒肝炎，此值以下診斷爲膽道閉鎖，則正確率只有78.4%。由於十二指腸液顔色分析之單一診斷正確率高，且可以同位素檢查同時進行作者等建議將二者合併使用，以提高診斷之正確率及客觀性；若十二指腸液爲黃色或淡黃色，則不管同位系值多少，均可診斷爲新生兒肝炎；若十二指腸液爲透明無色，而同位素值小於30×10^4cpm/ml，則診斷爲膽道閉鎖，但若此時同位素值大於30×10^4cpm/ml，則仍應診斷爲新生兒肝炎，依據以上之原則，作者等於37例中，只有1例膽道閉鎖者因爲十二指腸液爲淡黃色，診斷爲新生兒肝炎，其正確率可達97.3%，此病人經12天之臨床觀察乃更改診斷爲膽道閉鎖，並經開刀證實。因此我們認爲，由以上各種方法之選用，再配合肝穿刺病理檢查及大便顔色之詳細觀察，可例嬰兒稽延性滯留性黃疸之診斷正確率接近百分之百。至於肝臓之大小及肝動能檢查，雖亦有助於診斷，但正確率較低。

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並列摘要

This prospective study was attempted to establish a quick and reliable 3-day diagnostic work-up protocol for prolonged infantile cholestatic syndrome by comparing the various techniques used for differential diagnosis, Thirty-seven cases were studied while twenty-five were proved to he neonatal hepatitis and twelve, biliary atresia. The diagnostic accuracy for various techniques was in the order of 94.4% for the liver needle biopsy. 91.9% for the color of duodenal juice, 91.9% for persistence of typical day color stool and 89.2% for abdominal sonographic examination of the biliary tree al porta hepatis. Although the Tc-99m IDA isotope count in the duodenal juice was the most objective method, the diagnostic accuracy of 78.4% was not high enough for differential diagnosis when setting the cut off count above 30×10^4 cpm/ml for neonatal hepatitis. However, when the color of the duodenal juice and isotope count were examined simultaneously, a higher diagnostic accuracy was obtained. We found that when the duodenal juice was yellowish or light yellow, a diagnosis of neonatal hepatitis could be made, regardless of the isotope count. When the duodenal juice was colorless, then the isotope count of duodenal juice should be taken into consideration. An isotope count below 30×10^4 cpm/ml indicated a biliary atresia, whereas a higher count favored neenata1 hepatitis. Using this criteria, only one case of biliary atresia was missed and the operation delayed for 10 days. The diagnostic accuracy was 97.3%. In this study, we propose a protocol of appropriate combination of simple and non-invasive diagnostic procedures by which the differential diagnosis in the great majority of infants with prolonged cholestatic jaundice can be made with rapidity and high accuracy.

並列關鍵字

infantile prolonged obstructive jaundice ； bilidru atresia ； neonatal hepatitis

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嬰兒期稽延性滯留性疸之鑑別診斷－前瞻式研究

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