- 學位論文
不同年齡層膽道結石疾病患者的臨床表現
Clinical Presentations of Different Aging Cohort with Biliary Tract Stone diseases
摘要
研究背景： 在成年人口中，膽結石的盛行率約有5-10%。70歲以上的老年病患發現膽結石的比例甚至高達25-30%。根據過去的文獻報告，有10-20%的膽結石患者會併患為膽道結石。臨床上在病患接受膽囊切除術時，膽道結石的有無，將會影響後續治療的方法及步驟。而膽道結石的確診，是依據侵入性的逆行性內視鏡膽道鏡檢查(Endoscopic retrograde cholangiopancreatography, ERCP)結果為主。然而ERCP不僅昂貴，風險也高，而膽道疾病又是以中老年患者居多。所以，在進行ERCP之前，先以非侵入性的檢查，來選擇適當的病患再進行逆行性內視鏡膽道鏡檢查，在臨床上就是一重要的課題。在術前的非侵入性檢查評估中，主要依據病患本身的症狀、肝功能的檢查及腹部超音波的檢查，來推測有無膽道結石的存在。因為膽道結石疾病的患者，是以中老年人為主，而針對不同年齡層的膽道結石病患，其術前的臨床表現是否有所不同，值得進一步探討。 研究目的： 探討不同年齡層的膽道結石病患，其臨床症狀、肝功能的檢查及腹部超音波的檢查結果，是否有所不同。 研究方法： 本研究為回溯性研究，研究資料收集從2007年7月至2008年6月間，年齡在18至64歲之間，以及2004年7月至2008年6月間，年齡在65至85歲之間，因胰臟與膽道系統疾病於馬偕紀念醫院接受一般生化檢查，腹部超音波檢查及逆行性內視鏡膽胰管攝影術檢查及治療的病患。將這群病患分成18-64歲(成年組)、65-74歲(少老年組)、75-84歲(中老年組)、大於85歲(老老年組)等四個年齡層，分析不同年齡層病患，術前的臨床表徵，資料內容包含肝功能(包括aspartate amino- transferase(AST), alanine amino-transferase (ALT), alkaline phosphatase (ALK-P), total and direct bilirubin) 等檢驗，腹部超音波檢查結果。並以逆行性內視鏡膽道鏡檢查，作為膽道結石確診的依據。同時排除：病毒性肝炎、酒精性肝炎、藥物性肝炎、自體免疫性肝炎、代謝性肝臟疾病患者，及曾經接受內視鏡括約肌切開術的患者。在各年齡的分組中，以STATA ( for student)進行統計分析，以student’s t test檢測各個變項中，有無膽道結石者，有無明顯差異。 研究結果： 研究期間內總共收錄了443位病患進行分析，其中成年組：143人，少老年組：168人，中老年組：97人，老老年組：35人。在臨床表徵方面，於成年組及少老組中確診為膽道結石的患者，有膽絞痛(Biliary colic)表現者比例明顯偏高(成年組：89%，少老年：78%)，有黃疸表現者，於成年組中確診為膽道結石的患者，比例也較高(67% vs 39%, p<0.05)。而老老年患者，在臨床表徵上，則無明顯差異。在急性膽道炎的表現方面，少老年組中有膽道結石的患者，合併急性膽道炎者與無膽道結石者相比，比例較高(47% vs 22%, p<0.05)，但是在其他三組病患，則無此發現。於肝功能檢查方面，於成年組中確診為膽道結石的患者，包括AST, ALT, total and direct bilirubin檢查的平均值，均明顯高於無膽道結石的患者。對於成年組、少老年組、中老年組，AST及ALT檢查結果異常的比例皆明顯大於無膽道結石的患者。對老老年患者，肝功能的表現，在膽道結石的有無之間，無明顯差異。在腹部超音波檢查部分，於超音波診斷膽道結石的敏感度(sensitivity)及準確度(accuracy)，隨著年齡層的增加而上升。敏感度：成年組：0.15，少老年組：0.45，中老年組：0.57，老老年組：0.48。準確度：成年組：0.48，少老年組：0.63，中老年組：0.7，老老年組：0.71。 結論： 對於不同年齡的膽道疾病患者，臨床表現會有所不同。經逆行性內視鏡膽道鏡檢查確診為膽道結石的病患，於年齡較輕者，臨床表徵及肝功能異常的比例較高；而年紀較長者，以超音波診斷膽道結石的敏感度及準確度較高。若我們能經由非侵入的檢查結果來評估膽道疾病的情形，在臨床上能幫助我們決定處置病患的方向及方法。
並列摘要
BACKGROUND: The prevalence of gallstone disease in the general population was 5.3-10% in Taiwan. Common bile duct (CBD) stones would develop in about 10%-20% of patients with gallstones. The role of clinical symptoms, trans-abdominal ultrasound scan (USS) and liver function tests (LFTs) in evaluating common bile duct(CBD) stones in patients with suspected pancreatobiliary disease has been studied widely. However, it is not clear whether these predictive models are useful in different aging cohort population. OBJECTIVES: To investigate the clinical symptoms and signs, trans-abdominal ultrasonographic findings, LFTs and endoscopic retrograde cholangiopancreatography(ERCP) findings in different aging cohort patients with and without CBD stones. METHODS: The medical records of patients aged from 18 year-old or older who underwent USS and ERCP from July 2004 to June 2008 were collected. Four hundred thirty-three patients with pancreatobiliary diseases divided into cohorts according to decades as young(Y, n= 143), young-old (YO, 65–74, n=153), old-old (OO, 75–84, n=88), and very-old (VO, ≥85, n=32). Clinical symptoms, biochemical liver tests, trans- abdominal ultrasonographic findings and ERCP results in these 4 groups were demonstrated and compared. The categorical variables of the groups were compared by Chi-square analysis. The significance of the mean differences between patients with and without stones was evaluated by Student's t test. RESULTS: Four hundred thirty-three patients who received USS and ERCP procedures were included this study. Young and YO group patients were more likely to develop symptoms such as biliary colic when they had CBD stones. Mean serum AST level (205.32±213.60 vs 79.47±126.53, p<0.05) and ALT level (305.14±218.60 vs 100.65±128.72, p<0.05 ) were significant higher in Young groups patient with CBD stones than those without CBD stones. The proportion of abnormal serum AST and ALT were significant greater in Young, YO and OO groups patient with CBD stones than without CBD stones. Mean value and abnormal proportion of alkaline phosphatase (ALK-P) was higher in YO patients with CBD stone than without CBD stone (YO: 75.8%; OO: 50%; p=0.005). Sensitivity of USS for CBD stones in Young: 0.15; YO: 0.45; OO: 0.57; VO: 0.68. Accuracy of USS for detected CBD stone in Young: 48%; YO: 62.5%; OO: 70.1%; VO: 71.4%. Higher biliary pancreas malignancy rate might see in patients without CBD stone (Young: 18.6%; YO: 25%; OO: 21% VO: 23%). CONCLUSION: Combined evaluation of biochemical and USS findings may help predict the presence of CBD stones. In Young, Young-old and Old-old patients with CBD stones, the incidences of abnormal LFTs were higher. USS sensitivity and accuracy for CBD stone presentation was increased by aging.
參考文獻
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