探討內視鏡超音波在電腦斷層或者核磁共振造影無顯影之下的高、中以及低度危險性之膽道結石所扮演之角色

The role of EUS in the management of high, intermediate and low risk biliary stone in negative CT or MRI scan

謝睿穎(Jui-Ying Hsieh)

指導教授 ： 王秀伯

共同指導教授 ： 廖偉智(Wei-Chih Liao)

國立臺灣大學/醫學院/臨床醫學研究所/碩士(2021年)

https://doi.org/10.6342/NTU202103849

摘要

背景介紹：
急性膽管發炎一直是急診常見的診斷，造成的原因有很多，然而膽道結石是最為常見的原因。傳統上在第一線常使用腹部超音波(transabdominal ultrasound)來做檢查，另外則是使用費用較為昂貴的電腦斷層(computed tomography)以及核磁共振造影(magnetic resonance image)來評估。然而，有時因為腹部腸氣太多或者膽道結石太小而使得腹部超音波不易評估。另外，有些較為鬆散的膽管結石並非radiopaque，因此電腦斷層檢查就無法察覺。在上述原因之下，內視鏡超音波(endoscopic ultrasound)就成為了另一項評估膽道結石的選擇工具。有些研究指出，內視鏡超音波對於膽道結石的偵測率有顯著的專一性以及敏感性。在檢查出膽管結石之後，目前最常使用的治療方式為內視鏡逆行性膽胰膽攝影取石術(endoscopic retrograde cholangiopancreatography lithotripsy)。然而此內視鏡取石術有一定的併發症風險，像是胰臟炎(post ERCP pancreatitis)。也因此，若對於懷疑膽道結石的病人，在進一步侵入性檢查之前使用內視鏡超音波檢查，就有機會避免不必要的ERCP取石術，進而將可能的併發症機會降至最低。
研究方法與材料：
依照美國胃腸內視鏡協會(ASGE)2019年評估疑似膽道結石的準則以及有無膽囊為分組依據，且在電腦斷層或者核磁共振上無明顯膽道結石發現。
納入條件:
1. 病患有黃疸、右上腹痛以及其他疑似膽道結石要素之患者。
2. 年齡20歲以上。
排除條件:
1. 重要全身性疾病，如心臟衰竭、肝硬化、末期腎衰竭或惡性腫瘤。
2. 上消化道有急性發炎、出血、阻塞或狹窄的情形，不適宜進行上消化道內視鏡超音波。
3. 凝血功能異常。
4. 過去三天內曾經服用抗凝血劑(如coumadin、heparin、rivaroxaban等)或抗血小板劑(如aspirin、clopedogrel、dipyridamole等)。
全部收案受試者皆會接受上消化道內視鏡超音波 (Olympus company ; UCT 260, linear type; UE 260, radial type)，並於同一天接受進一步治療(內視鏡逆行性膽胰取石術，手術取石)。
結果：
總共收入19位受試者，根據美國胃腸內視鏡協會(ASGE)2019年的準則，納入高度風險組為9位，中度風險組為7位，低度風險組為3位。其中有13位經由內視鏡超音波發現有膽道結石或者膽道膽砂（高度風險組為7位，中度風險組為4位，低度風險組為2位）。在接下來的逆行性膽胰內視鏡取石術中，共有12位證實有膽道結石或膽砂（高度風險組為7位，中度風險組為4位，低度風險組為1位）。而其膽道結石或膽砂的大小分布：<=5mm:7位，5~10mm:4位，>10mm:1位。
結論：
內視鏡超音波對於微小的膽道結石或者膽砂具有相當優異的偵測率以及專一性。我們認為美國胃腸內視鏡協會(ASGE)2019年評估疑似膽道結石的準則應再進一步重新討論以及修正。

關鍵字

內視鏡超音波 ； 膽道結石 ； 逆行性膽胰內視鏡取石術 ； 急性膽管炎

並列摘要

Introduction:
Acute cholangitis is very common in emergency department. One of the cause of acute cholangitis is biliary stone. It may cause the obstruction of biliary system. The diagnostic tools are abdominal ultrasound(US), computer tomography (CT) or Magnetic resonance image (MRI). However, those tools have their limit. The abdominal ultrasound may be deferred easily by bowel gas and it is operator-dependent. Sometimes the stone is too tiny and is not radiopaque in CT scan. Therefore, endoscopic ultrasound (EUS) has been another choice to evaluate the existence of biliary stones in cholangitis. Some studies showed EUS is very sensitive in the detection of common bile duct (CBD) stone. It can be performed before endoscopic retrograde cholangiopancreatography (ERCP) and obviate unnecessary ERCP. Therefore, ERCP-related complications such as post ERCP pancreatitis can also be avoided
Concept of this study:
The American Society for Gastrointestinal endoscopy (ASGE) in 2019 ever published the predictor of risk of CBD stone in symptomatic patients. The predictors include age, image (US, CT and MRI), level of total bilirubin and the symptoms of cholangitis. The categories are divided into high, medium and low. However, some studies stated that there are still some controversial points. Otherwise, there is no consensus about the management of CBD stone related acute cholangitis in Taiwan.
Method:
The prospective study will include the patients referred for ERCP due to suspicious CBD stones and without evidences on CT/MRI. The patients will be divided into low (<10%), intermediate (10~50%) and high(>50%) risk of CBD stone in ASGE guideline. All the patients will be evaluated with EUS at the same day of ERCP. The rate of stone detection in EUS proved by ERCP in each group will be evaluated. The predictors of risk in the patients with and without gallbladder will also be evaluated.
Result:
There are 19 patients in our study so far. All patient received the evaluation of EUS and CBD stone was detected in 13 patients. After the examination of ERCP, only 1 patient has no CBD stone. (that patient is in low risk group). Most of CBD stone were microlithiasis (<10mm).
Conclusion:
EUS is suggested consider before the ERCP in the patients with the suspicious of choledocholithiasis. The ASGE guideline in 2019 should be discussed and reevaluated.

並列關鍵字

endoscopic ultrasound (EUS) ； endoscopic retrograde cholangiopancreatography (ERCP) ； choledocholithiasis ； CBD stone ； acute cholangitis

參考文獻

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