超声内镜联合磁共振胰胆管造影对可疑胆总管结石的诊断价值

目的探讨联合应用超声内镜(EUS)与磁共振胰胆管造影(MRCP)能否提高二者诊断可疑胆总管结石的诊断效能。方法选取2014年1月-2016年6月就诊于中国医科大学附属盛京医院并诊断为可疑胆总管结石患者78例。所有患者均于同一次住院期间行EUS与MRCP检查。依据影像学检查分为EUS组、MRCP组以及二者联合诊断组。以开腹胆道探查、腹腔镜胆总管探查术、经内镜逆行胰胆管造影/内镜下十二指肠乳头括约肌切开术以及出院6个月内无腹痛症状就诊记录为金标准。将3组检查结果分别与金标准进行比较,分别计算3组影像学检查结果的敏感度、特异度、准确度、阳性预测值、阴性预测值及Youden指数。联合诊断采用平行诊断试验,EUS与MRCP任一结果为阳性则为阳性,两者皆为阴性则为阴性。上述指标的差别性比较采用χ2检验。结果 EUS检查阳性共22例,真阳性20例,假阳性2例;阴性共56例,真阴性53例,假阴性3例。MRCP检查阳性22例,真阳性15例,假阳性7例;阴性共56例,真阴性48例,假阴性8例。二者联合诊断阳性共29例,真阳性22例,假阳性7例;阴性共49例,真阴性48例,假阴性1例。EUS组诊断准确度明显高于MRCP组(93. 6%vs 80. 8%,χ2=5. 735,P=0. 017)。联合诊断组与EUS组的诊断敏感度、特异度、准确度、阳性预测值及阴性预测值比较,差异均无统计学意义(P值均> 0. 05)。但联合诊断组的敏感度、阴性预测值均高于MRCP组,差异有统计学意义(95. 7%vs 65. 2%,χ2=6. 769,P=0. 009; 98. 0%vs 85. 7%,χ2=5. 000,P=0. 025)。结论EUS与MRCP诊断可疑胆总管结石各有优劣,可作为疾病诊断的首选检查,但EUS总体准确度更高,对于胆囊结石拟行腹腔镜胆囊切除术的患者,建议使用EUS排除可疑胆总管结石的存在,此方法更为可靠。EUS与MRCP联合诊断较单独应用MRCP可以提高敏感度与阴性预测值,建议当MRCP为阴性但与其他临床表现不符时,应进一步行EUS检查以明确可疑胆总管结石的存在。

Value of endoscopic ultrasonography combined with magnetic resonance cholangiopancreatography in diagnosis of patients suspected of common bile duct stones

Objective To investigate whether endoscopic ultrasonography(EUS)combined with magnetic resonance cholangiopancreatography(MRCP)can improve the diagnostic efficiency of such combination in the diagnosis of patients suspected of common bile duct stones.Methods A retrospectively analysis was performed for the clinical data of 78 patients who visited Shengjing Hospital of China Medical University from January 2014 to June 2016 and were diagnosed with suspected common bile duct stones.All patients underwent EUS and MRCP during the same period of hospitalization.The patients were divided into EUS group,MRCP group,and combined diagnosis group according to the imaging examination.Laparoscopic common bile duct exploration,laparoscopic common bile duct exploration,endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy,and no symptom of abdominal pain within 6 months after discharge were used as the gold standard.The results of the three groups were compared with the gold standard to calculate the sensitivity,specificity,accuracy,positive predictive value,negative predictive value,and Youden index of the imaging findings in three groups.The parallel test was used for combined diagnosis;positive results of EUS or MRCP were considered positive,and negative results of EUS and MRCP were considered negative.The chi-square test was used for comparison of the above indices.Results EUS found positive results in 22 patients,among whom 20 had true positive results and 2 had false positive results,and negative results in 56 patients,among whom 53 had true negative results and 3 had false negative results.MRCP found positive results in 22 patients,among whom 15 had true positive results and 7 had false positive results,and negative results in 56 patients,among whom 48 had true negative results and 8 had false negative results.EUS combined with MRCP found positive results in 29 patients,among whom 22 had true positive results and 7 had false positive results,and negative results in 49 patients,among whom 48 had true negative results and 1 had false negative results.The EUS group had a significantly higher diagnostic accuracy than the MRCP group(93.6%vs 80.8%,χ^2=5.735,P=0.017).There were no significant differences between the combined diagnosis group and the EUS group in sensitivity,specificity,accuracy,positive predictive value,and negative predictive value(P>0.05).The combined diagnosis group had significantly higher sensitivity and negative predictive value than the MRCP group(sensitivity:95.7%vs 65.2%,χ^2=6.769,P=0.009;negative predictive value:98.0%vs 85.7%,χ^2=5.000,P=0.025).Conclusion EUS and MRCP have their own advantages and disadvantages in the diagnosis of suspected common bile duct stones and can be used as the preferred choice for disease diagnosis.EUS has a higher overall accuracy than MRCP,and in patients who plan to undergo laparoscopic cholecystectomy due to gallstones,EUS is more reliable and it is recommended to perform EUS to exclude common bile duct stones.Compared with MRCP alone,EUS combined with MRCP can improve sensitivity and negative predictive value;when MRCP yields negative results which are not consistent with other clinical manifestations,EUS should be performed to confirm the presence of suspected common bile duct stones.