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ID naloge: 168 Letnik: 2003 Predmet: interna medicina
POMEN ENDOULTRAZVOKA (EUZ) V DIAGNOSTIKI AKUTNEGA BILIARNEGA PANKREATITISA
Avtor: David Drobne
Mentor: prof. dr. Saša Markovic
Somentor: mag. Srecko Štepec
IZHODIŠCE: Akutni biliarni pankreatitis (ABP) je akutno vnetje trebušne slinavke, ki ga povzroci zapora žolcevoda z žolcnimi kamni. Standardna diagnosticna metoda za potrjevanje kamnov v žolcevodu je endoskopska retrogradna holangiopankreatografija (ERCP). ERCP omogoca poleg ugotavljanja kamnov v žolcevodu tudi zdravljenje. V primeru ugotovljenih zagozdenih kamnov v žolcevodu - holedoholitijaze (HHL) lahko v okviru iste preiskave naredimo tudi poseg - endoskopsko papilotomijo sfinktra papile Vateri (EPT), s pomocjo katere kamne odstranimo iz žolcevoda. ERCP z EPT zgodaj v poteku ABP zmanjša morbiditeto.
NAMEN: ERCP povzroca zaplete, tudi hude, pri skoraj 10% bolnikov. ERCP se ni mogoce izogniti pri bolnikih, ki imajo HHL in zato potrebujejo EPT. Pri 30 do 60% bolnikov pa se kamni spontano izlocijo iz žolcevoda. Ti bolniki EPT ne potrebujejo, vendar kljub temu napravimo ERCP vsem bolnikom z ABP, ker z današnjimi preiskovalnimi metodami skupine bolnikov brez kamnov v žolcevodu drugace ni mogoce izdvojiti. Taka metoda bi utegnil biti endoskopski ultrazvok (EUZ), ki skoraj nima zapletov in ima visoko locljivost. Namen študije je ugotoviti, ali lahko EUZ pri bolnikih z ABP identificira bolnike s HHL in tako pomaga pri odlocitvi o nadaljevanju zdravljenja z ERCP ali ne.
HIPOTEZA: Dolocili smo obcutljivost in specificnost EUZ za ugotavljanje HHL pri bolnikih z ABP, da bi ugotovili, ce uporaba EUZ pri bolnikih z ABP lahko zmanjša uporabo ERCP.
METODE: V prospektivni študiji smo 30 zaporednim bolnikom z ABP pred ERCP naredili še EUZ, oboje na isti dan. Zdravnik, ki je delal ERCP, ni bil seznanjen z rezultatom EUZ. Temeljni cilj EUZ in ERCP je bil potrditi ali izkljuciti HHL. Dokoncno diagnozo HHL smo postavili na osnovi duodenoskopskega prikaza kamnov po EPT. EUZ in ERCP smo primerjali z McNemarjevim testom in izracunom koeficienta kapa ( ).
REZULTATI: 19/30 (63%) bolnikov je imelo HHL. EUZ je pokazal HHL pri vseh , ERCP pa pri 18/19 bolnikov s HHL. EUZ je bil dvakrat lažno pozitiven, ERCP pa enkrat. Obcutljivost in specificnost EUZ za HHL je bila 100% in 82%, ERCP pa 95% in 91%. Razlika med EUZ in ERCP ni bila statisticno znacilna (p=0,625), je bil 0,70 (p<0,001). V naši seriji bi EUZ lahko prihranil ERCP 9/30 (30%) bolnikom z ABP.
ZAKLJUCEK: Uporaba EUZ pri bolnikih z ABP lahko zmanjša uporabo ERCP, saj lahko EUZ izmed vseh bolnikov z ABP zanesljivo izdvoji skupino bolnikov, ki nimajo HHL, in tako bolnikom brez kamnov v žolcevodu prihrani ERCP z vsemi možnimi zapleti.
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[Abstract / English version]
POMEN ENDOULTRAZVOKA (EUZ) V DIAGNOSTIKI AKUTNEGA BILIARNEGA PANKREATITISA
Author: David Drobne
Mentor: prof. dr. Saša Markovic
Co-mentor: mag. Srecko Štepec
BACKGROUND: Acute biliary pancreatitis (ABP) is an acute inflammation of the pancreas resulting from obstruction of the common bile duct by gallstones - choledocholithiasis (HHL). Endoscopic retrograde cholangiopancreatography (ERCP) is the standard for detection of HHL in patients with ABP. In case of HHL endoscopic sphincterotomy of the papila of Vater (ES) with stone extraction can be performed within the same procedure. ERCP with ES performed early in the course of the disease decreases morbidity.
AIM: ERCP is associated with complications, which may be severe, in up to 10% of patients. In patients with HHL ERCP cannot be avoided, since ES can only be performed with ERCP. In 30 - 60% of the patients the bile duct stones pass spontaneously. These patients do not need ERCP. However, ERCP is performed in all patients with ABP since it is the only diagnostic tool capable of reliably identifying HHL. With its high resolution and almost no complications endoscopic ultrasound (EUS) is emerging as another technique for detecting HHL. The aim of this study was to prospectively evaluate the ability of EUS to identify HHL in patients with ABP in order to limit the use of ERCP only to patients with HHL.
HYPOTHESIS: We determined the sensitivity and specificity of EUS for identifying HHL in patients with ABP in order to find out if the use of EUS in patients with ABP can reduce the use of ERCP.
METHODS: In the prospective study of 30 consecutive patients with ABP EUS was performed before ERCP. Both were performed on the same day. The endoscopist performing ERCP was blinded to the results of EUS. The primary goal of EUS and ERCP was to confirm or exclude HHL. The final diagnosis of HHL was based on the endoscopic extraction of stones. EUS and ERCP were compared with the McNemar test and the coefficient kappa ( ).
RESULTS: 19/30 (63%) patients had HHL. EUS identified HHL in all patients, ERCP in 18/19 patients. EUS was false positive in two patients, ERCP in one patient. The sensitivity and specificity of EUS for HHL were 100% and 82%. The sensitivity and specificity of ERCP for HHL were 95% and 91%. The difference between EUS in ERCP was not statistically significant (p=0,625), was 0,70 (p<0,001). In our series the use of ERCP could have been avoided in 9/30 (30%) patients with ABP if EUS had been used to select patients with HHL.
CONCLUSIONS: EUS can select patients that need ERCP since it can reliably confirm or exclude HHL in patients with ABP. Using EUS we can reduce the use of ERCP in patients with ABP thus avoiding the potential complications of ERCP in patients without HHL.
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