胰腺结核的诊断及鉴别诊断

doi:10.3969/j.issn.1004-583X.2023.10.006

摘要/Abstract

摘要： 目的胰腺结核(PTB)是结核病的罕见类型,临床上容易误诊为胰腺肿瘤。本研究通过总结胰腺结核患者的临床特征,探讨胰腺结核诊断和鉴别诊断的关键点。方法回顾性分析北京协和医院2012年01月至2021年12月通过穿刺或手术获取胰腺病理并确诊的胰腺结核患者23例,按入院时间匹配胰腺恶性肿瘤(PMT)患者进行临床特征的对比分析。结果 23例PTB患者中,男性15例(65.2%),年龄(49±13)岁。PTB组患者最常见的症状是腹痛12例(52.2%),其次是体重下降8例(34.8%)和发热5例(21.7%)。PTB组C反应蛋白水平明显高于PMT组(Z=-2.151,P=0.03),两组间临床特征及其他实验室检查无明显差异。PTB组结核菌素皮试阳性率26.1%;结核酶联免疫斑点试验(T-SPOT.TB)阳性率为86.7%。PTB组病变部位以胰头为主(12/23,52.2%),伴胰周淋巴结肿大15例(65.2%)。PTB组胰周淋巴结肿大更常见(65.2% vs 30.0%,P=0.021),而PMT组胰管扩张更常见(50% vs 0,P<0.01)。23例PTB患者中,仅5例(21.7%)为病原学诊断。15例PTB患者入院时首先考虑恶性肿瘤,误诊率高达65.2%。PTB组14例(60.9%)和9例(39.1%)患者分别接受超声内镜细针穿刺(EUS-FNA)和腹腔手术。14例通过EUS-FNA确诊的PTB患者中,6例曾误诊为恶性肿瘤,由此避免了不必要的外科手术。结论 PTB难以通过临床表现和常规化验检查与PMT相鉴别,组织病理和病原检查是鉴别诊断的关键点。临床医生应提高对PTB的警惕性,及时进行EUS-FNA有可能避免不必要的手术。

关键词: 结核, 胰腺, 诊断, 病理

Abstract: Objective Pancreatic tuberculosis (PTB) is a rare type of tuberculosis, which is easily misdiagnosed as pancreatic neoplasms. The aim of this study is to discuss the key points of diagnosis and differential diagnosis of PTB. Methods Medical records of 23 patients with PTB diagnosed by biopsy from puncture or surgery from January 2012 to December 2021 in Peking Union Medical College Hospital were retrospectively reviewed. The pancreatic malignant tumor (PMT) patients matched by the admission date were selected as controls. Clinical and laboratory features were analyzed and compared between PTB and PMT patients. Results Among 23 patients with PTB, 15 (65.2%) were males. There mean age was (49±13) years. The predominant symptoms of PTB were abdominal pain (12/23, 52.2%), followed by weight loss (8/23, 34.8%) and fever (5/23, 21.7%). The level of C-reactive protein (CRP) in PTB group was significantly higher than that of PMT group (Z=-2.151, P=0.03). There were no significant differences in clinical features and other laboratory test findings between the two groups. The positive rate of Tuberculin skin test (TST) and enzyme-linked immunospot assay test (T-SPOT.TB) in PTB patients was 26.1% and 86.7%, respectively. The head of the pancreas was the most common involved site (12/23, 52.2%), and peripancreatic lymph node enlargement was revealed in 15 cases (65.2%). Peripancreatic lymph node enlargement was more common in PTB group (65.2% vs 30.0%, P=0.021), while dilatation of the pancreatic duct was more common in PMT group (50% vs 0, P<0.01). Among the 23 PTB patients, only 5 patients (21.7%) were bacteriologically diagnosed. Malignant tumor was considered as the first diagnosis in 15 PTB patients, and the misdiagnosis rate was as high as 65.2%. In 23 PTB patients, 14 (60.9%) and 9 cases (39.1%) received endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and surgery, respectively. Among the 14 PTB patients diagnosed by EUS-FNA, 6 patients were misdiagnosed as PMT at first and avoided unnecessary surgical resection. Conclusion It is difficult to distinguish PTB from pancreatic tumors based on clinical manifestations and laboratory tests. Tissue biopsy and bacteriological tests are key points for the diagnosis and differential diagnosis. PTB should be well concerned, and a timely examination of EUS-FNA is able to prevent unnecessary surgery.

Key words: tuberculosis, pancreas, diagnosis, pathology

中图分类号:

刘晔, 阮桂仁, 刘晓清, 侍效春, 费贵军. 胰腺结核的诊断及鉴别诊断[J]. 临床荟萃, 2023, 38(10): 898-903.

Liu Ye, Ruan Guiren, Liu Xiaoqing, Shi Xiaochun, Fei Guijun. Diagnosis and differential diagnosis of pancreatic tuberculosis[J]. Clinical Focus, 2023, 38(10): 898-903.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.10.006

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I10/898

图/表 4

表1 两组临床特征比较

Tab. 1 Comparison of clinical characteristics between groups

项目	PTB (n=23)	PMT (n=23)	统计值	P值
年龄(岁)	49±13	55±9	t=-1.797	0.079
性别[男,例(%)]	15(65.2)	15(65.2)	χ²=0	1
糖尿病[例(%)]	1(4.4)	5(21.7)	χ²=1.725	0.189
肺结核暴露史[例(%)]	3(13.0)	0(0.0)		0.233^*
既往结核病史[例(%)]	4(17.4)	0(0.0)		0.109^*
吸烟[例(%)]	6(26.1)	10(43.5)	χ²=1.533	0.216
饮酒[例(%)]	4(17.4)	7(30.4)	χ²=1.075	0.300
恶性肿瘤家族史[例(%)]	5(21.7)	6(26.1)	χ²=0.119	0.730
腹痛[例(%)]	12(52.2)	12(52.2)	χ²=0	1
发热[例(%)]	5(21.7)	2(8.7)	χ²=0.674	0.412
黄疸[例(%)]	2(8.7)	3(13.0)	χ²=0	1
腹部包块[例(%)]	1(4.4)	0(0.0)		1^*
体重下降[例(%)]	8(34.8)	8(34.8)	χ²=0	1
纳差[例(%)]	3(13.0)	3(13.0)	χ²=0	1
乏力[例(%)]	2(8.7)	3(13.0)	χ²=0	1

表2 两组实验室检查比较

Tab. 2 Comparison of laboratory examination between groups

项目	PTB ( $n$ =23)	PMT ( $n$ =23)	统计量	$P$ 值
WBC(10⁹/L)	6.19±2.25	6.06±2.47	$t$ =0.191	0.849
Hb(g/L)	129.74±15.14	129.13±14.72	$t$ =0.138	0.891
PLT(10⁹/L)	223(153, 276)	206(173, 229)	$Z$ =-0.901	0.368
ALT(U/L)	20(12, 37)	19(13, 27)	$Z$ =-0.418	0.676
AST(U/L)	23.5(16.25, 31.75)	21(16.5, 26.5)	$Z$ =-0.209	0.834
GGT(U/L)	27(20.5, 95.5)	23(14.5, 37)	$Z$ =-1.279	0.201
ALP(U/L)	85.5(75, 140)	81(66.5, 101)	$Z$ =-1.044	0.297
TBIL(μmol/L)	10.8(7.3, 15.9)	11.5(7.8, 15)	$Z$ =0	1
DBIL(μmol/L)	3.3(2.5, 5.6)	3.9(2.9, 5.2)	$Z$ =-0.682	0.495
ALB(g/L)	41.91±4.46	40.09±4.54	t=1.376	0.176
Scr(μmol/L)	67.74±10.32	66.48±11.45	t=0.392	0.697
AMY(U/L)	106.7±219.25	102.21±70.50	t=0.085	0.933
LIP(U/L)	213.83±168.75	498.16±686.83	t=-1.75	0.095
CRP(mg/L)	5.09(3.09, 36.89)	1.62(0.60, 11.09)	$Z$ =-2.151	0.031
CEA(ng/ml)	2.05(1.20, 2.85)	2.5(1.82, 3.28)	$Z$ =-1.419	0.156
CA199(U/L)	12.25(7.85, 25.80)	19.90(8.07, 96.88)	$Z$ =-0.585	0.559
CA125(U/L)	14(10.5, 57)	10.35(7.7, 15.4)	$Z$ =-1.134	0.257

表2 两组实验室检查比较

Tab. 2 Comparison of laboratory examination between groups

项目	PTB ( $n$ =23)	PMT ( $n$ =23)	统计量	$P$ 值
WBC(10⁹/L)	6.19±2.25	6.06±2.47	$t$ =0.191	0.849
Hb(g/L)	129.74±15.14	129.13±14.72	$t$ =0.138	0.891
PLT(10⁹/L)	223(153, 276)	206(173, 229)	$Z$ =-0.901	0.368
ALT(U/L)	20(12, 37)	19(13, 27)	$Z$ =-0.418	0.676
AST(U/L)	23.5(16.25, 31.75)	21(16.5, 26.5)	$Z$ =-0.209	0.834
GGT(U/L)	27(20.5, 95.5)	23(14.5, 37)	$Z$ =-1.279	0.201
ALP(U/L)	85.5(75, 140)	81(66.5, 101)	$Z$ =-1.044	0.297
TBIL(μmol/L)	10.8(7.3, 15.9)	11.5(7.8, 15)	$Z$ =0	1
DBIL(μmol/L)	3.3(2.5, 5.6)	3.9(2.9, 5.2)	$Z$ =-0.682	0.495
ALB(g/L)	41.91±4.46	40.09±4.54	t=1.376	0.176
Scr(μmol/L)	67.74±10.32	66.48±11.45	t=0.392	0.697
AMY(U/L)	106.7±219.25	102.21±70.50	t=0.085	0.933
LIP(U/L)	213.83±168.75	498.16±686.83	t=-1.75	0.095
CRP(mg/L)	5.09(3.09, 36.89)	1.62(0.60, 11.09)	$Z$ =-2.151	0.031
CEA(ng/ml)	2.05(1.20, 2.85)	2.5(1.82, 3.28)	$Z$ =-1.419	0.156
CA199(U/L)	12.25(7.85, 25.80)	19.90(8.07, 96.88)	$Z$ =-0.585	0.559
CA125(U/L)	14(10.5, 57)	10.35(7.7, 15.4)	$Z$ =-1.134	0.257

表3 两组影像学表现比较

Tab. 3 Comparison of imaging performance between groups

项目	PTB (n=23)	PMT (n=23)	χ²值	P值
超声	14	14
病灶部位[例(%)]
胰头	9(64.3)	5(35.7)	2.286	0.131
胰颈	0(0.0)	2(14.3)		0.481*
胰体	2(14.3)	3(21.4)	0	1
胰尾	3(21.4)	4(28.6)	0	1
回声表现[例(%)]
囊性	2(14.3)	2(14.3)	0	1
实性	3(21.4)	3(21.4)	0	1
囊实性	5(35.7)	6(42.9)	0.15	0.699
未描述	4(28.6)	3(21.4)	0	1
胰周淋巴结肿大[例(%)]	4(28.6)	1(7.1)	0.974	0.324
CT	21	20
病灶部位[例(%)]
胰头	12(57.1)	5(25.0)	4.361	0.037
胰颈	1(4.8)	4(20.0)	1.026	0.311
胰体	4(19.1)	5(30.0)	0.666	0.414
胰尾	2(9.5)	7(35.0)	2.536	0.111
病变大小(cm)	3.7(2.95, 5.55)	3.4(2.1, 5.5)	0.223	0.825
占位表现[例(%)]
低密度	19(90.5)	16(80.0)	0.257	0.612
高密度	1(4.8)	2(10.5)	0.008	0.928
密度不均	7(33.3)	2(11.1)	1.59	0.207
增强CT[例(%)]	18	18
无明显强化	1(5.6)	5(27.8)	1.8	0.18
环形强化	2(11.1)	1(5.6)	0	1
非环形强化	15(83.3)	12(66.7)	0.593	0.441
胰周淋巴结肿大[例(%)]	14(66.7)	5(25)	7.152	0.007
胰管扩张[例(%)]	0(0)	10(50)		<0.01^*
病变部位^#[例(%)]	23	23
胰头	12(52.2)	7(30.4)	2.242	0.134
胰颈	1(4.3)	4(17.4)	0.898	0.343
胰体	5(21.7)	6(26.1)	0.119	0.73
胰尾	3(13.0)	8(34.8)	2.987	0.084
胰周淋巴结肿大	15(65.2)	6(30.0)	5.310	0.021

表4 PTB病原学确诊的病例信息

Tab. 4 PTB patients information confirmed through etiological diagnosis

序号	年龄/ 性别	组织获取方式	组织病原学		免疫学			组织病理学
序号	年龄/ 性别	组织获取方式	抗酸染色	分枝杆菌培养	PCR	PPD	T-SPOT.TB	上皮样肉芽肿	干酪样坏死	多核巨细胞
1	66/女	手术	+	+	/	-	+	+	-	+
2	27/男	穿刺	+	+	/	-	+	+	-	+
3	45/男	穿刺	-	-	+	+	+	+	-	+
4	50/男	穿刺	+	/	/	-	+	+	+	+
5	49/女	手术	+	/	/	-	/	+	-	-

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