超声内镜引导下穿刺诊断胰腺结核14例

Endoscopic ultrasound‑guided fine needle aspiration for the diagnosis of pancreatic tuberculosis in 14 cases

摘要:

总结胰腺结核的临床特点，分析其超声内镜下表现、穿刺组织病理学及病原学结果。回顾性分析2018年１月至2022年1月在武汉协和医院收治的14例胰腺结核患者的病史、临床表现、实验室检查、影像学检查、超声内镜检查（endoscopic ultrasonography，EUS）下的表现、超声内镜引导细针穿刺抽吸术（endoscopic ultrasound‑guided fine needle aspiration，EUS‑FNA）获得的组织病理及病原学结果。胰腺结核患者中，男、女各7例，年龄（39.7±16.0）岁，临床表现主要为腹胀、腹痛、食欲下降、体重减轻、腹部包块、梗阻性黄疸、皮肤瘙痒、无症状等。7例患者合并其他器官结核，其中3例合并肺结核。实验室检查示贫血7例，血淀粉酶升高3例，胆红素升高2例，结核抗体阳性10例，结核T‑SPOT阳性12例，患者CA19‑9水平均正常。影像学检查示实性肿块9例，囊实性肿块4例，囊性占位1例，胰周淋巴结增大4例，胆管扩张2例。EUS示胰腺结核好发于胰头部。病灶EUS下均呈低回声，无血管侵犯，其中均匀低回声8例，不均匀低回声6例；病灶内部见高回声钙化灶2例，见无回声液化坏死区1例；病灶肿块长径（3.9±1.6）cm，其中肿块长径<3 cm者5例，肿块长径≥3 cm者9例。组织学检查示干酪样肉芽肿12例。病原学检查结果显示结核杆菌聚合酶链式反应检测阳性11例，抗酸染色找到阳性分枝杆菌3例，培养出结核分枝杆菌1例。全部患者确诊后给予正规药物抗结核治疗，3例黄疸患者行内镜逆行胰胆管造影术及胆道支架置入术。随访期间患者显示预后良好。对于胰腺占位性病变患者，应考虑胰腺结核的可能，胰腺结核的诊断依靠组织活检及病原学检查，EUS‑FNA是获取胰腺组织首选的方法，可避免不必要的手术，并提供及时、准确的诊断。正规抗结核治疗是胰腺结核的主要治疗方法。

Abstract:

To summarize the clinical features of pancreatic tuberculosis, analyze its endoscopic ultrasonography (EUS) findings, aspiration histopathology and etiological results, the medical history, clinical manifestations, laboratory tests, imaging findings, EUS findings, pathological and etiological results of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy, of 14 patients with pancreatic tuberculosis in Wuhan Union Hospital from January 2018 to January 2022 were retrospectively analyzed. Among the patients with pancreatic tuberculosis, 7 were male and 7 were female with the age of 39.7±16.0 years. The main clinical manifestations were abdominal distention, abdominal pain, loss of appetite, weight loss, abdominal mass, obstructive jaundice, skin pruritus, asymptomatic. Seven patients with pancreatic tuberculosis were complicated with tuberculosis in other organs, including 3 patients with pulmonary tuberculosis. Laboratory examination results showed 7 patients with anemia, 3 with elevated serum amylase, 2 with elevated bilirubin and 10 with positive anti-tuberculosis antibody, 12 positive for tuberculosis T-SPOT. Levels of CA19-9 in all patients were within normal range. Imaging examination results showed that 9 cases were solid mass, 4 cystic solid mass, 1 cystic mass, 4 with enlarged peripancreatic lymph node, and 2 with dilated bile duct. EUS showed that head of pancreas was the most common location of pancreatic tuberculosis. All the lesions were hyperechoic without vascular invasion, including 8 cases with homogeneous hyperecho, 6 cases with inhomogeneous hyperecho, 2 cases with hyperechoic calcification and 1 case of echoless colliquative necrosis area. The diameter of the mass was 3.9±1.6 cm, with 5 cases <3 cm and 9 cases ≥3 cm. Pathological biopsy showed 12 cases of caseous granuloma. Etiological examination results showed that 11 cases were positive for polymerase chain reaction for mycobacterium tuberculosis, 3 positive for acid-fast stain, 1 positive for culture. All the patients were treated with regular anti-tuberculosis drugs, and 3 patients with jaundice were treated with endoscopic retrograde cholangiopancreatography and biliary stent placement. All patients showed good prognosis during the follow-up period. For patients with pancreatic space-occupying lesions, the possibility of pancreatic tuberculosis should be considered. The current diagnostic method relies on tissue biopsy and aetiological examination. EUS-FNA is the preferred method for obtaining pancreatic tissue to avoid unnecessary surgery, and to provide timely and accurate diagnosis. Regular anti-tuberculosis treatment is the main treatment for pancreatic tuberculosis.