十二指肠乳头异位的内镜特点及治疗分析

Endoscopic characteristics and treatment of duodenal papilla ectopia

摘要:

目的 探讨十二指肠乳头异位的内镜下特点及治疗。方法 回顾性收集2003年4月至2022年4月于北部战区总医院内镜中心行内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography，ERCP）诊治的24 617例患者资料，分析其中十二指肠乳头异位患者的临床资料及ERCP诊治要点。结果 十二指肠乳头异位发生率为0.27%（67/24 617），其中男性占比为62.7%（42/67），37.3%（25/67）的患者乳头在球降交界部位；58例（86.6%）患者合并胆总管结石。有61.2%（41/67）的患者合并消化道溃疡或畸形，多发生在球部及球降交界（92.7%，38/41）。56.7%（38/67）的患者胆总管呈“钩状”。ERCP插管成功率为91.0%（61/67），23例（34.3%）患者发生术后并发症，包括术后胰腺炎（16.4%，11例）、高淀粉酶血症（13.4%，9例）和胆管炎（4.5%，3例）。58例胆总管结石患者中，54例成功插管并完成ERCP治疗，总体技术成功率为93.1%，其中完整取石34例（58.6%），部分取石4例（6.9%），经内镜鼻胆管引流8例（13.8%），经内镜胆道内支架置入引流8例（13.8%）。伴有十二指肠狭窄（P=0.039，OR=7.16，95%CI：1.10~46.51）、胆总管结石长径≥1.5 cm（P=0.009，OR=6.92，95%CI：1.18~40.52）、结石嵌顿（P=0.028，OR=16.05，95%CI：1.35~191.11）、多发结石（P=0.001，OR=28.12，95%CI：3.68~215.49），胆总管直径<1.5 cm（P=0.018，OR=7.58，95%CI：1.41~39.58）是ERCP未完整取石的独立危险因素。结论 十二指肠乳头异位在人群中发生率较低，常因胆胰疾病尤其是胆总管结石被发现，常见异位位置为球降交界处，通常伴有消化道溃疡或畸形。ERCP对于处理十二指肠乳头异位合并胆胰疾病有较高的成功率及较好的治疗效果。

Abstract:

Objective To investigate the endoscopic characteristics and treatment of duodenal papilla ectopia. Methods Data of 24 617 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Endoscopy Center of General Hospital of Northern Theater Command from April 2003 to April 2022 were retrospectively collected. Clinical data of diagnosis and treatment of the patients with ectopic duodenal papillae were analyzed. Results The incidence of duodenal papilla ectopia was 0.27% (67/24 617), in which 62.7% (42/67) were males, and 37.3% (25/67) located at the junction of descending duodenal bulb. Fifty‑eight (86.6%) patients had combined choledocholithiasis. There were 61.2% (41/67) patients with digestive tract ulcer or malformation, which were more likely to be located in the duodenal bulb and junction of descending duodenal bulb (92.7%, 38/41). The common bile duct was "hooked" in 56.7% (38/67) patients, and the success rate of ERCP intubation was 91.0% (61/67). Postoperative complications occurred in 23 (34.3%) patients, including postoperative pancreatitis (16.4%, 11 cases), hyperamylasemia (13.4%, 9 cases), and biliary tract infection (4.5%, 3 cases). Of the 58 patients with choledocholithiasis, 54 were successfully intubated and treated with ERCP, with an overall technical success rate of 93.1%. Among them, the stones were completely removed in 34 (58.6%) patients with choledocholithiasis, partially removed in 4 (6.9%) patients with choledocholithiasis, 8 cases (13.8%) had endoscopic drainage and 8 cases (13.8%) had endoscopic stent biliary drainage. Duodenal stenosis (P=0.039, OR=7.16, 95%CI: 1.10‑46.51), choledocholithiasis with long diameter≥1.5 cm (P=0.009, OR=6.92, 95%CI: 1.18‑40.52), incarcerated stones (P=0.028, OR=16.05, 95%CI: 1.35‑191.11), multiple stones (P=0.001, OR=28.12, 95%CI: 3.68‑215.49), and common bile duct diameter<1.5 cm (P=0.018, OR=7.58, 95%CI: 1.41‑39.58) were independent risk factors for incomplete stone removal by ERCP. Conclusion The incidence of ectopic duodenal papilla is relatively low, which is often found due to biliary and pancreatic diseases, especially choledocholithiasis. The common ectopic location is the descending bulbar junction, usually accompanied by digestive tract ulcer or malformation. ERCP demonstrates a high success rate and a good therapeutic effect on the treatment of ectopic duodenal papilla combined with biliary and pancreatic diseases.