重症胰腺炎CT影像与病情进展及血清淀粉酶、红细胞分布宽度、脂质运载蛋白2的关系.pdf

Correlation of CT imaging of severe pancreatitis with disease progression,serumamylase,red blood cell distribution width and lipocain-2LIU Chunyan1,XUE Ping2,MA Yadong3,YANG jiabei4,WANG Xiaoming5,YU Rui61Department of Integrative Medicine(General Medicine),Shangjin Nanfu Hospital,Chengdu 611730,China;2Department of IntegrativeMedicine,West China Hospital,Sichuan University,Chengdu 610041,China;3Department of Radiology,The 2nd Affiliated Hospital ofChengdu Medical College-Nuclear Industry 416 Hospital,Chengdu 610051,China;4Department of Medical Laboratory,The Affiliated Tradi-tional Chinese Medicine Hospital of Southwest Medical University,Luzhou 646000,China;5School of Computer Science,Xihua University,Chengdu 610039,China;6Third Department of Acupuncture,Moxibustion and Tuina,Jianyang Chinese Medicine Hospital,Jianyang641400,China摘要：目的 探究重症胰腺炎CT影像与病情进展及血清淀粉酶（AMS）、红细胞分布宽度（RDW）、脂质运载蛋白2（LCN2）的关系。方法 回顾性收集2019年3月2022年12月的105例重症胰腺炎患者临床资料，根据患者临床预后结果分为预后良好组（n=77）和预后不良组（n=28），比较两组患者CT影像结果胰周外炎症CT评分（EPIC）、改良CT严重指数（MCTSI）及血清AMS、RDW、LCN2水平，利用ROC曲线分析各指标对重症胰腺炎预后的评估价值。结果 预后不良组器官功能衰竭数多于预后良好组（P=0.039），APACHE 评分水平高于预后良好组（P=0.001）；预后不良组EPIC、MCTSI评分高于预后良好组（P0.001），血清AMS、RDW、LCN2水平均高于预后良好组（P0.001）；相关性分析显示，EPIC、MCTSI评分与血清AMS、RDW、LCN2水平呈正相关关系（r=0.591、0.668、0.684，0.573、0.637、0.652，P0.001）；EPIC、MCTSI评分评估重症胰腺炎预后的曲线下面积为0.791、0.762，敏感度为82.14%、67.86%，特异性为64.94%、72.73%；血清AMS、RDW、LCN2评估重症胰腺炎预后的曲线下面积为0.758、0.754、0.851，敏感度为64.29%、78.57%、78.57%，特异性为76.62%、66.23%、80.52%；血清AMS、RDW、LCN2联合评估重症胰腺炎预后的曲线下面积为0.925，敏感度为92.86%，特异性为79.22%。结论 重症胰腺炎患者较高的EPIC、MCTSI评分以及血清AMS、RDW、LCN2水平与预后不良有关，上述CT评分与血清学指标水平呈正相关关系，且均可用于评估患者病情进展后的不良结局，血清学指标联合评估效能最高。关键词：重症胰腺炎；CT；病情；血清淀粉酶；红细胞分布宽度；脂质运载蛋白2Abstract:Objective To explore the relationship between CT imaging of severe pancreatitis and disease progression,serumamylase(AMS),red blood cell distribution width(RDW)and lipocain-2(LCN2).Methods Clinical data of 105 patients withsevere pancreatitis from March 2019 to December 2022 were retrospectively collected.The patients were divided into goodprognosis group(n=77)and poor prognosis group(n=28)according to the clinical prognosis results of patients.CT imagingresults extra-pancreatic inflammation on CT(EPIC),modified CT severity index(MCTSI)and serum AMS,RDW and LCN2levels were compared between the two groups of patients.ROC curve was used to analyze the evaluated value of eachindicator on prognosis of severe pancreatitis.Results The number of cases with organ failure in poor prognosis group wasmore than that in good prognosis group(P=0.039),and the APACHE II score was higher than that in good prognosis group(P=0.001).EPIC score and MCTSI score were higher in poor prognosis group than those in good prognosis group(P0.001),andserum AMS,RDW and LCN2 levels were higher compared with those in good prognosis group(P0.001).Correlation analysisshowed that EPIC score and MCTSI score were positively correlated with serum AMS,RDW and LCN2 levels(r=0.591,0.668,0.684 and 0.573,0.637,0.652,P0.001).The areas under the curves of EPIC score and MCTSI score on evaluating the prognosisof severe pancreatitis were 0.791 and 0.762,and the sensitivities were 82.14%and 67.86%and the specificities were 64.94%and72.73%.The areas under the curves of AMS,RDW and LCN2 were 0.758,0.754,0.851,and the sensitivities were 64.29%,78.57%,78.57,the specificities were 76.62%,66.23%,80.52%respectively.The area under the curve,sensitivity and specificity ofthe combination of AMS,RDW and LCN2 on assessing the prognosis of severe pancreatitis were 0.925,92.86%and 79.22%.Conclusion High EPIC score,MCTSI score and serum AMS,RDW and LCN2 levels in patients with severe pancreatitis areassociated with poor prognosis.The above CT scoresare positively correlated with serological indicators.All the indicators can be used to evaluate the pooroutcomes after disease progression.The combinationof serological indicators has the highest efficiency.Keywords:severe pancreatitis;CT;disease condition;serum amylase;red blood cell distribution width;lipocain-2重症胰腺炎重症胰腺炎CTCT影像与病情进展及血清淀粉酶影像与病情进展及血清淀粉酶、红细胞分布宽红细胞分布宽度度、脂质运载蛋白脂质运载蛋白2 2的关系的关系刘春燕1，薛 平2，马亚东3，杨加贝4，王晓明5，余 锐61成都上锦南府医院中西医结合科（普内），四川 成都 611730；2四川大学华西医院中西医结合科，四川 成都610041；3成都医学院第二附属医院核工业四一六医院放射科，四川 成都 610051；4西南医科大学附属中医医院医学检验科，四川 泸州 646000；5西华大学计算机学院，四川 成都 610039；6简阳市中医医院针灸推拿三科，四川 简阳 641400收稿日期：2023-03-15基金项目：国家自然科学基金（82004154）Supported by National Natural Science Foundation of China(82004154)作者简介：刘春燕，医师，E-mail:doi 10.12122/j.issn.1674-4500.2023.04.11分子影像学杂志,2023,46(4):638-642 638胰腺炎是胰酶异常激活后引起胰腺自身及其在周围器官自我消化的炎症性疾病，重症者伴有持续性器官功能障碍或感染性坏死，病情凶险，进展迅速，病死率高达20%30%1-2。目前临床中常用急性生理功能和慢性健康状况评分系统（APACHE ）、胰腺外炎症CT评分（EPIC）和改良CT严重指数（MCTSI）等评分系统进行重症胰腺炎预测病情发展，不同评分系统存在其优势与不足，临床应用受到一定限制 3。血清淀粉酶（AMS）是胰腺炎常用诊断指标，与病情进展也密切相关 4。红细胞分布宽度（RDW）变化与疾病的炎症状态相关，有研究 5 指出其可用于胰腺炎病情评估。脂质运载蛋白2（LCN2）参与免疫炎症反应，同样与疾病炎症状态有关，其水平上调是胰腺疾病发展的常见辅助因素 6。目前CT系统评分以及血清AMS、RDW、LCN2水平与胰腺炎的关系已基本明确，但临床关于上述CT评分与血清学指标之间的关系及其对病情进展的评估价值尚未明确。本研究通过分析重症胰腺炎EPIC、MCTSI评分与病情进展及血清AMS、RDW、LCN2水平的关系，为患者病情发展情况、预后方面的评估提供参考和依据，进而为临床治疗决策提供指导。1 资料与方法1.1 一般资料回顾性收集2019年3月2022年12月的105例重症胰腺炎患者临床资料。纳入标准：参照 中国急性胰腺炎诊治指南(2019，沈阳)7 中重症胰腺炎的诊断标准，确诊；年龄1880岁；发病时间48 h；入院24 h内接受血清AMS、RDW、LCN2检测；入院48 h内完成CT检查，图像质量合格；资料完整。排除标准：合并恶性肿瘤；入院24 h内转院或家属放弃治疗或死亡；存在心、脑、肝、肾等其他器官严重疾病；存在免疫性疾病或有激素类药物长期应用史；伴其他急慢性炎症或感染；近1月内有外伤或手术史；在院外已接受液体治疗等相关治疗。105例患者中男68例，女37例，年龄4880（58.329.49）岁。本研究为回顾性分析，已免去知情同意及伦理审批。1.2 研究指标从医院病历系统中调取研究对象病历资料，收集、整理患者一般临床资料如下：人口学特征：年龄、性别；疾病特征：既往病史、病因分类、休克、器官功能衰竭情况及入院24 h APACHE 8、中转手术情况；CT检查：影像学特征、EPIC评分 9、MCTSI评分 10；实验室检查指标：入院24 h血清AMS、RDW、LCN2水平；临床随访：随访患者自入院治疗开始后30 d内的生存、死亡情况，生存者归入预后良好组（n=77），死亡者归入预后不良组（n=28）。1.3 统计学分析采用SPSS 22.0软件对研究数据进行统计学分析，符合正态分布的计量资料以均数标准差表示，组间两两比较采用独立样本t检验；计数资料以n（%）表示，组间比较采用2检验；指标间的相关性分析采用Pearson法；绘制ROC曲线并计算曲线下面积（AUC）评估各指标对重症胰腺炎预后的评估价值。以P0.05），预后不良组患者器官功能衰竭数多于预后良好组（P=0.039），APACHE 评分高于预后良好组（P=0.001，表1）。IndexAge（years,MeanSD）GenderMaleFemalePast medical historyHypertensionDiabetes mellitusCoronary heart diseaseEtiological classificationBiliaryAlcoholicHyperlipidemicOtherNumber of cases with organ failure12APACHE score(point,MeanSD)Conversion to surgeryGood prognosis group（n=77）57.2610.27512621141829201612453222.966.4822Poor prognosis group（n=28）61.228.79171186710774101827.545.86102/t1.8120.2740.0170.1400.0300.2184.2523.2820.494P0.0730.6000.8950.7080.8630.9740.0390.0010.482表1 两组人口学特征与疾病特征Tab.1 Demographic characteristics and disease characteristics of the two groups(n)APACHE:Acute physiology and chronic health evaluation.http:/www.j-分子影像学杂志,2023,46(4):638-642 6392.2 CT影像结果分析预后不良组患者EPIC、MCTSI评分高于预后良好组（P0.001，表2，图1）。2.3 血清AMS、RDW、LCN2水平预后不良组患者血清AMS、RDW、LCN2水平均高于预后良好组（P0.001，表3）。2.4 EPIC、MCTSI评分与血清AMS、RDW、LCN2水平的相关性分析相关性分析显示，EPIC、MCTSI评分与血清AMS、RDW、LCN2水平呈正相关关系（r=0.591、0.668、0.684和0.573、0.637、0.652，P0.001，表4）。2.5 EPIC、MCTSI评分与血清AMS、RDW、LCN2评估重症胰腺炎预后的ROC曲线EPIC、MCTSI评分评估重症胰腺炎预后的AUC为0.791，0.762，敏感度为 82.14%和 67.86%，特异性为64.94%和72.73%；血清AMS、RDW、LCN2评估重症胰腺炎预后的 AUC 为 0.758、0.754、0.851，敏感度为64.29%、78.57%、78.57%，特异性为76.62%、66.23%、80.52%；血清AMS、RDW、LCN2联合评估重症胰腺炎预后的 AUC 为 0.925，敏感度为 92.86%，特异性为79.22%（表5、图2）。图1 男性患者，59岁，预后良好Fig.1 A 59-year-old male patient with good prognosis.A:Before treatment,diffusepancreatic enlargement,decreased pancreatic tail enhancement,exudation and effu-sion were observed in peripheral space and bilateral prerenal space,with uniformdensity and unclear edge.Acute peripancreatic fluid accumulation was considered,with EPIC score of 7 points and MCTSI score of 6 points.B:After treatment,the dis-ease condition was improved and the prognosis was good.ABGroupGood prognosis group（n=77）Poor prognosis group（n=28）tPAMS（U/L）527.57201.11711.35170.504.3030.001RDW（%）13.911.8915.862.224.4590.001LCN2（g/L）275.0364.47379.8777.016.9880.001表3 两组血清血清AMS、RDW、LCN2水平Tab.3 Serum AMS,RDW and LCN2 levels in the two groups(MeanSD)AMS:Serum amylase;RDW:Red blood cell distribution width;LCN2:Lipocain-2.表4 EPIC、MCTSI评分与血清AMS、RDW、LCN2水平的相关性分析Tab.4 Correlation between EPIC score and MCTSI score and serum AMS,RDW and LCN2 levelsCT system scoreEPIC scoreMCTSI scoreAMSr0.5910.573P0.0010.001RDWr0.6680.637P0.0010.001LCN2r0.6840.652P0.0010.001表2 两组EPIC、MCTSI评分结果Tab.2 EPIC score and MCTSI score of the two groups(point,MeanSD)EPIC:Extrapancreatic inflammation on abdominal computedtomography;MCTSI:Modified CT severity index.GroupGood prognosis group（n=77）Poor prognosis group（n=28）tPEPIC score5.061.076.210.745.2420.001MCTSI score5.751.517.541.735.1640.001分子影像学杂志,2023,46(4):638-642http:/www.j- 6403 讨论鉴于重症胰腺炎的高病死率，早期评估病情进展并预测不良预后具有重要临床意义。APACHE 评分是早期评估重症胰腺炎病情的重要指标，具有较高的特异度性及敏感度，其评分水平与患者病死率相关，评分增加提示患者预后不良，可用于指导临床调整治疗方案以尽可能挽救患者生命 11。本研究中，预后不良组患者器官功能衰竭数多于预后良好组，APACHE 评分水平高于预后良好组，提示APACHE 评分与重症胰腺炎病情进展有关，高评分与预后不良有关，与前述研究结果一致。但值得注意的是，APACHE 评价内容多、步骤相对繁琐，操作费时费力，动态观察效果差，且可能只有部分患者拥有完整数据，这使其临床应用受到限制。因此，理想的评分系统不仅应具有较高且稳定的评估预测价值，还应兼具操作便捷性和评估及时性。EPIC、MCTSI评分均是基于CT检查结果产生的影像学评分，前者观察早期患者胸腔积液、腹水、腹膜后炎症反应等胰腺外炎症CT表现评估病情进展及预后，后者在CTSI评分基础上简化了胰周积液和实质性坏死范围评估标准并增加了对胰外并发症的评估 12。临床研究证实 EPIC、MCTSI评分在胰腺炎患者合并局部并发症、全身并发症、多器官衰竭以及死亡方面均具有评估价值，可用于预测患者预后 13-15。但EPIC和MCTSI评分依赖于CT检查结果，而CT检查需在4872 h内才能完成，故两种评分无法在很早期完成对重症胰腺炎的病情及预后评估。本研究中，预后不良组患者EPIC、MCTSI评分高于预后良好组，表明高EPIC、MCTSI评分与重症胰腺炎病情进展有关，评分更高者预后更差，与既往研究 16 结果一致。MCTSI评分侧重于对胰腺局部变化的评估，EPIC评分是重症胰腺炎导致的全身炎症反应在影像学上的早期表现，二者评分越高反映患者胰腺局部病变和炎症更严重，故患者预后越差。重症胰腺炎患者的血清AMS水平在其胰腺受损后期迅速攀升，参与胰腺损伤过程，可用于急性胰腺炎的VariablesEPICMCTSIAMSRDWLCN2AMS+RDW+LCN2AUC0.7910.7620.7580.7540.8510.925SE0.04180.05490.05030.05740.04790.027395%CI0.701-0.8640.669-0.8400.665-0.8360.661-0.8330.768-0.9130.857-0.968Cut-off value56648.38140.851Sensitivity（%）82.1467.8664.2978.5778.5792.86Specificity（%）64.9472.7376.6266.2380.5279.22表5 EPIC、MCTSI评分与血清AMS、RDW、LCN2评估重症胰腺炎预后的价值Tab.5 Value of EPIC score and MCTSI score and serum AMS,RDW and LCN2 on evaluating the prognosis of severe pancreatitis图2 EPIC、MCTSI评分与血清AMS、RDW、LCN2评估重症胰腺炎预后的ROC曲线Fig.2 ROC curves of EPIC score and MCTSI score and se-rum AMS,RDW and LCN2 in evaluating the prognosis ofsevere pancreatitisSensitivity(%)100%-Specificity(%)100806040200020406080100EPICMCTSIAMSRDWLCN2AMS+RDW+LCN2http:/www.j-分子影像学杂志,2023,46(4):638-642 641诊断评估中，同时也与患者疾病严重程度及预后密切相关，可为患者的感染控制及预后改善提供有效参考信息 17。炎症反应及氧化应激是重症胰腺炎病情发生、发展的重要机制，重症胰腺炎患者发病后机体中会释放大量炎症介质及氧化应激因子，进而促进红细胞死亡或抑制红细胞成熟，引起微循环障碍，使未成熟的红细胞释放进入血循环，导致血液中RDW水平增加 18。国外报道指出，重症胰腺炎患者RDW水平增加与患者机体炎症反应有关，可将RDW作为评估病情及预后的较为可靠的指标 19。LCN2为急性时相反应蛋白，反映上皮细胞损伤及机体炎症状态。国内有研究指出，LCN2可加剧机体炎症级联反应，参与胰腺炎患者肾功能损伤的发生、发展，与不良预后有关 20。本研究中，预后不良组血清AMS、RDW、LCN2水平均高于预后良好组，提示较高水平的血清AMS、RDW、LCN2与重症胰腺炎预后不良有关，与既往研究结果一致，可能原因是较高水平的AMS、RDW、LCN2水平反映患者胰腺受损严重、全身炎症反应更为剧烈，导致患者预后更差。本研究相关性分析显示，MCTSI、EPIC评分与血清AMS、RDW、LCN2水平呈正相关关系，CT系统评分与血清学指标在重症胰腺炎中表现出一致的升高趋势，分析原因为，MCTSI、EPIC评分和AMS、RDW、LCN2水平分别是重症胰腺炎胰周病变及炎症反应在影像学和血清学方面的表现，因此具有相同趋势。本研究绘制ROC曲线分析各指标对重症胰腺炎预后评估的价值显示，单项CT系统评分或血清学指标对重症胰腺炎的预后评估存在敏感度或特异性偏低，其中EPIC评分诊断效能稍高于MCTSI评分，与既往研究 21 类似。而血清学指标联合评估则具有良好效能，这对于患者早期治疗方案的制定有指导意义。但本研究纳入病例数较少，且未能随访至患者远期预后结局，有待改进。综上所述，EPIC、MCTSI 评分以及血清 AMS、RDW、LCN2可反映重症胰腺炎病情进展，与患者不良预后结局有关，血清学指标联合评估诊断效能较高。参考文献：1 唐山宝,安春霞,则学英.重症胰腺炎患者螺旋CT灌注参数与炎症指标及临床症状的关系 J .分子影像学杂志,2022,45(3):353-7.2 Luo YL,Fan L,Huang LX,et al.Expression of serum autophagy-related protein P62 in patients with severe pancreatitis and itscorrelation with prognosis J .Am J Transl Res,2022,14(2):1376-83.3 盛雅琪,朱华栋.急性胰腺炎相关血清学指标及评分系统综述 J .中华急诊医学杂志,2022,31(5):706-10.4 Inatomi O,Bamba S,Nakai Y,et al.Diagnostic value of serumamylaselevelsindicatingcomputedtomography-definedpost-endoscopic retrograde 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