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恶性肿瘤相关肝脓肿患者的临床特征分析
DOI: 10.3969/j.issn.1001-5256.2023.04.016
伦理学声明：本研究方案经由空军军医大学第二附属医院伦理委员会审批，批号为TDLL-第202210-01号。
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明：张谷芬负责撰写论文；王临旭、毕铭辕、康文参与收集数据；张野、姚娜修改论文；汪春付、连建奇负责课题设计，资料分析，指导撰写文章并最后定稿。
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摘要:
目的 对恶性肿瘤相关肝脓肿的临床特点进行分析和总结，早期判断病情进展，及时有效治疗。 方法 回顾性分析2005年3月—2018年7月空军军医大学第二附属医院收治的371例肝脓肿患者的临床资料。其中34例恶性肿瘤相关肝脓肿患者作为肿瘤组，按照约1∶2比例、时间匹配的原则，随机选择非恶性肿瘤相关肝脓肿患者(n=70)作为非肿瘤组，将两组的临床特点进行比较。正态分布的计量资料两组间比较采用成组t检验；非正态分布的计量资料两组间比较采用Mann-Whitney U检验；计数资料两组间比较采用χ2检验或Fisher检验。 结果 肿瘤组中肝胆系统肿瘤22例(64.7%)，胃肠道肿瘤7例(20.6%)，非消化道肿瘤5例(14.7%)。肿瘤组合并腹部手术史及肝硬化比例(44.1%、26.5%)高于较非肿瘤组(7.1%、7.1%)(χ2值分别为20.142、7.338，P值均＜0.05)；入院急性生理与慢性健康评分＞16分患者比例高于非肿瘤组(44.1% vs 15.7%, χ2=9.846，P=0.002)。肿瘤组白蛋白低于非肿瘤组[(27.2±5.2) g/L vs (30.8±2.6) g/L， t=-3.131，P=0.002]，而总胆红素显著高于非肿瘤组[54(13~313) μmol/L vs 33(7~96) μmol/L, U=1 816.0，P＜0.001]。肿瘤组以大肠埃希菌为主(23.5%)，非肿瘤组以肺炎克雷伯菌为主(27.1%)，前者两种以上细菌感染更为多见(11.8% vs 2.8%)。影像学提示肿瘤组多发脓肿更为多见(47.1% vs 24.3%，χ2=5.479，P=0.019)。与非肿瘤组相比，肿瘤组平均住院天数长(U=1 728.5，P＜0.001)、治疗失败率高(P=0.005)。 结论 恶性肿瘤相关肝脓肿多合并肝胆肿瘤，致病菌以大肠埃希菌为主，多部位脓肿较常见，预后较差。临床应选择合适抗生素，联合穿刺引流，针对高危人群，必要时可降低手术干预门槛，降低病死率。 Abstract:Objective To investigate the clinical features of malignant tumor-related pyogenic liver abscess (PLA), and to provide a basis for early judgment of disease progression and timely and effective treatment. Methods A retrospective analysis was performed for the clinical data of 371 patients with PLA who were admitted to the Second Affiliated of Air Force Medical University, from March 2005 to July 2018, among whom 34 patients with malignant tumor-related PLA were enrolled as tumor group, and after matching for time and at a ratio of 1∶2, 70 patients without malignant tumor-related PLA were enrolled as non-tumor group. Clinical features were compared between the two groups. The group t-test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between groups. Results In the tumor group, there were 22 patients with hepatobiliary tumor (64.7%), 7 patients with gastrointestinal tumor (20.6%), and 5 patients with non-gastrointestinal tumor (14.7%). Compared with the non-tumor group, the tumor group had a significantly higher proportion of patients with a history of abdominal surgery (44.1% vs 7.1%, χ2=20.142, P < 0.05), liver cirrhosis (26.5% vs 7.1%, χ2=7.338, P < 0.05), or an Acute Physiology and Chronic Health Evaluation Ⅱ score of > 16 (44.1% vs 15.7%, χ2=9.846, P=0.002). Compared with the non-tumor group in terms of laboratory examination, the tumor group had a significantly lower level of albumin [(27.2±5.2) g/L vs (30.8±2.6) g/L, t=-3.131, P=0.002] and a significantly higher level of total bilirubin [54(13~313) μmol/L vs 33(7~96) μmol/L, U=1 816.0, P < 0.001]. Escherichia coli was the main pathogen in the tumor group (23.5%), while Klebsiella pneumonia was the main pathogen in the non-tumor group (23.5%), and compared with the non-tumor group, the tumor group had a significantly higher proportion of patients infected with more than two types of bacteria (11.8% vs 2.8%). Radiological examination showed that the tumor group had a significantly higher proportion of patients with multiple abscesses than the non-tumor group (47.1% vs 24.3%, χ2=5.479, P=0.019). Compared with the non-tumor group, the tumor group had a significantly longer mean length of hospital stay (U=1 728.5, P < 0.001) and a significantly higher treatment failure rate (P=0.005). Conclusion Patients with malignant tumor-related PLA often have hepatobiliary tumor, with Escherichia coli as the main pathogen. Abscesses at multiple sites are common, and patients tend to have a poor prognosis. Appropriate antibiotics combined with percutaneous drainage should be used in clinical practice, and for the high-risk population, the threshold for surgical intervention can be lowered to reduce mortality. -
Key words:
- Liver Abscess /
- Neoplasms /
- Prognosis
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表 1 两组患者临床资料比较
Table 1. Comparison of clinical data between PLA patients with or without tumor
项目 肿瘤组(n=34) 非肿瘤组(n=70) 统计值 P值 性别[例(%)] χ2=0.156 0.625 男 23 50 女 11 20 年龄(岁) 59.3±11.3 56.9±14.9 t=0.830 0.409 合并疾病[例(%)] 糖尿病 2(5.8) 16(22.8) 0.025 胆道疾病 8(23.5) 8(11.4) χ2=2.574 0.169 肝硬化 9(26.5) 5(7.1) χ2=7.338 0.007 心血管疾病 1(2.9) 12(17.1) 0.033 临床表现[例(%)] 发热 30(88.2) 65(92.8) 0.329 腹痛或背痛 3(8.9) 16(22.8) 0.107 消化道症状 2(5.9) 10(14.3) 0.177 腹部手术史[例(%)] 15(44.1) 5(7.1) χ2=20.142 ＜0.001 APACHEⅡ评分[例(%)] χ2=9.846 0.002 ≤16分 19(55.9) 59(84.3) ＞16分 15(44.1) 11(15.7) 复发型[例(%)] 10(29.4) 4(5.7) 0.002 脓肿数量[例(%)] χ2=5.479 0.019 单个 18(52.9) 53(75.7) 多个 16(47.1) 17(24.3) 气腔形成[例(%)] 6(17.6) 12(17.1) χ2=0.004 0.949 分隔形成[例(%)] 18(23.5) 29(41.4) χ2=1.225 0.268 直径＞5 cm[例(%)] 22(64.7) 32(45.7) χ2=1.635 0.201 微生物学特征[例(%)] 大肠杆菌感染 8(23.5) 4(5.7) 0.018 肺炎克雷伯菌感染 1(2.9) 19(27.1) 0.003 两种细菌感染 4(11.8) 2(2.8) 0.088 
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表 2 两组患者实验室检查指标对比
Table 2. Comparison of laboratory tests between PLA patients with or without tumor
指标 肿瘤组(n=34) 非肿瘤组(n=70) 统计值 P值 白细胞计数(×109/L) 13.7±7.0 14.7±5.9 t=-0.772 0.442 中性粒细胞(%) 84.6±11.2 84.0±8.3 t=0.305 0.761 血红蛋白(g/L) 105±19 108±13 t=-0.052 0.958 ALT(U/L) 66(9~509) 67(11~724) U=1 217.5 0.849 ALP(U/L) 167(23~1 189) 156(56~678) U=1 110.5 0.582 GGT(U/L) 204(23~634) 161(45~564) U=1 388.0 0.170 总胆红素(μmol/L) 54(13~313) 33(7~96) U=1 816.0 ＜0.001 白蛋白(g/L) 27.2±5.2 30.8±2.6 t=-3.131 0.002
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表 3 两组患者并发症发生情况的比较
Table 3. Comparison of complication between PLA patients with or without tumor
并发症 肿瘤组(n=34) 非肿瘤组(n=70) χ2值 P值 肺部感染(例) 5 18 1.610 0.204 败血症(例) 5 4 0.149 腹膜炎(例) 3 2 0.327 胸腔积液(例) 4 8 1.000 其他部位合并脓肿(例) 7 2 0.005
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表 4 两组治疗方法及疗效转归比较
Table 4. Comparison of therapies and outcome between PLA patients with or without tumor
项目 肿瘤组(n=34) 非肿瘤组(n=70) U值 P值 治疗方法[例(%)] 0.340 单纯抗生素 2(5.8) 9(12.8) 抗生素+穿刺引流 28(82.3) 61(87.2) 抗生素+手术 4(11.9) 0 住院天数(d) 21(12~47) 16(7~32) 1 728.5 ＜0.001 无效[例(%)] 6(17.6) 1(1.4) 0.005
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