慢性乙型肝炎患者肠粘膜病变观察

doi:10.3969/j.issn.1672-5069.2021.02.010

摘要/Abstract

摘要： 目的观察CHB患者小肠黏膜病变表现和发生频率,以探讨小肠黏膜病变与患者临床资料、生化指标和肝纤维化指标的关系。方法 2015年1月～2019年12月我院收治CHB患者158例,行胶囊内镜检查,应用Lewis评分系统评价小肠粘膜病变,记录天冬氨酸氨基转移酶/血小板计数比值(APRI)、Forns指数、S指数、基于4因子指数(FIB-4)和BARD评分。结果在158例CHB患者中,胶囊内镜检查发现小肠黏膜正常者94例(59.5%),小肠黏膜异常者64例(40.5%);典型的黏膜异常表现为绒毛水肿、脆性增加、坏死性糜烂、粘膜溃疡、粘膜水肿伴糜烂和炎性狭窄等;黏膜异常组胆汁反流者40例(62.5%),显著高于黏膜正常组的33例(35.1%,P<0.05);黏膜异常组Lewis评分为(140.6±80.2)分,显著高于黏膜正常组【(0.0±0.0),P<0.05);黏膜异常组PLT、ALT、AST、GGT、ALB、TBIL、肌酐和尿素水平分别为(208.6±65.2)×10⁹/L、(32.5±10.6)U/L、(35.0±7.8)U/L、(47.9±12.5)U/L、(39.2±4.4)g/L、(18.8±15.2)μmol/L、(89.6±16.8)μmol/L和(6.6±2.7)mmol/L,与黏膜正常组比【分别为(248.2±72.6)×10⁹/L、(16.2±8.2)U/L、(15.8±8.6)U/L、(18.2±14.2)U/L、(43.6±5.2)g/L、(12.7±4.8)μmol/L、(80.4±15.6)μmol/L和(5.2±1.4)mmol/L】,差异具有统计学意义(P<0.05),而两组年龄、性别、吸烟史、饮酒史、HBV DNA和PT差异不具有统计学意义(P>0.05);黏膜异常组APRI、Forns指数、S指数、FIB-4和BARD评分分别为(0.35±0.42)、(7.52±1.51)、(0.08±0.13)、(1.80±1.31)和(2.11±0.71),与黏膜正常组【分别为(0.22±0.14)、(6.40±1.42)、(0.05±0.06)、(1.20±0.61)和(1.83±0.72)】比,差异具有统计学意义(P<0.05)。结论 CHB患者存在不同程度的小肠黏膜异常,其病变程度与肝功能损伤程度可能存在某种相关性,值得进一步研究。

关键词: 慢性乙型肝炎, 小肠黏膜, 胶囊内镜, Lewis评分系统

Abstract: Objective The purpose of this study was to observe the manifestations of small intestinal mucosal lesions in patients with chronic hepatitis B(CHB) and to explore the relationship between small intestinal mucosal lesions and clinical data, biochemical indexes and hepatic fibrosis indexes.Methods 158 patients with CHB were recruited in this study between January 2015 and December 2019, and all of them underwent capsule endoscopy. The intestinal mucosal manifestations were evaluated by Lewis score system. The typical mucosal abnormalities were chorionic edema, increased fragility, necrotizing erosion, mucosal ulcer, mucosal edema with erosion and inflammatory stenosis.Results Out the 158 patients with CHB, 94 patients (59.5%)had normal, and 64 patients (40.5%) had abnormal bowel mucosa; the incidence of bile reflux in patients with abnormal bowel mucosa was 62.5%, significantly higher than 35.1% in those with normal bowel mucosa (P<0.05); the Lewis score in patients with abnormal bowel mucosa was (140.6±80.2), significantly higher than that in patients with normal bowel mucosa 【(0.0±0.0), P<0.05); blood platelet count, serum ALT, AST, GGT, albumin, bilirubin, creatinine, and urea levels in in patients with abnormal bowel mucosa were(208.6±65.2)×10⁹/L, (32.5±10.6)U/L, (35.0±7.8)U/L, (47.9±12.5)U/L, (39.2±4.4)g/L, (18.8±15.2)μmol/L, (89.6±16.8)μmol/L and (6.6±2.7)mmol/L, all significantly different compared to 【(248.2±72.6)×10⁹/L, (16.2±8.2)U/L, (15.8±8.6)U/L, (18.2±14.2)U/L, (43.6±5.2)g/L, (12.7±4.8)μmol/L, (80.4±15.6)μmol/L and (5.2±1.4)mmol/L, respectively, P<0.05】 in patients with normal bowel mucosa, while they were no significant differences with respect to age, gender, smoking alcohol consumption, serum HBV DNA loads, and prothrombin times between the two groups (P>0.05); the APRI, Forns index, S index, FIB-4 and BARD score in patients with abnormal bowel mucosa were (0.35±0.42), (7.52±1.51), (0.08±0.13), (1.80±1.31) and (2.11±0.71), significantly different compared to 【(0.22±0.14), (6.40±1.42), (0.05±0.06), (1.20±0.61) and (1.83±0.72), respectively, P<0.05】 in those with normal bowel mucosa.Conclusion There are some kind of different degrees of intestinal mucosal abnormalities in patients with CHB, and the pathological changes might be related to some extent to the liver function injuries, and warrants further investigation.

Key words: Hepatitis B, Capsule endoscopy, Small intestinal mucosa, Lewis scoring system

杨永启, 郭彦东, 李鸿彬. 慢性乙型肝炎患者肠粘膜病变观察[J]. 实用肝脏病杂志, 2021, 24(2): 188-191.

Yang Yongqi, Guo Yandong, Li Hongbin. Observation of intestinal mucosal lesions in patients with chronic hepatitis B[J]. Journal of Practical Hepatology, 2021, 24(2): 188-191.

参考文献

[1] Pennazio M, Spada C, Eliakim R, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of smallbowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 2015, 47(4):352-376.
[2] Ben-Horin S, Lahat A, Amitai MM, et al. Assessment of small bowel mucosal healing by video capsule endoscopy for the prediction of short-term and long-term risk of Crohn's disease flare: a prospective cohort study. Lancet Gastroenterol Hepatol, 2019, 4(7):519-528.
[3] Xu B, Guo Y, Chen Y, et al. Is the irradiated small bowel volume still a predictor for acute lower gastrointestinal toxicity during preoperative concurrent chemo-radiotherapy for rectal cancer when using intensity-modulated radiation therapy? Radiat Oncol, 2015, 10:257.
[4] 郝志远, 曾欣, 林勇. 肠道微生态与肝胆疾病诊治. 中华消化杂志, 2020,40(1): 69-70.
[5] Tenorio-Jiménez C, Martínez-Ramírez MJ, Tercero-Lozano M, et al. Evaluation of the effect of Lactobacillus reuteri V3401 on biomarkers of inflammation, cardiovascular risk and liver steatosis in obese adults with metabolic syndrome: a randomized clinical trial (PROSIR). BMC Complement Altern Med, 2018, 18(1):306.
[6] De Palma GD, Rega M, Masone S, et al. Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc, 2005, 62:529-534.
[7] Tsiaoussis GI, Papaioannou EC, Kourea EP, et al. Expression ofα-defensins, CD20⁺ B-lymphocytes, and intraepithelial CD3⁺ T-lymphocytes in the intestinal mucosa of patients with liver cirrhosis: emerging mediators of intestinal barrier function. Dig Dis Sci, 2018, 63(10):2582-2592.
[8] 胡东胜, 刘建勇, 王英惠, 等. 急慢性肝炎和肝硬化患者上消化道黏膜病变与幽门螺杆菌感染的临床研究. 实用肝脏病杂志, 2006, 9(3):146-147.
[9] 中华医学会感染病学分会, 中华医学会肝病学分会. 慢性乙型肝炎防治指南(2019年版). 实用肝脏病杂志, 2020, 23(1):9-32.
[10] Jeon SR, Kim JO. Capsule endoscopy for portal hypertensive enteropathy. Gastroenterol Res Pract, 2016, 2016:8501394.
[11] Wu LH, Chen MH, Cai JY, et al. The correlation between intestinal mucosal lesions and hepatic dysfunction in patients without chronic liver disease. Medicine (Baltimore), 2020, 99(7):e18837.
[12] Erdogan A, Rao SS, Gulley D, et al. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil, 2015, 27(4):481-489.
[13] Abbasi MH, Zahedi M, Moghadam DS, et al. Small bowel bacterial overgrowth in patients with irritable bowel syndrome: the first study in Iran. Middle East J Dig Dis, 2015, 7(1):36-40.
[14] Berg RD, Garlington AW. Translocation of certain indigenous bacteria from the gastrointestinal tract to the mesenteric lymph nodes and other organsin a gnotobiotic mouse model. Infect Immun, 1979, 23(2):403-411.
[15] Porras D, Nistal E, Martinez-Florez S, et al. Protective effect of quercetin on high-fat diet-induced non-alcoholic fatty liver disease in mice is mediated by modulating intestinal microbiota imbalance and related gutliver axis activation. Free Radic Biol Med, 2017, 102:188-202.
[16] Halvorsen JF, Myking AO, Tvete S. Porto-hepatic bypass by organohepatopexy in rats with prehepatic portal hypertension. Formation of new venous porto-hepatic collaterals following omento-, jejuno-, and splenohepatopexy, and their effect on portal vein pressure. Eur Surg Res, 1979, 11(4):254-266.
[17] Nishimura S, Takahashi H, Akita H, et al. The anatomical pattern of the proximal jejunal vein as a prognostic factor in patients with pancreatic head cancer treated with preoperative chemoradiation therapy. Anticancer Res, 2019, 39(10):5821-5830.
[18] Rasmussen L, Mortensen MB, Troensegaard P, et al. The variability of the incremental postprandial portal vein flow response is partly caused by a relationship between fasting flow rate and phase activity of the migrating motor complex. Eur J Gastroenterol Hepatol, 1999, 11(2):171-174.
[19] Liu DY, Gan T, Rao NN, et al. Identification of lesion images from gastrointestinal endoscope based on feature extraction of combinational methods with and without learning process. Med Image Anal, 2016,32:281-294.
[20] Sun ZJ, Ye B, Sun Y, et al. Design and implementation of magnetically maneuverable capsule endoscope system with direction reference for image navigation. Proc Inst Mech Eng H, 2014, 228(7):652-664.
[21] Liao Z, Li ZS, Xu C. Reduction of capture rate in the stomach increases the complete examination rate of capsule endoscopy: a prospective randomized controlled trial. Gastrointest Endosc, 2009, 69(3 Pt1):418-425.
[22] Gan T, Liu S, Yang J, et al. A pilot trial of convolution neural network for automatic retention-monitoring of capsule endoscopes in the stomach and duodenal bulb. Sci Rep, 2020, 10(1):4103.