局灶性胰腺炎誤診為胰尾癌一例

李紹軍 王京芬 孫孚波

患者男，54歲。因“上腹部疼痛半年余”入院。患者半年前無明顯誘因出現(xiàn)上腹部持續(xù)性隱痛，不放射，發(fā)作無時(shí)間規(guī)律。在當(dāng)?shù)匾浴奥晕秆住敝委熚匆姾棉D(zhuǎn)，后行CT檢查，顯示胰尾低密度影，遂入我院。患者既往無吸煙及飲酒史。體檢：皮膚鞏膜無黃染，鎖骨上淋巴結(jié)未腫大，腹軟，左上腹部輕壓痛，無反跳痛。實(shí)驗(yàn)室檢查：血常規(guī)、血生化、AFP、CEA、CA19-9等均未見異常，尿淀粉酶1 547 U/L(正常值<1 000 U/L) 。CT顯示胰體尾交界區(qū)增大，可見斑片狀低密度區(qū)，大小約2.5 cm×3.7 cm，鄰近脾靜脈的邊緣不整。增強(qiáng)掃描后低密度區(qū)呈不均勻強(qiáng)化，其內(nèi)未見強(qiáng)化壞死區(qū)(圖1a～c)。考慮：①腫瘤性病變；②炎癥性病變。擇期行剖腹探查術(shù)。術(shù)中見胰頭、頸部質(zhì)軟，胰體尾部腫大，質(zhì)硬，以胰尾為著，周圍未及腫大淋巴結(jié)。取活檢性病理檢查，報(bào)告為慢性胰腺炎。行胰體尾切除術(shù)。術(shù)后恢復(fù)順利，無胰瘺等并發(fā)癥發(fā)生。術(shù)后病理診斷為慢性胰腺炎(圖1d)。

討論局灶性胰腺炎是長期的慢性胰腺炎纖維化過程或急性炎癥后的復(fù)發(fā)性胰腺炎后形成的炎性腫塊[1]，臨床上常難于與胰腺癌進(jìn)行鑒別[2]。

圖1 患者胰腺的CT征象(a～c)及手術(shù)切除標(biāo)本的病理改變(d,HE ×200)

胰腺癌患者的血清CA19-9濃度升高，局灶性或彌漫性胰腺炎患者的血清CA19-9也可升高[3-4]，兩者的影像學(xué)表現(xiàn)也很類似。胰腺內(nèi)存在假性囊腫或胰腺炎腫塊內(nèi)有小囊腫并非局灶性胰腺炎胰腺腫塊的特征，因?yàn)槿魏巫枞砸认傺锥伎赡芎喜⒓傩阅夷[形成[1，5]。CT鑒別慢性胰腺炎和胰腺癌準(zhǔn)確率分別為53%和77%[6-7]，增強(qiáng)CT時(shí)，局灶性胰腺炎顯示為均勻或不均勻強(qiáng)化，大部分時(shí)間與其余腺體無明顯區(qū)別[1，8]。局灶型胰腺炎的峰值逐漸增強(qiáng)，而胰腺癌的峰值早期增強(qiáng)，此增強(qiáng)模式可以鑒別腫塊型胰腺炎與胰腺癌[9]。MRCP和ERCP檢查鑒別局限性胰腺炎與胰腺癌的依據(jù)是胰管的征象，遠(yuǎn)端擴(kuò)張的主胰管突然中斷更多見于胰腺癌[10]。

慢性胰腺炎或癌的診斷金標(biāo)準(zhǔn)是病理學(xué)或細(xì)胞學(xué)證據(jù)。內(nèi)鏡超聲引導(dǎo)下細(xì)針穿刺是目前獲取胰腺組織樣本最好的方法，活檢標(biāo)本病理診斷的敏感性、 特異性和準(zhǔn)確性分別為80%～ 92%、100%和85%～95%[11-12]。檢測活檢組織的K-ras基因突變可進(jìn)一步確定胰腺癌的診斷，但仍有假陰性的可能，這是因?yàn)橐认侔┙M織中基因突變?yōu)榉蔷|(zhì)性或穿刺不能收集到足夠的胰腺癌標(biāo)本[13]。

慢性胰腺炎是臨床難治性疾病，導(dǎo)致的頑固性疼痛和內(nèi)外分泌功能不足或喪失及各種并發(fā)癥嚴(yán)重影響了患者的生活質(zhì)量,同時(shí)也潛在著致癌因素。但對(duì)具體的患者選用何種術(shù)式才能達(dá)到好的治療效果,目前尚無可靠的數(shù)據(jù)或設(shè)計(jì)良好的隨機(jī)對(duì)照試驗(yàn)研究來幫助外科醫(yī)師做出抉擇[14]。慢性胰腺炎的手術(shù)原則是胰管減壓和引流胰液或作病變部位胰腺組織的切除,并盡可能地保留內(nèi)、外分泌功能。本例患者為局灶性胰腺炎，胰體尾部的炎性增生性改變應(yīng)予以切除，選擇胰體尾切除是目前最為恰當(dāng)?shù)男g(shù)式。

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