伴高胆红素血症不明原因肝炎的临床诊断路径及病因构成分析  

Diagnostic pathways and etiological analysis of unexplained hepatitis with hyperbilirubinemia

作　　者：郭小青[1] 游绍莉 吕飒 皋月娟 徐天娇 李东泽 辛绍杰 朱冰 GUO Xiao-qing;YOU Shao-li;LV Sa;GAO Yue-juan;XU Tian-jiao;LI Dong-ze;XIN Shao-jie;ZHU Bing(Department of Liver Diseases,Third People's Hospital of Taiyuan,Taiyuan 030012,China;Department of Liver Failure Treatment and Research Center,Fifth Medical Center of Chinese PLA General Hospital,Beijing 100039,China)

机构地区：[1]太原市第三人民医院肝病科,太原030012 [2]解放军总医院第五医学中心肝衰竭诊疗与研究中心,北京100039

出　　处：《解放军医学杂志》2019年第4期327-331,共5页Medical Journal of Chinese People's Liberation Army

基　　金：北京市科委计划课题(Z161100000516172;Z141100002114038)

摘　　要：目的制订伴高胆红素血症不明原因肝炎的诊断路径并分析其病因构成。方法在对既往伴高胆红素血症不明原因肝炎患者进行回顾性分析及随访调查的基础上,参考国内外研究进展,分级制订各项检查项目,归纳伴高胆红素血症不明原因肝炎的临床诊断路径。2014年6月-2017年6月解放军总医院第五医学中心收治的伴高胆红素血症不明原因肝炎患者223例,均按上述临床诊断路径依次进行初步、深入、终极筛查。对伴高胆红素血症不明原因肝炎的病因检出情况进行分析,在此基础上进一步探讨伴高胆红素血症不明原因肝炎的病因构成。结果 223例患者中,通过路径筛查明确病因者共181例(81.17%),其中初级筛查明确2例(0.90%),深入筛查明确18例(8.07%),终极筛查明确161例(72.20%);42例(18.83%)未能明确诊断病因,其中14例(6.28%)完成诊断路径仍不能明确诊断,28例(12.55%)因病情危重或拒绝肝穿刺或拒绝基因检测未能完成诊断路径。完成诊断路径的195例患者中,明确病因181例,实际病因检出率92.82%。223例患者中,病因为药物性肝损害143例(64.13%),遗传代谢性肝病11例(4.93%),自身免疫性肝病8例(3.58%),感染性病因5例(2.24%),其他系统疾病14例(6.28%),未确定病因42例(18.83%)。结论伴高胆红素血症不明原因肝炎以药物性肝损害、遗传代谢性肝病较为常见;"伴高胆红素血症不明原因肝炎三级筛查诊断路径"确诊有效性较好,简便易行,值得临床推广试行。Objective To sum up the diagnosis experience of unexplained hepatitis with hyperbilirubinemia(UHH)for establishing its diagnostic pathways and etiological factors.Methods By referring to the research progress at home and abroad,various examination items were made in order to form the clinical diagnosis pathway of UHH,on the basis of retrospective analysis and follow-up investigation of UHH patients.Using this pathway we carried out prospective diagnosis analysis for 223 patients admitted to Fifth Medical Center of Chinese PLA General Hospital from June 2014 to June 2017,in the order of preliminary,indepth,and ultimate screening.Results A total of 181 cases were identified through the pathway screening(181/223,81.17%).Two cases were etiologically diagnosed by primary screening(2/223,0.90%),18(18/223,8.07%)by in-depth screening,and 161(161/223,72.20%)by ultimate screening.There were still 42 cases(42/223,18.83%)failing to make a definite diagnosis,among which 14 cases(14/223,6.28%)failed to make a definite diagnosis after completing the diagnostic pathway,and 28(28/223,12.55%)failed to complete the diagnostic pathway due to the critical condition and failure of liver puncture or rejection of genetic test.Among the 195 patients who completed diagnostic pathway,181 cases were identified,and the actual etiology diagnosis rate was 92.82%.Among the 223 cases,143(64.13%)were caused by drug-induced liver damage,11(4.93%)by hereditary metabolic liver disease,8(3.58%)by autoimmune liver disease,5(2.24%)by infectious diseases,14(6.28%)by other systemic diseases,and 42(18.83%)by undetermined causes.Conclusion Drug-induced liver damage,and genetic metabolic liver disease are common causes of UHH.The three-step screening pathway is effective for the diagnosis of UHH,and also simple and easy to practice,thus being worthy of promotion on a trial basis.

关 键 词：高胆红素血症 不明原因肝炎 病因 诊断路径 

分 类 号：R575.1[医药卫生—消化系统] R446[医药卫生—内科学]