ACM Advances in Clinical Medicine 2161-8712 Scientific Research Publishing 10.12677/ACM.2021.117453 ACM-43986 ACM20210700000_41322994.pdf 医药卫生 ERCP在胆胰系统疾病的诊治应用现状及研究进展 Current Status and Research Progress of ERCP in the Diagnosis and Treatment of Biliary and Pancreatic System Diseases 李 跃华 2 1 龚 建平 2 1 重庆医科大学附属第二医院肝胆外科，重庆 null 02 07 2021 11 07 3123 3130 © Copyright 2014 by authors and Scientific Research Publishing Inc. 2014 This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

内镜逆行胆胰管造影术(ERCP)自20世纪60年代应用于临床，经过近半个世纪的发展，已经成为目前临床诊治胆胰系统疾病的重要手段。近年来随着内镜仪器的不断更新、内镜医生技术的进步以及对胆胰系统疾病认识的进展，使得ERCP在胆胰疾病诊治中的应用越来越广泛，诊疗程序越来越规范。同时随着无创影像学技术的进步，ERCP的诊断作用略有下降，但其介入治疗的作用更加突显，减少了对于传统创伤治疗的依赖。本文就ERCP技术在胆胰系统疾病中的诊治应用现状及近年来的研究进展作一综述，并对未来的应用前景进行展望。 Endoscopic retrograde cholangiopancreatography (ERCP) has been used clinically since the 1960s, after nearly half a century of development, it has become an important method for clinical diagnosis and treatment of biliary and pancreatic system diseases. In recent years, with the continuous updating of endoscopy equipment, the advancement of endoscopists’ technology, and the progress in understanding of biliary and pancreatic diseases, the application of ERCP in the diagnosis and treatment of biliary and pancreatic diseases has become more extensive, and the diagnosis and treatment procedures have become more standardized. At the same time, the diagnostic role of ERCP has declined slightly with the advancement of noninvasive imaging technology. But its intervention role in treatment is more prominent, reducing dependence on traditional trauma therapy. This article summarizes the application status of ERCP technology in biliary and pancreatic system diseases and the research progress in recent years, and look forward to the future application prospects.

 内镜逆行胆胰管造影术，胆胰系统疾病，诊断，治疗, Endoscopic Retrograde Cholangiopancreatography Biliary Pancreatic System Disease Diagnosis Therapy 摘要

内镜逆行胆胰管造影术(ERCP)自20世纪60年代应用于临床，经过近半个世纪的发展，已经成为目前临床诊治胆胰系统疾病的重要手段。近年来随着内镜仪器的不断更新、内镜医生技术的进步以及对胆胰系统疾病认识的进展，使得ERCP在胆胰疾病诊治中的应用越来越广泛，诊疗程序越来越规范。同时随着无创影像学技术的进步，ERCP的诊断作用略有下降，但其介入治疗的作用更加突显，减少了对于传统创伤治疗的依赖。本文就ERCP技术在胆胰系统疾病中的诊治应用现状及近年来的研究进展作一综述，并对未来的应用前景进行展望。

 关键词

内镜逆行胆胰管造影术，胆胰系统疾病，诊断，治疗

 Current Status and Research Progress of ERCP in the Diagnosis and Treatment of Biliary and Pancreatic System Diseases<sup> </sup>

Yuehua Li, Jianping Gong*

Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing

Received: Jun. 12th, 2021; accepted: Jul. 1st, 2021; published: Jul. 20th, 2021

 ABSTRACT

Endoscopic retrograde cholangiopancreatography (ERCP) has been used clinically since the 1960s, after nearly half a century of development, it has become an important method for clinical diagnosis and treatment of biliary and pancreatic system diseases. In recent years, with the continuous updating of endoscopy equipment, the advancement of endoscopists’ technology, and the progress in understanding of biliary and pancreatic diseases, the application of ERCP in the diagnosis and treatment of biliary and pancreatic diseases has become more extensive, and the diagnosis and treatment procedures have become more standardized. At the same time, the diagnostic role of ERCP has declined slightly with the advancement of noninvasive imaging technology. But its intervention role in treatment is more prominent, reducing dependence on traditional trauma therapy. This article summarizes the application status of ERCP technology in biliary and pancreatic system diseases and the research progress in recent years, and look forward to the future application prospects.

Keywords:Endoscopic Retrograde Cholangiopancreatography, Biliary Pancreatic System Disease, Diagnosis, Therapy

Copyright © 2021 by author(s) and beplay安卓登录

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

 1. 引言

胆胰系统疾病是临床上常见的疾病，而胆胰系统疾病的诊断和治疗通常需要对胆管或胰管进行检查和操作。传统内镜逆行胆胰管造影术(ERCP)提供了Vater壶腹(胆管和胰腺管的进入点)的可视化，并通过造影剂及X光线的配合达到了对于胆胰管间接可视化操作。近年来随着柔性内窥镜仪器的不断更新，已实现了真正的胆胰管可视化操作，目前已广泛应用于临床困难胆管结石的治疗、良恶性胆胰管占位的诊断以及治疗等。且随着内镜医生的技术的进步以及对胆胰系统疾病认识的进展，使得ERCP在胃肠道或胆胰管正常解剖结构改变的患者、高龄患者、儿童及妊娠期妇女得到安全有效的开展。

 2. 诊断

ERCP通过内镜直视以及造影剂和介入的配合使用以达到对于胆胰壶腹部以及胆胰管道的可视化，从而实现对于胆胰系统疾病的诊断，具有不错的敏感性及特异性。随着近年来影像学技术的进展，使得ERCP在胆胰疾病的诊断作用逐渐下降，但近年来随着柔性内窥镜仪器的不断更新，经口胆胰管镜已广泛应用于临床胆胰良恶性病变的诊断中，且研究表明其弥补了传统ERCP敏感度较低的缺点 [ 1 ]。

2.1. 胆总管结石

ERCP因其相关并发症并不推荐作为胆总管结石诊断常规检查，胆总管结石首选肝功能及腹部超声检查，随着影像学的发展，超声内镜(EUS)以及磁共振胰胆管造影(MRCP)在诊断胆总管结石均被证明有不弱于ERCP的诊断敏感性及特异性，且具有较低的并发症发生率，已逐渐取代ERCP在胆总管结石诊断的地位。对于中度怀疑胆总管结石的患者，推荐在ERCP前常规行MRCP或MUS检查以明确诊断，避免ERCP的滥用 [ 2 ]。且研究表明EUS相对于MRCP具有更高的敏感性，尤其是在小结石的检测上。对于MRCP及EUS的选择上暂无明确推荐，可根据是否有胃肠道手术史以及心脏起搏器安置等具体情况选择合适的检查方法 [ 3 ]。ERCP目前仅在高度怀疑胆总管结石的患者进行，以便确诊后可同期行胆总管结石的治疗 [ 4 ]。

 2.2. 胰胆管合流异常

胰胆管合流异常通常由于胰胆管连接不良导致，胰胆管连接不良的患者中Oddi括约肌无法起到调节胆汁、胰液流通的作用，导致胰液以及胆汁的相互流通，增加了发生胆道恶性肿瘤以及胰腺炎的风险 [ 5 ]。既往胆胰管合流异常通常采用ERCP进行诊断，但随着近年影像学技术的进展，多探头CT及MRCP因其无创性逐渐取代ERCP成为主流的检查方式 [ 6 ]，且MRCP因其不具有放射性，在儿童患者中常作为首选 [ 7 ]。但在胰胆管共同通道相对较短及胰胆管连接较为复杂的患者中，ERCP可以直接证明证明Oddi括约肌有没有起到调节调节胆汁、胰液流通的作用，具有优于CT以及MRCP的诊断效果 [ 8 ]。但因其术后胰腺炎等并发症，通常在MRCP及多探头CT无法明确诊断时进行。

 2.3. 胆胰管及壶腹部占位性病变 2.3.1. 胆管占位性病变

对于性质不明确的胆道占位性病变，可优先行MRCP检查判断胆道情况。对于怀疑存在恶性病变的胆道狭窄可行ERCP检查，且既往有研究表明单独行内镜超声引导下细针穿刺(EUS-FNA)诊断胆道恶性病变的敏感性及特异性均略高于单独行ERCP [ 9 ]，但联合两种内镜方式进行取样对可疑恶性胆管狭窄的诊断优于单独的两种方法 [ 10 ]。近年来随着柔性内窥镜仪器进步，经口胆胰管镜的出现使得胆管直接可视化，以及配合可控活检钳(C-BF)的使用增加了组织取样的准确性，明显提高了ERCP对于诊断胆道恶性病变的敏感性及特异性 [ 11 ] [ 12 ]，研究表明ERCP联合导管内超声(IDUS)诊断胆道恶性病变的敏感性及特异性高于EUS-FNA [ 13 ]，且在ERCP过程中必要时可同期行胆道减压治疗。

 2.3.2. 胰管占位性病变

对于胰管占位性病变，因为CT、MRI以及EUS均具有不亚于甚至优于ERCP的诊断敏感性及特异性，所以并不推荐ERCP作为诊断的常规检查，首选行CT检查。内镜超声引导下细针穿刺(EUS-FNA)也有助于获取病变组织进行活检，鉴别局灶自身免疫性胰腺炎、胰腺囊肿等良性病变，筛选出胰腺上皮内瘤变、导管内乳头状黏液性肿瘤、黏液囊性肿瘤等癌前病变，以及为部分胰腺恶性肿瘤术前新辅助化疗提供证据 [ 14 ]。虽然EUS-FNA增加了恶性肿瘤种植播散的机率，但研究表明其低于CT引导下经皮穿刺造成播散机率。在CT、MRI以及EUS均未明确诊断的情况下，可考虑进一步行ERCP进行细胞刷检以及组织活检，经口胆胰管镜可提供更高的敏感性以及特异性 [ 11 ]。

 2.3.3. 壶腹部占位性病变

在影像学检查发现壶腹部占位性病变后，通常采用ERCP获取组织活检，明确占位性质，且研究表明壶腹部组织活检并不会增加ERCP术后并发症的发生机率，且ERCP具有较高的诊断敏感性及特异性 [ 15 ]，术中可以对胆胰管进行可视化检查以及导管内超声检查，有助于帮助明确壶腹部恶性病变的分期，可同期对早期的壶腹部恶性病变进行内镜下治疗。

 2.4. Oddi括约肌功能障碍(SOD)

Oddi括约肌功能障碍可通过阻碍胰腺和胆汁的流动而引起疼痛，通常被认为是胆囊切除术后出现其他原因不明的胰胆型疼痛的患者。可根据临床表现分为三型：I型是指肝功能升高和胆总管扩张的患者；类型II包含这些标准中的一个但不是两个都包含；类型III没有上述表现。目前认为ERCP测压是诊断SOD的唯一标准 [ 16 ]，诊断同期可行内镜下乳头括约肌切开术(EST)进行治疗，研究认为EST对于SODI型是明确有效的，但EST对于SODII型的治疗效果尚存争议，SODIII型则不建议行EST治疗 [ 17 ]。

 3. 治疗

ERCP通过内镜下导丝、弓刀、支架、球囊、网篮等各种配套器械的配合使用可以对胆胰管结石、胆道狭窄、胆瘘、胆道恶性肿瘤等胆胰系统疾病达到治疗的目的。近年来随着经口胆胰管镜、光动力、胆道射频消融等技术的进展，ERCP在胆胰系统疾病中的治疗应用范围也逐渐扩大。

3.1. 胆总管结石

胆总管结石常继发于胆囊结石，可引起胆道梗阻、胆管炎、胆源性胰腺炎等，对于无症状胆总管结石，指南推荐尽早行取石治疗，但近期有研究表明对于无症状胆总管结石行ERCP取石并不一定优于不治疗，需进一步研究评估无症状胆总管结石的管理策略 [ 18 ]。对于单纯胆总管结石和胆总管结石合并胆囊结石的患者，ERCP与腹腔镜下胆总管切开取石在治疗效果及并发症上并未表现出明显的差异 [ 19 ]，但对于有胆囊切除手术病史的患者建议行ERCP取石。对于胆总管结石合并胆囊结石的患者，可同期行ERCP及腹腔镜下胆囊切除术，研究表明并不会增加围手术期并发症发生机率，且减少了住院时间 [ 20 ]。对于直径较大的胆总管结石可行乳头括约肌切开联合球囊扩张(ES-LBD)，具有良好的结石取出率以及安全性 [ 21 ]。对于ES-LBD取石失败的患者可采用经口胆胰管镜行激光碎石取石，研究表明其安全性及疗效不逊于胆总管切开取石，且因其微创性，应优先考虑 [ 22 ]。对于胆源性胰腺炎的患者，如伴有胆管炎、胆道梗阻建议早期行ERCP处理，但对于无急性胆管炎表现的胆源性胰腺炎并不推荐早期行ERCP [ 23 ]。

 3.2. 胰管结石

胰管结石通常是慢性胰腺炎的后遗症，常常伴有腹痛的症状，去除胰管结石减轻胆管压力有助于缓解腹痛。对于直径较小的胰管结石(直径 < 5 mm)单纯ERCP具有较高的取石成功率，对于直径较大的结石建议行碎石术，对于胰尾部及多发的胰管结石可考虑外科手术治疗。体外冲击波碎石术(ESWL)已成为一种较为成熟的碎石方法，具有较高的成功率及微创的优势，可多次反复进行，建议根据术后复查影像学结果决定是否再次行ERCP取石 [ 24 ]。随着经口胰管镜的发展，胰管镜下电动液压碎石术(EHL)和激光碎石术(LL)已广泛应用于直径较大及的困难取出的胰管结石的治疗，且具有不弱于ESWL的成功率及安全性，激光碎石术(LL)被证明具有相对电动液压碎石术(EHL)更高的成功率 [ 25 ]。

 3.3. 胆瘘

胆瘘常见于肝脏及胆道手术引起的医源性胆道损伤，尤其常见于腹腔镜胆囊切除术以及肝部分切除术，也可见于外伤性的肝脏及胆道损伤。对于怀疑胆瘘的患者，ERCP既是诊断的手段，也可同时行胆道支架及鼻胆管引流，研究表明ERCP对术后胆瘘的治疗有效率可达88%以上，具有可以降低再次手术率，并针对胆道损伤后狭窄进行扩张等治疗 [ 26 ]。对于内镜下括约肌切开、支架植入引流等治疗手段失败的难治性胆瘘，内镜下弹簧圈栓塞胆管以及内镜下注射纤维蛋白胶可以作为胆漏的替代治疗方法 [ 27 ] [ 28 ]。

 3.4. 胆道良恶性狭窄 3.4.1. 良性胆道狭窄

良性胆道狭窄最常见的原因是术后损伤和慢性炎症，对于长期随访细胞学及组织学检查诊断为良性病变的胆道狭窄，ERCP是大多数患者的一线治疗手段，治疗目的是达到长期的胆道通畅。ERCP下可行胆道狭窄扩张及支架引流，对于术后早期狭窄(<4周)的球囊扩张，以降低胆道损伤及胆瘘的风险 [ 29 ]。球囊扩张联合支架植入在减少胆道狭窄复发方面明显优于单纯球囊扩张，留置多个塑料支架优于留置单个塑料支架，且使用全覆膜金属支架效果优于多个塑料支架 [ 30 ]。对于良性胆道狭窄不推荐使用金属裸支架，避免支架嵌入，无法内镜下取出。支架植入后需定期随访，及时更换支架，避免长期(>1年)胆道支架植入引起的胆管炎及支架堵塞 [ 31 ]。经皮经肝胆管以及EUS超声引导穿刺引流以及支架植入常常用于ERCP失败以及胃肠道改道手术术后的患者。

 3.4.2. 恶性胆道狭窄

恶性胆道狭窄常见于胆道恶性肿瘤、胰头肿瘤、十二指肠乳头占位等情况。对于可行手术切除的恶性肿瘤，研究认为术前胆道引流对术后恢复无明显益处，并增加了并发症发生率，除了发生胆管炎症状以及因新辅助化疗或其他原因需推迟手术时间的患者可行术前行ERCP胆道引流，全覆膜金属支架植入可作为首选，其余可手术切除患者术前并不推荐常规做ERCP胆道引流。对于不可行手术切除的恶性胆道狭窄，ERCP引导下支架植入、胆道内光动力疗法、胆道射频消融等常用于恶性胆道狭窄的姑息性治疗 [ 32 ]。对于存在胆道梗阻症状的患者，ERCP下支架植入是通畅引流的首选手段，且首选全覆膜金属支架，对于使用药物洗脱支架的使用虽然表现出抑制肿瘤生长，延长生存期的潜在疗效 [ 33 ]，但目前仍缺少临床试验的数据支持。ERCP引导下的光动力疗法以及胆道射频消融治疗也被证明具有延缓肿瘤进展，缓解胆道梗阻的效果，常常联合胆道支架植入共同使用，对于胆道腔内生长的恶性肿瘤具有较好的疗效 [ 34 ] [ 35 ]。对于ERCP治疗失败的患者，可考虑EUS超声引导以及经皮经肝胆管穿刺引流。

 4. 特殊人群ERCP

随着内镜医生的技术的进步以及对胆胰系统疾病认识的进展，使得ERCP在胃肠道或胆胰管正常解剖结构改变的患者、高龄患者、儿童及妊娠期妇女得到安全有效的开展。在不同年龄段的婴儿和儿童实行ERCP是安全有效的，具有和成人类似的成功率以及并发生发生率，但是需要经验丰富的内窥镜医师以及儿童配套型号的ERCP仪器下完成 [ 36 ]。对于高龄(>80岁)患者进行ERCP是安全可行的，其风险主要来源于患者心肺功能以及镇静药物的选择 [ 37 ]。妊娠期妇女在必要时可以行ERCP胆道减压，以避免危及孕妇及胎儿的不良后果，ERCP可在采用防护措施的低剂量辐射或者无辐射下进行，研究表明均未产生胎儿畸形的后果 [ 38 ]。对于胃肠道或胆胰管正常解剖结构改变的患者，也可在球囊肠镜、腹腔镜或者EUS辅助下选择不同入路行ERCP，球囊肠镜辅助下ERCP因其微创性常作为首选 [ 39 ]。

 5. 总结

目前随着影像学技术的发展，ERCP的诊断作用因其并发症而逐渐下降，但随着内窥镜仪器以及对胆胰系统疾病的认知的的更新，ERCP的介入治疗作用日益突显，总结为以下几点：(1) 对于仅为诊断作用的ERCP以及恶性胆道狭窄术前引流应严格把握适应症，避免ERCP的滥用才能减少并发症的发生；(2) 随着经口胰胆管镜的出现，使得ERCP在胆胰管狭窄的诊断以及困难型胆胰管结石的治疗上出现了新的应用前景，值得在临床上进一步的研究以及推广；(3) 随着胆道内光动力疗法以及胆道内射频消融的出现，不可手术切除的恶性胆道肿瘤的治疗出现新的曙光，而药物洗脱支架的治疗效果仍需要大量临床数据的支持；(4) 随着内镜医生的技术的进步以及对胆胰系统疾病认识的进展，使得高龄、儿童、妊娠、胃肠道解剖改变的患者不再成为ERCP的禁忌。随着未来研究进展，ERCP在胆胰系统疾病的诊治应用肯定会得到进一步的规范以及拓展。

 文章引用

李跃华,龚建平. ERCP在胆胰系统疾病的诊治应用现状及研究进展Current Status and Research Progress of ERCP in the Diagnosis and Treatment of Biliary and Pancreatic System Diseases[J]. 临床医学进展, 2021, 11(07): 3123-3130. https://doi.org/10.12677/ACM.2021.117453

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