谭文惠?陈睿妍?吴嘉钏?李滢?王芳?梁彪

【摘要】目的 观察复发型胆总管结石患者胆道微生物的特征，分析胆道微生物对胆总管结石复发的影响。方法 回顾性分析接受了经内镜逆行性胰胆管造影术术后1年随访的40例復发型胆总管结石患者（复发型组）的临床资料，以同期接受同术式术后1年随访的40例非复发型胆总管结石患者（非复发型组）为对照。观察并比较2组胆道微生物的特征，分析胆道微生物对胆总管结石复发的影响。结果 复发型组和非复发型组的胆道微生物病原菌分别为37株和33株，复发型组的革兰阴性菌株数与非复发型组相同;复发型组的革兰阳性菌和真菌多于非复发型组，但比较差异无统计学意义（χ2 = 0.573，P = 0.449）;复发型组大肠埃希菌、金黄色葡萄球菌、肠球菌、痤疮丙酸杆菌占比高于非复发型组（P < 0.05）。Logistic回归分析显示，大肠埃希菌、金黄色葡萄球菌、肠球菌、痤疮丙酸杆菌增殖是复发型胆总管结石的影响因子（OR均> 1，P均< 0.05）。绘制受试者工作特征曲线发现，大肠埃希菌、金黄色葡萄球菌、肠球菌、痤疮丙酸杆菌检测用于预测复发型胆总管结石的曲线下面积分别为0.813、0.809、0.807、0.806，均有一定预测价值。结论 复发型胆总管结石患者胆道微生物存在明显异常，检出的病原微生物较非复发型患者显著，如大肠埃希菌、金黄色葡萄球菌、肠球菌、痤疮丙酸杆菌等，这些病原微生物的增殖可能与胆总管结石的发生及复发有关，建议密切关注初次接受治疗的胆总管结石患者治疗后的胆道微生物变化情况，针对检出上述病原微生物的患者及时采取措施，这可能对减少胆总管结石复发有积极意义。

【关键词】胆总管结石;复发;胆道微生物;大肠埃希菌;金黄色葡萄球菌;肠球菌;痤疮丙酸杆菌;影响

Characteristics of biliary tract microorganisms in patients with recurrent choledocholithiasis Tan Wenhui， Chen Ruiyan， Wu Jiachuan， Li Ying， Wang Fang， Liang Biao. Digestive Endoscopy Center， Guangdong Second Provincial Center Hospital， Guangzhou 510317， China

Corresponding author， Chen Ruiyan， E-mail： 544769538@ qq. com

【Abstract】Objective To observe the characteristics of biliary tract microorganisms in patients with recurrent choledocholithiasis， aiming to evaluate the effect of biliary tract microorganisms on the recurrence of choledocholithiasis. Methods Clinical data of 40 patients with recurrent choledocholithiasis （recurrence group） who underwent endoscopic retrograde cholangiopancreatography and received postoperative 1-year follow-up were retrospectively analyzed. Forty patients with non-recurrent choledocholithiasis who were followed up for 1 year were assigned into the non-recurrence group. The characteristics of biliary tract microorganisms were observed and compared between two groups. The effect of biliary tract microorganisms on the recurrence of choledocholithiasis was assessed. Results Thirty-seven strains of biliary microbial pathogens were identified in the recurrence group and 33 strains in the non-recurrence group. The number of Gram-negative strains was the same between two groups. The number of Gram-positive bacteria and fungi in the recurrence group was higher than that in the non-recurrence group，but the difference was not statistically significant （χ2 = 0.573， P = 0.449）. The proportions of Escherichia coli， Staphylococcus aureus， Enterococcus and Propionibacterium acnes in the recurrence group were significantly higher than those in the non-recurrence group （all P < 0.05）. Logistic regression analysis showed that the proliferation of Escherichia coli， Staphylococcus aureus， Enterococcus and Propionibacterium acnes was the influencing factor for recurrent choledocholithiasis （all OR > 1，all P < 0.05）. Receiver operating characteristic （ROC） curve demonstrated that the area under ROC curve （AUC） of Escherichia coli， Staphylococcus aureus， Enterococcus and Propionibacterium acnes for predicting recurrent choledocholithiasis were 0.813， 0.809， 0.807 and 0.806， indicating that these microorganisms had certain predictive values. Conclusions Patients with recurrent choledocholithiasis have significant abnormality in the biliary tract microorganisms， and a larger quantity of pathogenic microorganisms are detected than that in non-recurrent counterparts， such as Escherichia coli， Staphylococcus aureus， Enterococcus and Propionibacterium acnes， etc. The proliferation of these pathogenic microorganisms may be associated with the incidence and recurrence of choledocholithiasis. The changes of the biliary tract microorganisms in patients with choledocholithiasis who receive clinical treatment for the first time should be intimately monitored. Corresponding interventions should be timely delivered for patients infected with these pathogenic microorganisms， which probably plays a positive role in reducing the recurrence of choledocholithiasis.

【Key words】Choledocholithiasis;Recurrence;Biliary tract microorganism;Escherichia coli;Staphylococcus aureus;Enterococcus;Propionibacterium acnes;Effect

隨着医学技术的进步，胆总管结石治疗现状不断得到改善，大多数胆总管结石可通过经内镜逆行性胰胆管造影术（ERCP）取石治愈[1]。但是，胆总管结石取石术后的复发仍然是临床深受困扰的问题[2]。因此，探索有效措施减低胆总管结石较为重要。胆总管结石患者存在不同程度的感染，感染可能引起胆道微生物的变化与细菌感染，对胆总管结石的发病和病情造成影响。已有研究表明，胆道微生物情况与胆总管结石具有密切的联系[3]。胆道微生物的异常可能对脂多糖、细菌蛋白的分泌产生影响，而这些物质可能与胆结石的形成和发展具有联系。……