【作者】 李伟；

【导师】 庄华；

【作者基本信息】 四川大学 ， 影像医学与核医学（专业学位）， 2021， 硕士

【摘要】 目的:探讨联合应用灰阶超声(B-mode Ultrasound,B-US)、彩色多普勒超声(Color Doppler Ultrasound,C-US)及剪切波超声弹性成像(Elastography Ultrasound,E-US)的多模态超声检查判断克罗恩病(Crohn’s disease,CD)黏膜愈合(Mucosal Healing,MH)的价值。材料和方法:收集四川大学华西医院2019年9月-2020年12月间临床诊断为CD的85例患者的临床及超声检查资料。以内镜检查结果作为判断CD的MH的参考标准,将85例CD患者共249个病变肠段划分为达到MH组及未达到MH(nonMucosal Healing,NMH)组,其中MH组包括64个节段,NMH组包括185个节段。1)收集各肠段的超声参数,包括:病变肠壁厚度(Bowel Wall Thickness,BWT)、肠壁层次(Bowel Wall Stratification,BWS)、肠系膜脂肪厚度(Mesenteric Fat Thickness,MFT)、肠系膜淋巴结(Mesenteric lymph nodes,LN)、Limberg分级(Limberg Grade,LG)、杨氏模量平均值(Mean Elasticity,E)、剪切波传导速度平均值(The Velocity of the Shear Wave,SWV)、肠周积液(ascites,AS)分析上述参数在CD各组间有无差异;2)分析上述参数与CD疾病MH的关系;绘制有关上述参数反映CD的MH的ROC曲线,筛选出与MH密切相关的超声参数(P<0.05,AUC>0.7),建立多参数的评估MH的Logistic回归模型。结果:1、85例CD患者的临床分型以A2、L3、B1型为主,A2型为63例(63/85,74.1%),L3型为68例(68/85,80.0%),B1型为61例(61/85,71.7%)。85例CD患者共纳入249个肠段进行研究,其中达到MH64个肠段,BWT为2.66±0.62mm,E为6.44±3.20kpa,SWV为1.36±0.42m/s,MFT为5.89±2.21mm;其中58个肠段Limberg(LG)分级为0级和1级,5个肠段为2级,1个肠段为3级;54个肠段周围无淋巴结,10个肠段周围查见淋巴结;55个肠段肠壁层次清楚,9个肠段肠壁层次不清;64个肠段周围均无积液。未达到MH185个肠段,BWT为4.22±1.27mm,E为9.24±5.13kpa,SWV为1.65±0.46m/s,MFT为10.38±3.21mm;41个肠段LG为1级,110个肠段为2级,34个肠段为3级;120个肠段周围无淋巴结,65个肠段周围查见淋巴结;159个肠段肠壁层次不清楚,26个肠段肠壁层次清楚;141个肠段周围无积液,44个肠段周围查见积液。2、MH组与NMH组间各超声指标的差异:MH组肠壁厚度2.66±0.62mm,NMH组肠壁厚度4.22±1.27mm,MH肠壁厚度小于NMH组,其差异具有统计学意义(p<0.01)。MH组E值为6.442±3.201kpa,NMH组E值为9.24±5.13kpa,MH组E值小于NMH组,其差异有统计学意义(p<0.01)。MH组SWV值为1.65±0.42m/s,NMH组SWV1.65±0.46m/s,MH组SWV值小于NMH组,其差异有统计学意义(p<0.01)。MH组MFT值为5.89±2.21mm,NMH组MFT值为10.38±3.21mm,MH组MFT值小于NMH组,其差异有统计学意义(p<0.01)。MH组其中58个肠段LG分级为0级和1级,5个肠段为2级,1个肠段为3级,NMH组41个肠段LG为1级,110个肠段为2级,34个肠段为3级,两组间差异有统计学意义(p<0.01)。MH组55个肠段肠壁层次清楚,9个肠段肠壁层次不清,NMH组159个肠段肠壁层次不清楚,36个肠段肠壁层次清楚,两组间差异有统计学意义(p<0.01)。MH组64个肠段周围均无积液,NMH组141个肠段周围无积液,44个肠段周围查见积液,两组间差异有统计学意义(p<0.01)。MH组54个肠段周围无淋巴结,10个肠段周围查见淋巴结,NMH组120个肠段周围无淋巴结,65个肠段周围查见淋巴结,两组间差异有统计学意义(p=0.03)。3、超声各指标在MH组与NMH组之间的截断值研究:通过ROC曲线分析发现,BWT截断值(BWTcutoff)=3.35mm,此时约登指数最大,为0.70,ROC曲线下面积(AUC)=0.923(P<0.001,95%CI:0.882-0.965),敏感度、特异度、阳性预测值、阴性预测值分别为77.8%、92.2%、96.6%、59.0%,OR=7.44;LGcutoff=0级或1级时,约登指数最大,为0.684,其AUC=0.889(P<0.001,95%CI:0.853-0.963),敏感度、特异度、阳性预测值、阴性预测值分别为77.8%、90.6%、96.0%、58.6%,OR=2.83;BWScutoff=清楚,此时约登指数最大,为0.718,其AUC=0.859(P<0.001,95%CI:0.809-0.909),敏感度、特异度、阳性预测值、阴性预测值分别为85.9%、85.9%、94.6%、67.9%,OR=25.24;MFTcutoff=7.500时,约登指数最大,为0.589,其AUC=0.874(P<0.001,95%CI:0.826-0.922),敏感度、特异度、阳性预测值、阴性预测值分别为77.6%、81.3%、92.2%、55.9%,OR=1.618。4、以肠镜检查结果作为判断是否达到MH的标准,4个超声参数(参数包括BWT、LG、BWS、MFT)被纳入,得到预测是否达到MH的标准化的回归方程:IF=-0.0012+2.6616BWT+3.2288BWS+1.0417LG+1.17171MFT。结论:1.多模态超声检查能够评估CD肠道病变的MH情况。2.肠壁厚度、肠壁血流分级、肠壁层次结构、肠系膜脂肪厚度、肠壁杨氏模量值、肠壁剪切波传播速度、肠系膜淋巴结、肠周积液在MH组及NMH组间的差异具有统计学意义。3.我们建立了判断是否达到黏膜愈合的标准化的回归方程:IF=-0.0012+2.6616 BWT +3.2288BWS+1.0417LG+1.17171MFT。更多还原

【Abstract】 Objective:To explore the value of B-mode Ultrasound(B-US),Color Doppler Ultrasound(C-US)combined with Elastography Ultrasound(E-US)in evaluating Mucosal Healing(MH)in patients with Crohn’s disease(CD)patients.Materials and Methods:The clinical and ultrasonographic data of 85 patients clinically diagnosed with CD in West China Hospital of Sichuan University from September 2019 to December 2020 were collected.The endoscopic results were used as the reference criteria for determining MH in CD.A total of 249 diseased intestinal segments in 85 patients with CD were divided into the MH group and the non-Mucosal Healing(NMH)group,of which the MH group included 64 segments and the NMH group185 segments.1.Various ultrasonic parameters of B-US,C-US,and E-US were collected,including: bowel wall thickness(BWT),bowel wall stratification(BWS),,mesenteric fat thickness(MFT),lymph node enlargement(LN),Limberg grade(LG),mean elasticity(E)、mean of shear wave velocity(SWV),ascites(AS).The difference of the above parameters between the CD groups was analyzed.2.To analyze the relationship between the above parameters and MH,the ROC curves of MH with the above parameters reflecting CD were drawn,and the ultrasonic parameters closely related to MH were screened out(P<0.05,AUC>0.7).A multi-parameter Logistic regression model was established to evaluate MH.Results:1.The clinical types of 85 CD patients were mainly A2,L3 and B1,with 63 cases of A2(63/85,74.1%),68 cases of L3(68/85,80.0%),and 61 cases of B1(61/85,71.7%).A total of 249 intestinal segments of 85 patients with CD were included in the study,including 64 intestinal segments of MH,with a BWT value of2.66±0.62 mm,an E value of 6.442 ±3.201 k Pa,a SWV value of 1.36±0.42m/s and a MFT value of 5.89 ±2.21 mm.Fifty-eight segments were classified as Limberg grade0 and 1,five segments were classified as Limberg grade 2 and 1 segments were Grade 3.No lymph nodes were found around 54 segments,and lymph nodes were found around the rest of 10 segments.The BWS of 55 segments were clear,and the rest of 9 segments were unclear.There was no effusion around the total 64 intestinal segments.185 intestinal segments of NMH,The BWT was 4.22±1.27 mm,E was9.24±5.13 k Pa,SWV was 1.65±0.46m/s and MFT was 10.38±3.21 mm.Forty-one segments of LG were Grade 1,110 segments were Grade 2,and 34 segments were Grade 3.No lymph nodes were found around 120 intestinal segments and lymph nodes were found aroundthe rest of 65 intestinal segments.The BWS in 159 segments was not clear,and that in the rest of 26 segments was clear.There was no effusion around 141 intestinal segments,and effusion was found around the rest of44 intestinal segments.2.The differences of ultrasonic parameters between the MH group and the NMH group were as follows: BWT of the MH group was 2.66±0.62 mm,and that of the NMH group was 4.22±1.27 mm.BWT of MH group was smaller than that of the NMH group,and the difference was statistically significant(P < 0.01).The E value of the MH group was 6.44 ±3.20 k Pa,and that of the NMH group was 9.24±5.13 k Pa.The E value of the MH group was lower than that of the NMH group,and the difference was statistically significant(P < 0.01).SWV value of MH group was 1.36±0.42m/s,and that of NMH group was 1.65±0.46m/s.SWV value of MH group was lower than that of NMH group,with statistical significance(P<0.01).The MFT of the MH group was 5.89 ±2.21 mm,and that of the NMH group was 10.38 ±3.21 mm.The MFT of the MH group was lower than that of the NMH group,and the difference was statistically significant(P<0.01).In MH group,LG of 58 intestinal segments were graded as grade 0 and 1,5 intestinal segments were graded as grade2,1 segments were Grade 3 and in NMH group,LG of 41 intestinal segments were graded as grade 1,110 intestinal segments were graded as grade 2,and 34 intestinal segments were graded as grade 3,with statistical significance between the two groups(P<0.01).In MH group,BWS of 55 segments were clear and 9 segments were unclear.In the NMH group,BWS of 159 segments were unclear,and BWS of26 segments were clear,and the difference between the two groups was statistically significant(P<0.01).There was no effusion around 64 intestinal segments in the MH group,while there was no effusion around 141 intestinal segments in the NMH group,and effusion around 44 intestinal segments in the NMH group.The difference between the two groups was statistically significant(P<0.001).No lymph nodes were found around 54 intestinal segments in the MH group,and lymph nodes were found around 10 intestinal segments in the NMH group.No lymph nodes were found around 120 intestinal segments,and lymph nodes were found around 65 intestinal segments in the NMH group.The difference between the two groups was statistically significant(P=0.03).3.Study on the cutoff value of each ultrasonic index between MH group and NMH group: through ROC curve analysis,it is found that when the cutoff value of BWT = 3.35 mm,the Youden index is the largest,which is 0.70,and the area under the ROC(AUC)=0.923(P<0.001,95%CI:0.882-0.965),sensitivity,specificity,positive predictive value,negative predictive value were 77.8%,92.2%,96.6%,59.0%,OR=7.44;when LG cutoff=grade 0 or 1,the Youden index is the largest and is 0.684,and its AUC = 0.889(P<0.001,95%CI: 0.853-0.963),sensitivity,specificity,positive predictive value,negative predictive value were 77.8%,90.6%,96.0%,58.6%,OR=2.83;when BWS cutoff= clear,Youden index is the largest,is0.718,its(AUC)= 0.859(P<0.001,95%CI:0.809-0.909),sensitivity,specificity,positive predictive value,negative predictive value were 85.9%,85.9%,94.6%,67.9%,OR=25.24;When the cutoff of MFT is 7.500,the Youden index is the largest,which is 0.589,and its(AUC)= 0.874(P<0.001,95%CI:0.826-0.922),sensitivity,specificity,positive predictive value,negative predictive value were 77.6%,81.3%,92.2%,55.9%,OR=1.618.4.The results of colonoscopy were used as the criteria to determine whether mucosal healing was achieved.Four ultrasonic parameters(including BWT,LG,BWS,and MFT)were included to obtain a regression model for predicting MH:IF=-0.0012+2.6616 BWT +3.2288BWS+1.0417LG+1.17171 MFT.Conclusion:1.Multimodal ultrasound can be used to evaluate MH in intestinal lesions in CD.2.The differences of BWT,LG,BWS,MFT,E,SWV,LN,AS between MH group and NMH group were statistically significant.3.We established a regression model to assess mucosal healing in Crohn’s disease.IF=-0.0012+2.6616 BWT +3.2288BWS+1.0417LG+1.17171 MFT.更多还原