反复腹痛原因不明?罪魁祸首竟然是它!

2018-06-07 吕瑛 彭春艳 张松 医学界消化肝病频道

自1995年AIP的概念被首次提出以来,我们对AIP的认识不断提高,具有典型影像学特征、血清或组织IgG4明显升高的病例相信已经难不倒大家了,但是,对于影像学怀疑AIP但IgG4阴性的病例,临床思维该如何建立?相信下面这个案例的分享会给大家带来启发。

AIP是一种以梗阻性黄疸、腹部不适等为主要临床表现的特殊类型的胰腺炎。该病由自身免疫介导,以胰腺淋巴细胞及浆细胞浸润并发生纤维化、影像学表现胰腺肿大和胰管不规则狭窄、血清IgG4 水平升高、类固醇激素疗效显著为特征。AIP按组织学表现分为1型和2型,1型又称为淋巴浆细胞硬化性胰腺炎(lymphoplasmacytic sclerosing pancreatitis, LPSP),2型又称为特发性导管中心性慢性胰腺炎 (idiopathic duct centric pancreatitis, IDCP)。

自1995年AIP的概念被首次提出以来,我们对AIP的认识不断提高,具有典型影像学特征、血清或组织IgG4明显升高的病例相信已经难不倒大家了,但是,对于影像学怀疑AIP但IgG4阴性的病例,临床思维该如何建立?相信下面这个案例的分享会给大家带来启发。

初现端倪,疑点重重

患者37岁,男性,因“上腹痛一月余”入院。患者一月余前突发上腹痛,伴有后背痛,至外院急诊就诊,查血清淀粉酶:376U/L,肝功能正常;电子胃镜提示浅表性胃炎,HP(-);腹部CT平扫提示胰腺体积稍增大,腹腔多发小淋巴结(见图1)。急诊诊断考虑为急性胰腺炎可能,给予抑酸、抑制胰腺分泌及营养补液等对症支持治疗,后患者上述症状略有好转。


图1:腹部CT平扫提示胰腺体积稍增大,腹腔多发小淋巴结

两周后复查血清淀粉酶较前下降(116U/L),进一步完善MRCP提示胰腺形态饱满,脾大,腹腔多发小淋巴结,胆、胰管未见明显扩张(见图2)。


图2:MRCP提示胰腺形态饱满,脾大,
腹腔多发小淋巴结,
胆、胰管未见明显扩张

入院前四天,患者再发上腹痛及后背痛,大便带血,伴有发热,热峰38.8℃,复查血清淀粉酶:72U/L,复查腹部CT结果较前相仿。患者为进一步诊疗,急诊拟“急性胰腺炎”收住入院。

回顾患者的病史,我们难免心生困惑,患者反复发作上腹痛的原因到底是什么?虽然病程中反复发作腹痛,淀粉酶有轻度升高,CT/MRI提示胰腺肿大,但给患者扣上“急性胰腺炎”的帽子就可以高枕无忧了吗?同时,患者病程中出现的便血和发热原因为何?是否可以用“一元论”来解释?

真假李逵,元凶为何

带着这些困惑,我们为患者进一步完善了相关检查。入院后查血清免疫球蛋白IgG4为0.03g/L,在正常值范围;查大便培养、EB病毒、巨细胞病毒、T细胞γ干扰素、肝炎全套、降钙素原等感染指标均为阴性;查自身抗体、抗中性粒细胞胞浆抗体、线粒体抗体谱等免疫指标也均为阴性。

但是,一个月内患者肝功能出现了显著的异常,肝酶和胆系酶均出现不同程度的升高(谷丙转氨酶:499.0U/L,谷草转氨酶:205.9/L,碱性磷酸酶:243.7U/L,谷酰转肽酶:132.4U/L)(见图3)。


图3:患者复查肝功能提示肝酶和胆系酶
均出现不同程度的升高

为明确患者肝功能异常的原因,建议患者复查MRCP。MRCP提示胰腺弥漫性肿胀似呈腊肠状,周围似见假包膜,胆总管中下段狭窄伴以上肝内外胆管扩张,胰管未见明显异常,胆囊体积增大,脾大(见图4)。我们推测患者肝功能异常可能与胆管狭窄继发胆道高压有关,然而,是什么原因导致胆管在短时间内出现如此显著的变化(见图5)?患者“腊肠状的胰腺”成为我们关注的焦点,影像学资料及生化指标提示患者1型AIP的可能性大,但反复多次血清IgG检查均为阴性。


图4:MRCP:胰腺肿胀更为明显,呈腊肠状,
周围似可见假包膜,胆囊张力增高,
胆管的胰腺段纤细且近端肝内外胆管显著扩张


图5:MRCP:(右图)胆囊张力增高,
胆管的胰腺段纤细且近端肝内外胆管显著扩张,
与前片(左图)形成鲜明对比

为解除胆道高压以及明确胆管狭窄原因,我们为患者实施了ERCP及相关技术。术中造影显示胆总管下段狭窄,胰管粗细不均但不扩张;IDUS显示胆管壁无明显增厚(见图6)。术中胆管细胞刷检未查见恶性肿瘤细胞;为进一步明确诊断我们进行了十二指肠乳头活检,但活检病理显示慢性活动性小肠炎,固有膜内见多量浆细胞浸润(密集区域约200个/HPF)及少量嗜酸性粒细胞浸润,IgG4(-)。患者ERCP术中可见胆总管下段狭窄,IDUS显示狭窄段管壁结构正常,因此考虑胆总管狭窄为肿大的胰腺压迫所致。


图6:ERCP术中造影显示胆总管下段狭窄;
胰管粗细不均但不扩张;
IDUS显示胆管壁无明显增厚;
术中于胆管置入塑料支架一枚,可见胆汁引出

因患者病程中有便血,入院后查大便隐血阳性,我们为患者完善了电子肠镜检查,结果显示全结肠黏膜充血、水肿,散在糜烂,血管紊乱模糊(见图7);同期病理示(降结肠)慢性活动性肠炎伴隐窝脓肿形成。患者肠镜表现可疑为早期溃疡性结肠炎(UC),建议患者密切随访。


图7:电子肠镜提示全结肠黏膜充血、水肿,
散在糜烂,血管纹理模糊

水落石出,真相大白

患者病程中CT/MRI影像学检查提示胰腺弥漫性肿大,呈腊肠样改变,似可见假包膜,符合AIP的影像学特点,但患者血清IgG4在正常值范围,组织学(十二指肠乳头)病理示IgG4阴性,同时患者合并可疑溃疡性结肠炎,诊断倾向于2型AIP可能。因此,我们锁定肿大的胰腺,完善胰腺CT平扫+增强,并通过“胰腺疾病最完美的诊断方法”—EUS-FNA获取病理学依据。

胰腺CT平扫+增强提示胰腺体积增大伴强化欠均匀,脾脏体积增大,腹腔多发淋巴结(见图8);超声内镜显示胰腺回声偏低,弥漫性肿大,胰管无扩张,超声造影显示高增强,提示胰腺组织富血供(见图9);我们使用19G穿刺针为患者实施了EUS-FNA术,术后病理示胰腺腺泡呈小叶状分布伴多量急慢性炎症细胞浸润,部分小叶内部分腺泡萎缩,纤维组织增生,部分腺泡内见多量中性粒细胞浸润并浸润腺泡上皮;萎缩的小叶内和腺泡间间质纤维化;免疫组化示IgG4阴性。


图8:胰腺CT平扫+增强:胰腺体积增大
伴强化欠均匀,
脾脏体积增大,腹腔多发淋巴结


图9:EUS显示胰腺回声偏低,弥漫性肿大,
胰管无扩张,
超声造影显示高增强,提示胰腺组织富血供

对照2011年颁布的AIP国际诊断标准(见图10)[1],该患者具备:
典型的影像学特征:增强CT示胰腺实质延迟期不均匀强化;

典型的胰管显像:ERP示胰管局段纤细且不伴近端胰管的扩张;

临床诊断炎症性肠病可能:患者肠镜及活检病理提示溃疡性结肠炎(UC)可能;

特征性的病理学表现:EUS-FNA病理提示腺泡内多量中性粒细胞浸润并浸润腺泡上皮且IgG4阴性。

患者如果激素治疗有效,可确诊为2型AIP。因此,排除激素使用禁忌后,患者开始口服强的松 30mg qd(30mg,1次/日),治疗一月后患者症状完全缓解,复查腹部CT提示胰腺体积较前明显缩小(见图11),提示激素治疗有效。


图10:2型AIP国际诊断标准


图11: CT提示胰腺体积较前明显缩小

思考

这例2型AIP的诊治同样给我们带来一些思考。目前一致认为组织学检查为诊断AIP的金标准,但想获得满意的活检标本较为困难。开腹探查取得的病理结果阳性率高,但创伤大,用于AIP的诊断显然行不通。EUS-FNA自1992年Vilmann等[2]首次应用以来,已被广泛应用于多种疾病的诊断,是胰腺疾病“近乎完美的诊断方法”。

然而,EUS-FNA获取的组织量较少,有时不能满足AIP诊断的需要。AIP的病理评估需要观察小叶间导管和腺泡的炎症浸润情况,因此,对AIP患者实施EUS-FNA需尽可能的获取满意的组织条。文献报道显示,使用组织活检针进行EUS-FNB所获取的病理,至少可以达到AIP国际诊断标准2级的要求[3]。EUS-FNB为AIP的诊断打开了新的思路,今后有望成为AIP安全、高效的组织获取手段。

原始出处:

[1] Tooru Shimosegawa, Suresh T. Chari, Luca Frulloni, et al. International Consensus Diagnostic Criteria for Autoimmune Pancreatitis. Pancreas 2011;40: 352-358

[2] Vilmann P, Jacobsen GK, Henriksen FW, et al. Endoscopic ultrasonography with guided fine needle aspiration biopsy inpancreatic disease. Gastrointest Endosc, 1992, 38:172-173.

[3] Detlefsen S, Joergensen MT, Mortensen MB.Microscopic findings in EUS-guided fine needle (SharkCore) biopsies with type 1 and type 2 autoimmune pancreatitis. Pathol Int. 2017, 67(10): 514-520.

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#插入话题
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  2. [GetPortalCommentsPageByObjectIdResponse(id=1272276, encodeId=edaa12e227605, content=<a href='/topic/show?id=c01e85565e8' target=_blank style='color:#2F92EE;'>#腹痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85565, encryptionId=c01e85565e8, topicName=腹痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e4aa106, createdName=crystal0562, createdTime=Sat Jun 09 11:12:00 CST 2018, time=2018-06-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322450, encodeId=1cac322450af, content=学习了!涨知识., beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3bff1980026, createdName=愚公后知后觉, createdTime=Fri Jun 08 08:47:28 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322415, encodeId=50b33224156a, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:32:01 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322412, encodeId=af2f322412dc, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:29:25 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322397, encodeId=35a432239e1d, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 08 07:10:44 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322316, encodeId=68883223167c, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Thu Jun 07 21:53:53 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322309, encodeId=708f322309fc, content=AIP是一种以梗阻性黄疸.腹部不适等为主要临床表现的特殊类型的胰腺炎.该病由自身免疫介导.以胰腺淋巴细胞及浆细胞浸润并发生纤维化.影像学表现胰腺肿大和胰管不规则狭窄.血清IgG4水平升高.类固醇激素疗效显著为特征.AIP按组织学表现分为1型和2型.1型又称为淋巴浆细胞硬化性胰腺炎(lymphoplasmacyticsclerosingpancreatitis,LPSP).2型又称为特发性导管中心性慢性胰腺炎(idiopathicductcentricpancreatitis,IDCP)., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Thu Jun 07 21:17:52 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-08 愚公后知后觉

    学习了!涨知识.

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1272276, encodeId=edaa12e227605, content=<a href='/topic/show?id=c01e85565e8' target=_blank style='color:#2F92EE;'>#腹痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85565, encryptionId=c01e85565e8, topicName=腹痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e4aa106, createdName=crystal0562, createdTime=Sat Jun 09 11:12:00 CST 2018, time=2018-06-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322450, encodeId=1cac322450af, content=学习了!涨知识., beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3bff1980026, createdName=愚公后知后觉, createdTime=Fri Jun 08 08:47:28 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322415, encodeId=50b33224156a, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:32:01 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322412, encodeId=af2f322412dc, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:29:25 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322397, encodeId=35a432239e1d, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 08 07:10:44 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322316, encodeId=68883223167c, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Thu Jun 07 21:53:53 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322309, encodeId=708f322309fc, content=AIP是一种以梗阻性黄疸.腹部不适等为主要临床表现的特殊类型的胰腺炎.该病由自身免疫介导.以胰腺淋巴细胞及浆细胞浸润并发生纤维化.影像学表现胰腺肿大和胰管不规则狭窄.血清IgG4水平升高.类固醇激素疗效显著为特征.AIP按组织学表现分为1型和2型.1型又称为淋巴浆细胞硬化性胰腺炎(lymphoplasmacyticsclerosingpancreatitis,LPSP).2型又称为特发性导管中心性慢性胰腺炎(idiopathicductcentricpancreatitis,IDCP)., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Thu Jun 07 21:17:52 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-08 深海的鱼

    学习学习学习

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1272276, encodeId=edaa12e227605, content=<a href='/topic/show?id=c01e85565e8' target=_blank style='color:#2F92EE;'>#腹痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85565, encryptionId=c01e85565e8, topicName=腹痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e4aa106, createdName=crystal0562, createdTime=Sat Jun 09 11:12:00 CST 2018, time=2018-06-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322450, encodeId=1cac322450af, content=学习了!涨知识., beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3bff1980026, createdName=愚公后知后觉, createdTime=Fri Jun 08 08:47:28 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322415, encodeId=50b33224156a, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:32:01 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322412, encodeId=af2f322412dc, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Fri Jun 08 07:29:25 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322397, encodeId=35a432239e1d, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Fri Jun 08 07:10:44 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322316, encodeId=68883223167c, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Thu Jun 07 21:53:53 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322309, encodeId=708f322309fc, content=AIP是一种以梗阻性黄疸.腹部不适等为主要临床表现的特殊类型的胰腺炎.该病由自身免疫介导.以胰腺淋巴细胞及浆细胞浸润并发生纤维化.影像学表现胰腺肿大和胰管不规则狭窄.血清IgG4水平升高.类固醇激素疗效显著为特征.AIP按组织学表现分为1型和2型.1型又称为淋巴浆细胞硬化性胰腺炎(lymphoplasmacyticsclerosingpancreatitis,LPSP).2型又称为特发性导管中心性慢性胰腺炎(idiopathicductcentricpancreatitis,IDCP)., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Thu Jun 07 21:17:52 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-08 深海的鱼

    学习学习学习

    0

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    2018-06-08 张新亮1853311252142e2fm

    好文献学习了

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    2018-06-07 cscdliu

    学习了.谢谢

    0

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    2018-06-07 有备才能无患

    AIP是一种以梗阻性黄疸.腹部不适等为主要临床表现的特殊类型的胰腺炎.该病由自身免疫介导.以胰腺淋巴细胞及浆细胞浸润并发生纤维化.影像学表现胰腺肿大和胰管不规则狭窄.血清IgG4水平升高.类固醇激素疗效显著为特征.AIP按组织学表现分为1型和2型.1型又称为淋巴浆细胞硬化性胰腺炎(lymphoplasmacyticsclerosingpancreatitis,LPSP).2型又称为特发性导管中心性慢性胰腺炎(idiopathicductcentricpancreatitis,IDCP).

    0

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