Clinical Features And Related Factors In Patients With Liver Injury Caused By Cholelithiasis With Negative Imaging At Initial Diagnosis

Objective:Retrospective analysis of the clinical characteristics and related factors of patients with liver injury caused by cholelithiasis with negative imaging at the first diagnosis,so as to provide some guidance for clinicians for the early diagnosis of patients with liver injury caused by cholelithiasis.MATERIALS AND METHODS:A total of 230 patients with liver injury caused by cholelithiasis who met the inclusion and exclusion criteria in the Department of Hepatobiliary and Pancreatic Medicine and the Department of Hepatobiliary and Pancreatic surgery in our hospital from January 2016 to March 2021 were selected.The basic information（age,sex）,clinical symptoms and signs,common diseases（hypertension,diabetes,kidney stones）,laboratory indexes（liver function,blood routine,blood lipids,blood glucose,urine routine）and imaging results（including the location of gallstones and the widening of bile duct）were collected.After removing the number of cases with serious data loss,137 patients with liver injury caused by cholelithiasis were finally divided into two groups: the group of liver injury caused by cholelithiasis with negative imaging at the initial diagnosis（n = 41）as case group 1 and the group of liver injury caused by cholelithiasis with positive imaging at the initial diagnosis（n = 96）as case group 2.At the same time,152 people in the physical examination center in the same period were selected as control group 2.83 of them were selected as control group 1 after sex and age matching.SPSS26.0 software was used for statistical analysis,and Logistics regression analysis was used to sum up the independent risk factors of liver injury caused by cholelithiasis with negative imaging at the first diagnosis.Result:（1）The total number of patients with liver injury caused by cholelithiasis was 137,including 71 males（51.8%）and 66 females（48.2%）.The ratio of male to female was about1.08:1,with an average age of 55（40.5,64）.Among them,there were 41 cases of liver injury caused by cholelithiasis with negative imaging at initial diagnosis（case group 1）.There were 23 males（56.1%）and 18 females（43.9%）.The ratio of male to female was about 1.28:1,and the average age was 58（50.5,66）.There were 96 cases of liver injury caused by cholelithiasis with positive imaging at initial diagnosis（case group 2）.There were48 males and 48 females（50% each）.The ratio of male to female was 1:1,with an average age of 51.5（31,64）.There was no significant difference in sex between the two groups（P >0.05）,but there was significant difference in age（P < 0.05）.The average age of patients with liver injury caused by cholelithiasis with negative imaging was slightly older than that of patients with liver injury caused by cholelithiasis with positive imaging at first diagnosis.（2）By describing the symptoms and signs of patients in case group 1 and case group 2,it was found that abdominal pain was the most common symptom,followed by nausea and vomiting,abdominal tenderness and yellow staining were the most common signs,and other symptoms and signs included radiation pain,abdominal distension,fever,clay stool,skin itching,fatigue,diarrhea,anorexia,weight loss,Murphy sign positive,liver percussion pain,but the proportion was low.Some patients have multiple symptoms and signs at the same time.Through the comparison of the laboratory indicators,imaging conditions and co-morbidities between the two groups,The ratios of alanine aminotransferase（ALT）,aspartate aminotransferase（AST）and alanine aminotransferase（ALT）/ alkaline phosphatase（ALP）in case group 1 were lower than those in case group 2,The difference was statistically significant（P 0.05）,The difference in diabetes mellitus was significant（P 0.05）;Regarding the location of the gallstones,Gallstones were the most common in both groups,Secondly,it is the coexistence of internal gallbladder and common bile duct stones.（3）In the case-control study of case group 1 and control group 1,univariate analysis showed that there was no significant difference in white blood cell（WBC）,platelet（PLT）,triglyceride（TG）,blood glucose and hypertension between the two groups.While alanine aminotransferase（ALT）,aspartate aminotransferase（AST）,glutamyl transpeptidase（GGT）,alkaline phosphatase（ALP）,total bile acid（TBA）,total bilirubin（TBIL）,direct bilirubin（DBIL）,globulin（Glb）,albumin（ALB）,ALT/AST,ALT/ALP,GGT/ALP,GGT/ALT,neutrophil percentage（NE%）,red blood cell（RBC）,There were significant differences in erythrocyte distribution width（RDW）,mean platelet volume（MPV）,platelet distribution width（PDW）,cholesterol（TC）,low density lipoprotein cholesterol（LDL）,high density lipoprotein cholesterol（HDL）,urinary bilirubin,urinary bilirubin,urinary protein,kidney stone and diabetes mellitus.Multivariate regression analysis showed that TBIL（OR=1.214,P=0.035）and GGT/ALP ratio（%）（OR=1.067,P=0.012）were independent risk factors of cholelithiasis liver injury with negative imaging at initial diagnosis.The area under the ROC curve of the ratio of TBIL to GGT/ALP（%）was 0.976（95% CIRV 0.941,1.00,P < 0.001）and 0.968（95% CIRV,0.927,1.00,P < 0.001）.When TBIL is 22.9umol/L,the sensitivity is95.1%,and the specificity is 97.6%.When the ratio（%）is 79.06,the sensitivity is 95.1% and the specificity is 92.8%.（4）In the case control research center of case group 2 and control group 2,the univariate analysis showed that there were significant differences in ALT,AST,GGT,ALP,TBA,TBIL,DBIL,Glb,ALB,ALT/AST,ALT/ALP,GGT/ALP,WBC,NE%,RBC,RDW,MPV,PDW,TC,LDL,HDL,urinary bilirubin,urinary bilirubin,urinary protein,kidney stone,diabetes and hypertension.There was no significant difference in GGT/ALT,PLT,TG and blood glucose.Multivariate regression analysis showed that TBIL（OR=1.204,P < 0.001）and ALT/ALP ratio（%）（OR=1.074,P=0.002）were independent risk factors for liver injury in patients with cholelithiasis with positive imaging at initial diagnosis.The ROC curve was drawn,and the results showed that the AUC of the ratio of TBIL to ALT/ALP（%）was 0.974（95%CI: 0.954,0.993,P < 0.001）and 0.923（95% CIRV,0.876,0.970,respectively,P <0.001）.When TBIL is 22.15umol/L,the sensitivity is 92.7%,and the specificity is 96.7%.When the ratio（%）is 59.12,the sensitivity is 86.5%,and the specificity is 96.1%.Conclusion:（1）The patients with liver injury caused by cholelithiasis with negative imaging at initial diagnosis were mainly middle-aged and elderly patients,and the proportion of males was slightly higher than that of females.The most common clinical symptoms were abdominal pain,followed by nausea and vomiting,abdominal tenderness and yellow staining were the most common signs.Moreover,in this study,such patients were more likely to have kidney stones and diabetes mellitus compared with those without cholelithiasis.（2）Compared with the patients with liver injury caused by cholelithiasis with negative imaging at initial diagnosis,the levels of alanine aminotransferase（ALT）and aspartate aminotransferase（AST）and the ratio of alanine aminotransferase（ALT）/ alkaline phosphatase（ALP）in the imaging negative group were lower than those in the imaging positive group.（3）For the patients with liver injury caused by cholelithiasis with positive imaging at the first diagnosis,although there are cholelithiasis,it is not clear whether they are complicated with other causes at the first visit.This study shows that the increase of the ratio of TBIL and ALT/ALP is highly related to the liver injury caused by cholelithiasis with positive imaging at the first diagnosis.（4）The increase of the ratio of TBIL and GGT/ALP has high predictive value for liver injury caused by cholelithiasis with negative imaging at first diagnosis.（5）It is suggested that for patients with liver injury,especially middle-aged and elderly men who are at high risk of accompanied by kidney stones or diabetes,when they have abdominal pain,nausea,vomiting and other symptoms,or signs such as skin,scleral yellow staining,abdominal tenderness,liver function is manifested as TBIL,GGT,ALP,ALT elevated,especially when GGT/ When the ALP ratio is greater than 0.7906,it should be taken seriously by clinicians,even if their initial imaging tests do not suggest cholelithiasis,they should still be alert to the possibility of cholelithiasis,and further review or other imaging tests should be required.