Abstract: The establishment of a predictive model for cancerous intestinal obstruction and the clinical analysis of cancerous and Crohn's disease associated obstruction        DUAN Ming *, WU En-hao , CAO Lei, et al.*Department of General Surgery, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China.
Corresponding author: ZHU Wei-ming ，E-mail：juwiming@nju.edu.cn.
Abstract    Objective    To investigate the clinical differential diagnosis and different treatment principles of cancerous intestinal obstruction and Crohn's disease (CD) associated intestinal obstruction. Methods    Data of 406 patients with  intestinal obstruction from January 2015 to December 2019 in the Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, were retrospectively included.According to the etiology, the patients with cancerous intestinal obstruction and CD associated intestinal obstruction were divided into cancer group (63 cases) and CD group (183 cases). The differences of clinical and abdominal CT-related indexes between the two groups were compared. Multivariate logistic regression analysis was performed to establish and verified the predictive model of cancerous obstruction. Results    In the cancer group, the onset age was higher (54.9±2.2 vs. 39.9±1.0 years, t=-6.3, P <0.01), and the disease duration was shorter than that of the CD group (12.9±1.6 vs. 26.3±3.1 weeks, t=3.8，P<0.01).  In cancer group, the incidence of vomiting, abdominal distention, less flatus and stool and emergency surgery were significantly higher than those in CD group ［39 (61.9%) vs. 16 (8.7%)，χ2=78.0, P<0.01; 58(92.1%) vs. 82(44.8%)，χ2=44.9, P<0.01; 53 (84.1%) vs. 61 (33.3%)，χ2=50.6, 45 (71.4%) vs. 17 (9.3%)，χ2=98.1, P<0.01］. The increased extent and number of tumor markers in the cancer group were significantly higher than those of the CD group ［2.3(1.1-15.6) vs. 1.5(1.0-4.0)，Z=-2.5, P=0.014; 1.0(1.0-5.0) vs. 1.0(1.0-2.0)，Z=-4.8, P<0.01］. The bowel wall thickness (11.5±0.5 vs. 7.5±0.2 mm，t=-6.9, P<0.01) and the proximal and distal diameter ratio［3.7(1.9-13.8) vs. 3.0(1.3-11.2)，Z=-3.3, P<0.01］ of the cancer group were higher than those of the CD group, and the diameter of the intestinal stenosis ［3.0(1.0-6.0)mm vs. 5.0(2.0-9.8)mm，Z=-4.9, P<0.01］ was significantly smaller than that of the CD group. Based on the logistic multivariate analysis and step regression, the predictive model of cancerous intestinal obstruction was established including the age of onset, disease duration, vomiting, number of tumor marker elevation and CT combined variables (nomogram). The area under the curve was 0.982 (95% confidence interval: 0.959-1.000), and the calibration curve showed a good fit between the predicted probability and the actual probability. Conclusion    The differential diagnosis of cancerous and CD intestinal obstruction should be based on the combination of demography, history of present illness, tumor markers and imaging results. The predictive model of cancerous intestinal obstruction has certain diagnostic efficacy and needs further confirmation. 

Key words: intestinal obstruction, bowel cancer, Crohn’s disease, tumor marker, nomogram

摘要： 目的    探讨癌性肠梗阻和克罗恩病（CD）肠梗阻临床鉴别诊断及不同治疗原则。方法    回顾性分析2015年1月至2019年12月在南京大学医学院附属金陵医院普通外科接受手术的406例肠梗阻病人临床资料。根据病因将癌性肠梗阻和CD肠梗阻病人分为肠癌组（63例）和CD组（183例）。比较两组临床及腹部CT相关指标差异，通过多因素Logistic回归分析建立癌性肠梗阻疾病预测模型并进行验证。结果    肠癌组发病年龄高于CD组［（54.9±2.2）岁 vs. （39.9±1.0）岁，t=-6.3，P<0.01］，病程短于CD组［（12.9±1.6）周vs.（ 26.3±3.1）周，t=3.8，P<0.01）。肠癌组呕吐、腹胀、肛门排气排便减少发生率［39例（61.9%） vs. 16例（8.7%），χ2=78.0，P<0.01；58例（92.1%）vs. 82例（44.8%），χ2=44.9，P<0.01；53例（84.1%）vs .61例（33.3%），χ2=50.6，P<0.01］及急诊手术率［45例（71.4%） vs. 17例（9.3%），χ2=98.1，P<0.01］均高于CD组。肠癌组肿瘤标记物标化值升高程度［2.3（1.1~15.6） vs. 1.5（1.0~4.0），Z=-2.5，P=0.014］及升高的肿瘤标记物数目［1.0（1.0~5.0） vs. 1.0（1.0~2.0），Z=-4.8，P<0.01］均高于CD组。肠癌组病变部位肠壁厚度［（11.5±0.5）mm vs.（7.5±0.2） mm，t=-6.9，P<0.01］大于CD组，狭窄肠腔近远端直径比［3.7（1.9~13.8） vs. 3.0（1.3~11.2），Z=-3.3，P<0.01］、狭窄部位肠管直径［3.0（1.0~6.0）mm  vs. 5.0（2.0~9.8） mm，Z=-4.9，P<0.01］小于CD组。基于Logistic多因素分析及逐步回归，最终纳入发病年龄、病程、呕吐、肿瘤标记物升高数目及CT联合变量构建癌性肠梗阻疾病预测模型。C-指数及模型预测癌性肠梗阻的曲线下面积为0.982（95%CI 0.959-1.000），校准曲线显示预测概率和实际概率拟合良好。结论    应从人口学、现病史、肿瘤标记物及影像学资料综合进行癌性肠梗阻和CD肠梗阻的鉴别诊断。癌性肠梗阻疾病预测模型具有一定诊断价值，但仍需进一步验证。

关键词: 肠梗阻, 肠癌, 克罗恩病, 肿瘤标记物, 列线图