外科學教學課件：阻塞性黃疸 Obtructive Jaundice

阻塞性黃疸ObtructiveJaundice黃疸各種原因導致血中膽紅素濃度增高所致的鞏膜、皮膚、粘膜和某些體液黃染的現(xiàn)象定義阻塞性黃疸(機械性黃疸)肝內外膽道系統(tǒng)的機械性阻塞或者合并感染所致的膽紅素代謝異常而引起的黃疸膽紅素正常值

總膽紅素1.7～17.1μmol/L

直接膽紅素0～3.42μmol/L

間接膽紅素1.7～13.68μmol/L

膽道的調節(jié)功能肝分泌膽汁壓力39cmHO2膽總管內壓12cmHO2膽囊管開放壓8cmHO2膽囊內壓10cmHO2空腹括約肌壓力12-15cmHO2肝細胞對膽紅素的處理肝細胞攝取

游離膽紅素光面內質網(wǎng)葡萄糖醛酸酯結合膽紅素排泄排泄膽道腸道尿膽元或膽素元隨糞便排出腸肝循環(huán)膽紅素的代謝膽紅素的來源血紅蛋白80－85％血紅素酶類15-20%釋放血紅蛋白衰老的紅細胞與結合球蛋白結合釋放血紅蛋白膽紅素吞噬細胞吞噬分解為膽紅素和鐵血漿中肝細胞攝取肝細胞攝取梗阻性黃疸的常見病因

1.膽管結石

2.腫瘤

3.良性狹窄

4.胰腺炎癥

5.先天性膽道囊性擴張梗阻性黃疸的臨床診斷

最有診斷價值

對病人的影響最小檢查方法

耗費最少診斷梗阻性黃疸我們需要做什么？定性？定位？定外科處理的可行性？定外科處理途徑？膽道疾病影象學檢查常用的檢查方法：

B超

CT、CT成象

X線檢查

MIR、MRCP

ERCP

PTC

項目溶血性肝細胞性阻塞性TB（總疸）增加增加增加

CB（直疸）正常增加明顯增加

CB/TB＜15—20%＞30—40%＞50—60%

尿膽紅素—+++

尿膽原增加輕度增加減少、消失ALT、AST正常明顯增高增高

ALP正常增高明顯增高

GGT正常增高明顯增高

PT正常延長延長膽固醇正常降低明顯增加血漿蛋白正常降低正常三種黃疸實驗室檢查區(qū)別Couvroisier定律結石梗阻性黃疸膽囊萎縮腫瘤所致梗阻性黃疸膽囊腫大阻塞性黃疸的鑒別診斷膽總管結石：Charcot三聯(lián)征

Reynolds五聯(lián)征

膽源性胰腺炎Mirrizzi綜合征：膽囊結石嵌壓迫膽總管膽囊炎的膽管炎肝門部膽管癌：阻塞性黃疸、膽囊空虛胰頭癌：阻塞性黃疸、進行性加重膽囊增大壺腹部腫瘤：阻塞性黃疸、有波動阻黃病人的圍手術期處理1.保肝:極化液2.改善凝血機制貧血3.補充蛋白及維生素尤其維生素K14.改善病人營養(yǎng)狀態(tài)5.對危重梗阻性黃疸病人可先行簡單有效的引流阻塞性黃疸治療病變性質是治療基礎膽總管結石切開取石+T管引流膽總管良性狹窄、占位T管引流、膽腸吻合術惡性病變胰十二指腸切除術阻塞性黃疸治療姑息性治療內鏡逆行置管引流（ERCP）經(jīng)皮肝穿刺膽道引流術（PTCD）膽道支架置入治療WhataretheSurgicalProceduresdoneforObstructiveJaundice?CaGB:RadicalCholecystectomywithwedgeressectionandCBDexcisionCholedocholithiasis:ERCPremovalorCBDexploration/bilio-entericanastmosisCholangioCa:LiverresectionandorlocalexcisionofthelesionorWhippleBiliaryStricture:Hepatico-jejunostomy/liverresection

WhataretheSurgicalProcedures

PeriampullaryCa:Whipple’sProcedureChronicPancreatitswithheadMass:Whipple/bilio-entericanastmosisWhataretheSurgicalProcedures

BiliaryTumors

Cholangiocarcinomaand

CanceroftheGallBladder膽管癌A.Extrahepatictumor(Klatskin’stumor-tumorlocatedinthehepaticductbifurcation)B.intrahepatictumorresultinginbiliaryductdilation.膽管癌發(fā)生在肝外膽管的惡性腫瘤Aslowgrowingmalignancyofthebiliarytractwhichtendtoinfiltratelocallyandmetastasizelate.GallBladdercancer=6,900/yrBileductcancer=3,000/yrHepatocellularCa=15,000/yr膽管癌90%areextra-hepaticM=F60’sand70’sHighestincidenceinJapan,Israel,andNativeAmericansIncreased3foldinthelast30yrsintheUSAM/F=3/2Cholangiocarcinoma

Extra-hepatic:DistributionRightorlefthepaticduct=10%Bifurcation=20%ProximalCBD=30%DistalCBD=30%CarcinomaofBileDuctPathology上1/3占50-75%，中1/3占10-25%，下1/3占10-20%大體形態(tài)：乳頭狀癌、結節(jié)狀癌、彌漫性癌組織學類型：腺癌（高、中、低分化）、鱗狀SclerosingtypeofCholangiocarcinoma大多為腺癌、分化好Klatskintumor的分型ThemodifiedBismuth-CorletteClassificationTypeITypeIVTypeIIIbTypeIIIaTypeIICarcinomaofBileDuctClinicalpresentationsanddiagnosis60歲以上多發(fā)黃疸：90%以上病人，無痛性、進行性，少數(shù)呈波動性皮膚瘙癢尿色深黃、大便呈陶土色右上腹隱痛膽管炎癥狀LabexaminationsAKP、SGPT、BIL升高、CA19-9、CA125、CEA升高BUS、CT、MRI、PTC、ERCP超聲診斷MRCPMRCPERCPMRCP和ERCP術前檢查判斷可切除性術前檢查示行肝門部

膽管加右半肝切除術前檢查不可切除Cholangiocarcinoma

Extra-hepaticUSrevelsbileductdilatationQuadphaseCTPercutaneousCholangiogramwithInternalStentandBrushBiopsyERCPwithStentandBrushBiopsyMRCP/MRICholangiocarcinoma

PathologyAlmostallareadenocarcinomaPapillary,nodular,andsclerosingBestprognosisiswithpapillarydistaltumorsCholangiocarcinoma

Extentofsurgicaltherapyisdeterminedbythelocation,hepaticfunction,andunderlyingcirrhosis.Anatomicresectionshavelowestrecurrencerates.Howevernonanatomicresectionincreasespotentialsurgicalcandidatesandimprovessurvival.HepaticdevascularizationpriortoresectionispreferredAblativetherapygivesgoodlocalcontrol.Cholangiocarcinoma

Intra-hepaticDiseaseLocallyaggressivetumor:65%presentwithsatellitenodules,perineuralinvasionForresidualdiseaseuseRadiationtherapyand5-FUbasedtherapyRe-imageallevery6mofor2yr.Startworkupoverforanewmass.Cholangiocarcinoma

Extra-hepaticDisease:SurgicalTherapyCT+/-cholangiogramIfproximal,resectbacktosecondarybifurcationoronelobeandprimarybifurcation,takenodesandcaudatelobe.Stentanastamoses.IfMidCBD,excisebacktonegativemarginsandcreateRouxenYhepaticojejunostomy.Fordistaldisease:WhippleCarcinomaofBileDuctTreatment手術治療上段膽管癌：切除后行膽腸吻合術

切除范圍：肝外膽管、膽囊及膽囊管、肝十二指腸韌帶內脂肪及淋巴結，（部分肝臟）。中段膽管癌：切除后行膽腸吻合術下段膽管癌：胰十二指腸切除術肝門部膽管癌根治術肝門部膽管癌根治術膽總管下段癌胰十二指腸切除術CarcinomaofBileDuct姑息治療梗阻以上膽管-空腸Roux-en-Y吻合置管膽腸轉流術通過腫瘤置支撐管引流術經(jīng)PTC、ERCP置入內支架放療和化療:療效不佳CholangiocarcinomaCholangiocarcinomaCholangiocarcinomaCholangiocarcinoma

Extra-hepaticDisease:PositiveMarginsorUnresectableStentandChemo/RadiationTherapy-BracyTherapy5-FUbasedorClinicalTrialSurvivalwithsurgeryandchemo/radiationis24to36m.Withchemo/radiationalonesurvivalis12to18m.Cholangiocarcinoma

Extra-hepaticDisease:UnstentableBypassifpossibleIfnotuseproximaldecompressionandfeedingjejunostomyChemotherapy/RadiationCholangiocarcinoma

PrognosisBestResultarewithdistalCBDtumorscompletelyexcised.Cure=40%Incompleteresectionplusradiationgivesamediansurvivalof30m.Stentingpluschemo/radiationgivesamediansurvivalof17to27mThosestentedaloneliveonlyafewmonths

胰腺癌PancreaticCarcinomaNoscreeningtestLateappearanceofsymptomsRapidgrowthandspreadTheChallengeofPancreaticCancer

發(fā)病率Incidence:10in100000populationMedianageatdiagnosis:69yearsMaletofemaleratio:1.2-1.5to1Overalloneyearsurvival:12%Overallfiveyearsurvival:0.4-4%胰腺癌易感從群和因素慢性胰腺炎患者吸煙和飲酒胰腺癌病理

部位胰體(15%)胰尾(5%)彌漫(

20%)胰頭(60%)外觀:切面呈灰白或灰黃色胰腺癌病理腺癌(90%)超源于導管上皮含大量纖維組織難與慢性胰腺炎鑒別

胰腺癌病理腺泡細胞癌(1%)腺細胞分葉狀、界限清、切面呈黃白色粘液囊性癌胰母細胞癌粘液囊性癌胰腺癌病理

轉移方式局部浸潤十二指腸及膽總管橫結腸及系膜胰周及神經(jīng)叢淋巴結轉移血行轉移胰腺癌病理與臨床關系腫瘤未侵及鄰近組織無癥狀疼痛為首發(fā)表現(xiàn)消瘦、乏力示晚期腫瘤表現(xiàn)胰頭癌浸潤壓近膽總管阻塞性黃疸浸潤壓近十二指腸上消化道梗阻或出血胰體、體癌早期無癥狀晚期腰背部疼痛(神經(jīng)叢受侵犯)糖尿病區(qū)域性門靜脈高壓癥胰腺癌LaboratorystudiesTotalBilirubinAKPr-GTLDHCEACA19-9Ultrasound顯示胰腺輪廓、腫瘤、膽管（肝外）和胰管、膽囊低張十二指腸造影受壓和受侵擴大倒“e”征象平掃CT栓查顯示胰腺和膽管的改變胰周淋巴結及浸潤肝內是否有轉移MR、MRCP了解膽總管梗阻部位和性質ERCP十二指腸、乳頭改變膽管、胰管狹窄、擴張咬取標本檢查PTC了解梗阻部位和性質PTCD做好術前準備Cytologicalstudy用于>2cm的腫瘤陽性率達88%胰體癌出現(xiàn)癥狀已屬晚期PeriampullaryCarcinoma膽總管未端、V