膽道臨床診療課件

膽道疾病

膽道疾病

膽道系統(tǒng)的應(yīng)用解剖和生理肝內(nèi)膽管模式圖肝內(nèi)膽管組織學(xué)膽道系統(tǒng)的應(yīng)用解剖和生理肝內(nèi)膽管模式圖肝內(nèi)膽管組織學(xué)膽道系統(tǒng)的應(yīng)用解剖和生理Anatomy&Physiology

肝內(nèi)膽管

肝內(nèi)膽管起自毛細(xì)膽管，繼而匯集成小葉間膽管，肝段、肝葉膽管及肝內(nèi)部分的左右肝管。膽道系統(tǒng)的應(yīng)用解剖和生理Anatomy&Physio

左、右肝管出肝后，在肝門(mén)部匯合形成肝總管（commonhepaticduct）。肝總管直徑為0.14~0.6cm，長(zhǎng)約3~4cm，其下端與膽囊管匯合形成膽總管（commonbileduct）。膽總管長(zhǎng)約4~8cm，直徑0.6~0.8cm。肝外膽道左、右肝管出肝后，在肝門(mén)部匯合形成肝總管（commo

肝外膽道包括左、右肝管、肝總管、膽總管、膽囊。肝外膽道包括左、右肝管、肝總管、膽總管、膽囊。Oddi括約肌主要包括膽管括約肌、胰管括約肌和壺腹括約肌控制和調(diào)節(jié)膽總管和胰管的排放防止十二指腸內(nèi)容物返流Oddi括約肌主要包括膽管括約肌、胰管括約肌和壺腹括約肌膽汁的生成、分泌和代謝

成人每日分泌膽汁約800~1200ml，膽汁主要由肝細(xì)胞分泌。膽汁中97%是水，其他成分主要有膽汁酸與膽鹽、膽固醇、磷脂和膽紅素等。膽汁的生成、分泌和代謝成人每日分泌膽汁約800~1FunctionofgallbladderConcentrationandpreservationofthebile.SecretionContractionandemptyFunctionofgallbladder膽道疾病的特殊檢查方法X-rayUltrasonography,EUS,IDUSCTMRI,MRCP(Magneticresonancecholagiopancreatography)PTC,PTBDERCPScintigraphyCholedochoscopyCholangiography膽道疾病的特殊檢查方法X-ray膽道疾病的特殊檢查方法膽道特殊檢查--US判斷膽管有無(wú)擴(kuò)張，對(duì)黃疸原因進(jìn)行定位定性術(shù)中B超檢查B超引導(dǎo)下行經(jīng)皮肝穿刺膽管造影膽道疾病的特殊檢查方法膽道特殊檢查--US判斷膽管有無(wú)膽道疾病的特殊檢查方法膽道特殊檢查--US無(wú)創(chuàng)、安全、快速、簡(jiǎn)便、經(jīng)濟(jì)、準(zhǔn)確診斷膽道疾病的首選方法膽囊結(jié)石診斷準(zhǔn)確率95%以上膽道疾病的特殊檢查方法膽道特殊檢查--US無(wú)創(chuàng)、安全、膽道疾病的特殊檢查方法X線檢查腹部平片膽道疾病的特殊檢查方法X線檢查腹部平片膽道疾病的特殊檢查方法口服膽囊造影靜脈膽道造影膽道疾病的特殊檢查方法口服膽囊造影靜脈膽道造影膽道疾病的特殊檢查方法術(shù)中造影IntraoperativeCholangiography膽道疾病的特殊檢查方法術(shù)中造影膽道疾病的特殊檢查方法經(jīng)皮經(jīng)肝膽管造影術(shù)(PTC,PercutaneousTranshepaticCholangiography)經(jīng)皮經(jīng)肝膽管造影引流術(shù)(PTCD,PercutaneousTranshepaticCholangiographyDrainage)

膽道疾病的特殊檢查方法經(jīng)皮經(jīng)肝膽管造影術(shù)膽道疾病的特殊檢查方法CT/US引導(dǎo)PTCD顯示膽管病變部位、范圍、性質(zhì)、程度膽道疾病的特殊檢查方法CT/US引導(dǎo)PTCDPTC顯示肝總管狹窄可通過(guò)造影管行膽管引流（PTCD）或置放膽管內(nèi)支架用作治療。PTC顯示肝總管狹窄可通過(guò)造影管行膽管引流（PTCD）或置放膽道疾病的特殊檢查方法ERCP內(nèi)鏡下逆行胰膽管造影術(shù)Endoscopicretrogradecholangiopancreatography

是電子十二指腸鏡直視下通過(guò)十二指腸乳突將導(dǎo)管插人膽管和（或）胰管內(nèi)進(jìn)行造影。可直接觀察十二指腸及乳頭部的情況和病變，取材活檢；收集十二指腸液、膽汁、胰液。取石，放置支架或鼻膽（胰）管引流，EST，IDUS，子母鏡（SpyGlass）等膽道疾病的特殊檢查方法ERCP內(nèi)鏡下逆行胰膽管造影術(shù)99m锝-二乙基亞氨二醋酸iV肝細(xì)胞清除分泌隨膽汁排泄動(dòng)態(tài)觀察在膽道流經(jīng)的圖像核素掃描99m锝-二乙基亞氨二醋酸iV核素掃描

膽道梗阻時(shí)顯像時(shí)間的延遲，有助于黃疽的鑒別診斷。本法為無(wú)創(chuàng)檢查，輻射物劑量小，對(duì)病人無(wú)損害。突出優(yōu)點(diǎn)是在肝功能損傷，血清膽紅素中度升高時(shí)亦可應(yīng)用。膽道梗阻時(shí)顯像時(shí)間的延遲，有助于黃疽的鑒別診斷。本法常見(jiàn)膽道疾病CommonBiliaryDisease常見(jiàn)膽道疾病常見(jiàn)膽道疾病1，先天性疾病（膽道閉鎖，膽總管囊腫,膽胰管匯合異常）2，結(jié)石（肝內(nèi)外膽管結(jié)石，膽囊結(jié)石,Mirizzi綜合征）3，腫瘤（膽囊癌，膽管癌）4，寄生蟲(chóng)（蛔蟲(chóng)）5，醫(yī)源性膽管損傷（LC時(shí)損傷膽管）6,急、慢性膽囊炎和急性膽管炎（急性梗阻性化膿性膽管炎AOSC）7，原發(fā)性硬化性膽管炎常見(jiàn)膽道疾病1，先天性疾?。懙篱]鎖，膽總管囊腫,膽胰管匯合

膽道閉鎖是新生兒持續(xù)性黃疸的最常見(jiàn)病因。病變可累及整個(gè)膽道，亦可僅累及肝內(nèi)或肝外的部分膽管，其中以肝外膽道閉鎖常見(jiàn)，占85%~90%。發(fā)病率女性高于男性。膽道閉鎖膽道閉鎖是新生兒持續(xù)性黃疸的最常見(jiàn)病因。病變可累及整病因

膽管閉鎖是一種進(jìn)展性的膽管閉鎖和硬化性病變。很多患兒出生時(shí)能排泄膽汁，以后進(jìn)展成為完全性膽管閉鎖。其病因主要有兩種學(xué)說(shuō)：①先天性發(fā)育畸形學(xué)說(shuō)②病毒感染學(xué)說(shuō)膽道閉鎖病因膽管閉鎖是一種進(jìn)展性的膽管閉鎖和硬化性病變。膽道閉鎖病理

膽管閉鎖所致梗阻性黃疽，可致肝細(xì)胞損害，肝臟因淤膽而顯著腫大、變硬，呈暗綠或褐綠色，肝功能異常。若膽道梗阻不能及時(shí)解除，則可發(fā)展為膽汁性肝硬化，晚期為不可逆性改變。膽道閉鎖病理膽管閉鎖所致梗阻性黃疽，可致肝細(xì)胞損膽道閉鎖大體類(lèi)型主要分為三型：Ⅰ型完全性膽管閉鎖Ⅱ型近端膽管閉鎖，遠(yuǎn)端膽管通暢Ⅲ型近端膽管通暢，遠(yuǎn)端膽管纖維化以Ⅰ、Ⅱ型常見(jiàn)。膽道閉鎖大體類(lèi)型主要分為三型：膽道閉鎖膽道閉鎖膽道閉鎖臨床表現(xiàn)黃疸：梗阻性黃疽是本病突出表現(xiàn)。營(yíng)養(yǎng)及發(fā)育不良肝脾腫大：是本病特點(diǎn)。膽道閉鎖臨床表現(xiàn)黃疸：梗阻性黃疽是本病突出表現(xiàn)。膽道閉鎖診斷

凡出生后1~2個(gè)月出現(xiàn)持續(xù)性黃疽，陶土色大便，伴肝腫大者均應(yīng)懷疑本病。下列各點(diǎn)有助于確診：①黃疽超過(guò)3~4周仍呈進(jìn)行性加重，對(duì)利膽藥物治療無(wú)效；對(duì)苯巴比妥和激素治療試驗(yàn)無(wú)反應(yīng)；血清膽紅素動(dòng)態(tài)觀測(cè)呈持續(xù)上升，且以直接膽紅素升高為主；膽道閉鎖診斷凡出生后1~2個(gè)月出現(xiàn)持續(xù)性黃疽膽道閉鎖②十二指腸引流液內(nèi)無(wú)膽汁；③B超檢查顯示肝外膽管和膽囊發(fā)育不良或缺如；④99mTc-EHIDA掃描腸內(nèi)無(wú)核素顯示；⑤ERCP和MRCP能顯示膽管閉鎖的長(zhǎng)度。膽道閉鎖②十二指腸引流液內(nèi)無(wú)膽汁；膽道閉鎖

手術(shù)治療是唯一有效方法。手術(shù)宜在出生后2個(gè)月進(jìn)行，此時(shí)尚未發(fā)生不可逆性肝損傷。若手術(shù)過(guò)晚，病兒已發(fā)生膽汁性肝硬化，則愈后極差。治療膽道閉鎖手術(shù)治療是唯一有效方法。手術(shù)宜在出生后2個(gè)月膽道閉鎖手術(shù)方式：①尚有部分肝外膽管通暢，膽囊大小正常者，可用膽囊或肝外膽管與空腸行Roux-en-Y型吻合。②肝外膽管完全閉鎖，肝內(nèi)仍有膽管腔者可采用Kasai肝門(mén)空腸吻合術(shù)。③肝移植膽道閉鎖手術(shù)方式：先天性膽總管囊腫

先天性膽道擴(kuò)張癥可發(fā)生于肝內(nèi)、肝外膽管的任何部分，好發(fā)于膽總管。本病好發(fā)于東方國(guó)家，尤以日本常見(jiàn)。女性多見(jiàn)，男女之比約為1:3~4。幼兒期即可出現(xiàn)癥狀，約80%病例在兒童期發(fā)病。先天性膽總管囊腫先天性膽道擴(kuò)張癥可發(fā)生于肝內(nèi)、肝外膽管的先天性膽總管囊腫病理根據(jù)膽管擴(kuò)張的部位、范圍和形態(tài)，分為五種類(lèi)型：Ⅰ型：囊性擴(kuò)張。臨床上最常見(jiàn)。Ⅱ型：憩室樣擴(kuò)張。Ⅲ型：膽總管開(kāi)口部囊性脫垂。Ⅳ型：肝內(nèi)外膽管擴(kuò)張。Ⅴ型：肝內(nèi)膽管擴(kuò)張（Caroli?。?。先天性膽總管囊腫病理根據(jù)膽管擴(kuò)張的部位、范圍和形態(tài)，分為先天性膽總管囊腫臨床表現(xiàn)

典型臨床表現(xiàn)為腹痛、腹部包塊和黃疽三聯(lián)癥。腹痛位于右上腹部，可為持續(xù)性鈍痛；黃疽呈間歇性；80%以上病人右上腹部可扣及表面光滑的囊性腫塊。晚期可出現(xiàn)膽汁性肝硬化和門(mén)靜脈高壓癥的臨床表現(xiàn)。囊腫破裂可導(dǎo)致膽汁性腹膜炎。先天性膽總管囊腫臨床表現(xiàn)典型臨床表現(xiàn)為腹痛、腹部先天性膽總管囊腫診斷

對(duì)于有典型“三聯(lián)癥”及反復(fù)發(fā)作膽管炎者診斷不難。但“三聯(lián)癥”俱全者僅占20%~30%，多數(shù)病人僅有其中1~2個(gè)癥狀，故對(duì)懷疑本病者需借助其他檢查方法確診。先天性膽總管囊腫診斷對(duì)于有典型“三聯(lián)癥”及反復(fù)發(fā)先天性膽總管囊腫治療

本病一經(jīng)確診應(yīng)盡早手術(shù)，否則可因反復(fù)發(fā)作膽管炎導(dǎo)致肝硬化、癌變或囊腫破裂等嚴(yán)重并發(fā)癥。完全切除囊腫和膽腸Roux-en-Y吻合是本病的主要治療手段，療效好。先天性膽總管囊腫治療本病一經(jīng)確診應(yīng)盡早手術(shù)，否則膽石癥(Cholelithiasis)膽囊結(jié)石(Gallstone)Gallstonesareclassifiedascholesterol,pigmenttypes.Butmoststonesdonotfitintothisrigidclassificationsystem膽管結(jié)石

總膽管結(jié)石(CommonBileDuctStone)肝內(nèi)膽管結(jié)石(IntrahepaticDuctStone)膽石癥(Cholelithiasis)膽囊結(jié)石(GallstPathogenesisofGallstones

主要為膽固醇性結(jié)石或以膽固醇為主的混合型結(jié)石。女性常見(jiàn)，男女比例1：3。形成的原因：膽汁的成分和理化性質(zhì)發(fā)生變化，膽汁中的膽固醇呈過(guò)飽和狀態(tài)，易于沉淀析出、結(jié)晶形成結(jié)石；膽汁中存在促成核因子，可分泌大量的糖蛋白促使成核和結(jié)石形成；膽囊收縮能力降低，膽囊內(nèi)膽汁淤積也有利于結(jié)石形成。Cholesterolsaturationofbile,stasisofbilewithinthegallbladder,andnucleatingfactorsappeartobeimportant.PathogenesisofGallstonesDiagnosis-GallstoneRecurrentattacksofrightupperquadrantorepigastricpainordiscomfort,nauseaandvomitingGallbladdercolic,resultsfromthetemporaryobstructionofthegallbladderoutletbyastoneinthecysticductortheinfundibulumPhysicalfindings:rightupperquadrantorepigastrictendernesstopalpationandvoluntarymuscleguarding.Jaundiceisnotafeatureofcholelithiasisunlesscommonductobstruction.Diagnosis-GallstoneRecurrentDiagnosisImagingstudies:Ultrasonographydemonstrationthatthestonesmovetothedependentportionofthegallbladderwhenthepositionofthepatientischangedandthestoneproducesacousticshadowing.BloodRTDiagnosisImagingstudies:UltrTreatmentThedefinitivetreatmentofsymptomaticgallstonesislaparoscopiccholecystectomy.Themajoradvantagesofthelaparoscopicprocedurearethatpatientshavelesspainandashorterhospitalisationandareabletoreturntotheiractivitiessooner.Treatment

Opencholecystectomyisindicatedonlyinpatientsinwhomthelaparoscopicisimpossibleorunsafe.ImpossibletoestablishsafeaccesstotheperitonealcavityAdhesionsAnatomicabnormalitiesOpencholecystectomyisindTreatment

OthertreatmentsOraldissolutiontherapy:(UDCA)Contactdissolutiontherapy:Methyltert-butylExtracorporealshockwavelithotripsyTreatmentOthertreatments膽囊切除(Cholecystectomy)

剖腹膽囊切除(open)

腹腔鏡膽囊切除

(LaparoscopicCholecystectomy)膽囊造瘺(Cholecystostomy)膽囊結(jié)石治療膽囊切除(Cholecystectomy)膽囊結(jié)石治療膽石癥(Cholelithiasis)Mirizzi綜合征及其分型膽石癥(Cholelithiasis)Mirizzi綜合征及是一種少見(jiàn)的膽囊結(jié)石并發(fā)癥容易漏診和誤診可引起肝總管狹窄和梗阻并發(fā)阻塞性黃疸和肝功能損害國(guó)內(nèi)報(bào)道其占同期膽囊切除術(shù)的l％~3％國(guó)外發(fā)病率為0.7％~1.4％Mirizzi綜合征(Mirizzisyndrome，MS)是一種少見(jiàn)的膽囊結(jié)石并發(fā)癥Mirizzi綜合征(Mirizz定義MS是指膽囊結(jié)石長(zhǎng)期嵌頓于膽囊壺腹部或頸部，從外部壓迫肝總管、膽總管，導(dǎo)致后者狹窄、梗阻，并發(fā)膽囊炎、膽管炎、梗阻性黃疸、肝功能損傷及各種膽內(nèi)瘺的綜合征

定義MS是指膽囊結(jié)石長(zhǎng)期嵌頓于膽囊壺腹部或頸部，從外部壓迫肝發(fā)現(xiàn)1905年，Kehr首先描述了膽囊結(jié)石引起的膽道部分梗阻及相關(guān)炎癥過(guò)程Mirizzi教授1940年將該類(lèi)疾病以綜合征的形式進(jìn)行了系統(tǒng)介紹，成為MS相關(guān)最早的報(bào)道Puestow，首先報(bào)道了膽囊結(jié)石相關(guān)自發(fā)性膽內(nèi)瘺，指出內(nèi)瘺可發(fā)生于膽囊和胸、腹腔臟器，如胃、十二指腸、結(jié)腸以及支氣管間，補(bǔ)充了MS復(fù)雜的解剖特點(diǎn)

發(fā)現(xiàn)1905年，Kehr首先描述了膽囊結(jié)石引起的膽道部分梗阻解剖學(xué)特點(diǎn)膽囊結(jié)石嵌頓于膽囊頸部或壺腹部，膽囊萎縮，囊壁異常增厚或變薄膽囊管多發(fā)生閉塞膽囊結(jié)石外部壓迫膽管或侵透膽管壁膽囊管過(guò)長(zhǎng)或過(guò)短，或平行于膽總管低位匯入病變近側(cè)膽道炎癥明顯，膽管壁增厚，而遠(yuǎn)側(cè)膽管結(jié)構(gòu)正?？尚纬赡憙?nèi)瘺，涉及膽管、胃、十二指腸、結(jié)腸、甚至氣管，瘺管欠規(guī)則解剖學(xué)特點(diǎn)膽囊結(jié)石嵌頓于膽囊頸部或壺腹部，膽囊萎縮，囊壁異常臨床表現(xiàn)發(fā)生于任何年齡，患者多分布于50-70歲，男女比例相當(dāng)結(jié)石長(zhǎng)期存在引起MS的中位時(shí)間約29.6年可呈急性發(fā)作，如急性膽囊炎、膽管炎或急性胰腺炎，也可呈現(xiàn)慢性過(guò)程一半以上的患者主訴右上腹疼痛，60%以上的患者出現(xiàn)梗阻性黃疸，膽石性腸梗阻時(shí)有發(fā)生部分患者CA-199異常升高，導(dǎo)致MS與以梗阻性黃疸為主要表現(xiàn)的膽胰惡性腫瘤鑒別困難臨床表現(xiàn)發(fā)生于任何年齡，患者多分布于50-70歲，男女比例相臨床分型1982年，Mcsherry等根據(jù)ERCP所見(jiàn)，提出了一種分類(lèi)法：I型為膽囊管或膽囊頸巨大結(jié)石嵌頓壓迫肝總管：Ⅱ型為結(jié)石部分或完全突破進(jìn)入肝總管，形成膽囊膽管瘺1989年，Csendes等通過(guò)對(duì)219例MS的研究，認(rèn)為所謂MS和膽囊膽管瘺是同一病理過(guò)程的不同發(fā)展階段，并進(jìn)行了分型：I型為膽囊頸或膽囊管結(jié)石嵌頓壓迫肝總管(即經(jīng)典MS)；Ⅱ型為膽囊膽管瘺形成，瘺管口徑小于膽管周徑的1／3；Ⅲ型為瘺管口徑累及膽管周徑2／3：IV型為膽管壁因結(jié)石壓迫而完全受損臨床分型1982年，Mcsherry等根據(jù)ERCP所見(jiàn)，提出術(shù)前診斷B超是篩查MS的首要診斷工具對(duì)肝膽系統(tǒng)結(jié)石、膽囊炎癥及膽囊囊腫大的診斷有很高的敏感性對(duì)MS診斷的敏感性只有27％膽囊增大，肝總管擴(kuò)張而膽總管正?！狹S?術(shù)前診斷B超是篩查MS的首要診斷工具術(shù)前診斷PTC和ERCP是診斷MS的重要手段直接顯示：結(jié)石壓迫導(dǎo)致的膽管偏位、偏側(cè)性(外壓性)充盈缺損，邊緣光整術(shù)前診斷PTC和ERCP是診斷MS的重要手段術(shù)前診斷MRCP非介入性胰膽管成像技術(shù)，無(wú)需造影劑、無(wú)損傷、無(wú)痛苦、無(wú)并發(fā)癥很好地顯示膽道系統(tǒng)的正常及異常解剖，直接提示肝管受壓于膽囊管結(jié)石，肝總管以上區(qū)域擴(kuò)張MRCP為診斷MS的最佳檢查方法術(shù)前診斷MRCP非介入性胰膽管成像技術(shù)，無(wú)需造影劑、無(wú)損傷、術(shù)前診斷反復(fù)右上腹部疼痛多年，發(fā)作時(shí)伴黃染實(shí)驗(yàn)室與體檢：急性發(fā)作時(shí)有直接膽紅素升高、肝功能損害B超提示：膽囊結(jié)石、膽囊腫大或萎縮及膽囊管結(jié)石伴嵌頓CT提示：肝內(nèi)膽管擴(kuò)張，膽囊管擴(kuò)張，膽總管直徑正常MRCPERCP術(shù)前診斷反復(fù)右上腹部疼痛多年，發(fā)作時(shí)伴黃染術(shù)前診斷術(shù)前明確診斷對(duì)術(shù)中處理有一定的幫助，能有針對(duì)性地處理好嵌頓的膽囊管結(jié)石，避免損傷膽管根據(jù)MS不同類(lèi)型．采用不同的治療方法．以達(dá)最佳治療術(shù)前診斷術(shù)前明確診斷對(duì)術(shù)中處理有一定的幫助，能有針對(duì)性地處理MS的外科治療膽囊切開(kāi)取石造瘺術(shù)適用于各型急性膽管炎急診手術(shù)時(shí)．術(shù)中炎癥重，解剖不清，不勉強(qiáng)行膽囊切除手術(shù)，否則易損傷膽管而造成嚴(yán)重后果

3個(gè)月后再行二期手術(shù)急診ERCP+ENBD/ERBD+二期手術(shù)急診處理MS的外科治療膽囊切開(kāi)取石造瘺術(shù)急診處理膽囊或膽囊大部分切除術(shù)----I型MS膽囊大部切除加膽管修補(bǔ)及T管引流術(shù)----II型應(yīng)用最廣將膽囊大部或部分切除后，保留膽囊頸部避免損傷膽管用膽囊頸部殘端修補(bǔ)缺損的膽管在膽管修補(bǔ)的下方放置T管作支架需注意保留足夠多的膽囊壁、無(wú)張力修補(bǔ)，選擇合適的T管，T臂跨過(guò)缺損處，T管引流時(shí)間為3個(gè)月，以防修補(bǔ)處膽管狹窄MS的外科治療膽囊或膽囊大部分切除術(shù)----I型MSMS的外科治療切除膽囊，行膽管空腸Roux—Y吻合術(shù)，適用于膽管缺損比較大的III、IV型患者，以避免膽管狹窄，引起反復(fù)發(fā)作性的膽管炎MS的外科治療切除膽囊，行膽管空腸Roux—Y吻合術(shù)，適用于膽管缺損比較大

Va型病例，可行膽囊切除或部分切除，對(duì)十二指腸、胃、結(jié)腸或小腸內(nèi)瘺可越過(guò)受累組織，行單純縫合MirizziVb型存在腸梗阻癥狀，須予以先行解決，經(jīng)3個(gè)月以上恢復(fù)期后再行二期手術(shù)

MS的外科治療Va型病例，可行膽囊切除或部分切除，對(duì)十二指腸、胃、結(jié)腸或Choledocholithiasis

CholedocholithiasisClinicalManifestationsandDiagnosis

Commonductcalculimaybeasymptomaticorcausebiliarycolic,bileductobstruction,cholangitisorpancreatitis.Jandicewillbeintermittentiftheobstructionispartialandintermittent,oritmaybeprogressiveifastonebecomesimpactedinthedistalduct.Chillsandfeverareusuallyassociatedwithslightabdominaldiscomfortandamildelevationofserumbilirubin,butanyofthesesignsofcholangitismaybeabsent.ClinicalManifestationsandDiClinicalManifestationsandDiagnosis

Physicalexaminationmaybenormal.Jaundiceandmildtendernessintheepigastriumandrightupperquadrantmaybepresent.Ultrasonographyisnotreliableinthedetectionofcommonductstones.Endoscopicretrogradecholangiopancreatography(ERCP)isindicatedformostpatientwhohavebileductobstruction.Percutaneoustranshepaticcholangiography(PTC)isanalternative,butERCPpermitsvisualizationofotherportionsofthegastrointestinaltractandallowsfortheperformanceofpancreatographyandendoscopicsphincterotomywithstoneextraction,whenindicated.

ClinicalManifestationsandDiTreatment

Shouldbetreatedwithantibiotic.AOSC(AcuteObstructiveSuppurativeCholangitis)

maybepresent,anddecompressionoftheductsystemmustbecarriedoutimmediately.Thiscanbedonebyestablishingpercutaneoustranshepaticbiliarydrainageorbyendoscopicsphincterotomy,butimmediatelaparotomyandinsertionofaT-tubeshouldbedoneifthesesimplerproceduresfailorarenoravailable.TreatmentShouldbetreatedwiTreatmentPatientsthoughttohavecholedocholithiasispreoperativelyundergoERCP.whenstonesareidentified,endoscopicsphincterotomyandstoneextractionisperformedOpencholedocholithotomyandcholecystectomyareperformediftheductsystemcannotbeclearedofstones.TreatmentPatientsthoughttohOpenCholedocholithotomy

PatientswhoarenotcandidatesforlaparoscopicproceduresandthoseinwhomendoscopiccholangiographyandstoneextractionarenotpossiblemayrequireopencholedocholithotomyAfterthestoneshavebeenremoved,theductshouldbeclosedwithaT-tube,whichhasalargesidearm,allowingpercutaneousstonesremovallater,ifnecessary.OpenCholedocholithotomy

PatieAcuteCalculousCholecystitis

AcuteCalculousCholecystitisAcutecholecystitisisachemicalorbacterialinflammationofthegallbladderthatmaycausesevereperitonitisanddeathunlesspropertreatmentisinstituted.Inabout95%ofcases,gallstonesarepresentinthegallbladder,andinabout5%theyarenot.TheincidenceofAcutecalculouscholecystitisishigherinfemales,withafemale-to-maleratioof3:1

AcutecholecystitisisachemiPathogenesis

Obstruction:ObstructionofthecysticductorthejunctionofthegallbladderandthecysticductbyastoneorbyedemaformedastheresultoflocalmucosalerosionandinflammationcausedbyastoneBacteria:Positiveculturesofbileorgallbladderwallarefoundin50%to75%ofcases.Deathsandcomplicationsfromuntreatedcholecystitisarealmostalwaysrelatedtosepticcomplicationsofthedisease.Otherfactors:Inanimalexperiments,thepresenceofpancreaticjuice,gastricjuice,orconcentratedbileinthelumenoftheobstructedgallbladdercausesacutecholecustitis.

PathogenesisObstruction:Pathology

TheinflamedgallbladderisenlargedTheserosalsurfaceiscongestedMayhaveareasofgangreneornecrosisThewallisedematousandthickened.Pathology

TheinflamedgallblaManifestationsMostpatientshavesymptomsreferabletothegallbladderpriortothedevelopmentofacutecholecystitisbut20%to40%areasymptomatic.Thedevelopmentofacutecholecystitisprogressesthroughthesequenceofdistention,andlaterbyinflammationofthegallbladderandadjacentperitonealsurfaces.Radiationofthepainaroundtherightsidetowardthetipofthescapula.Nauseaandvomitingoccurin60%to70%ofpatients,aretheonlyothersignificantsymptoms.ManifestationsMostpatientshaPhysicalFindings

Tendernessintherightupperquadrant,theepigastrium,orboth.MostcommonandreliableAbouthalfofallpatientshavemusclerigidityintherightupperquadrant,andaboutonefourthhavereboundtenderness.Murphy’ssign.consistingofinspiratoryarrestduringdeeppalpationoftherightupperquadrant,isnotaconsistentfindingbutisalmostpathognomonicwhenpresent.Jaundiceoccursinapproximately10%ofpatients.Bowelsoundsareabsentinonlyabout10%ofpatientsFevermaybeabsentPhysicalFindingsTendernessiLaboratoryFinding

Whitebloodcellcountiselevatedin85%ofcasesOnehalfhaveelevationoftheserumbilirubinSerumamylaseisincreasedinonethirdLaboratoryFinding

WhitebloodImagingStudies

Ultrasonography:Notspecific,athickenedgallbladderwallandpericholecysticfluidaresometimespresent.ImagingStudies

UltrasonographComplications

Perforation:

Onethirdofthesecomplications.OccurswhenagangrenousareabecomesnecroticandbileleaksintotheperitonealcavityPericholecysticabscess:Resultfromaperforationofthegallbladderthatiswalledoffbyomentumoradjacentorganssuchasthecolon,stomach,orduodenum.Fistula:15%.occurswhenthegallbladderbecomesattachedtoaportionofthegastrointestinaltractandperforatesintoit.ComplicationsPerforation:Treatment

Preoperativemanagementshouldincludeadministrationofanantibioticthatiseffectiveagainsttheentericorganismsfoundinthebileofapproximately80%ofpatientswithgallstonesandacutecholecystitis.Theseorganismsincludebothgram-positiveand–negativeaerobesandanaerobes.Thedefinitivetreatmentofacutecholecystitisischolecystectomy.Thetimingofoperationwasdebated.Treatment

PreoperativemanagemTreatmentConversiontoopencholecystectomyisindicatedwhenthelaparoscopicprocedurecannotbecompletedsafelyorwhenbleedingorabileleakcannotbestoppedwithoutriskinginjurytoimportantstructures.Cholecystectomyforacutecholecystitisisperformedwithamortalityrateoflessthan0.2%andamajormorbidityrateoflessthan5%.Theincidenceofbileductinjuryisapproximately0.4%.TreatmentConversiontoopenchChronicCholecystitis

ChronicCholecystitisThetermchroniccholecystitiswithcholelithiasisisoftenusedtoconnotesymptomaticgallbladderdisease.Chronicinflammatorychangesarefoundinthegallbladders.Approximately98%ofpatientswithsymptomaticgallbladderdiseasehavegallstones.ThetermchroniccholecystitisPathology

Thepathologicfindingsinchroniccholecystitisarebestinterpretedinlightoftheclinicalmanifestationsofthedisease.twotypesofchroniccholecystitisexist:Secondarychroniccholecystitis:Followsanepisodeofacutecholecystitis.Acutecholecystitisiscausedbygallbladderoutletobstruction,alwaysbyastone.Incasesthatdonotprogresstoperforation,theseabnormalitiesgraduallyresolveover3to4weeks.Simultaneously,granulomaformationbegins.Themucosaitselfbecomesthinandlosesitsvillousappearance.PathologyThepathologicfPathologyPrimarychroniccholecystitis:OccursprimarilywithoutantecedentacutecholecystitisIscharacterizedbyathin-walledgallbladder,withanintactmucosathatretainsitsvillousconfigurationStonesarealmostpresentinbothformsofchroniccholecystitis.PathologyPrimarychroniccholeDiagnosis

Recurrentattacksofrightupperquadrantorepigastricpainordiscomfort,usuallyfollowingmeals.Nauseaandvomitingmayoccurduringtheattack.Intervalsbetweenattacksarevariable,maybecontinuousorseparatedbyseveralyears.Nofeverorothersignsofinflammationarepresent.DiagnosisRecurrentattacksofTreatment

Thedefinitivetreatmentforsymptomaticgallstonesislaparoscopiccholecystectomy.

TreatmentThedefinitivetreatChronicAcalculousCholecystitis

Acuteinflammationofthegallbladderwithoutstonesisarecognizedentitythatrequirescholecystectomy.Occasionally,patientshavesignsandsymptomsofgallbladderdisease,butstonescannotbedemonstratedbyrepeatedultrasonographyororalcholecystography.Thecriteriaforcholecystectomyinthissituationarenotclearlydefined.ChronicAcalculousCholecystitCholangitis

CholangitisCholangitis,originallydescribedbyCharcotin1877,isabacterial,parasitic,orchemicalinflammationofthebileductsystem.Cholangitis,originallydescri

Howbacteriaenterthebileductsystem:Smallnumbersofbacteriapassintotheportalvenoussystemfromtheintestine.AscendfromtheduodenumCanbeintroducedintoanormalorabnormalbileductsystembythetubes,catheters,scopes,guidewires,andotherinstrumentsusedfordiagnosisandtreatment.HowbacteriaenterthebilAssociatedPathology

Choledocholithiasis(mostcommon)MalignantstricturesCholangiocarcinomaPancteaticcancerAmpullarycancerGallbladdercancerBenignstrictures(secondcommon)AnastomoticstenosisImpactedstoneAmpullarystenosisIndwellingtubesorstentsAssociatedPathologyCholedochAssociatedPathologyCholangiographyT-tubePercutaneoustranshepaticEndoscopicretrogradeParasiticinfestationsClonorchissinensisAscarislumbricoidesIschemiaChemicalirritationCarbamazepineClinorilAssociatedPathologyCholangiogBacteriology

Theorganismsfoundinthebileofpatientswithgallstonesandotherdiseaseofthebiliarytractarethosethatareculturedfromthebloodandthebiliarytractduringepisodesofacutecholangitisoracutetoxiccholangitis.Mostareaerobicbacteria,includingthegram-negativeorganisms,andgram-positiveorganisms.BacteriologyTheorganismsfouClinicalManifestations

TheoriginaldescriptionofcholangitisbyCharcotconsistedofintermittentchillsandfever,jaundice,andabdominalpain.Charcot’striadremainsthehallmarkofacutecholangitisbydefinition.ReynoldsandDargandescribedpatientswhohadshockandcentralnervoussystem(CNS)depressioninadditiontoCharcot’striadandnotedthatthislethalcombinationofsymptoms,nowknownasReynolds’pentad.Reynolds’pentadisthatthisconditionisrapidlylethalwithoutemergencyintervention,whereasCharcot’striadisanacutebutlesstoxicconditionforwhichimmediateinterventionisusuallynotnecessary.ClinicalManifestationsTheorClinicalManifestationsThecompletesymptomtriadofchillsandfever,abdominalpain,andjaundiceoccursinonly50%to70%ofpatientswhohavecholangitis.Otherthanelevatedtemperatureandjaundice,thepositivephysicalfindingsarelimitedtotheabdomen.60%to80%ofpatientshaveabdominaltenderness,whichisalmostalwaysintherightupperquadrantorepigastrium.Occasionally,amassmaybepresentintherightupperquadrantduetoanenlargedgallbladder,atumor,oranabscess.

ClinicalManifestationsThecomClinicalManifestationsTheorganismsmostfrequentlyculturedfromthebloodofpatientswithacutecholangitisare,indecreasingorder,E.coli,Klebsiellapneumoniae,andS.faecalisClinicalManifestationsClinicalManifestationsAOSC(acuteobstructivesuppurativecholangitis)Reynolds’PentadThesymptomsofAOSCaremoresevere,butthecharacteristicfeaturesarethepersistentandprogressivenatureofthesymptomsandthepatient’sfailuretorespondrapidlytoconventionaltherapyforsepsis.Inacutetoxiccholangitis,thismeansemergencydecompressionofthebileductsystem.ClinicalManifestationsAOSC(aDiagnosisoftheUnderlyingCondition

Cholangiography:Isthedefinitivetestandisnecessaryforplanningdefinitivetherapy,butitshouldnotbedoneuntiltheacuteprocessisundercontrol.Ultrasound:Withspecialemphasisonthepresenceorabsenceofcholelithiasis,buleductdilatation,massesintheheadofthepancreasorwithinthehepaticportal,andcholedocholithiasisComputerizedtomography:Delineatetheextent,aswellastoassesstheliverforhepaticmetastases.DiagnosisoftheUnderlyingCoDiagnosisoftheUnderlyingConditionCholescintigraph