1、胆道疾病,第一节 解剖生理概要,一、胆道系统应用解剖：,胆道系统: 肝内胆管肝外胆管胆囊Oddi括约肌等起于毛细胆管末端与胰管汇合开口于十二指肠乳头外有Oddi括约肌围绕,胆道系统,1. 肝外胆管:,左、右肝管: 左肝管: 细长(2.54cm)与肝总管90夹角右肝管: 粗短(13cm)与肝总管150夹角 肝总管:直径0.40.6cm, 长3cm注意副肝管(610%) 胆总管:长79cm，直径0.60.8cm胆囊、胆囊管,肝外胆管,2. 胆囊：,胆囊：4060mlHartmann袋 胆囊管：长23cm直径0.3cmHeister瓣 Calot三角,Calot三角,3.胆胰管汇合部:,有壶腹,两管
2、分别开口,不形成壶腹,十二指肠小乳头,十二指肠大乳头,Oddi 括约肌,十二指肠乳头,胆胰管汇合、Vater壶腹,4. 血管分布：,动脉(前面观),静脉(前面观),1). 胆汁分泌和功能:,分泌量: 成人8001200ml/d酸碱度: 中性或弱碱性成分: 水(97%)胆汁酸与胆盐、胆固醇、卵磷脂、胆色素脂肪酸、氨基酸、酶类、无机盐、刺激因子功能: 乳化脂肪, 促使脂肪、胆固醇和脂溶性维生素吸收抑制肠内致病菌和内毒素刺激肠蠕动中和胃酸等,2). 胆汁分泌调节,神经内分泌调节: 促进胆汁分泌因素:迷走神经兴奋促胰液素、胃泌素、胰高糖素、肠血管活性肽等。 抑制胆汁分泌因素:交感神经兴奋生长抑素、胰多
3、肽等。药物、食物影响:胃酸、脂肪和蛋白质分解产物十二指肠刺激十二指肠粘膜分泌促胰素、促胆囊收缩素(CCK) 胆囊平滑肌收缩Oddi括约肌松弛、胰液分泌。,第二节 特 殊 检 查,1. B超检查:,用途: 诊断胆道结石：特征：强回声光团伴声影; 诊断准确率：8095%;胆总管下端因常受胃肠道气体干扰, 检查准确率降低。 鉴别黄疸原因：根据胆管有无扩张、扩张部位和程度，逆行定位和定性诊断；准确率90%。 诊断胆囊炎、胆囊及胆管肿瘤、胆道蛔虫、先天性胆道畸形等;可在B超引导下行经皮肝胆管穿刺造影、引流和取石等。 术中B超：利用特制探头放置肝、胆管表面直接检查；可提高肝胆疾病诊断率, 及时发现结石,
4、指导取石，减少术后残石。,2. 普通X线检查:,腹部平片: 可在腹部平片上显示15%胆囊结石。胆道内积气: 胆肠内瘘或Oddi括约肌功能失常。胆囊整个或大部分钙化。口服法胆囊造影: 准确性受多种因素影响，现已渐为超声检查替代。静脉法胆道造影: 本法显影常不清晰，受多种因素影响。术中及术后胆管造影: 胆道手术时经胆囊管、胆总管置管行胆道造影, 了解胆管狭窄、残石、胆总管下端通畅，以确定是否行胆总管探查及手术方式。 胆总管T管引流或胆管置管引流, 拔管前常规行胆道造影。,3. CT、螺旋CT胆道成像:,能清楚显示肝胆管的扩张范围、程度，梗阻水平，肿瘤部位、大小，以及胆囊病变等；诊断结石不如B超；螺
5、旋CT胆道成像具有重要价值。,4. MRI或磁共振胆胰管成像 (MRCP) :,具有成像无重叠、对比分辨力高、无损伤、安全、准确的特点。能清楚显示肝内外胆管扩张的范围和程度，结石的分布，肿瘤的部位、大小，胆管梗阻的水平，以及胆囊病变等。,5. PTC、PTCD：,经皮肝穿刺胆管造影(PTC):是在x线电视或B超监视下, 利用特制穿刺针经皮穿入肝内胆管, 再将造影剂直接注入胆道而使肝内外胆管显影的一种顺行性胆道直接造影方法。本法可清楚显示肝内外胆管的病变部位、范围、程度和性质等，有助于胆道疾病，特别是黄疸的诊断和鉴别诊断。缺点:有创性检查, 可能发生胆漏、出血、胆道感染等并发症。通过PTC管可行
6、胆管引流(PTCD) 或置放胆管内支架(stent)用作治疗。,6.逆行胰胆管造影(ERCP):,方法: 在纤维十二指肠镜直视下通过十二指肠乳头将导管插入胆管和（或）胰管内进行造影的方法。用途: 直接观察十二指肠及乳头部情况和病变, 对可疑病变可直接取材作活检；通过造影可显示胆系、胰管的解剖和病变, 对胆道疾病尤其黄疸鉴别诊断有较大价值。用于治疗: 如鼻胆管引流, Oddi括约肌切开, 胆总管下端取石, 胆道蛔虫病取虫等治疗。,7.胆道闪烁成像:,99mTc-EHIDA闪烁成像，用相机摄影或单光子束发射计算机断层扫描仪（SPECT）动态观察。有助于黄疸、胆道梗阻鉴别诊断；胆囊管梗阻时胆囊不显影
7、。,8. 胆道镜检查:,术中胆道镜检查:术后胆道镜检查:,Cholelithiasis 胆石症,Types of gall stone and aetiology,Normal bile consists of 70% bile salts 22% phospholipids (lecithin), 4% cholesterol, 3% proteins, and 0.3% bilirubin.,Cholesterol or cholesterol predominant (mixed) stones form when there is supersaturation of bile wit
8、h cholesterol and aided by decreased gallbladder motility. Black pigment stones consist of 70% calcium bilirubinate,Brown pigment stones are formed within the intraheptic and extrahepatic bile ducts as well as the gall bladder.,They form as a result of stasis and infection within the biliary system,
9、 usually in the presence of Escherichia coli and Klebsiella spp, which produce lucuronidase that converts soluble conjugated bilirubin back to the insoluble unconjugated state leading to the formation of soft, earthy, brown stones,Risk factors associated with formation of cholesterol gall stones,Age
10、 40 years Female sex (twice risk in men) Genetic or ethnic variation High fat, low fibre diet Obesity Pregnancy (risk increases with number of pregnancies),Hyperlipidaemia Bile salt loss (ileal disease or resection) Diabetes mellitus Cystic fibrosis Antihyperlipidaemic drugs (clofibrate) Gallbladder
11、 dysmotility Prolonged fasting Total parenteral nutrition,胆囊结石,1. 病因: 综合性因素所致,胆汁胆固醇过饱和: 胆汁胆固醇过饱和学说胆汁胆固醇成核异常: 胆固醇结晶成核学说胆囊功能异常: 对水电解质吸收增加，使胆汁浓缩胆囊分泌粘蛋白增加胆囊收缩减弱，胆汁淤滞于胆囊内环境因素改变: 主要指饮食改变基因与遗传: 遗传倾向多基因疾病,胆固醇结晶形成成核学说：,促成核因子(粘糖Pr、免疫球Pr、Ca+游离脂肪酸、 蛋白结合钙),胆汁中微泡(vesicles)、微胶粒(micelles)小泡,聚集融合,胆固醇单水结晶,胆固醇结石,抑成核因子
12、 (小分子Pr、载脂蛋白A-1、 载脂蛋白A-2),胆汁中成大泡,胆固醇结石危险因素：,导致胆固醇高分泌: 致石基因、年龄、饮食药物（雌激素、安妥明、奥曲肽）；长期禁食导致胆囊胆汁浓缩； 导致胆囊内胆汁淤滞: 肥胖和降体重、妊娠、肠外营养、胃切除老年女性糖尿病、脊髓损伤和奥曲肽； 饮食危险因素: 高热量、动物脂肪、总蛋白和动物蛋白、磷脂酰丝氨酸。,2. 临床表现:,与胆囊结石病类型, 结石大小、部位, 是否合并感染、梗阻及胆囊功能有关。 静止性或无症状性胆囊结石（约2040%）。,临床表现,症状性胆囊结石主要临床表现和并发症为：进食或进油腻后上腹或右上腹隐痛不适等胃肠道症状。典型胆绞痛。胆囊结
13、石嵌顿不缓解，则胆囊增大、积液，可发展为急性化脓性胆囊炎或胆囊坏疽，此时除腹痛加剧外尚伴有腹膜炎和全身中毒表现。,临床表现,Mirizzi综合征。小结石通过胆囊管进入并停留于胆总管内形成继发性胆管结石。胆源性胰腺炎。胆囊十二指肠瘘，胆石性肠梗阻。诱发胆囊癌变。,MANIFESTATION临床表现,biliary pain Nausea or vomiting Acute cholecystitis pancreatitis,3. 诊 断:,病史、体检。B超检查: 胆囊内结石光团、声影，伴胆囊增大或囊壁增厚，首选。口服胆囊造影: 可显示胆囊内充盈缺损并了解胆囊功能，对诊断有一定帮助。CT、MRI
14、可显示胆囊结石，因价格昂贵不作首选。,诊断 DIAGNOSIS,B超 CT MRI,Acute cholecystitis,Gallbladder stone,Gallbladder stone,Gallbladder stone,Gallbladder stone,Gallstone ileus,Acute cholecystitis -gall bladder to adhere to jejunum or duodenum- a fistula between these structures -passage of a gall stone into the bowelLarge st
15、ones may become impacted and obstruct the small bowel.,Gallstone ileus,Abdominal radiography shows obstruction of the small bowel and air in the biliary tree.Treatment is by laparotomy and “milking“ the obstructing stone into the colon or by enterotomy and extraction.,Small bowel obstruction and gas
16、 in bile ducts in patient with gallstone ileus,Mirrizi syndrome,Type 1 Mirrizis syndrome: gallbladder stone in Hartmanns pouch compressing common bile duct and causing deranged liver function,4. 预 防:,胆石病三级预防。调整饮食习惯。胆汁载脂蛋白（Apo）A1、长链脂肪酸胆汁酸结合物食物卵磷脂。预防胆石病药物: 阿莫西林、西沙比林、红霉素、胃动素、CCK、雨蛙肽熊去氧胆酸、多价不饱和脂在流行病学危险因
17、素方面: 人群中实施预防胆石形成战略，减少无症状胆石病人出现症状和并发症，降低体重、限制饮食药物控制糖尿病,5. 治 疗:,手术治疗: 以各种胆囊切除术的手术治疗为主。非手术治疗,Treatment of gallbladderstone,LC OC 小切口胆囊切除术 溶石疗法dissolution 碎石疗法 lithotrypsy 经皮胆镜碎石percutaneous choledochoscopic lithotrypsy,LC,Disadvantage of LC,The main disadvantage of the laparoscopic technique has been a
18、 higher incidence of injury to the common hepatic or bile ducts). Higher rates of injury are associated with inexperienced surgeons and acute cholecystitis.,Disadvantage of LC,injuries to the common bile duct tend to be more extensive with laparoscopic surgery. rates of injury are now falling.,Cause
19、s of pain after cholecystectomy,Retained or recurrent stone (dilatation of common bile duct seen in only 30% of patients) Iatrogenic biliary leak or stricture of common bile duct,Causes of pain after cholecystectomy,Papillary stenosis or dysfunctional sphincter of Oddi Incorrect preoperative diagnos
20、is - for example, irritable bowel syndrome, peptic ulcer, gastro.oesophageal reflux,non-surgical techniques,Less than 10% of gall stones are suitable for non.surgical treatment Stones are cleared in around half of appropriately selected patients. In addition, patients require expensive, lifelong tre
21、atment to counteract bile acid in order to prevent stones from reforming.,Criteria for non-surgical treatment of gall stones,Cholesterol stones 20 mm in diameter Fewer than 4 stones Functioning gall bladder Patent cystic duct Mild symptoms,无症状结石定期随访,Two thirds of gall stones are asymptomatic Prophyl
22、actic cholecystectomy is not recommended when stones are discovered incidentally the risk of developing cancer in patients with asymptomatic gall stones is 0.01%,肝外胆管结石,1. 分类:,原发性胆管结石: 系胆管内形成的结石, 主要为胆色素或胆色素混合结石。继发性胆管结石: 为胆囊结石排至胆总管者，主要为胆固醇结石。,2. 成 因,胆道感染： Maki -葡萄糖醛酸酶(-G)学说胆红素钙沉淀溶解平衡学说胆道寄生虫病：胆道蛔虫、中华分
23、支睾吸虫是胆道感染重要原因蛔虫残体或肝吸虫作为胆石核心。,3. 临床表现:,临床表现: Charcot三联症: 腹痛寒战高热黄疸：间歇性梗阻性黄疸持续性梗阻性黄疸,临床表现,体格检查：巩膜和皮肤黄染剑突下和右上腹深压痛，甚至局限性腹膜炎肝区叩痛, 肿大触痛胆囊。,临床表现,Patients may present with jaundice or pain fever and acute pancreatitis; the results of liver function tests are characteristic of cholestasis a dilated common bil
24、e duct is visible on ERCP CT MRCP and ultrasonography.,4. 诊断:,典型Charcot三联症实验室检查: 血白细胞增高;梗阻性黄疸的肝功能改变。B超: 胆总管结石、肝内外胆管扩张、有时胆囊增大。MRCP、CT、ERCP/PTC或内镜超声: 可提供结石的部位、数量、大小, 胆管梗阻的部位、程度。诊断困难时可选用。,5. 治疗原则,积极手术, 解除胆道梗阻, 引流减压；即使休克亦应积极抗休克, 及时手术。,治疗原则,取净结石，去除病灶；保持胆道引流通畅，预防胆石再发；合理应用抗生素。,手术治疗:,胆总管切开取石、T管引流术(开腹或腹腔镜) 胆
25、肠吻合术(胆肠内引流术)Oddi括约肌成形术,经内镜下括约肌切开取石术（endoscopic sphincterotomy，EST）,Managing common bile duct stones,The optimal treatment - two stages by ERCP followed by LC or as a single stage cholecystectomy with exploration of the common bile duct by laparoscopic or open surgery.,A patient with gallbladder and
26、CBD stone,Remove CBD stone by ERCP,肝内胆管结石,是位于肝管分叉以上的结石。结石特性、形成机制和原发性胆管结石相同。左叶明显多于右叶 东亚、东南亚一些国家地区，我国农村、边缘地区，发病率较高。,病 因,复发性化脓性胆管炎等肝内胆道慢性炎症、细菌感染;胆道寄生虫病,如胆道蛔虫病和中华分支睾吸虫感染，蛔虫残骸或肝吸虫为核心的胆石较多见；胆管变异梗阻、胆汁淤滞；营养因素等。,病 理,基本病理改变：肝内胆管的炎症、结石梗阻、含结石的肝胆管扩张、管壁增厚和纤维组织增生。除肝外胆管结石的病理改变外，还有：肝内胆管狭窄和扩张：胆管炎；结石存在的肝段（叶）实质萎缩，对侧肝代偿
27、性增大；胆管长期受结石、炎症及胆汁中致癌物刺激, 发生癌变。,临床表现,临床表现: 因肝内胆管结石存在部位、因人而异。未合并肝外胆管结石时, 可多年无症状,或仅有肝区、胸背胀痛不适，一般无黄疸。合并肝外胆管结石，其临床表现与肝外胆管结石相似。一旦梗阻和继发感染，则出现寒战、高热、轻度黄疸，甚至休克，,临床表现,易引起胆源性肝脓肿，甚至穿至膈下、胸腔和肺，形成胆管支气管瘘。 病程长者可发生胆汁淤积性肝硬化、门静脉高压症及肝功能障碍。 体格检查: 肝不对称性肿大，肝区压叩痛。合并感染和并发症时，则出现相应体征。,诊断,B超: 可显示肝内胆管结石、肝胆管狭窄和扩张、肝萎缩。 PTC MRCP CT、
28、螺旋CT胆胰管成像,治疗,原则: 采用以手术方法为主的综合治疗。方法: 手术治疗 原则是取净结石、解除狭窄、切除病肝、通畅引流和预防复发，其中解除狭窄是手术治疗的关键。中西医结合消炎利胆溶石，或“总攻”疗法。残余结石的处理,手术治疗,高位胆管切开取石。肝叶（段）切除：主要切除狭窄、扩张和充满结石的病损严重肝组织。胆管狭窄的切开、整形及胆肠内引流。肝移植术：如全肝内胆管充满结石，无法取净，且肝功能损害有生命危险者，可施行肝移植术。,急性胆囊炎,1. 病因:,胆囊管梗阻: 80%由结石阻塞或嵌顿于胆囊管或胆囊颈引起;胆囊管扭转、狭窄、胆道蛔虫、胆囊肿瘤等。 细菌感染:多为继发性感染; 途径: 通过
29、胆道逆行侵入胆囊;经血循环或淋巴途径进入胆囊;经十二指肠乳头逆流。 致病菌: 革兰氏阴性杆菌如大肠杆菌、肠球菌、绿脓杆菌等;厌氧菌亦较常见。,2. 病理:,分型: 急性单纯性胆囊炎急性化脓性胆囊炎 急性坏疽性胆囊炎坏疽胆囊穿孔急，胆汁性腹膜炎；坏疽胆囊穿孔慢，胆囊周围脓肿。 转归: 炎症逐渐消退，恢复原来结构;转为慢性胆囊炎，甚至胆囊萎缩;引起胆管或胰腺炎；胆囊胃肠道瘘;胆石性肠梗阻。,3. 临床表现:,右上腹突发阵发性绞痛，常在饱餐、进油腻食物后，或在夜间发作。疼痛可放射至右肩部、肩胛部和背部。伴恶心、呕吐、厌食等消化道症状。发热，通常无畏寒; 如胆囊积脓、穿孔或合并有急性胆管炎则出现明显寒
30、战高热。10%25%病人可出现轻度黄疸，主要是炎症引起Oddi括约肌痉挛、乳头水肿所致。若黄疸较重且持续，表示有胆总管结石并梗阻可能。体格检查：右上腹不同程度、不同范围压痛、反跳痛及肌紧张，Murphy征阳性。有的扪及肿大触痛胆囊。如胆囊发生坏死、穿孔，可出现弥漫性腹膜炎。,4. 诊断:,胆囊疾病发作史;典型临床表现;白细胞升高, 血清转氨酶、AKP、胆红素或淀粉酶升高。影像学检查：B超检查显示胆囊增大，囊壁增厚，甚至“双边”征，胆囊内结石光团伴声影。CT对诊断也有帮助。,注意与消化性溃疡穿孔、急性胰腺炎、高位阑尾炎、肝脓肿、结肠肝曲癌或憩室穿孔，以及右侧肺炎、胸膜炎和肝炎等疾病鉴别。,治疗,
31、手术治疗: 首选治疗方法。开腹胆囊切除术 LC；LC中发现胆囊管炎症重、周围粘连、解剖不清, 应及时中转开腹手术胆囊造瘘术: cholecystectomy should be performed during the same admission.,非手术: 禁食、胃肠减压、解痉;输液、纠正水电解质及酸碱平衡失调, 支持疗法;广谱或联合应用抗生素。,慢性胆囊炎 （chronic cholecystitis）,1. 概述：,定义: 慢性胆囊炎是急性胆囊炎反复发作或胆 囊结石长期存在的结果，常表现为胆囊壁增厚、胆囊萎缩， 约7095病人合并胆囊结石。分类: 慢性结石性胆囊炎慢性非结石性胆囊炎,病
32、理,胆囊粘膜萎缩; 胆囊壁因纤维结缔组织增生和细胞浸润而增厚; 与周围组织粘连; 胆囊壁瘢痕形成，萎缩，失去功能。 高龄、病程长、胆囊壁明显增厚、结石较大等时， 有恶变可能。,3. 临床表现:,临床症状常不典型; 胆绞痛史; 厌油腻饮食、腹胀、暖气等消化道症状; 右上腹和肩背部隐痛, 少有畏寒高热和黄疸。 体检可发现右上腹胆囊区轻度压痛和不适感，Murphy征可呈阳性。,4. 诊断:,右上腹和肩背部隐痛病史;B超检查显示胆囊缩小，囊壁增厚，内有结石或充满结石，胆囊收缩功能很差;口服胆囊造影表现为胆囊显影淡薄或不显影，收缩功能减低，亦有助于诊断。,5. 治疗:,对伴有胆石者均应行胆囊切除术。对不
33、伴结石、症状较轻、影像学显示胆囊无明显萎缩有一定功能者，手术治疗应慎重，特别是年轻女性病人, 可先行消炎利胆及制酸非手术治疗。对年老体弱、伴重要器官严重器质性病变、不能耐受手术者，可采用非手术治疗，包括低脂饮食,服用胆盐、消炎利胆药，中西医结合治疗。,急性梗阻性化脓性胆管炎 AOSC,定义,急性梗阻性化脓性胆管炎 (acute obstructive suppurative cholangitis，AOSC）胆道 梗阻的基础上发生的胆道系统的急性性感 染或炎症，是胆道感染疾病中的严重型，故亦称急性重症型胆管炎,病因,原因: 胆管结石、胆道蛔虫症胆管良性狭窄胆管壶腹部肿瘤胆肠吻合术后吻合口狭窄原
34、发性硬化性胆管炎T管造影或PTC术后。 致病菌：几乎都为肠道细菌经肠道逆行进入胆管；主要为G-杆菌(大肠、绿脓、变形、克雷伯等杆菌);粪链球菌、肠球菌等G+菌；厌氧菌亦多见；也可混合感染。,When an obstructed common bile duct becomes contaminated with bacteria, cholangitis may develop.,病理, 胆管内压升高, 梗阻以上胆管扩张、壁厚; 肝脏充血肿大, 肝细胞坏死, 肝多发性脓肿、胆道出血; 当胆管内压30cmH2O时, 胆汁中大量细菌和毒素逆行进入肝窦，产生严重脓毒血症, 发生感染性体克、全身性化脓
35、性感染和多器官功能损害; 胆砂性血栓经肝静脉、下腔静脉进入肺循环, 发生肺动静脉胆沙性血栓栓塞，肺局灶性梗死。,临床表现 Charcot-Reynolds五联征,上腹疼痛: 因原有病变和梗阻部位而异: 胆总管结石、胆道蛔虫症多为剧烈绞痛；肝管狭窄、胆道肿瘤为右上腹、肝区剧烈胀痛；肝外梗阻者腹痛明显，肝内梗阻者腹痛较轻。寒战高热: 39以上，甚至4041，寒战和弛张高热。,临床表现,梗阻黄疸: 中毒休克: 血压下降，中毒性休克。 神经系统表现: 躁动谵妄、或淡漠嗜睡、神志不清、甚至昏迷,诊断,典型Charcot-Reynolds五联征。 实验室检查: 白细胞升高(20109/L),血小板降低(1
36、020109/L);凝血酶原时间延长，肝功能受损；尿蛋白及颗粒管型;血培养，部分病人有细菌生长。 B超、 CT、MRCP胆总管或肝内胆管结石、胆道梗阻部位性质以及肝内外胆管扩张、胆管壁增厚、胆囊增大等。,治疗,治疗原则: 紧急手术，切开胆总管减压，解除胆道梗阻,通畅引流胆道。,治疗,ENBD PTBD EST,非手术治疗, 改善病人情况, 为手术做准备, 故一般应控制在6h内。 对病情较轻，经短期治疗好转，可在严密观察下继续如病情严重或治疗后病情恶化，出现休克或休克加重, 则应紧急手术治疗，即边抗休克边进行手术治疗。,非手术治疗, 抗感染: 足量、联合、有效、广谱抗生素。 维持有效循环血容量，
37、防治休克。 纠正水、电解质紊乱和代谢性酸中毒。 使用肾上腺皮质激素。 改善低氧和通气功能，防治多器官功能衰竭。 全身支持和对症治疗, 包括解痉止痛、降温、 吸氧、 输血、补充白蛋白、维生素等。,Urgent treatment is required with broad spectrum antibiotics,early decompression of the biliary system by endoscopic or radiological stenting or surgical drainage Delay may result in septicaemia or liver
38、 abscesses, which are associated with a high mortality,原发性硬化性胆管炎PSC,病因不 有溃疡性结肠炎史 表现 黄疸 肝脾大 肝硬化 诊断 ERCP MRCP PTC 治疗 缺乏有效治疗方法 肝移植,第六节 胆 道 蛔 虫 病,一、概述：,胆道蛔虫病（biliary ascariasis）：常见外科急腹症；多发生在青少年和儿童；发病率：农村高于城市，明显下降。,三、临床表现:,腹痛：突发、剑突下、钻顶样、剧烈绞痛，体征轻微，间隙性； 恶心、呕吐或呕吐蛔虫；合并胆道感染：发热、黄疸；并发胰腺炎、肝脓肿，则出现相应症状体征。,四、诊断：,青少
39、年、儿童，不洁饮食史；剧烈剑突下钻顶样绞痛，但腹部体征轻微；血常规嗜酸粒性细胞升高，大便查见蛔虫卵；B超示胆管内平行强光带，偶见蛔虫蠕动；ERCP偶见胆总管开口处蛔虫；鉴别胆石症、急性胰腺炎、急性肠梗阻、上消化道穿孔等急腹症。,五、治疗：,非手术治疗: 解痉止痛: 注射阿托品、山莨菪碱等; 利胆驱蛔: 发作时: 服用乌梅汤、食醋、30%硫酸镁,经胃管注入氧气;缓解期: 驱虫净、哌嗪（驱蛔灵）或左旋咪唑; 抗感染; ERCP取虫。 手术治疗:指征: 非手术积极治疗35天症状无缓解或加重；胆管内蛔虫多而难用非手术疗法治愈者, 或蛔虫结石并存；胆囊蛔虫病；合并严重并发症如AOSC、坏死性胰腺炎、肝脓
40、肿、胆汁性腹膜炎。方法: 胆总管探查取虫及T管引流。合并症者采取相应术式。,先天性胆总管囊状扩张症,表现 腹痛 黄疸 发热 腹部肿块 青少年 女性 诊断 B超 ERCP MRCP CT 治疗 彻底切除囊肿 胆肠吻合,胆道损伤,胆瘘 胆汁性腹膜炎 黄疸 医源性损伤占多数 B超 MRCP ERCP 可诊断 手术治疗为主,Neoplasm of bile duct,二、胆囊息肉 (gallbladder polyps),病理分类,非肿瘤性息肉: 胆固醇息肉、炎性息肉、腺肌增生、腺瘤样增生，黄色肉芽肿； 肿瘤性息肉: 腺瘤-癌前病变，少见的有血管瘤、脂肪瘤、平滑肌瘤等； 统称“胆囊息肉样病变” (po
41、lypoid lesions of gallbladder)或“胆囊隆起性病变”。,诊断,多数病人无症状，少数右上腹隐痛不适;诊断主要依据是B超发现; 以下情况为恶变危险因素: 直径超过1cm； 年龄超过50岁； 单发病变, 息肉逐渐增大； 合并胆囊结石等。,三、治疗:,手术治疗指征: 有症状病人排除胃十二指肠、其它胆道疾病;有以下情况的无症状病人：直径lcm单个病变年龄50岁连续B超发现增大、腺瘤样息肉或宽基 合并胆囊结石或囊壁增厚。方法: 直径2cm或高度怀疑恶变-剖腹手术以便根治切除。随访: 如无以上情况者， B超随访，1次/36m。,Polyp of gallbladder,Polyp
42、 of gallbladder,Gallbladder Cancer,gallbladder cancer is still the 5th leading cause of GI malignancies with 5,000 cases annually. Many cases are found incidently at the time of laparoscopic cholecystectomy.,Gallbladder cancer,Gallbladder cancer,when gallbladder cancer is found prior to surgery, rad
43、ical cholecystectomy is recommended. removal of the gallbladder, partial removal of the liver, and removal of the draining lymph glands.,When cancer is found after simple cholecystectomy, reoperation to resect part of the adjacent liver and the nearby lymph nodes may improve survival This is especia
44、lly true when the tumor invades the muscular wall of the gallbladder.,When only the mucosa of the gallbladder is involved then no further surgery is required.,treatment,surgery is the only potentially curative therapy.Chemotherapy has little role with disappointing response rates ( 10%). Radiation t
45、herapy may have some benefit in individual cases but remains to be proven in clinical trials.,manifestation,always a diagnostic dilemma there may be no symptoms in the early stages,manifestation,flatulent dyspepsia, pain in the right upper abdomenattack of jaundice or yellowish discoloration of skin
46、,manifestation,Unfortunately, when abdominal findings do appear, it is often already an advanced disease.,diadnosis,If the above symptoms are present, the doctor may order a series of imaging investigations and other tests to find out the problem. Usually, it is still difficult to find out cancer of
47、 the gallbladder unless the patient undergoes a surgery.,ultrasound,The first basic investigation which is ordered is an ultrasound .,胆囊癌（结节型）。结节内及蒂部见血瘤信号 胆囊癌（实块型）。整个胆囊均癌浸润,A more definitive investigation is in the form of a CT scan CT shows the thickness or change in thickness of the gallbladder wa
48、ll and liver infiltration,But many a times this may be missed. Especially so, if gallstones are associated with the problem,staging and grading,stage a cancer, to establish carefully degree of spread of the cancer and to what extent and involving which organs. grading well differentiated means less
49、aggressive moderately differentiated intermediately aggressive poorly differentiated more aggressive,Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, Bone scan or chest X-ray.,treatment,surgery radiation and chemotherapy have also been tried out, usually cancer of the gallbladder is not very amenable to these other modalities of treatment.,The ideal treatment for localized gallbladder cancer is radical cholecystectomy.( the gallbladder is removed along with a section of the liver, along with the associated lymph nodes ),
