外科学课件：胆道疾病

1、胆道疾病Disease of Biliary Tract,1. Special inspection method of biliary disease Etiology, diagnosis & treatment of Gallstones (Cholelithiasis) & Acute Calculous Cholecystitis & Chronic Cholecystitis Choledocholithiasis & Cholangitis 3. Etiology, diagnosis & treatment of Carcinoma of the Gallbladder Bil

2、e Duct Cancer,Biliary anatomy and physiology Metabolism of bilirubin 3. Pathogenesis of obstructive jaundice,【Self-Study】,Intrahepatic bile ducts Glissons system Extrahepatic bile ducts Left and right hepatic ducts common hepatic ducts common bile ducts Gallbladder,Bile ducts,胆道系统的应用解剖和生理 Anatomy &

3、Physiology,The shape of the gallbladder a pear. Its about 8cm long and holds 40 to 60ml of bile. The gallbladder is divided into four sections: fundus, body, neck and cystic duct. The corpus nestles into the substance of the liver. The neck of the gallbladder is lax, because it is not bound to the l

4、iver by peritoneum. The distal portion of the gallbladder has the appearance of a diverticulum, which is called Hartmanns pouch.,胆道系统的应用解剖和生理 Anatomy & Physiology,The cystic duct is 2 to 4 cm long and contains the spiral valves of Heister, which allow easy entry of bile into gallbladder but offer re

5、sistance to its outflow. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. The extrahepatic bile ducts lie within the hepatoduodenal ligament.,胆道系统的应用解剖和生理 Anatomy & Physiology,The triangle of Calot, a surgi

6、cal landmark used to identify important structures during cholecystectomy, is bounded by the cystic duct , the common hepatic duct, and the inferior border of the liver. The right hepatic and cystic arteries are located within it, and anomalous structures often pass through it.,胆道系统的应用解剖和生理 Anatomy

7、& Physiology,肝内胆管模式图,肝内胆管组织学,胆道系统的应用解剖和生理 Anatomy & Physiology,肝内胆管,肝内胆管起自毛细胆管，继而汇集成小叶间胆管，肝段、肝叶胆管及肝内部分的左右肝管。,左、右肝管出肝后，在肝门部汇合形成肝总管（common hepatic duct）。肝总管直径为0.140.6cm，长约34cm，其下端与胆囊管汇合形成胆总管（common bile duct）。胆总管长约48cm，直径0.60.8cm。,肝外胆道,肝外胆道包括左、右肝管、肝总管、胆总管、胆囊。,Oddi 括约肌主要包括胆管括约肌、胰管括约肌和壶腹括约肌 控制和调节胆总管和胰管的

8、排放 防止十二指肠内容物返流,胆汁的生成、分泌和代谢,成人每日分泌胆汁约8001200ml，胆汁主要由肝细胞分泌。 胆汁中97%是水，其他成分主要有胆汁酸与胆盐、胆固醇、磷脂和胆红素等。,Function of gallbladder Concentration and preservation of the bile. Secretion Contraction and empty,胆道疾病的特殊检查方法,X- ray Ultrasonography, EUS, IDUS CT MRI, MRCP(Magnetic resonance cholagiopancreatography) PTC

9、, PTBD ERCP Scintigraphy Choledochoscopy Cholangiography,胆道疾病的特殊检查方法,胆道特殊检查 - US,判断胆管有无扩张，对黄疸原因进行定位定性 术中B超检查 B超引导下行经皮肝穿刺胆管造影,胆道疾病的特殊检查方法,胆道特殊检查 - US,无创、安全、快速、简便、经济、准确 诊断胆道疾病的首选方法 胆囊结石诊断准确率95%以上,胆道疾病的特殊检查方法,X线检查,腹部平片,胆道疾病的特殊检查方法,口服胆囊造影,静脉胆道造影,胆道疾病的特殊检查方法,术中造影 Intraoperative Cholangiography,胆道疾病的特殊检查方

10、法,经皮经肝胆管造影术 ( PTC , Percutaneous Transhepatic Cholangiography) 经皮经肝胆管造影引流术 ( PTCD , Percutaneous Transhepatic Cholangiography Drainage),胆道疾病的特殊检查方法,CT / US引导PTCD 显示胆管病变部位、范围、性质、程度,PTC显示肝总管狭窄,可通过造影管行胆管引流（PTCD）或置放胆管内支架用作治疗。,胆道疾病的特殊检查方法,ERCP,内镜下逆行胰胆管造影术 Endoscopic retrograde cholangiopancreatography,是电

11、子十二指肠镜直视下通过十二指肠乳突将导管插人胆管和（或）胰管内进行造影。可直接观察十二指肠及乳头部的情况和病变，取材活检；收集十二指肠液、胆汁、胰液。取石，放置支架或鼻胆（胰）管引流，EST，IDUS，子母镜（Spy Glass）等,99m锝-二乙基亚氨二醋酸 iV 肝细胞清除分泌随胆汁排泄 动态观察在胆道流经的图像,核素扫描,胆道梗阻时显像时间的延迟，有助于黄疽的鉴别诊断。本法为无创检查，辐射物剂量小，对病人无损害。突出优点是在肝功能损伤，血清胆红素中度升高时亦可应用。,常见胆道疾病 Common Biliary Disease,常见胆道疾病,1，先天性疾病（胆道闭锁，胆总管囊肿,胆胰管汇合

12、异常） 2，结石（肝内外胆管结石，胆囊结石,Mirizzi综合征） 3，肿瘤（胆囊癌，胆管癌） 4，寄生虫（蛔虫） 5，医源性胆管损伤（LC时损伤胆管） 6, 急、慢性胆囊炎和急性胆管炎（急性梗阻性化脓性胆 管炎AOSC） 7， 原发性硬化性胆管炎,胆道闭锁是新生儿持续性黄疸的最常见病因。病变可累及整个胆道，亦可仅累及肝内或肝外的部分胆管，其中以肝外胆道闭锁常见，占85%90%。发病率女性高于男性。,胆道闭锁,病 因,胆管闭锁是一种进展性的胆管闭锁和硬化性病变。很多患儿出生时能排泄胆汁，以后进展成为完全性胆管闭锁。其病因主要有两种学说： 先天性发育畸形学说 病毒感染学说,胆道闭锁,胆道闭锁,病

13、 理,胆管闭锁所致梗阻性黄疽，可致肝细胞损害，肝脏因淤胆而显著肿大、变硬，呈暗绿或褐绿色，肝功能异常。若胆道梗阻不能及时解除，则可发展为胆汁性肝硬化，晚期为不可逆性改变。,胆道闭锁,大体类型主要分为三型： 型 完全性胆管闭锁 型 近端胆管闭锁，远端胆管通畅 型 近端胆管通畅，远端胆管纤维化 以、型常见。,胆道闭锁,胆道闭锁,临床表现,黄疸：梗阻性黄疽是本病突出表现。 营养及发育不良 肝脾肿大：是本病特点。,胆道闭锁,诊 断,凡出生后12个月出现持续性黄疽，陶土色大便，伴肝肿大者均应怀疑本病。下列各点有助于确诊： 黄疽超过34周仍呈进行性加重，对利胆药物治疗无效；对苯巴比妥和激素治疗试验无反应；

14、血清胆红素动态观测呈持续上升，且以直接胆红素升高为主；,胆道闭锁,十二指肠引流液内无胆汁； B超检查显示肝外胆管和胆囊发育不良或缺如； 99mTc-EHIDA扫描肠内无核素显示； ERCP和MRCP能显示胆管闭锁的长度。,胆道闭锁,手术治疗是唯一有效方法。手术宜在出生后2个月进行，此时尚未发生不可逆性肝损伤。若手术过晚，病儿已发生胆汁性肝硬化，则愈后极差。,治 疗,胆道闭锁,手术方式： 尚有部分肝外胆管通畅，胆囊大小正常者，可用胆囊或肝外胆管与空肠行Roux-en-Y型吻合。 肝外胆管完全闭锁，肝内仍有胆管腔者可采用Kasai肝门空肠吻合术。 肝移植,先天性胆总管囊肿,先天性胆道扩张症可发生于

15、肝内、肝外胆管的任何部分，好发于胆总管。本病好发于东方国家，尤以日本常见。女性多见，男女之比约为 1 : 34。幼儿期即可出现症状，约80%病例在儿童期发病。,先天性胆总管囊肿,病 理,根据胆管扩张的部位、范围和形态，分为五种类型： 型：囊性扩张。临床上最常见。 型：憩室样扩张。 型：胆总管开口部囊性脱垂。 型：肝内外胆管扩张。 型：肝内胆管扩张（Caroli病）。,先天性胆总管囊肿,临床表现,典型临床表现为腹痛、腹部包块和黄疽三联症。腹痛位于右上腹部 ，可为持续性钝痛；黄疽呈间歇性 ；80%以上病人右上腹部可扣及表面光滑的囊性肿块。晚期可出现胆汁性肝硬化和门静脉高压症的临床表现。囊肿破裂可导

16、致胆汁性腹膜炎。,先天性胆总管囊肿,诊 断,对于有典型“三联症”及反复发作胆管炎者诊断不难。但“三联症”俱全者仅占20%30%，多数病人仅有其中12个症状，故对怀疑本病者需借助其他检查方法确诊。,先天性胆总管囊肿,治 疗,本病一经确诊应尽早手术，否则可因反复发作胆管炎导致肝硬化、癌变或囊肿破裂等严重并发症。完全切除囊肿和胆肠Roux-en-Y吻合是本病的主要治疗手段，疗效好。,胆石症(Cholelithiasis),胆囊结石(Gallstone) Gallstones are classified as cholesterol, pigment types. But most stones d

17、o not fit into this rigid classification system 胆管结石 总胆管结石 (Common Bile Duct Stone) 肝内胆管结石 (Intrahepatic Duct Stone),Pathogenesis of Gallstones,主要为胆固醇性结石或以胆固醇为主的混合型结石。女性常见，男女比例1：3。 形成的原因：胆汁的成分和理化性质发生变化，胆汁中的胆固醇呈过饱和状态，易于沉淀析出、结晶形成结石；胆汁中存在促成核因子，可分泌大量的糖蛋白促使成核和结石形成；胆囊收缩能力降低，胆囊内胆汁淤积也有利于结石形成。,Cholesterol sa

18、turation of bile, stasis of bile within the gallbladder, and nucleating factors appear to be important.,Diagnosis - Gallstone,Recurrent attacks of right upper quadrant or epigastric pain or discomfort, nausea and vomiting Gallbladder colic, results from the temporary obstruction of the gallbladder o

19、utlet by a stone in the cystic duct or the infundibulum Physical findings: right upper quadrant or epigastric tenderness to palpation and voluntary muscle guarding. Jaundice is not a feature of cholelithiasis unless common duct obstruction.,Diagnosis,Imaging studies: Ultrasonography demonstration th

20、at the stones move to the dependent portion of the gallbladder when the position of the patient is changed and the stone produces acoustic shadowing. Blood RT,Treatment,The definitive treatment of symptomatic gallstones is laparoscopic cholecystectomy. The major advantages of the laparoscopic proced

21、ure are that patients have less pain and a shorter hospitalisation and are able to return to their activities sooner.,Open cholecystectomy is indicated only in patients in whom the laparoscopic is impossible or unsafe. Impossible to establish safe access to the peritoneal cavity Adhesions Anatomic a

22、bnormalities,Treatment,Other treatments Oral dissolution therapy: (UDCA) Contact dissolution therapy: Methyl tert-butyl Extracorporeal shock wave lithotripsy,胆囊切除 (Cholecystectomy) 剖腹胆囊切除 (open) 腹腔镜胆囊切除 (Laparoscopic Cholecystectomy) 胆囊造瘘 (Cholecystostomy),胆囊结石治疗,胆石症(Cholelithiasis),Mirizzi综合征及其分型,是

23、一种少见的胆囊结石并发症 容易漏诊和误诊 可引起肝总管狭窄和梗阻 并发阻塞性黄疸和肝功能损害 国内报道其占同期胆囊切除术的l3 国外发病率为0.71.4,Mirizzi综合征(Mirizzi syndrome，MS),定义,MS是指胆囊结石长期嵌顿于胆囊壶腹部或颈部，从外部压迫肝总管、胆总管，导致后者狭窄、梗阻，并发胆囊炎、胆管炎、梗阻性黄疸、肝功能损伤及各种胆内瘘的综合征,发现,1905年，Kehr首先描述了胆囊结石引起的胆道部分梗阻及相关炎症过程 Mirizzi教授1940年将该类疾病以综合征的形式进行了系统介绍，成为MS相关最早的报道 Puestow，首先报道了胆囊结石相关自发性胆内瘘，

24、指出内瘘可发生于胆囊和胸、腹腔脏器，如胃、十二指肠、结肠以及支气管间，补充了MS复杂的解剖特点,解剖学特点,胆囊结石嵌顿于胆囊颈部或壶腹部，胆囊萎缩，囊壁异常增厚或变薄 胆囊管多发生闭塞 胆囊结石外部压迫胆管或侵透胆管壁 胆囊管过长或过短，或平行于胆总管低位汇入 病变近侧胆道炎症明显，胆管壁增厚，而远侧胆管结构正常 可形成胆内瘘，涉及胆管、胃、十二指肠、结肠、甚至气管，瘘管欠规则,临床表现,发生于任何年龄，患者多分布于50-70岁，男女比例相当 结石长期存在引起MS的中位时间约29.6年 可呈急性发作，如急性胆囊炎、胆管炎或急性胰腺炎，也可呈现慢性过程 一半以上的患者主诉右上腹疼痛，60%以上

25、的患者出现梗阻性黄疸，胆石性肠梗阻时有发生 部分患者CA-199异常升高，导致MS与以梗阻性黄疸为主要表现的胆胰恶性肿瘤鉴别困难,临床分型,1982年，Mcsherry等根据ERCP所见，提出了一种分类法：I型为胆囊管或胆囊颈巨大结石嵌顿压迫肝总管：型为结石部分或完全突破进入肝总管，形成胆囊胆管瘘 1989年，Csendes等通过对219例MS的研究，认为所谓MS和胆囊胆管瘘是同一病理过程的不同发展阶段，并进行了分型：I型为胆囊颈或胆囊管结石嵌顿压迫肝总管(即经典MS)；型为胆囊胆管瘘形成，瘘管口径小于胆管周径的13；型为瘘管口径累及胆管周径23：IV型为胆管壁因结石压迫而完全受损,术前诊断,

26、B超是筛查MS的首要诊断工具 对肝胆系统结石、胆囊炎症及胆囊囊肿大的诊断有很高的敏感性 对MS诊断的敏感性只有27 胆囊增大，肝总管扩张而胆总管正常MS?,术前诊断,PTC和ERCP是诊断MS的重要手段 直接显示：结石压迫导致的胆管偏位、偏侧性(外压性)充盈缺损，边缘光整,术前诊断,MRCP非介入性胰胆管成像技术，无需造影剂、无损伤、无痛苦、无并发症 很好地显示胆道系统的正常及异常解剖，直接提示肝管受压于胆囊管结石，肝总管以上区域扩张 MRCP为诊断MS的最佳检查方法,术前诊断,反复右上腹部疼痛多年，发作时伴黄染 实验室与体检：急性发作时有直接胆红素升高、肝功能损害 B超提示：胆囊结石、胆囊肿

27、大或萎缩及胆囊管结石伴嵌顿 CT提示：肝内胆管扩张，胆囊管扩张，胆总管直径正常 MRCP ERCP,术前诊断,术前明确诊断对术中处理有一定的帮助，能有针对性地处理好嵌顿的胆囊管结石，避免损伤胆管 根据MS不同类型采用不同的治疗方法以达最佳治疗,MS的外科治疗,胆囊切开取石造瘘术 适用于各型急性胆管炎急诊手术时术中炎症重，解剖不清，不勉强行胆囊切除手术，否则易损伤胆管而造成严重后果 3个月后再行二期手术 急诊ERCP+ENBD/ERBD+二期手术,急诊处理,胆囊或胆囊大部分切除术-I型MS 胆囊大部切除加胆管修补及T管引流术-II型 应用最广 将胆囊大部或部分切除后，保留胆囊颈部避免损伤胆管 用

28、胆囊颈部残端修补缺损的胆管 在胆管修补的下方放置T管作支架 需注意保留足够多的胆囊壁、无张力修补，选择合适的T管，T臂跨过缺损处，T管引流时间为3个月，以防修补处胆管狭窄,MS的外科治疗,切除胆囊，行胆管空肠RouxY吻合术，适用于胆管缺损比较大的III、IV型患者，以避免胆管狭窄，引起反复发作性的胆管炎,MS的外科治疗,Va型病例，可行胆囊切除或部分切除，对十二指肠、胃、结肠或小肠内瘘可越过受累组织，行单纯缝合 Mirizzi Vb型存在肠梗阻症状，须予以先行解决，经3个月以上恢复期后再行二期手术,MS的外科治疗,Choledocholithiasis,Clinical Manifestat

29、ions and Diagnosis,Common duct calculi may be asymptomatic or cause biliary colic, bile duct obstruction, cholangitis or pancreatitis. Jandice will be intermittent if the obstruction is partial and intermittent, or it maybe progressive if a stone becomes impacted in the distal duct. Chills and fever

30、 are usually associated with slight abdominal discomfort and a mild elevation of serum bilirubin, but any of these signs of cholangitis may be absent.,Clinical Manifestations and Diagnosis,Physical examination may be normal. Jaundice and mild tenderness in the epigastrium and right upper quadrant ma

31、y be present. Ultrasonography is not reliable in the detection of common duct stones. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated for most patient who have bile duct obstruction. Percutaneous transhepatic cholangiography (PTC) is an alternative, but ERCP permits visualization

32、of other portions of the gastrointestinal tract and allows for the performance of pancreatography and endoscopic sphincterotomy with stone extraction, when indicated.,Treatment,Should be treated with antibiotic. AOSC (Acute Obstructive Suppurative Cholangitis) may be present, and decompression of th

33、e duct system must be carried out immediately. This can be done by establishing percutaneous transhepatic biliary drainage or by endoscopic sphincterotomy, but immediate laparotomy and insertion of a T-tube should be done if these simpler procedures fail or are nor available.,Treatment,Patients thou

34、ght to have choledocholithiasis preoperatively undergo ERCP. when stones are identified, endoscopic sphincterotomy and stone extraction is performed Open choledocholithotomy and cholecystectomy are performed if the duct system cannot be cleared of stones.,Open Choledocholithotomy,Patients who are no

35、t candidates for laparoscopic procedures and those in whom endoscopic cholangiography and stone extraction are not possible may require open choledocholithotomy After the stones have been removed , the duct should be closed with a T-tube, which has a large side arm, allowing percutaneous stones remo

36、val later, if necessary.,Acute Calculous Cholecystitis,Acute cholecystitis is a chemical or bacterial inflammation of the gallbladder that may cause severe peritonitis and death unless proper treatment is instituted. In about 95% of cases, gallstones are present in the gallbladder, and in about 5% t

37、hey are not. The incidence of Acute calculous cholecystitis is higher in females, with a female-to-male ratio of 3:1,Pathogenesis,Obstruction : Obstruction of the cystic duct or the junction of the gallbladder and the cystic duct by a stone or by edema formed as the result of local mucosal erosion a

38、nd inflammation caused by a stone Bacteria: Positive cultures of bile or gallbladder wall are found in 50% to 75% of cases. Deaths and complications from untreated cholecystitis are almost always related to septic complications of the disease. Other factors: In animal experiments , the presence of p

39、ancreatic juice, gastric juice, or concentrated bile in the lumen of the obstructed gallbladder causes acute cholecustitis.,Pathology,The inflamed gallbladder is enlarged The serosal surface is congested May have areas of gangrene or necrosis The wall is edematous and thickened.,Manifestations,Most

40、patients have symptoms referable to the gallbladder prior to the development of acute cholecystitis but 20% to 40% are asymptomatic. The development of acute cholecystitis progresses through the sequence of distention, and later by inflammation of the gallbladder and adjacent peritoneal surfaces . R

41、adiation of the pain around the right side toward the tip of the scapula. Nausea and vomiting occur in 60% to 70% of patients ,are the only other significant symptoms.,Physical Findings,Tenderness in the right upper quadrant, the epigastrium , or both. Most common and reliable About half of all pati

42、ents have muscle rigidity in the right upper quadrant, and about one fourth have rebound tenderness. Murphys sign. consisting of inspiratory arrest during deep palpation of the right upper quadrant, is not a consistent finding but is almost pathognomonic when present. Jaundice occurs in approximatel

43、y 10% of patients. Bowel sounds are absent in only about 10% of patients Fever maybe absent,Laboratory Finding,White blood cell count is elevated in 85% of cases One half have elevation of the serum bilirubin Serum amylase is increased in one third,Imaging Studies,Ultrasonography: Not specific, a th

44、ickened gallbladder wall and pericholecystic fluid are sometimes present.,Complications,Perforation: One third of these complications. Occurs when a gangrenous area becomes necrotic and bile leaks into the peritoneal cavity Pericholecystic abscess: Result from a perforation of the gallbladder that i

45、s walled off by omentum or adjacent organs such as the colon , stomach , or duodenum. Fistula: 15%. occurs when the gallbladder becomes attached to a portion of the gastrointestinal tract and perforates into it.,Treatment,Preoperative management should include administration of an antibiotic that is

46、 effective against the enteric organisms found in the bile of approximately 80% of patients with gallstones and acute cholecystitis. These organisms include both gram-positive and negative aerobes and anaerobes. The definitive treatment of acute cholecystitis is cholecystectomy. The timing of operat

47、ion was debated.,Treatment,Conversion to open cholecystectomy is indicated when the laparoscopic procedure cannot be completed safely or when bleeding or a bile leak cannot be stopped without risking injury to important structures. Cholecystectomy for acute cholecystitis is performed with a mortalit

48、y rate of less than 0.2% and a major morbidity rate of less than 5%. The incidence of bile duct injury is approximately 0.4%.,Chronic Cholecystitis,The term chronic cholecystitis with cholelithiasis is often used to connote symptomatic gallbladder disease. Chronic inflammatory changes are found in t

49、he gallbladders. Approximately 98% of patients with symptomatic gallbladder disease have gallstones.,Pathology,The pathologic findings in chronic cholecystitis are best interpreted in light of the clinical manifestations of the disease. two types of chronic cholecystitis exist: Secondary chronic cho

50、lecystitis: Follows an episode of acute cholecystitis. Acute cholecystitis is caused by gallbladder outlet obstruction, always by a stone. In cases that do not progress to perforation, these abnormalities gradually resolve over 3 to 4 weeks. Simultaneously, granuloma formation begins. The mucosa its

51、elf becomes thin and loses its villous appearance.,Pathology,Primary chronic cholecystitis: Occurs primarily without antecedent acute cholecystitis Is characterized by a thin- walled gallbladder, with an intact mucosa that retains its villous configuration Stones are almost present in both forms of

52、chronic cholecystitis.,Diagnosis,Recurrent attacks of right upper quadrant or epigastric pain or discomfort, usually following meals. Nausea and vomiting may occur during the attack . Intervals between attacks are variable, maybe continuous or separated by several years. No fever or other signs of i

53、nflammation are present.,Treatment,The definitive treatment for symptomatic gallstones is laparoscopic cholecystectomy.,Chronic Acalculous Cholecystitis,Acute inflammation of the gallbladder without stones is a recognized entity that requires cholecystectomy. Occasionally, patients have signs and sy

54、mptoms of gallbladder disease, but stones cannot be demonstrated by repeated ultrasonography or oral cholecystography. The criteria for cholecystectomy in this situation are not clearly defined.,Cholangitis,Cholangitis, originally described by Charcot in 1877, is a bacterial , parasitic, or chemical

55、 inflammation of the bile duct system .,How bacteria enter the bile duct system: Small numbers of bacteria pass into the portal venous system from the intestine. Ascend from the duodenum Can be introduced into a normal or abnormal bile duct system by the tubes, catheters, scopes, guide wires, and ot

56、her instruments used for diagnosis and treatment.,Associated Pathology,Choledocholithiasis(most common) Malignant strictures Cholangiocarcinoma Pancteatic cancer Ampullary cancer Gallbladder cancer Benign strictures(second common) Anastomotic stenosis Impacted stone Ampullary stenosis Indwelling tub

57、es or stents,Associated Pathology,Cholangiography T-tube Percutaneous transhepatic Endoscopic retrograde Parasitic infestations Clonorchis sinensis Ascaris lumbricoides Ischemia Chemical irritation Carbamazepine Clinoril,Bacteriology,The organisms found in the bile of patients with gallstones and ot

58、her disease of the biliary tract are those that are cultured from the blood and the biliary tract during episodes of acute cholangitis or acute toxic cholangitis. Most are aerobic bacteria, including the gram-negative organisms, and gram-positive organisms.,Clinical Manifestations,The original descr

59、iption of cholangitis by Charcot consisted of intermittent chills and fever, jaundice, and abdominal pain. Charcots triad remains the hallmark of acute cholangitis by definition. Reynolds and Dargan described patients who had shock and central nervous system (CNS) depression in addition to Charcots

60、triad and noted that this lethal combination of symptoms, now known as Reynolds pentad. Reynolds pentad is that this condition is rapidly lethal without emergency intervention, whereas Charcots triad is an acute but less toxic condition for which immediate intervention is usually not necessary.,Clin