胆道临床诊疗课件

胆道疾病

胆道疾病

胆道系统的应用解剖和生理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。胆道系统的应用解剖和生理Anatomy&Physio

左、右肝管出肝后，在肝门部汇合形成肝总管（commonhepaticduct）。肝总管直径为0.14~0.6cm，长约3~4cm，其下端与胆囊管汇合形成胆总管（commonbileduct）。胆总管长约4~8cm，直径0.6~0.8cm。肝外胆道左、右肝管出肝后，在肝门部汇合形成肝总管（commo

肝外胆道包括左、右肝管、肝总管、胆总管、胆囊。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排放防止十二指肠内容物返流Oddi括约肌主要包括胆管括约肌、胰管括约肌和壶腹括约肌胆汁的生成、分泌和代谢

成人每日分泌胆汁约800~1200ml，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。胆汁的生成、分泌和代谢成人每日分泌胆汁约800~1FunctionofgallbladderConcentrationandpreservationofthebile.SecretionContractionandemptyFunctionofgallbladder胆道疾病的特殊检查方法X-rayUltrasonography,EUS,IDUSCTMRI,MRCP(Magneticresonancecholagiopancreatography)PTC,PTBDERCPScintigraphyCholedochoscopyCholangiography胆道疾病的特殊检查方法X-ray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判断胆管有无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胆道特殊检查--US无创、安全、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IntraoperativeCholangiography胆道疾病的特殊检查方法术中造影胆道疾病的特殊检查方法经皮经肝胆管造影术(PTC,PercutaneousTranshepaticCholangiography)经皮经肝胆管造影引流术(PTCD,PercutaneousTranshepaticCholangiographyDrainage)

胆道疾病的特殊检查方法经皮经肝胆管造影术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、程度胆道疾病的特殊检查方法CT/US引导PTCDPTC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。PTC显示肝总管狭窄可通过造影管行胆管引流（PTCD）或置放胆道疾病的特殊检查方法ERCP内镜下逆行胰胆管造影术Endoscopicretrogradecholangiopancreatography

是电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（SpyGlass）等胆道疾病的特殊检查方法ERCP内镜下逆行胰胆管造影术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99m锝-二乙基亚氨二醋酸iV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。胆道梗阻时显像时间的延迟，有助于黄疽的鉴别诊断。本法常见胆道疾病CommonBiliaryDisease常见胆道疾病常见胆道疾病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

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：①先天性发育畸形学说②病毒感染学说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。胆道闭锁病理

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。胆道闭锁病理胆管闭锁所致梗阻性黄疽，可致肝细胞损胆道闭锁大体类型主要分为三型：Ⅰ型完全性胆管闭锁Ⅱ型近端胆管闭锁，远端胆管通畅Ⅲ型近端胆管通畅，远端胆管纤维化以Ⅰ、Ⅱ型常见。胆道闭锁大体类型主要分为三型：胆道闭锁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。胆道闭锁临床表现黄疸：梗阻性黄疽是本病突出表现。胆道闭锁诊断

凡出生后1~2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：①黄疽超过3~4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；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；胆道闭锁诊断凡出生后1~2个月出现持续性黄疽胆道闭锁②十二指肠引流液内无胆汁；③B超检查显示肝外胆管和胆囊发育不良或缺如；④99mTc-EHIDA扫描肠内无核素显示；⑤ERCP和MRCP能显示胆管闭锁的长度。胆道闭锁②十二指肠引流液内无胆汁；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。治疗胆道闭锁手术治疗是唯一有效方法。手术宜在出生后2个月胆道闭锁手术方式：①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。②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。③肝移植胆道闭锁手术方式：先天性胆总管囊肿

先天性胆道扩张症可发生于肝内、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1:3~4。幼儿期即可出现症状，约80%病例在儿童期发病。先天性胆总管囊肿先天性胆道扩张症可发生于肝内、肝外胆管的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：Ⅰ型：囊性扩张。临床上最常见。Ⅱ型：憩室样扩张。Ⅲ型：胆总管开口部囊性脱垂。Ⅳ型：肝内外胆管扩张。Ⅴ型：肝内胆管扩张（Caroli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。囊肿破裂可导致胆汁性腹膜炎。先天性胆总管囊肿临床表现典型临床表现为腹痛、腹部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1~2个症状，故对怀疑本病者需借助其他检查方法确诊。先天性胆总管囊肿诊断对于有典型“三联症”及反复发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。先天性胆总管囊肿治疗本病一经确诊应尽早手术，否则胆石症(Cholelithiasis)胆囊结石(Gallstone)Gallstonesareclassifiedascholesterol,pigmenttypes.Butmoststonesdonotfitintothisrigidclassificationsystem胆管结石

总胆管结石(CommonBileDuctStone)肝内胆管结石(IntrahepaticDuctStone)胆石症(Cholelithiasis)胆囊结石(GallstPathogenesisofGallstones

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。Cholesterolsaturationofbile,stasisofbilewithinthegallbladder,andnucleatingfactorsappeartobeimportant.PathogenesisofGallstonesDiagnosis-GallstoneRecurrentattacksofrightupperquadrantorepigastricpainordiscomfort,nauseaandvomitingGallbladdercolic,resultsfromthetemporaryobstructionofthegallbladderoutletbyastoneinthecysticductortheinfundibulumPhysicalfindings:rightupperquadrantorepigastrictendernesstopalpationandvoluntarymuscleguarding.Jaundiceisnotafeatureofcholelithiasisunlesscommonductobstruction.Diagnosis-GallstoneRecurrentDiagnosisImagingstudies:Ultrasonographydemonstrationthatthestonesmovetothedependentportionofthegallbladderwhenthepositionofthepatientischangedandthestoneproducesacousticshadowing.BloodRTDiagnosisImagingstudies:UltrTreatmentThedefinitivetreatmentofsymptomaticgallstonesislaparoscopiccholecystectomy.Themajoradvantagesofthelaparoscopicprocedurearethatpatientshavelesspainandashorterhospitalisationandareabletoreturntotheiractivitiessooner.Treatment

Opencholecystectomyisindicatedonlyinpatientsinwhomthelaparoscopicisimpossibleorunsafe.ImpossibletoestablishsafeaccesstotheperitonealcavityAdhesionsAnatomicabnormalitiesOpencholecystectomyisindTreatment

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

剖腹胆囊切除(open)

腹腔镜胆囊切除

(LaparoscopicCholecystectomy)胆囊造瘘(Cholecystostomy)胆囊结石治疗胆囊切除(Cholecystectomy)胆囊结石治疗胆石症(Cholelithiasis)Mirizzi综合征及其分型胆石症(Cholelithiasis)Mirizzi综合征及是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l％~3％国外发病率为0.7％~1.4％Mirizzi综合征(Mirizzisyndrome，MS)是一种少见的胆囊结石并发症Mirizzi综合征(Mirizz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

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，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

发现1905年，Kehr首先描述了胆囊结石引起的胆道部分梗阻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表现发生于任何年龄，患者多分布于50-70岁，男女比例相临床分型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：Ⅱ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)；Ⅱ型为胆囊胆管瘘形成，瘘管口径小于胆管周径的1／3；Ⅲ型为瘘管口径累及胆管周径2／3：IV型为胆管壁因结石压迫而完全受损临床分型1982年，Mcsherry等根据ERCP所见，提出术前诊断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B超是筛查MS的首要诊断工具术前诊断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PTC和ERCP是诊断MS的重要手段术前诊断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MRCP非介入性胰胆管成像技术，无需造影剂、无损伤、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MRCPERCP术前诊断反复右上腹部疼痛多年，发作时伴黄染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MS的外科治疗胆囊切开取石造瘘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的外科治疗胆囊或胆囊大部分切除术----I型MSMS的外科治疗切除胆囊，行胆管空肠Roux—Y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的外科治疗切除胆囊，行胆管空肠Roux—Y吻合术，适用于胆管缺损比较大

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MirizziVb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Va型病例，可行胆囊切除或部分切除，对十二指肠、胃、结肠或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.DiagnosisoftheUnderlyingCoDiagnosisoftheUnderlyingConditionCholescintigraphy:

Differentiatebetweenacutecholecystitisandacutecholangitis.Cholangiography:Canbeobtainedbythepercutaneoustranshepaticorendoscopicretrogradetechnique.DiagnosisoftheUnderlyingCoTreatment

Principles:AchievecompletecontrolofthesepticprocessCorrecttheunderlyingcauseTreatmentPrinciples:TreatmentAntibioticchoiceshouldbebasedontheorganismsmostoftenculturedfromtheblood

Inpatientswithmildcholangitisandnoevidenceofcontinuing,severesepsis,antibiotictherapwithasecond-orthird-generationcephalosporinisadequate.Monitoringofhemodynamicparameters,urineoutput,andbloodgases.Mostcholangitispatientsrepondrapidlytotherapy.aftertheyhavebeenafebrilefor48hours,cholangiographyandotherindicatedstudiesshouldbedoneundercontinuingantibioticcoverage.TreatmentAntibioticchoiceshoTreatmentPatientswithacutecholangitiswhodonotrespondcompletelytoantibiotictherapyandsupportivecareorwhodeteriorateshouldhaveemergencydecompressionofthebileductsystem.Whentranshepaticorendoscopicdecompressionofthebiliarysystemisnotavailableorpossible,immediatelaprotomyandinsertionofaT-tubeintothecommonbileductshouldbecarriedout.TreatmentResults

and

Complications

Theresultsoftreatmentofmildacutecholangitisareexcellent.DeathsarealmostalwaysrelatedtocomplicationsoftheoperationperformedfortheunderlyingconditionandareunrelatedtotheoriginalepisodeofcholangitisResultsandComplicationsThe急性胆管炎(AcuteCholangitis)

病理机制结石阻塞胆管胆管内高压+细菌感染急性胆管炎严重时急性阻塞性化脓性胆管炎

AOSC(AcuteObstructiveSuppurativeCholangitis)急性胆管炎(AcuteCholangitis)

病理机制急性胆管炎Charcot三联症腹痛寒颤发热黄疸急性阻塞性胆管炎Reynold五联症Charcot+休克+中枢神经系统抑制预后AOSC死亡率(4.5~43.5%)急性胆管炎AOSC

外科常见病，也是胆道疾病中最凶险的疾病以胆道梗阻和感染为病理基础绝大多数是由胆总管结石引起胆道通畅引流是治疗本病的关键急诊手术风险高，病死率高达20~40%

麻醉及创伤可加重休克，

AOSC外科常见病，也是胆道疾病中最凶险的疾病ERCP治疗AOSC的优势符合AOSC治疗原则迅速有效地解除胆道梗阻创伤小、见效快、疗效好病死率明显下降，降至1O%

部分病人已行一次或多次胆道手术，因胆管周围粘连，解剖不清，增加了手术难度，而内镜治疗避开此矛盾ERCP治疗AOSC的优势符合AOSC治疗原则微创、安全、有效、短时、简便取代传统的胆道手术引流避免了急诊手术中的麻醉、手术风险特别适用于伴有休克、严重内科疾病、手术耐受差、高龄（最大104岁）的危重患者危重胆道疾病AOSC的急诊内镜治疗微创、安全、有效、短时、简便危重胆道疾病AOSC的急诊内镜治谢谢谢谢胆道疾病

胆道疾病

胆道系统的应用解剖和生理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。胆道系统的应用解剖和生理Anatomy&Physio

左、右肝管出肝后，在肝门部汇合形成肝总管（commonhepaticduct）。肝总管直径为0.14~0.6cm，长约3~4cm，其下端与胆囊管汇合形成胆总管（commonbileduct）。胆总管长约4~8cm，直径0.6~0.8cm。肝外胆道左、右肝管出肝后，在肝门部汇合形成肝总管（commo

肝外胆道包括左、右肝管、肝总管、胆总管、胆囊。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排放防止十二指肠内容物返流Oddi括约肌主要包括胆管括约肌、胰管括约肌和壶腹括约肌胆汁的生成、分泌和代谢

成人每日分泌胆汁约800~1200ml，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。胆汁的生成、分泌和代谢成人每日分泌胆汁约800~1FunctionofgallbladderConcentrationandpreservationofthebile.SecretionContractionandemptyFunctionofgallbladder胆道疾病的特殊检查方法X-rayUltrasonography,EUS,IDUSCTMRI,MRCP(Magneticresonancecholagiopancreatography)PTC,PTBDERCPScintigraphyCholedochoscopyCholangiography胆道疾病的特殊检查方法X-ray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判断胆管有无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胆道特殊检查--US无创、安全、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IntraoperativeCholangiography胆道疾病的特殊检查方法术中造影胆道疾病的特殊检查方法经皮经肝胆管造影术(PTC,PercutaneousTranshepaticCholangiography)经皮经肝胆管造影引流术(PTCD,PercutaneousTranshepaticCholangiographyDrainage)

胆道疾病的特殊检查方法经皮经肝胆管造影术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、程度胆道疾病的特殊检查方法CT/US引导PTCDPTC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。PTC显示肝总管狭窄可通过造影管行胆管引流（PTCD）或置放胆道疾病的特殊检查方法ERCP内镜下逆行胰胆管造影术Endoscopicretrogradecholangiopancreatography

是电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（SpyGlass）等胆道疾病的特殊检查方法ERCP内镜下逆行胰胆管造影术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99m锝-二乙基亚氨二醋酸iV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。胆道梗阻时显像时间的延迟，有助于黄疽的鉴别诊断。本法常见胆道疾病CommonBiliaryDisease常见胆道疾病常见胆道疾病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

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：①先天性发育畸形学说②病毒感染学说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。胆道闭锁病理

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。胆道闭锁病理胆管闭锁所致梗阻性黄疽，可致肝细胞损胆道闭锁大体类型主要分为三型：Ⅰ型完全性胆管闭锁Ⅱ型近端胆管闭锁，远端胆管通畅Ⅲ型近端胆管通畅，远端胆管纤维化以Ⅰ、Ⅱ型常见。胆道闭锁大体类型主要分为三型：胆道闭锁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。胆道闭锁临床表现黄疸：梗阻性黄疽是本病突出表现。胆道闭锁诊断

凡出生后1~2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：①黄疽超过3~4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；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；胆道闭锁诊断凡出生后1~2个月出现持续性黄疽胆道闭锁②十二指肠引流液内无胆汁；③B超检查显示肝外胆管和胆囊发育不良或缺如；④99mTc-EHIDA扫描肠内无核素显示；⑤ERCP和MRCP能显示胆管闭锁的长度。胆道闭锁②十二指肠引流液内无胆汁；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。