biliary tract diseases

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胆道感染整理

Biliary Tract Diseases胆道疾病胆石症：胆囊结石胆管结石（肝外、肝内）胆道感染：胆囊炎胆管炎（化脓性、硬化性）Glisson鞘Glisson’s capsule结缔组织鞘，包绕肝内胆管，肝动脉以及门静脉Hartmann’s 袋Hartmann’s pouch胆囊颈上部呈囊性扩大，称Hartmann's 袋，胆囊结石常滞留于此处Heister 瓣Valves of Heister胆囊起始部内壁粘膜形成螺旋状皱襞，Heister 瓣（功能？）胆囊三角Calot三角Calot’s Triangle胆囊管、肝总管、肝下缘所构成的三角称为胆囊三角。

胆囊动脉、肝右动脉、副右肝管常在此处穿过，可作为手术寻找胆囊动脉和胆囊管的重要的标志胆汁生理功能1.乳化脂肪：胆盐+脂肪→脂肪微粒→容易吸收2.胆盐：抑制肠内致病菌生长繁殖；抑制内毒素形成3.刺激肠蠕动4.中和胃酸胆汁分泌的调节a.迷走神经↑，交感神经↓b.促胰液素、胰高血糖素、肠血管活性肽→促分泌c.生长抑素、胰多肽→抑分泌胆管的生理功能：输送胆汁到胆囊十二指肠分泌胆汁胆囊的生理功能Main functions of the gallbladder①---to concentrate and store hepatic bile during the fasting state 浓缩储存胆汁②----to deliver bile into the duodenum in response to a meal 排出胆汁③----to secret glycoproteins and hydrogen ions →mucus barrier 分泌“white bile”胆囊管梗阻，胆汁中胆红素被吸收，胆囊黏膜分泌黏液增加，胆囊内积存的液体呈无色透明，称为白胆汁。

Diagnosis of Biliary Tract Diseasea.Ultrasound：无创、安全、快速、简便、经济、准确。

内镜下逆行性胰胆管造影术及其相关技术在恶性胆管狭窄诊断中的应用进展

内镜下逆行性胰胆管造影术及其相关技术在恶性胆管狭窄诊断中的应用进展王蒲雄志1于嵩1 陈巍1 戚大川2*（1. 上海交通大学医学院附属第六人民医院普外科上海 200233；2. 上海市第四人民医院普外科上海 200081）摘要胆管狭窄在临床上较为常见，其病因多样，良、恶性质的判断一直很困难。

自内镜下逆行性胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）问世以来，ERCP及其相关技术已从最初用于胰胆管造影发展至如今融影像学、病理学诊断和植入支架引流、射频消融治疗等诊疗技术于一体，成为恶性胆道疾病诊治的最重要手段之一。

本文概要介绍ERCP及其相关技术在胆道疾病诊治中的最新应用进展，同时探讨ERCP及其相关技术在恶性胆管狭窄诊断中的应用价值。

关键词内镜下逆行性胰胆管造影术恶性胆管狭窄诊断中图分类号：R575.7; R445.9 文献标志码：A 文章编号：1006-1533(2019)23-0012-04Advances in ERCP and related techniques in the diagnosisof malignant biliary stricturesWANG-PU Xiongzhi1, YU Song1, CHEN Wei1, QI Dachuan2*(1. Department of General Surgery, Shanghai 6th People’s Hospital, School of Medicine, Shanghai Jiao Tong University,Shanghai 200233, China; 2. Department of General Surgery, Shanghai 4th People’s Hospital, Shanghai 200081, China)ABSTRACT Biliary stricture is a common clinical disease and its causes are diverse. The assessment of its benign or malignant properties has always been a controversial clinical problem. In recent years, endoscopic retrograde cholangiopancreatography (ERCP) has become one of the most important methods for the diagnosis and treatment of malignant biliary diseases, ranging from initial cholangiopancreatography to comprehensive diagnostic and therapeutic techniques such as fusion imaging, pathological diagnosis, stent drainage and radiofrequency ablation. This article reviews the latest progress in the application of ERCP technology in biliary tract diseases, and explores the application value of ERCP technology in the diagnosis of malignant biliary stricture.KEy WORDS endoscopic retrograde cholangiopancreatography; malignant biliary stricture; diagnosis胆管狭窄是临床上常见的一种胆道疾病，会导致胆汁排出受阻、淤积，引起梗阻性黄疸，引发继发性胆道感染。

肝胆疾病

PART 14 Disorders of the Gastrointestinal SystemC HAPTER301Approach to the PatientWith Liver DiseaseM arc GhanyJ ay H.HoofnagleA diagnosis of liver disease usually can be made accurately by acareful history, physical examination, and application of a fewlaboratory tests. In some circumstances, radiologic examinationsare helpful or, indeed, diagnostic. Liver biopsy is considered thecriterion standard in evaluation of liver disease but is now neededless for diagnosis than for grading and staging of disease. This chap-ter provides an introduction to diagnosis and management of liverdisease, briefly reviewing the structure and function of the liver; themajor clinical manifestations of liver disease; and the use of clinicalhistory, physical examination, laboratory tests, imaging studies, andliver biopsy.L IVER STRUCTURE AND FUNCTIONⅥT he liver is the largest organ of the body, weighing 1–1.5 kg andrepresenting 1.5–2.5% of the lean body mass. The size and shapeof the liver vary and generally match the general body shape—longand lean or squat and square. The liver is located in the right upperquadrant of the abdomen under the right lower rib cage againstthe diaphragm and projects for a variable extent into the left upperquadrant. The liver is held in place by ligamentous attachments tothe diaphragm, peritoneum, great vessels, and upper gastrointesti-nal organs. It receives a dual blood supply; ~20% of the blood flowis oxygen-rich blood from the hepatic artery, and 80% is nutrient-rich blood from the portal vein arising from the stomach, intestines,pancreas, and spleen.T he majority of cells in the liver are hepatocytes, which constitutetwo-thirds of the mass of the liver. The remaining cell types areKupffer cells (members of the reticuloendothelial system), stellate(Ito or fat-storing) cells, endothelial cells and blood vessels, bileductular cells, and supporting structures. Viewed by light micros-copy, the liver appears to be organized in lobules, with portal areasat the periphery and central veins in the center of each lobule.However, from a functional point of view, the liver is organized intoacini, with both hepatic arterial and portal venous blood enteringthe acinus from the portal areas (zone 1) and then flowing throughthe sinusoids to the terminal hepatic veins (zone 3); the interven-ing hepatocytes constituting zone 2. The advantage of viewing theacinus as the physiologic unit of the liver is that it helps to explainthe morphologic patterns and zonality of many vascular and biliarydiseases not explained by the lobular arrangement.P ortal areas of the liver consist of small veins, arteries, bile ducts,and lymphatics organized in a loose stroma of supporting matrixand small amounts of collagen. Blood flowing into the portal areasis distributed through the sinusoids, passing from zone 1 to zone 3of the acinus and draining into the terminal hepatic veins (“centralveins”). Secreted bile flows in the opposite direction, in a counter-current pattern from zone 3 to zone 1. The sinusoids are lined byunique endothelial cells that have prominent fenestrae of variablesize, allowing the free flow of plasma but not cellular elements. Theplasma is thus in direct contact with hepatocytes in the subendothe-lial space of Disse.H epatocytes have distinct polarity. The basolateral side of thehepatocyte lines the space of Disse and is richly lined withmicrovilli; it demonstrates endocytotic and pinocytotic activity,with passive and active uptake of nutrients, proteins, and othermolecules. The apical pole of the hepatocyte forms the canalicularmembranes through which bile components are secreted. Thecanaliculi of hepatocytes form a fine network, which fuses into thebile ductular elements near the portal areas. Kupffer cells usually liewithin the sinusoidal vascular space and represent the largest groupof fixed macrophages in the body. The stellate cells are located inthe space of Disse but are not usually prominent unless activated,when they produce collagen and matrix. Red blood cells stay in thesinusoidal space as blood flows through the lobules, but white bloodcells can migrate through or around endothelial cells into the spaceof Disse and from there to portal areas, where they can return to thecirculation through lymphatics.H epatocytes perform numerous and vital roles in maintaininghomeostasis and health. These functions include the synthesis ofmost essential serum proteins (albumin, carrier proteins, coagula-tion factors, many hormonal and growth factors), the production ofbile and its carriers (bile acids, cholesterol, lecithin, phospholipids),the regulation of nutrients (glucose, glycogen, lipids, cholesterol,amino acids), and metabolism and conjugation of lipophilic com-pounds (bilirubin, anions, cations, drugs) for excretion in the bileor urine. Measurement of these activities to assess liver function iscomplicated by the multiplicity and variability of these functions.The most commonly used liver “function” tests are measurementsof serum bilirubin, albumin, and prothrombin time. The serumbilirubin level is a measure of hepatic conjugation and excretion,and the serum albumin level and prothrombin time are measuresof protein synthesis. A bnormalities of bilirubin, albumin, andprothrombin time are typical of hepatic dysfunction. Frank liverfailure is incompatible with life, and the functions of the liver aretoo complex and diverse to be subserved by a mechanical pump;dialysis membrane; or concoction of infused hormones, proteins,and growth factors.L IVER DISEASESW hile there are many causes of liver disease (T able 301-1), they gen-erally present clinically in a few distinct patterns, usually classified ashepatocellular, cholestatic (obstructive), or mixed. In h epatocellulardiseases(such as viral hepatitis or alcoholic liver disease), features ofliver injury, inflammation, and necrosis predominate. In c holestaticdiseases(such as gallstone or malignant obstruction, primary biliarycirrhosis, some drug-induced liver diseases), features of inhibitionof bile flow predominate. In a mixed pattern, features of both hepa-tocellular and cholestatic injury are present (such as in cholestaticforms of viral hepatitis and many drug-induced liver diseases). Thepattern of onset and prominence of symptoms can rapidly suggesta diagnosis, particularly if major risk factors are considered suchas the age and sex of the patient and a history of exposure or riskbehaviors.2520CHAPTER 301 Approach to the Patient With Liver DiseaseT ypical presenting symptoms of liver disease include jaundice, fatigue, itching, right upper quadrant pain, nausea, poor appe-tite, abdominal distention, and intestinal bleeding. A t present, however, many patients are diagnosed with liver disease who have no symptoms and who have been found to have abnor-malities in biochemical liver tests as a part of a routine physical examination or screening for blood donation or for insurance or employment. The wide availability of batteries of liver tests makes it relatively simple to demonstrate the presence of liver injury as well as to rule it out in someone suspected of liver disease.E valuation of patients with liver disease should be directed at(1) establishing the etiologic diagnosis, (2) estimating the disease severity (grading), and (3) establishing the disease stage (staging).TABLE 301-1 Liver Diseases2521PART 14 Disorders of the Gastrointestinal System D iagnosis should focus on the category of disease such as hepato-cellular, cholestatic, or mixed injury, as well as on the specific etio-logic diagnosis. G rading refers to assessing the severity or activity ofdisease—active or inactive, and mild, moderate, or severe. S tagingrefers to estimating the place in the course of the natural historyof the disease, whether acute or chronic; early or late; precirrhotic,cirrhotic, or end-stage.T he goal of this chapter is to introduce general, salient conceptsin the evaluation of patients with liver disease that help lead to thediagnoses discussed in subsequent chapters.C LINICAL HISTORYⅥT he clinical history should focus on the symptoms of liver disease—their nature, patterns of onset, and progression—and on potentialrisk factors for liver disease. The symptoms of liver disease includeconstitutional symptoms such as fatigue, weakness, nausea, poorappetite, and malaise and the more liver-specific symptoms of jaun-dice, dark urine, light stools, itching, abdominal pain, and bloating.Symptoms can also suggest the presence of cirrhosis, end-stage liverdisease, or complications of cirrhosis such as portal hypertension.Generally, the constellation of symptoms and their patterns of onsetrather than a specific symptom points to an etiology.F atigue is the most common and most characteristic symptomof liver disease. It is variously described as lethargy, weakness,listlessness, malaise, increased need for sleep, lack of stamina, andpoor energy. The fatigue of liver disease typically arises after activ-ity or exercise and is rarely present or severe in the morning afteradequate rest (afternoon versus morning fatigue). Fatigue in liverdisease is often intermittent and variable in severity from hour tohour and day to day. In some patients, it may not be clear whetherfatigue is due to the liver disease or to other problems such as stress,anxiety, sleep disturbance, or a concurrent illness.N ausea occurs with more severe liver disease and may accom-pany fatigue or be provoked by odors of food or eating fatty foods.Vomiting can occur but is rarely persistent or prominent. Poorappetite with weight loss occurs commonly in acute liver diseasesbut is rare in chronic disease, except when cirrhosis is present andadvanced. Diarrhea is uncommon in liver disease, except withsevere jaundice, where lack of bile acids reaching the intestine canlead to steatorrhea.R ight upper quadrant discomfort or ache (“liver pain”) occurs inmany liver diseases and is usually marked by tenderness over theliver area. The pain arises from stretching or irritation of Glisson’scapsule, which surrounds the liver and is rich in nerve endings.Severe pain is most typical of gallbladder disease, liver abscess, andsevere venoocclusive disease but is an occasional accompanimentof acute hepatitis.I tching occurs with acute liver disease, appearing early inobstructive jaundice (from biliary obstruction or drug-inducedcholestasis) and somewhat later in hepatocellular disease (acutehepatitis). Itching also occurs in chronic liver diseases, typically thecholestatic forms such as primary biliary cirrhosis and sclerosingcholangitis where it is often the presenting symptom, occurringbefore the onset of jaundice. However, itching can occur in any liverdisease, particularly once cirrhosis is present.J aundice is the hallmark symptom of liver disease and perhapsthe most reliable marker of severity. Patients usually report dark-ening of the urine before they notice scleral icterus. Jaundice israrely detectable with a bilirubin level <43 μmol/L (2.5 mg/dL).With severe cholestasis there will also be lightening of the colorof the stools and steatorrhea. Jaundice without dark urine usuallyindicates indirect (unconjugated) hyperbilirubinemia and is typicalof hemolytic anemia and the genetic disorders of bilirubin conjuga-tion, the common and benign form being Gilbert’s syndrome andthe rare and severe form being Crigler-Najjar syndrome. Gilbert’ssyndrome affects up to 5% of the population; the jaundice is morenoticeable after fasting and with stress.M ajor risk factors for liver disease that should be sought in theclinical history include details of alcohol use, medications (includ-ing herbal compounds, birth control pills, and over-the-countermedications), personal habits, sexual activity, travel, exposure tojaundiced or other high-risk persons, injection drug use, recentsurgery, remote or recent transfusion with blood and blood prod-ucts, occupation, accidental exposure to blood or needlestick, andfamilial history of liver disease.F or assessing the risk of viral hepatitis, a careful history of sexualactivity is of particular importance and should include the numberof lifetime sexual partners and, for men, a history of having sex withmen. Sexual exposure is a common mode of spread of hepatitis Bbut is rare for hepatitis C. A family history of hepatitis, liver disease,and liver cancer is also important. Maternal-infant transmissionoccurs with both hepatitis B and C. Vertical spread of hepatitis Bcan now be prevented by passive and active immunization of theinfant at birth. Vertical spread of hepatitis C is uncommon, butthere are no reliable means of prevention. Transmission is morecommon in HIV-co-infected mothers and is also linked to pro-longed and difficult labor and delivery, early rupture of membranes,and internal fetal monitoring. A history of injection drug use, evenin the remote past, is of great importance in assessing the risk forhepatitis B and C. Injection drug use is now the single most com-mon risk factor for hepatitis C. Transfusion with blood or bloodproducts is no longer an important risk factor for acute viral hepa-titis. However, blood transfusions received before the introductionof sensitive enzyme immunoassays for antibody to hepatitis C virus(anti-HCV) in 1992 is an important risk factor for chronic hepatitisC. Blood transfusion before 1986, when screening for antibody tohepatitis B core antigen (anti-HBc) was introduced, is also a risk fac-tor for hepatitis B. Travel to an underdeveloped area of the world,exposure to persons with jaundice, and exposure to young childrenin day-care centers are risk factors for hepatitis A. Hepatitis E isone of the more common causes of jaundice in Asia and Africa butis uncommon in developed nations, although mild cases have beenassociated with eating raw or undercooked pork or game (deer andwild boars). Tattooing and body piercing (for hepatitis B and C) andeating shellfish (for hepatitis A) are frequently mentioned but areactually quite rare types of exposure for acquiring hepatitis.A history of alcohol intake is important in assessing the causeof liver disease and also in planning management and recommen-dations. In the United States, for example, at least 70% of adultsdrink alcohol to some degree, but significant alcohol intake is lesscommon; in population-based surveys, only 5% have more thantwo drinks per day, the average drink representing 11–15 g alcohol.Alcohol consumption associated with an increased rate of alcoholicliver disease is probably more than two drinks (22–30 g) per dayin women and three drinks (33–45 g) in men. Most patients withalcoholic cirrhosis have a much higher daily intake and have drunkexcessively for ≥10 years before onset of liver disease. In assessingalcohol intake, the history should also focus on whether alcoholabuse or dependence is present. A lcoholism is usually defined bythe behavioral patterns and consequences of alcohol intake, noton the basis of the amount of alcohol intake. A buse is defined bya repetitive pattern of drinking alcohol that has adverse effects onsocial, family, occupational, or health status. D ependence is definedby alcohol-seeking behavior, despite its adverse effects. Many alco-holics demonstrate both dependence and abuse, and dependence isconsidered the more serious and advanced form of alcoholism. Aclinically helpful approach to diagnosis of alcohol dependence andabuse is the use of the CAGE questionnaire (T able 301-2), which isrecommended in all medical history-taking.25222523CHAPTER 301Approach to the Patient With Liver DiseaseFamily history can be helpful in assessing liver disease. Familial causes of liver disease include Wilson’s disease; hemochromatosis and α 1antitrypsin (α 1 A T) deficiency; and the more uncommon inherited pediatric liver diseases of familial intrahepatic cholestasis, benign recurrent intrahepatic cholestasis, and A lagille syndrome. Onset of severe liver disease in childhood or adolescence with a family history of liver disease or neuropsychiatric disturbance should lead to investigation for Wilson’s disease. A family history of cirrhosis, diabetes, or endocrine failure and the appearance of liver disease in adulthood should suggest hemochromatosis and lead to investigation of iron status. Adult patients with abnormal iron stud-ies warrant genotyping of the H FE gene for the C282Y and H63D mutations typical of genetic hemochromatosis. In children and ado-lescents with iron overload, other non-HFE causes of hemochro-matosis should be sought. A family history of emphysema should provoke investigation of α 1 A T levels and, if low, for Pi genotype. P HYSICAL E XAMINATION ⅥT he physical examination rarely demonstrates evidence of liver dysfunction in a patient without symptoms or laboratory findings, nor are most signs of liver disease specific to one diagnosis. Thus, the physical examination complements rather than replaces the need for other diagnostic approaches. In many patients, the physi-cal examination is normal unless the disease is acute or severe and advanced. Nevertheless, the physical examination is important in that it can be the first evidence for the presence of hepatic failure, portal hypertension, and liver decompensation. In addition, the physical examination can reveal signs that point to a specific diag-nosis, either in risk factors or in associated diseases or findings.T ypical physical findings in liver disease are icterus, hepato-megaly, hepatic tenderness, splenomegaly, spider angiomata, pal-mar erythema, and excoriations. Signs of advanced disease include muscle wasting, ascites, edema, dilated abdominal veins, hepatic fetor, asterixis, mental confusion, stupor, and coma. In males with cirrhosis, particularly when related to alcohol, signs of hyperestro-genemia such as gynecomastia, testicular atrophy, and loss of male-pattern hair distribution may be found. I cterus is best appreciated by inspecting the sclera under natural light. In fair-skinned individuals, a yellow color of the skin may be obvious. In dark-skinned individuals, the mucous membranes below the tongue can demonstrate jaundice. Jaundice is rarely detectable if the serum bilirubin level is <43 μmol/L (2.5 mg/dL) but may remain detectable below this level during recovery from jaundice (because of protein and tissue binding of conjugated bilirubin).S pider angiomata and palmar erythema occur in both acute and chronic liver disease and may be especially prominent in persons with cirrhosis, but they can occur in normal individuals and are frequently present during pregnancy. Spider angiomata are super-ficial, tortuous arterioles and, unlike simple telangiectases, typically fill from the center outward. Spider angiomata occur only on thearms, face, and upper torso; they can be pulsatile and may be dif-ficult to detect in dark-skinned individuals.H epatomegaly is not a very reliable sign of liver disease, because of the variability of the size and shape of the liver and the physical impediments to assessing liver size by percussion and palpation. Marked hepatomegaly is typical of cirrhosis, venoocclusive dis-ease, infiltrative disorders such as amyloidosis, metastatic or pri-mary cancers of the liver, and alcoholic hepatitis. Careful assess-ment of the liver edge may also demonstrate unusual firmness, irregularity of the surface, or frank nodules. Perhaps the most reliable physical finding in examining the liver is hepatic tender-ness. Discomfort on touching or pressing on the liver should be carefully sought with percussive comparison of the right and left upper quadrants.S plenomegaly occurs in many medical conditions but can be a subtle but significant physical finding in liver disease. The availabil-ity of ultrasound (US) assessment of the spleen allows for confirma-tion of the physical finding.S igns of advanced liver disease include muscle-wasting and weight loss as well as hepatomegaly, bruising, ascites, and edema. A scites is best appreciated by attempts to detect shifting dullness by careful percussion. US examination will confirm the finding of ascites in equivocal cases. Peripheral edema can occur with or with-out ascites. In patients with advanced liver disease, other factors frequently contribute to edema formation, including hypoalbumin-emia, venous insufficiency, heart failure, and medications.H epatic failure is defined as the occurrence of signs or symptoms of hepatic encephalopathy in a person with severe acute or chronic liver disease. The first signs of hepatic encephalopathy can be subtle and nonspecific—change in sleep patterns, change in personality, irritability, and mental dullness. Thereafter, confusion, disorienta-tion, stupor, and eventually coma supervene. In acute liver failure, excitability and mania may be present. Physical findings include asterixis and flapping tremors of the body and tongue. F etor hepati-cus refers to the slightly sweet, ammoniacal odor that can occur in patients with liver failure, particularly if there is portal-venous shunting of blood around the liver. Other causes of coma and dis-orientation should be excluded, mainly electrolyte imbalances, sed-ative use, and renal or respiratory failure. The appearance of hepatic encephalopathy during acute hepatitis is the major criterion for diagnosis of fulminant hepatitis and indicates a poor prognosis. In chronic liver disease, encephalopathy is usually triggered by a medi-cal complication such as gastrointestinal bleeding, over-diuresis, uremia, dehydration, electrolyte imbalance, infection, constipation, or use of narcotic analgesics.A helpful measure of hepatic encephalopathy is a careful mental status examination and use of the trail-making test, which consists of a series of 25 numbered circles that the patient is asked to con-nect as rapidly as possible using a pencil. The normal range for the connect-the-dot test is 15–30 seconds; it is considerably delayed in patients with early hepatic encephalopathy. Other tests include drawing abstract objects or comparison of a signature to previous examples. More sophisticated testing such as with electroencepha-lography and visual evoked potentials can detect mild forms of encephalopathy, but are rarely clinically useful.O ther signs of advanced liver disease include umbilical hernia from ascites, hydrothorax, prominent veins over the abdomen, and c aput medusa , which consists of collateral veins seen radiating from the umbilicus and resulting from the recanulation of the umbilical vein. Widened pulse pressure and signs of a hyperdynamic circu-lation can occur in patients with cirrhosis as a result of fluid and sodium retention, increased cardiac output, and reduced peripheral resistance. Patients with long-standing cirrhosis and portal hyper-tension are prone to develop the hepatopulmonary syndrome,defined by the triad of liver disease, hypoxemia, and pulmonary∗One “yes” response should raise suspicion of an alcohol use problem, and more than one is a strong indication that abuse or dependence exists.PART 14 Disorders of the Gastrointestinal System arteriovenous shunting. The hepatopulmonary syndrome is char-acterized by platypnea and orthodeoxia, representing shortnessof breath and oxygen desaturation that occur paradoxically uponassuming an upright position. Measurement of oxygen saturationby pulse oximetry is a reliable screening test for the presence ofhepatopulmonary syndrome.S everal skin disorders and changes occur commonly in liver dis-ease. Hyperpigmentation is typical of advanced chronic cholestaticdiseases such as primary biliary cirrhosis and sclerosing cholangitis.In these same conditions, xanthelasma and tendon xanthomataoccur as a result of retention and high serum levels of lipids andcholesterol. A slate-gray pigmentation to the skin also occurs withhemochromatosis if iron levels are high for a prolonged period.Mucocutaneous vasculitis with palpable purpura, especially on thelower extremities, is typical of cryoglobulinemia of chronic hepatitisC but can also occur in chronic hepatitis B.S ome physical signs point to specific liver diseases. Kayser-Fleischer rings occur in Wilson’s disease and consist of a golden-brown copper pigment deposited in Descemet’s membrane at theperiphery of the cornea; they are best seen by slit-lamp examination.Dupuytren contracture and parotid enlargement are suggestive ofchronic alcoholism and alcoholic liver disease. In metastatic liverdisease or primary hepatocellular carcinoma, signs of cachexia andwasting may be prominent, as well as firm hepatomegaly and ahepatic bruit.L ABORATORY TE STINGⅥD iagnosis in liver disease is greatly aided by the availability of reli-able and sensitive tests of liver injury and function. A typical batteryof blood tests used for initial assessment of liver disease includesmeasuring levels of serum alanine and aspartate aminotransferases(ALT and AST), alkaline phosphatase (AlkP), direct and total serumbilirubin, and albumin and assessing prothrombin time. The patternof abnormalities generally points to hepatocellular versus cholestaticliver disease and will help to decide whether the disease is acute orchronic and whether cirrhosis and hepatic failure are present. Basedon these results, further testing over time may be necessary. Otherlaboratory tests may be helpful, such as γ-glutamyl transpeptidase(gGT) to define whether alkaline phosphatase elevations are due toliver disease; hepatitis serology to define the type of viral hepatitis;and autoimmune markers to diagnose primary biliary cirrhosis (anti-mitochondrial antibody; A MA), sclerosing cholangitis (peripheralantineutrophil cytoplasmic antibody; P-A NCA), and autoimmunehepatitis (antinuclear, smooth-muscle, and liver-kidney microsomalantibody). A simple delineation of laboratory abnormalities andcommon liver diseases is given in T able 301-3.T he use and interpretation of liver function tests is summarizedin Chap. 302.D IAGNOSTIC IMAGINGⅥT here have been great advances made in hepatic imaging, althoughno method is suitably accurate in demonstrating underlying cirrho-sis. There are many modalities available for imaging the liver. US,CT, and MRI are the most commonly employed and are comple-mentary to each other. In general, US and CT have a high sensitivityfor detecting biliary duct dilatation and are the first-line optionsfor investigating the patient with suspected obstructive jaundice.A ll three modalities can detect a fatty liver, which appears brighton imaging studies. Modifications of CT and MRI can be used toquantify liver fat, which may ultimately be valuable in monitoringtherapy in patients with fatty liver disease. Magnetic resonancecholangiopancreatography (MRCP) and endoscopic retrogradecholangiopancreatography (ERCP) are the procedures of choicefor visualization of the biliary tree. MRCP offers several advantagesover ERCP; there is no need for contrast media or ionizing radia-tion, images can be acquired faster, it is less operator dependent,and it carries no risk of pancreatitis. MRCP is superior to US andCT for detecting choledocholithiasis but less specific. It is useful inthe diagnosis of bile duct obstruction and congenital biliary abnor-malities, but ERCP is more valuable in evaluating ampullary lesionsand primary sclerosing cholangitis. ERCP allows for biopsy, directvisualization of the ampulla and common bile duct, and intraductalultrasonography. It also provides several therapeutic options inpatients with obstructive jaundice such as sphincterotomy, stoneextraction, and placement of nasobiliary catheters and biliary stents.Doppler US and MRI are used to assess hepatic vasculature andhemodynamics and to monitor surgically or radiologically placedvascular shunts such as transjugular intrahepatic portosystemicshunts. CT and MRI are indicated for the identification and evalu-ation of hepatic masses, staging of liver tumors, and preoperativeassessment. With regard to mass lesions, sensitivity of hepaticimaging continues to increase; unfortunately, specificity remainsa problem, and often two and sometimes three studies are neededbefore a diagnosis can be reached. Recently, methods using elastog-raphy have been developed to measure hepatic stiffness as a meansof assessing hepatic fibrosis. US and MR elastrography are nowAbbreviations: HAV, HBV, HCV, HDV, HEV: hepatitis A, B, C, D, or E virus; HBsAg,hepatitis B surface antigen; anti-HBc, antibody to hepatitis B core (antigen); HBeAg,hepatitis e antigen; ANA, antinuclear antibodies; SMA, smooth-muscle antibody;P-ANCA, peripheral antineutrophil cytoplasmic antibody.2524。

胆道疾病-精品医学课件

PTC（Percutaneous Transhepatic Cholangiography）
ERCP (Endoscopic Retrograde Cholangio-pancreatogrphy)
⑺ CT (Computerized Tomography)
3. Hepatobiliary Scintigraphy （核素显像扫描）
• ⑴ 消化不良，类似胃炎（呃逆、饱胀、右上腹部不适）； • ⑵ Biliary Colic：油腻进餐后，睡眠体位改变，恶心、呕吐； • ⑶ Mirizzi Syndrome：0.7%~1%； • ⑷ 胆囊积液：白胆汁； • ⑸ Second CBD Stone、胆源性胰腺炎、胆囊~十二指肠瘘、
胆石性肠梗阻、诱发癌变。
AOSC
（Acute Obstruct
Suppurative Cholangitis）
=ACST
(Acute Cholangitis of Severe Type)：
Reynolds五联征：腹痛、寒战高热、黄疸、休克、中枢神经系统抑制。
四、诊断（Diagnosis）
• 1. 临床特点： • ⑴ 多见于青壮年，20~40岁多见。 • ⑵ 长期反复发生上腹部疼痛及胆管炎病史。 • ⑶ 腹痛、发冷发热、黄疸症候群。 • ⑷ 恶心、呕吐。 • ⑸ 病情进展快，常并发脓毒症(Sepsis)，血细菌培养阳性。 • ⑹ 触到肿大的胆囊。 • ⑺ 肝大、触痛和叩痛。 • ⑻ WBC明显升高。 • ⑼ 肝功能受损，贫血及低蛋白血症。
• ⑷ 胆囊穿孔 (Perforated Cholecystitis)。
四、诊断和鉴别诊断
（Diagnosis & Differential diagnosis）

64层螺旋CT3D成像技术在胆道梗阻性疾病病变的检出率、准确率及鉴别诊断的价值

64层螺旋CT3D成像技术在胆道梗阻性疾病病变的检出率、准确率及鉴别诊断的价值范磊长江大学附属仙桃市第一人民医院介入医学科，湖北仙桃 433000[摘要] 目的探析64层螺旋CT3D成像技术在胆道梗阻性疾病病变的检出率、准确率及提高鉴别诊断的临床应用价值。

方法选取2018年3月～2019年3月我院160例胆道梗阻性疾病患者，对患者行64层螺旋CT3D成像技术和磁共振胆胰管水成像技术诊断，比较两种诊断方法检出率和定位准确率，分析诊断价值。

结果磁共振胆胰管水成像诊断良性病变诊断率为77.8%，恶性病变诊断率为73.1%，64排螺旋CT胆道成像诊断良性病变诊断率为92.6%，恶性病变诊断率为88.5%，与磁共振胆胰管水成像诊断比较，64排螺旋CT胆道成像诊断定位准确率更高（P＜0.05）。

结论 64层螺旋CT3D成像技术对病变部位及胆道占位性病变显像，可为疾病治疗提供更准确理论资料，有利于患者临床症状改善和治疗有效率提升。

[关键词] 64层螺旋CT；3D成像技术；胆道梗阻性疾病；检出率；准确率[中图分类号] R814.42；R575.7 [文献标识码] A [文章编号] 2095-0616（2020）23-200-04 Investigation of the clinical application value of the detection rate, accuracy rate and improvement of differential diagnosis of 64-slice spiral CT3D imaging technology in biliary tract obstructive diseasesFAN LeiDepartment of Interventional Medicine, Xiantao First People's Hospital, Affiliated to Yangtze University, Hubei, Xiantao 433000, China[Abstract] Objective To explore the clinical application value of 64-slice spiral CT3D imaging technology in the detection rate and accuracy of biliary obstructive diseases and to improve the differential diagnosis. Methods 160 patients with biliary obstructive diseases in our hospital from March 2018 to March 2019 were selected, and the patients were diagnosed with 64-slice spiral CT3D imaging technology and magnetic resonance cholangiopancreatic hydrography, and the two diagnostic methods were compared. Detection rate and positioning accuracy rate, analysis and diagnosis value. Results The diagnosis rate of MR cholangiopancreatography was 77.8% for benign lesions and 73.1% for malignant lesions. The diagnosis rate for 64-slice spiral CT cholangiography was 92.6% for benign lesions and 88.5% for malignant lesions. Compared with the diagnosis of resonance cholangiopancreatography, 64-slice spiral CT biliary imaging has a higher diagnostic positioning accuracy (P＜0.05). Conclusion The 64-slice spiral CT3D imaging technology can visualize the lesions and biliary space-occupying lesions, and can provide more accurate theoretical data for disease treatment, which is beneficial to the improvement of patients' clinical symptoms and the improvement of treatment efficiency.[Key words] 64-slice spiral CT; 3D imaging technology; Biliary tract obstructive diseases; Detection rate; Accuracy rate目前胆道梗阻性疾病发病率不断上升，磁共振胆胰管水成像技术、内镜逆行胰胆管造影、CT、经皮肝穿刺造影、彩超为临床当中的主要诊断方式[1]。

胆道支架的研究现状

·综述·DOI： 10.3969/j.issn.1001-5256.2023.10.031胆道支架的研究现状阿布都喀哈尔·阿布都拉1，哈力木拉提·吾布力卡斯木2，3，段绍斌2，31 新疆医科大学研究生学院，乌鲁木齐 830054；2 新疆医科大学第四附属医院普外一科，乌鲁木齐830099；3 新疆维吾尔自治区中医药研究院，乌鲁木齐 830099通信作者：段绍斌，********************（ORCID： 0000－0003－1234－7514）摘要：胆道疾病是我国肝胆系统常见疾病类型，发病率较高，且相关并发症是严重影响患者健康的重要原因。

胆道支架主要用于缓解和解除良恶性胆道狭窄和梗阻，具有创伤小、安全性高、符合胆道生理解剖结构等特征，已成为无法根治性切除的胰胆肿瘤引起的胆道梗阻首选姑息型治疗手段。

然而，目前常用的胆道支架因细菌黏附、胆汁淤积、支架阻塞、支架迁移等缺点，未能达到理想治疗效果。

近年来众多学者对胆道支架堵塞成因、改进支架设计、延长引流时效等方面进行了广泛而深入的研究和尝试，取得了一些进展。

本文对各类胆道支架的类型、优缺点及发展史进行综述，并展望了胆道支架未来的研究方向和应用价值。

关键词：胆道疾病；支架；治疗学基金项目：天山青年计划青年博士科技人才培养项目（2020Q088）Current research status of biliary stentsABUDUKAHAER Abudula1，HALMURAT Obulkasim2，3，DUAN Shaobin2，3.（1. Graduate School of Xinjiang Medical University， Urumqi 830054， China； 2. First Department of General Surgery， The Forth Affiliated Hospital of Xinjiang Medical University， Urumqi 830099， China； 3. Xinjiang Institute of Traditional Chinese Medicine， Urumqi 830099， China）Corresponding author： DUAN Shaobin，********************（ORCID： 0000－0003－1234－7514）Abstract：Biliary tract diseases are a common type of hepatobiliary diseases in China and have a relatively high incidence rate， and related complications are important influencing factors for the health of Chinese patients. Biliary stents are mainly used to alleviate and relieve benign or malignant biliary stricture and obstruction，with the features of little trauma，high safety， and in line with the physiological and anatomical structure of biliary tract， and it has become the preferred palliative treatment method for biliary obstruction caused by unresectable pancreaticobiliary tumors. However，there is still a lack of satisfactory treatment outcomes since commonly used biliary stents have the shortcomings such as bacterial adhesion，cholestasis， stent obstruction， and stent migration. In recent years， scholars have conducted extensive and in－depth studies on the causes of biliary stent obstruction， the improvement of stent design， and the extension of drainage duration and have made certain progress. This article reviews the types， advantages and disadvantages， and development history of biliary stents and proposes the future research directions and application value of biliary stents.Key words：Biliary Tract Diseases； Stents； TherapeuticsResearch funding：Tianshan Youth Program Young doctor Science and Technology Talent Training Program（2020Q088）胆道疾病是引起胆道狭窄、胆道梗阻和黄疸的最常见的原因之一，若治疗不及时，可引起严重的并发症，甚至危及生命［1］。

胆汁酸膜受体TGR5在胆道疾病中的研究进展

.胆汁酸膜受体ＴＧＲ５在胆道疾病中的研究进展陈思平１，２，韩　丽１，２，舒　鹏２，代　鑫２，程　龙２１西南交通大学医学院，成都６１００３１；２西部战区总医院全军普外中心，成都６１００８３摘要：ＴＧＲ５是一种胆汁酸激活的Ｇ蛋白偶联受体，在胆道系统生理及病理过程中发挥着重要作用。

本文简述了在正常生理情况下，ＴＧＲ５在肝脏及胆管中的正常表达情况，及发挥调节胆汁酸分泌、代谢，细胞保护作用等功能。

归纳了在病理生理情况下，ＴＧＲ５表达及功能的变化通过炎症反应、细胞增殖、凋亡等途径来影响疾病的发生与发展的机制。

ＴＧＲ５可能是未来治疗胆道疾病的潜在靶点。

关键词：胆道疾病；胆酸类；受体，Ｇ－蛋白偶联基金项目：四川省青年科技基金（２０１６ＪＱ００２３）ＲｅｓｅａｒｃｈａｄｖａｎｃｅｓｉｎｔｈｅｂｉｌｅａｃｉｄｍｅｍｂｒａｎｅｒｅｃｅｐｔｏｒＴＧＲ５ｉｎｂｉｌｉａｒｙｔｒａｃｔｄｉｓｅａｓｅｓＣＨＥＮＳｉｐｉｎｇ１，２，ＨＡＮＬｉ１，２，ＳＨＵＰｅｎｇ２，ＤＡＩＸｉｎ２，ＣＨＥＮＧＬｏｎｇ２．（１．ＳｏｕｔｈｗｅｓｔＪｉａｏｔｏｎｇＵｎｉｖｅｒｓｉｔｙＣｏｌｌｅｇｅｏｆＭｅｄｉｃｉｎｅ，Ｃｈｅｎｇｄｕ６１００３１，Ｃｈｉｎａ；２．ＧｅｎｅｒａｌＳｕｒｇｅｒｙＣｅｎｔｅｒｏｆＰＬＡ，ＴｈｅＧｅｎｅｒａｌＨｏｓｐｉｔａｌｏｆＷｅｓｔｅｒｎＴｈｅａｔｅｒＣｏｍｍａｎｄ，Ｃｈｅｎｇｄｕ６１００８３，Ｃｈｉｎａ）Ｃｏｒｒｅｓｐｏｎｄｉｎｇａｕｔｈｏｒ：ＣＨＥＮＧＬｏｎｇ，ｔｍｍｕｌｏｎｇ＠１６３．ｃｏｍ（ＯＲＣＩＤ：００００－０００２－０３８２－８２１２）Ａｂｓｔｒａｃｔ：ＴＧＲ５ｉｓａｂｉｌｅａｃｉｄ－ａｃｔｉｖａｔｅｄＧｐｒｏｔｅｉｎ－ｃｏｕｐｌｅｄｒｅｃｅｐｔｏｒａｎｄｐｌａｙｓａｎｉｍｐｏｒｔａｎｔｒｏｌｅｉｎｔｈｅｐｈｙｓｉｏｌｏｇｉｃａｌａｎｄｐａｔｈｏｌｏｇｉｃａｌｐｒｏｃｅｓｓｅｓｏｆｔｈｅｂｉｌｉａｒｙｓｙｓｔｅｍ．ＴｈｉｓａｒｔｉｃｌｅｄｅｓｃｒｉｂｅｓｔｈｅｎｏｒｍａｌｅｘｐｒｅｓｓｉｏｎｏｆＴＧＲ５ｉｎｔｈｅｌｉｖｅｒａｎｄｂｉｌｅｄｕｃｔｕｎｄｅｒｎｏｒｍａｌｐｈｙｓｉｏｌｏｇｉｃａｌｃｏｎｄｉｔｉｏｎｓａｎｄｉｔｓｆｕｎｃｔｉｏｎｓｉｎｃｌｕｄｉｎｇｔｈｅｒｅｇｕｌａｔｉｏｎｏｆｂｉｌｅａｃｉｄｓｅｃｒｅｔｉｏｎａｎｄｍｅｔａｂｏｌｉｓｍａｎｄｃｙｔｏｐｒｏｔｅｃｔｉｏｎ．ＴｈｉｓａｒｔｉｃｌｅａｌｓｏｓｕｍｍａｒｉｚｅｓｔｈｅｃｈａｎｇｅｓｉｎｔｈｅｅｘｐｒｅｓｓｉｏｎａｎｄｆｕｎｃｔｉｏｎｏｆＴＧＲ５ｕｎｄｅｒｐａｔｈｏｐｈｙｓｉｏｌｏｇｉｃａｌｃｏｎｄｉｔｉｏｎｓａｎｄｔｈｅｍｅｃｈａｎｉｓｍｏｆＴＧＲ５ｉｎａｆｆｅｃｔｉｎｇｔｈｅｄｅｖｅｌｏｐｍｅｎｔａｎｄｐｒｏｇｒｅｓｓｉｏｎｏｆｂｉｌｉａｒｙｔｒａｃｔｄｉｓｅａｓｅｓｔｈｒｏｕｇｈｉｎｆｌａｍｍａｔｏｒｙｒｅｓｐｏｎｓｅａｎｄｃｅｌｌｐｒｏｌｉｆｅｒａｔｉｏｎａｎｄａｐｏｐｔｏｓｉｓ．ＴＧＲ５ｍａｙｂｅａｐｏｔｅｎｔｉａｌｔａｒｇｅｔｆｏｒｔｈｅｔｒｅａｔｍｅｎｔｏｆｂｉｌｉａｒｙｔｒａｃｔｄｉｓｅａｓｅｓｉｎｔｈｅｆｕｔｕｒｅ．Ｋｅｙｗｏｒｄｓ：ＢｉｌｉａｒｙＴｒａｃｔＤｉｓｅａｓｅｓ；ＣｈｏｌｉｃＡｃｉｄｓ；Ｒｅｃｅｐｔｏｒｓ，Ｇ－Ｐｒｏｔｅｉｎ－ＣｏｕｐｌｅｄＲｅｓｅａｒｃｈｆｕｎｄｉｎｇ：ＴｈｅＹｏｕｔｈＦｏｕｎｄａｔｉｏｎｏｆＳｃｉｅｎｃｅａｎｄＴｅｃｈｎｏｌｏｇｙＤｅｐａｒｔｍｅｎｔｏｆＳｉｃｈｕａｎＰｒｏｖｉｎｃｅ（２０１６ＪＱ００２３）ＤＯＩ：１０．３９６９／ｊ．ｉｓｓｎ．１００１－５２５６．２０２２．０３．０４７收稿日期：２０２１－０７－２１；录用日期：２０２１－０９－１７通信作者：程龙，ｔｍｍｕｌｏｎｇ＠１６３．ｃｏｍ胆汁酸不仅作为清洁分子参与脂肪消化和疏水性化合物（如脂溶性维生素）吸收，也作为重要信号分子参与分泌、代谢、细胞增殖及分化、再生、纤维化和炎症等生理及病理生理过程［１］。

超声内镜对胆道占位性病变的诊断价值

㊃专题㊃通信作者:冯志杰,E m a i l :z h i j i e f e n g2005@163.c o m 超声内镜对胆道占位性病变的诊断价值张迪,冯志杰,赵东强(河北医科大学第二医院消化内科,河北石家庄050000) 摘要:胆道占位性病变是引起梗阻性黄疸的主要原因,但由于其位置特殊,传统的影像学诊断较为困难,超声内镜(E U S )利用消化道自然腔道,有效避开腹壁脂肪和肠道气体的干扰,使胆道系统呈现清晰的显像;尤其是近年来开展的E U S 引导下的细针穿刺㊁造影增强超声内镜对胆道占位性病变有较高的诊断价值,在其鉴别诊断方面也发挥着越来越重要的作用㊂关键词:腔内超声检查;活组织检查,针吸;胆管癌;胆总管结石中图分类号:R 445.1 文献标志码:A 文章编号:1004-583X (2019)09-0785-05d o i :10.3969/j.i s s n .1004-583X.2019.09.004D i a g n o s t i c v a l u e o f e n d o s c o p i c u l t r a s o n o g r a p h y f o r s p a c e -o c c u p y i n g l e s i o n s o f b i l i a r yt r a c t Z h a n g D i ,F e n g Z h i j i e ,Z h a oD o n g q i a n gD e p a r t m e n t o f G a s t r o e n t e r o l o g y ,t h eS e c o n d H o s p i t a l o f H e b e iM e d i c a lU n i v e r s i t y ,S h i j i a z h u a n g 050000,C h i n a C o r r e s p o n d i n g a u t h o r :F e n g Z h i j i e ,E m a i l :z h i j i e f e n g2005@163.c o m A B S T R A C T :T h e s p a c e -o c c u p y i n g l e s i o n s o f b i l i a r y t r a c t i s t h em a i n c a u s e o f o b s t r u c t i v e j a u n d i c e .B e c a u s e o f t h e s p e c i a l l o c a t i o no f t h eb i l i a r y s y s t e m ,t r a d i t i o n a l i m a g i n g i sd i f f i c u l t t od i a g n o s e .E n d o s c o p i cu l t r a s o n o g r a p h y (E U S )c a n e f f e c t i v e l y a v o i d t h e i n t e r f e r e n c e o f a b d o m i n a l f a t a n d i n t e s t i n a l g a s ,a n d c l e a r l y s h o wt h e b i l i a r y s y s t e m.I n r e c e n t y e a r s ,E U S g u i d e df i n en e e d l ea s p i r a t i o na n dc o n t r a s t -e n h a n c e de n d o s c o p i cu l t r a s o n o g r a p h y t e c h n i q u e sh a v eh i g h d i a g n o s t i c v a l u e i n t h e s p a c e -o c c u p y i n g l e s i o n s o f b i l i a r y t r a c t a n d p l a y a n i m p o r t a n t r o l e i n t h e d i f f e r e n t i a l d i a g n o s i s o f b i l i a r y tr a c t d i s e a s e s .K E Y W O R D S :e n d o s o n o g r a p h y ;b i o p s y ,n e e d l e ;c h o l a n gi o c a r c i n o m a ;b i l e d u c t s t o n es 冯志杰,教授㊁主任医师㊁博士生导师,河北医科大学第二医院消化内科主任㊂担任河北省医学会消化内镜学分会主任委员,中华医学会消化内镜学分会委员,中国医师协会内镜分会消化内镜专业委员会委员,中华医学会消化内镜分会胶囊协作组副组长,中华医学会消化内镜学分会影像协作组副组长,河北省急救医学会消化专业委员会主任委员,河北省药学会消化药学专业委员会主任委员㊂胆道系统周围毗邻胰腺㊁肝脏㊁胃肠道等多个组织器官㊁结构复杂,单纯应用影像学检查很难清晰完整地显示胆道系统结构㊂超声内镜(E U S )是一种新型内镜技术,将高频超声探头置入内镜前端,利用消化道的自然腔道有效避开腹壁脂肪及胃肠气体的干扰,获得高分辨图像信息,在胆道系统疾病的诊疗中发挥重要作用㊂E U S 引导下的细针穿刺术(E U S -F N A )是一种明确病变性质的诊断方法,旨在E U S 引导下,用细针对病变组织进行穿刺活检㊁进而获取病理学组织明确诊断㊂E U S -F N A 对胆道系统占位性病变,尤其是难以明确的胆道占位性病变有很高的诊断价值㊂1 E U S 对胆道恶性肿瘤的诊断1.1 E U S 对胆管癌的诊断胆管癌是胆道系统最常见的恶性肿瘤,其中以肝外胆管癌多见,发病率仅次于肝细胞癌,居肝胆恶性肿瘤的第2位,约占整个消化道肿瘤的3%[1]㊂肝外胆管癌又分为肝门部胆管癌㊁远端胆管癌(约占40%),早期的肝外胆管癌患者无典型症状,糖类抗原19-9(C A 19-9)等实验室检查缺乏特异性,腹部超声(T U S )㊁C T ㊁磁共振胰胆管造影(M R C P )等影像学检查早期病变无典型特征,早期发现较为困难,因此胆管癌患者的总体预后差㊁生存率低㊂近年来,通过E U S 检查不仅可以早期发现病变,而且能够了解肿瘤的病变大小㊁浸润深度㊁有无周围及远处淋巴结转移㊁血管受累,从而获得准确的术前分期,对指导制定最佳治疗方案和选择手术方法具有重要意义㊂1.1.1 E U S 对肝门部胆管癌的诊断价值肝门部胆管癌又称高位胆道恶性梗阻,预后差,很难获得病㊃587㊃‘临床荟萃“ 2019年9月20日第34卷第9期 C l i n i c a l F o c u s ,S e pt e m b e r 20,2019,V o l 34,N o .9Copyright ©博看网. All Rights Reserved.理学明确诊断,目前有研究发现通过E R C P进行胆管细胞刷检阳性率仅为30%~60%[2]㊂E U S可很好观察胆总管至肝门部胆管的结构变化,并通过细针穿刺活检对于内镜进行胰胆管造影术(E R C P)刷检阴性或E R C P难以操作的肝门部胆管癌进行组织和细胞学诊断[3]㊂在一项通过C T或E R C P诊断为肝门部狭窄的前瞻性研究中,44例患者通过E U S-F N A检查,其中31例为恶性肿瘤,12例为良性病变,且其中有一半患者因为E U S检查后明确诊断而改变了预定的手术方案,通过这项研究发现E U S-F N A的正确率㊁敏感度和特异度分别为91%㊁89%和100%,且穿刺过程安全,无并发症发生[4]㊂E U S 还可以进一步评估患者的淋巴结转移情况,有一项针对肝门部胆管癌患者拟行肝移植前进行术前评估的研究,通过影像学检查未发现明确淋巴结转移,但E U S检查发现部分患者病变周围存在肿大淋巴结,并通过E U S-F N A对淋巴结穿刺活检,约17%的患者因发现恶性转移而放弃肝移植手术方案[5]㊂H i g a s h i g u c h i等[6]报道了1例肝门部胆管癌患者合并区域淋巴结转移,通过E U S-F N A对化疗前后淋巴结反复活检,可有效评估化疗效果㊂另有研究指出,对肝门部胆管癌患者行E U S-F N A或E U S-F N B 诊断阳性率差异无明显统计学意义(80.5%v s 87.5%)[7]㊂此外,E l o u b e i d i等[8]报道肝门部胆管癌患者直接进行手术中位生存期为17.8个月,而术前进行E U S-F N A评估后进行手术治疗的中位生存期为18.5个月,因此E U S-F N A并不影响肝门部胆管癌患者的总体生存期㊂鉴于肝门部胆管癌靠近胆总管近端,E R C P活检㊁刷检及胆汁细胞学检查阳性率较低,E U S-F N A/F N B诊断率及敏感度均较高,且操作安全㊁有效,推荐作为明确诊断的一线方法㊂1.1.2 E U S对下段胆总管癌的诊断价值胆总管下段的恶性肿瘤又称为低位胆道恶性肿瘤,因梗阻表现为胆总管远端狭窄㊁近端扩张㊂由于其位置特殊,有研究报道至少15%~20%的患者仅通过E U S 发现胆总管远端肿瘤,而腹部影像学检查未发现明显占位㊂2018年一项294例患者的回顾性分析发现,E U S-F N A和E R C P对胆管癌诊断的敏感度分别为75%和49%,特异度为100%和96.33%,此外,经手术后证明其阳性预测值分别为100%和98.33%[9]㊂这与W e i l e r t等[10]之前在一项前瞻性研究中得出的结论是一致的,与E R C P细胞学检查相比,在可疑恶性胆道狭窄的诊断方面,E U S-F N A的正确率和敏感度更高,因此,对于怀疑恶性胆道梗阻的患者,应首先进行E U S-F N A检查㊂在一项纳入了957例恶性胆道梗阻患者的M e t a分析中指出, E U S-F N A检查的不良事件发生率仅占0.3%[11]㊂这些研究表明,E U S-F N A检查对于胆管癌的诊断不仅具有高度的特异度及灵敏度,且十分安全㊂此外,胆管腔内超声(I D U S)是在E R C P引导下直接将高频超声探头置入胆总管进行超声检查的一种方式㊂一项I D U S和E U S在诊断胆道梗阻方面的前瞻性研究中发现,I D U S在诊断准确率㊁敏感度㊁对肿瘤的T分期方面较E U S正确率高(89.1%v s 75.6%,91.1%v s75.7%,77.7%v s54.1%),但对肿瘤淋巴结分期的诊断二者无明显差别[12]㊂另有一项对65例疑似恶性胆道狭窄的前瞻性研究发现,经I D U S引导下的毛细管活检(T P B)诊断效能明显高于E R C P下常规活检(90.8%v s76.9%)[13]㊂这些研究表明,I D U S不仅能提高胆道占位病变诊断的敏感度,而且经I D U S引导的活检可进一步提高组织病理学诊断的正确率㊂1.2 E U S对胆囊癌的诊断价值胆囊癌是胆道较少见的恶性肿瘤,具有隐匿性㊁发展速度快㊁预后差等特点㊂E U S可清晰显示病变形态㊁范围㊁管壁层次,能够提供关于胆囊癌定性诊断和侵犯深度的确切评价[14]㊂近年来随着造影增强超声内镜(C E-E U S)的应用,通过C E-E U S观察到不规则血管及灌注缺损用于诊断胆囊恶性息肉,其敏感度和特异度分别为90.3%和96.6%[15]㊂I m a z u等[16]发现胆囊癌患者C E-E U S表现为胆囊壁不均匀增强,对E U S与C E-E U S诊断恶性胆囊壁增厚的敏感度㊁特异度和正确率进行比较,分别为83.3%v s89.6%㊁65.0%v s 98.0%和73.1%v s94.4%㊂此外,E U S-F N A还为胆囊癌的病理组织学诊断提供了依据,同时进行周围淋巴结活检明确肿瘤的分期及预后㊂一项对41例胆囊癌手术的患者进行回顾性研究发现,E U S对T i s准确度为100%,T1为76%,T2为85%,T3-4为93%[17]㊂综上,C E-E U S可显著提高胆囊癌诊断的特异度及敏感度,而结合E U S-F N A可明确胆囊肿瘤的诊断及有效评估相邻淋巴结的转移情况,对于指导外科手术㊁改善患者预后具有重要意义㊂2E U S对胆道良性病变的诊断价值2.1 E U S对胆总管远端/壶腹部腺瘤的诊断价值胆总管的良性病变较少见,主要见于胆总管腺瘤,好发于胆总管远端,常见于壶腹部㊂早在2004年就有㊃687㊃‘临床荟萃“2019年9月20日第34卷第9期 C l i n i c a l F o c u s,S e p t e m b e r20,2019,V o l34,N o.9Copyright©博看网. All Rights Reserved.个案报道:1例64岁妇女因胆总管结石行E U S检查发现胆总管绒毛状腺瘤[18]㊂H e i n z o w等[19]对72例经E R C P诊断为胆总管远端占位或壶腹部占位的患者行I D U S检查,发现40例为壶腹部腺瘤㊂另有一项40例壶腹部肿瘤的前瞻性研究发现,经E U S或I D U S诊断为腺瘤的共7例,其正确率为62%[20]㊂由此可见,胆总管腺瘤样病变发病率较低,常与胆管癌相混淆,E U S/I D U S有助于鉴别良恶性肿瘤,为是否进行手术治疗提供更多的诊断依据㊂2.2 E U S对胆囊息肉样病变的诊断价值大多数的胆囊息肉是在T U S或者腹部C T检查中偶然发现的,大约有95%的息肉为良性息肉,由于慢性炎症㊁黏膜增生或脂质沉积所致㊂腺瘤是最常见的胆囊息肉类型㊂由于恶性肿瘤的风险会随着息肉的增大而增加,通常大于1c m的息肉需要胆囊切除,因此对息肉的诊断及随访都至关重要[21]㊂在一项对194例直径小于20mm的胆囊息肉样病变患者进行E U S 检查,发现其在检测肿瘤的正确率方面优于T U S (97%v s76%)[22]㊂另有一项研究基于E U S评价直径在5~15mm之间的胆囊息肉,其敏感度和正确率分别为81%和86%[23]㊂近年来,C E-E U S可通过观察息肉样病变内有无血管或灌注缺陷更好预测息肉的良恶性[15]㊂W e n n m a c k e r等[24]的一项M e t a分析指出,T U S对于是否存在胆囊息肉敏感度比较高,但对于真性息肉和假性息肉以及增生性息肉㊁癌㊁腺瘤诊断的正确率较差,而E U S在这些方面优于T U S㊂综上,E U S不仅可以检查出胆囊息肉的大小㊁侵及深度,还可以对息肉进行随访,对其是否存在肿瘤特征进行监控㊂2.3 E U S对胆总管囊肿的诊断价值胆总管囊肿是发生在肝内外胆管的一种先天性囊性扩张症,根据胆管扩张的部位㊁范围和形态分为5型,Ⅰ型:胆总管囊性扩张,可累及胆总管㊁肝总管,胆管成球状或梭状扩张,临床最常见,约占90%;Ⅱ型:胆总管憩室样扩张;Ⅲ型:胆总管开口部囊性脱垂;Ⅳ型:肝内㊁外胆管均呈囊性扩张;Ⅴ型:C a r o l i病,表现为肝内胆管扩张[25]㊂目前已明确胆总管囊肿是胆管癌的高危因素,因此早期诊断及治疗显得极其重要㊂胆总管囊肿的诊断主要依赖影像学检查,包括T U S㊁C T㊁M R C P等,E U S检查对于较小的㊁不易明确诊断的胆道囊肿有较好的诊断价值㊂在最近的一项回顾性研究中发现,56例患者经T U S或腹部C T 检查发现胆总管扩张,随后进行E U S检查可发现2例确诊为胆总管囊肿[26]㊂此外,由于Ⅱ型胆总管囊肿靠近胰腺,憩室膨出通过狭窄的茎与胆管相连,有时与胰腺囊肿很难区分㊂有研究发现对于较难区分的胆总管囊肿,E U S检查是有利的确诊手段,它可以显示小于1mm的非常小的间隔,并且可以通过E U S-F N A获取囊液进行分析,进一步明确胆道囊肿或其他囊性结构[27]㊂2.4 E U S对胆道结石的诊断价值胆道结石发病率较高,以胆总管结石比较常见,它与代谢㊁慢性炎症和寄生虫关系密切,是引起黄疸的原因之一㊂T U S对于泥沙样结石,特别是胆总管下段的微小结石诊断率较低,仅为55%;腹部C T对高密度结石能够明确显影,但对泥沙样结石或等密度结石诊断困难㊂M R C P是一种无创的㊁可清晰显示胆管及胰腺的技术,近年来在胆总管结石的诊断中受到广泛应用㊂有文献报道,M R C P与E U S在诊断胆总管结石的敏感度和特异度方面,准确率均可达90%以上,因此,2017年英国的胆总管结石指南推荐二者作为诊断胆总管结石的首选检查[28]㊂但M R C P在病理性肥胖及安装起搏器患者中可行性较低,且当结石的直径小于4mm或对于胆系的泥沙样结石,M R C P 诊断的敏感度明显降低㊂因此,E U S逐渐成为诊断胆总管结石的首选方案㊂根据文献报道对40例M R C P阴性的患者行E U S检查,发现15例患者存在胆总管结石,并随后经E R C P证实诊断[29]㊂即便与E R C P相比,诊断胆总管微小结石或泥沙样结石E U S也有明显优势,其敏感度为90%(E R C P敏感度仅为23%)[30]㊂P o l k o w s k i等[31]在一项98例患者的随机对照研究中发现,经过逆行性胆管造影(E R C)治疗后再次发现胆总管结石的概率为40%,而E U S 仅为10%,且E U S检查方法无创且更安全㊂由此我们得出E U S对胆总管结石特别是微小结石在诊断的敏感度㊁特异度及准确率方面均优于T U S㊁C T㊁E R C P和M R C P㊂而且与E R C P和M R C P相比,E U S还具有动态实时显像的优势㊂综上,E U S作为一种安全㊁有效的检查方法,在胆道良㊁恶性疾病的诊断与鉴别诊断中发挥着不可或缺的作用,而I D U S㊁E U S-F N A及C E-E U S的应用将大大提高疾病诊断的准确率,为胆道占位性病变的微创或手术治疗提供了有利的依据㊂当然,由于E U S检查沿着消化道管腔进行,因此具有一定的局限性:例如由于外科手术改变正常解剖结构而影响探查;各种原因引起的胃或十二指肠狭窄,内镜不㊃787㊃‘临床荟萃“2019年9月20日第34卷第9期 C l i n i c a l F o c u s,S e p t e m b e r20,2019,V o l34,N o.9Copyright©博看网. All Rights Reserved.能到达十二指肠球降部进行检查;胃肠道走形所限导致E U S对肝门部及右肝图像不能很好显示等㊂因此,E U S检查应对病变进行仔细辨别,避免操作者主观判断,必要时仍需结合影像学检查趋利避害㊂参考文献:[1] N a y a rMK,M a n a s D M,W a d e h r a V,e ta l.R o l eo fE U S/E U S-g u i d e dF N A i n t h e m a n a g e m e n t o f p r o x i m a l b i l i a r ys t r i c t u r e s[J].H e p a t o g a s t r o e n t e r o l o g y,2011,58(112):1862-1865.[2] N a v a n e e t h a nU,N j e iB,L o u r d u s a m y V,e ta l.C o m p a r a t i v ee f f e c t i v e n e s so fb i l i a r y b r u s hc y t o l o g y a n di n t r a d u c t a lb i o p s yf o rd e t e c t i o n o f m a l ig n a n t b i l i a r y s t r i c t u r e s:a s y s t e m a t i cr e v i e wa n d m e t a-a n a l y s i s[J].G a s t r o i n t e s tE n d o s c,2015,81(1):168-176.[3] F i r t s c h e r-R a v e n sA,B r o e r i n g D C,S r i r a m P V,e ta l.E U S-g u i d e d f i n e-n e e d l ea s p i r a t i o nc y t o d i a g n o s i so fh i l a r N:ac a s es e r i e s[J].G a s t r o i n t e s tE n d o s c,2000,52(4):534-540.[4] F i r t s c h e r-R a v e n sA,B r o e r i n g D C,K n o e f e lWT,e t a l.E U S-g u i d e d f i n e-n e e d l e a s p i r a t i o n o f s u s p e c t e d h i l a rc h o l a n g i o c a r c i n o m a i n p o t e n t i a l l y o p e r a b l e p a t i e n t s w i t hn e g a t i v eb r u s hc y t o l o g y[J].A m J G a s t r o e n t e r o l,2004,99(1):45-51.[5] Tél l e z-Áv i l aF I,B e r n a l-Mén d e z A R,G u e r r e r o-V췍z q u e zC G,e t a l.D i a g n o s t i c y i e l do fE U S-g u i d e dt i s s u ea c q u i s i t i o na saf i r s t-l i n e a p p r o a c h i n p a t i e n t s w i t h s u s p e c t e d h i l a rc h o l a n g i o c a r c i n o m a[J].A mJG a s t r o e n t e r o l,2014,109(8):1294-1296.[6] H i g a s h i g u c h iM,Y a m a d aD,A k i t a H,e ta l.S u c c e s s f u lR0r e s e c t i o no f h i l a r c h o l a n g i o c a r c i n o m ab y e x t r a h e p a t i cb i l ed u c tr e s e c t i o n d u e t o a c c o m p a n y i n g l i v e r d y s f u n c t i o n a f t e rn e o a d j u v a n t G e m c i t a b i n e/C i s p l a t i n/S-1c o m b i n a t i o nc h e m o t h e r a p y-ac a s e r e p o r t[J].G a n T o K a g a k u R y o h o,2019,46(2):342-344.[7] G l e e s o nF C,R a j a nE,L e v y M J,e ta l.E U S-g u i d e dF N A o fr e g i o n a ll y m p h n o d e s i n p a t i e n t s w i t h u n r e s e c t a b l e h i l a rc h o l a n g i o c a r c i n o m a[J].G a s t r o i n t e s tE nd o s c,2008,67(3):438-443.[8] E l o u b e i d i MA,C h e n V K,J h a l a N C,e t a l.E n d o s c o p i cu l t r a s o u n d-g u i d e df i n en e e d l ea s p i r a t i o n b i o p s y o fs u s p e c t e dc h o l a n g i o c a r c i n o m a[J].C l i nG a s t r o e n t e r o lH e p a t o l,2004,2(3):209-213.[9] D e M o u r a D T H,M o u r a E G H,B e r n a r d o WM,e t a l.E n d o s c o p i c r e t r o g r a d e c h o l a n g i o p a n c r e a t o g r a p h y v e r s u se n d o s c o p i c u l t r a s o u n df o r t i s s u ed i ag n o s i so fm a l i g n a n tb i l i a r ys t r i c t u r e:s y s t e m a t i cr e v i e w a n d m e t a-a n a l y s i s[J].E n d o s cU l t r a s o u n d,2018,7(1):10-19.[10] W e i l e r tF,B h a t YM,B i n m o e l l e r K F,e ta l.E U S-F N A i ss u p e r i o r t oE R C P-b a s e d t i s s u e s a m p l i n g i n s u s p e c t e dm a l i g n a n tb i l i a r y o b s t r uc t i o n:r e s u l t s o f a p r o s p e c t i v e,s i n g l e-b l i n d,c o m p a r a t i v e s t ud y[J].G a s t r o i n te s tE n d o s c,2014,80(1):97-104.[11]S a d e g h iA,M o h a m a d n e j a d M,I s l a m iF,e ta l.D i a g n o s t i cy i e l do fE U S-g u i d e d F N A f o r m a l i g n a n tb i l i a r y s t r i c t u r e:a s y s t e m a t i c r e v i e wa n d m e t a-a n a l y s i s[J].G a s t r o i n t e s tE n d o s c, 2016,83(2):290-298.[12] M e n z e l J,P o r e m b aC,D i e t l K H,e t a l.P r e o p e r a t i v e d i a g n o s i so f b i l e d u c t s t r i c t u r e s--c o m p a r i s o n o f i n t r a d u c t a l u l t r a s o n o g r a p h y w i t h c o n v e n t i o n a l e n d o s o n o g r a p h y[J].S c a n d JG a s t r o e n t e r o l,2000,35(1):77-82.[13] K i m H S,M o o n J H,L e eY N,e t a l.P r o s p e c t i v e c o m p a r i s o n o fi n t r a d u c t a lu l t r a s o n o g r a p h y-g u i d e dt r a n s p a p i l l a r y b i o p s y a n dc o n v e n t i o n a lb i o p s y o n f l u o r o s c o p y i n s u s p e c t ed m a l i g n a n tb i l i a r y s t r ic t u r e s[J].G u tL i v e r,2018,12(4):463-470.[14]S u g i m o t oM,T a k a g iT,S u z u k iR,e ta l.C o n t r a s t-e n h a n c e dh a r m o n i c e n d o s c o p i c u l t r a s o n o g r a p h y i n g a l l b l a d d e r c a n c e r a n dp a n c r e a t i c c a n c e r[J].F u k u s h i m a JM e dS c i,2017,63(2):39-45.[15] C h o iJ H,S e o DW,C h o iJ H,e t a l.U t i l i t y o fc o n t r a s t-e n h a n c e d h a r m o n i c E U S i n t h e d i a g n o s i s of m a l ig n a n tg a l l b l a d d e r p o l y p s(w i t h v i d e o s)[J].G a s t r o i n t e s t E n d o s c,2013,78(3):484-493.[16]I m a z u H,M o r iN,K a n a z a w a K,e ta l.C o n t r a s t-e n h a n c e dh a r m o n i c e n d o s c o p i c u l t r a s o n o g r a p h y i n t h e d i f f e r e n t i a ld i a g n o s i s o f g a l l b l a d de rw a l l t h i c k e n i n g[J].D i g D i s S c i,2014,59(8):1909-1916.[17]S a d a m o t o Y,K u b o H,H a r a d a N,e t a l.P r e o p e r a t i v ed i a g n o s i sa n ds t a g i n g o f g a l l b l a d de rc a r c i n o m ab y E U S[J].G a s t r o i n t e s tE n d o s c,2003,58(4):536-541.[18] G o h J,K e l l e h e rB,C l a r k eE,e ta l.E a r l y n e o p l a s i a so f t h eg a l l b l a d d e r a n d b i l e d u c t:a n u n s t a b l e b i l i a r y e p i t h e l i u m?[J]E n d o s c o p y,2003,35(6):538-541.[19] H e i n z o w H S,L e n zP,L a l l i e rS,e ta l.A m p u l l ao f V a t e rt u m o r s:i m p a c to fi n t r a d u c t a lu l t r a s o u n da n dt r a n s p a p i l l a r ye n d o s c o p i cb i o p s i e so nd i a g n o s t i ca c c u r a c y a n dt h e r a p y[J].A c t aG a s t r o e n t e r o lB e l g,2011,74(4):509-515.[20]I t oK,F u j i t a N,N o d a Y,e ta l.P r e o p e r a t i v ee v a l u a t i o no fa m p u l l a r y n e o p l a s m w i t h E U Sa n dt r a n s p a p i l l a r y i n t r a d u c t a lU S:a p r o s p e c t i v e a n dh i s t o p a t h o l o g i c a l l y c o n t r o l l e d s t u d y[J].G a s t r o i n t e s tE n d o s c,2007,66(4):740-747.[21] P e r s l e y KM.G a l l b l a d d e r p o l y p s[J].C u r r T r e a t O p t i o n sG a s t r o e n t e r o l,2005,8(2):105-108.[22]S u g i y a m a M,A t o m i Y,Y a m a t o T.E n d o s c o p i cu l t r a s o n o g r a p h y f o r d i f f e r e n t i a l d i a g n o s i s o f p o l y p o i d g a l lb l a d d e r l e s i o n s:a n a l y s i s i ns u r g ic a l a n df o l l o w u p s e r i e s[J].G u t,2000,46(2):250-254.[23] C h o iW B,L e e S K,K i m MH,e t a l.An e ws t r a t e g y t o p r e d i c tt h en e o p l a s t i c p o l y p so ft h e g a l l b l a d d e rb a s e d o n as c o r i n g s y s t e m u s i n g E U S[J].G a s t r o i n t e s tE n d o s c,2000,52(3): 372-379.[24] W e n n m a c k e r S Z,L a m b e r t s M P,D i M a r t i n o M,e t a l.T r a n s a b d o m i n a l u l t r a s o u n d a n d e n d o s c o p i c u l t r a s o u n d f o r㊃887㊃‘临床荟萃“2019年9月20日第34卷第9期 C l i n i c a l F o c u s,S e p t e m b e r20,2019,V o l34,N o.9Copyright©博看网. All Rights Reserved.d i a g n o s i so f g a l l b l a d de r p o l y p s[J].C o c h r a n e D a t a b a s eS y s tR e v,2018,8:C D012233.[25]S o a r e s K C,G o l d s t e i n S D,G h a s e b MA,e t a l.P e d i a t r i cc h o l ed o c h a lc y s t s:d i a g n o s i sa n d c u r re n t m a n a g e m e n t[J].P e d i a t r S u r g I n t,2017,33(6):637-650.[26]S o u s aM,F e r n a n d e sS,P r o e n c aL,e t a l.D i a g n o s t i c y i e l do fe n d o s c o p i c u l t r a s o n o g r a p h yf o r ad i l a a t i o no f t h e c o mm o nb i l ed u c t o fa ni n de t e r m i n a t ec a u s e[J].R e v E s p E nf e r m D i g,2019,111(10):757-759.[27] O d u y e b oI,L a w J K,Z a h e e r A,e t a l.C h o l e d o c h a l o rp a n c r e a t i c c y s t R o l eo fe n d o s c o p i cu l t r a s o u n da sa na d j u n c tf o r d i ag n o s i s:ac a s es e r i e s[J].S u r g E n d o s c,2015,29(9):2832-2836.[28] W i l l i a m s E,B e c k i n g h a m I,E l S a y e d G,e t a l.U p d a t e dg u i d e l i n eo n t h e m a n a g e m e n t o fc o mm o n b i l e d u c ts t o n e s(C B D S)[J].G u t,2017,66(5):765-782.[29] R a n aS S,B h a s i n D K,S h a r m a V,e ta l.R o l eo fe n d o s c o p i cu l t r a s o u n di n e v a l u a t i o n o f u n e x p l a i n e d c o mm o n b i l e d u c td i l a t a t i o n o n m a g ne t i c r e s o n a n c e c h o l a n g i o p a n c r e a t o g r a p h y[J].A n nG a s t r o e n t e r o l,2013,26(1):66-70.[30] K a r a k a n T,C i n d o r u k M,A l a g o z l u H,e ta l.E U S v e r s u se n d o s c o p i c r e t r o g r a d e c h o l a n g i o g r a p h yf o r p a t i e n t s w i t hi n t e r m e d i a t e p r o b a b i l i t y o f b i l e d u c ts t o n e s:a p r o s p e c t i v er a n d o m i z e d t r i a l[J].G a s t r o i n t e s tE n d o s c,2009,69(2):244-252.[31] P o l k o w s k i M,R e g u l a J,T i l s z e r A,e t a l.E n d o s c o p i cu l t r a s o u n dv e r s u se n d o s c o p i cr e t r o g r a d ec h o l a n g i o g r a p h y f o r p a t i e n t sw i t hi n t e r m e d i a t e p r o b a b i l i t y o fb i l ed u c ts t o n e s:a r a n d o m i z e dt r i a lc o m p a r i n g t w o m a n a g e m e n ts t r a t e g i e s[J].E n d o s c o p y,2007,39(4):296-303.收稿日期:2019-10-17编辑:王秋红㊃987㊃‘临床荟萃“2019年9月20日第34卷第9期 C l i n i c a l F o c u s,S e p t e m b e r20,2019,V o l34,N o.9Copyright©博看网. All Rights Reserved.。

固定器固定T管减少出院患者院外T管脱管

固定器固定T管减少出院患者院外T管脱管我科为胆道专科，”T”管为我科专科管道，基本所有的胆道术后患者都将带”T”管出院，因此”T”管的院外护理保护特别重要。

胆道疾病手术后患者带”T”管是胆总管切开探查取石、胆肠吻合术、胆道肿瘤切除、术中胆道损伤等常规处置，除具有引流胆汁、降低胆道压力、控制胆管类疾病、促进胆道水肿消退，防止胆管切口裂开、加速切口愈合外，还可根据T管引流胆汁的色、颜色、量了解胆道是否有感染、出血、胆汁外漏等，并能发现胆道残留结石和经T管窦道取结石。

因此”T”管的院外护理保护特别重要，要严防术后T管滑脱、堵塞等并发症的发生[1]。

Abstract：I division for biliary specialist，“T” tube for my college pipeline，basic all of the patients with biliary postoperative hospital will take the “T” tube，so the “T” tube outside the school of nursing protection is particula rly important. Biliary tract disease patients after operation with “T” tube is the stones cut common bile duct exploration，gallbladder，biliary tumor resection and intestinal anastomosis biliary injury such as conventional treatment，in addition to the drainage of bile，the bile duct diseases to control and reduce biliary pressure，and promote the biliary edema subsided，prevention of bile duct incision dehiscence，accelerate the healing of incision，can also according to the amount of color，color and T tube drainage of bile to understand whether the biliary tract infection，bleeding，bile leakage，etc.，and can be found in bile duct residual stones and take stones through the T tube fistula. Therefore outside of the “T” tube care protection is particularl y important，carefully postoperative complications of T tube slippage，jam，etc.Key words：T tube；Outside the court fixed“T”管通常情况下需留置2～3个月，甚至长达263d[2]。

SpyGlass单人操作胆道镜系统对胆道疾病的诊治价值

：ＡｂｓｔｒａｃｔＯｂｊｅｃｔｉｖｅＴｏｉｎｖｅｓｔｉｇａｔｅｔｈｅｖａｌｕｅｏｆＳｐｙＧｌａｓｓｓｉｎｇｌｅ－ｏｐｅｒａｔｏｒｃｈｏｌｅｄｏｃｈｏｓｃｏｐｙｓｙｓｔｅｍｉｎｔｈｅｄｉａｇｎｏｓｉｓａｎｄｔｒｅａｔｍｅｎｔｏｆｐａ
，，ｔｉｅｎｔｓｗｉｔｈｕｎｅｘｐｌａｉｎｅｄｂｉｌｉａｒｙｓｔｒｉｃｔｕｒｅｃｏｍｐｌｅｘｂｉｌｅｄｕｃｔｓｔｏｎｅｓｏｒｏｔｈｅｒｂｉｌｉａｒｙｔｒａｃｔｄｉｓｅａｓｅｓ．ＭｅｔｈｏｄｓＡｒｅｔｒｏｓｐｅｃｔｉｖｅａｎａｌｙｓｉｓｗａｓ
ＶａｌｕｅｏｆＳｐｙＧｌａｓｓｓｉｎｇｌｅ－ｏｐｅｒａｔｏｒｃｈｏｌｅｄｏｃｈｏｓｃｏｐｙｓｙｓｔｅｍｉｎｔｈｅｄｉａｇｎｏｓｉｓａｎｄｔｒｅａｔｍｅｎｔｏｆｐａｔｉｅｎｔｓｗｉｔｈｂｉｌｉａｒｙｔｒａｃｔｄｉｓｅａｓｅｓ
，，，，，（，ＺＨＡＯＳｉＷＵＸｕｅｒｕＹＩＮＬｉｎｌｉｎＭＩＡＯＬｉｎＪＩＧｕｏｚｈｏｎｇＺＨＡＮＧＸｉｕｈｕａ．ＭｅｄｉｃａｌＣｅｎｔｅｒｆｏｒＤｉｇｅｓｔｉｖｅＤｉｓｅａｓｅｓＴｈｅＳｅｃｏｎｄＡｆｆｉｌｉａｔｅｄ，，）ＨｏｓｐｉｔａｌｏｆＮａｎｊｉｎｇＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙＮａｎｊｉｎｇ２１００１１Ｃｈｉｎａ
回顾性收集２０１７年１２月—２０２０年６月在南京医科大学第二附属医院行ＳｐｙＧｌａｓｓ下诊治胆道疾病患者的临床资料。胆管狭窄患
者在ＳｐｙＧｌａｓｓ引导下对病灶部位进行充分可视化，必要时取活检；胆管结石患者行ＳｐｙＧｌａｓ胆道镜直视下激光碎石；胆囊病变患者
通过ＳｐｙＧｌａｓｓ辅助下超选胆囊管。分析ＳｐｙＧｌａｓｓ系统诊治的敏感度、特异度、准确度、碎石成功率、结石清除率、操作成功率以及并

胆道感染患者病原学特征及危险因素分析

•论著-胆道感染患者病原学特征及危险因素分析冯丹，赵秀红，李博锦州市中心医院，辽宁锦州121000【摘要】目的分析胆道感染患者病原学特征并探讨其发病危险因素，为相关防治工作提供参考。

方法选取锦州市中心医院2019年11月至2020年10月诊治的792例胆道疾病患者作为研究对象，将所有胆道感染患者的胆汁标本进行细菌培养、菌株鉴定和药敏分析。

观察不同性别、年龄、体质指数、基础疾病、胆道疾病类型、经内镜逆行胰胆管造影史、胆道手术史的患者胆道感染发生率，分析胆道感染的危险因素。

结果共纳入154例胆道感染患者，胆道感染发生率为19.4%(154/792)。

共培养分离病原菌179株，以革兰阴性菌为主(69.8%),其次为革兰阳性菌（22.3%)、真菌（7.9%)。

革兰阴性菌以大肠埃希菌(26.3%)、肺炎克雷伯菌（19.0%)所占比例较高，革兰阳性菌以金黄色葡萄球菌（8.9%)、表皮葡萄球菌（6.1%)所占比例较高。

主要革兰阴性菌中，大肠埃希菌对哌拉西林(83.0%)、环丙沙星（70.2%)耐药率高，对亚胺培南（0.0%)敏感；肺炎克雷伯菌对哌拉西林（79.4%)、头孢他啶(67.6%)耐药率高，对亚胺培南（0.0%)敏感。

主要革兰阳性菌中，金黄色葡萄球菌对青霉素（75.0%)、红霉素(62.5%)耐药率高，对万古霉素(0.0%)敏感；表皮葡萄球菌对青霉素(81.8%)、氨苄西林(63.6%)耐药率高，对万古霉素(0.0%)、替考拉宁(0.0%)敏感。

多因素Logistic回归分析结果显示，年龄越大（0/? = 2.214)、恶性胆道疾病(Oft =2.373)、经内镜逆行胰胆管造影史(0/? =3.979)、胆道手术史(0K= 2.912)为胆道感染的危险因素。

结论胆道感染患者具有一定的病原学特点，感染以革兰阴性菌为主，可根据药敏试验结果选择有效治疗药物。

胆道感染有患者年龄大、恶性胆道疾病、经内镜逆行肢胆管造影史、胆道手术史多种危险因素，应当采取针对性干预措施，降低感染发生率。

胆囊运动亢进的研究进展

胆囊运动亢进的研究进展梁文平，罗丹，刘　博，薛东波，马哈尔滨医科大学附属第一医院微创胆道外科，哈尔滨１５０００１摘要：近年来，消化系统疾病的发病率逐年升高，胆道运动障碍也愈发受到人们关注，特别是其中所包含的胆囊运动亢进。

本文从国内外该领域研究现状出发，对胆囊运动亢进的基本概念、流行病学、发病机制、病理、临床与影像学表现、诊断与治疗相关临床研究进展进行了系统阐述，并在此基础上对未来相关研究方向给出建议。

关键词：胆囊运动障碍；胆道疾病；胆囊疾病基金项目：黑龙江省自然科学基金（ＬＨ２０２１Ｈ０５０）ＴｈｅｐｒｏｇｒｅｓｓｉｏｎｏｆｂｉｌｉａｒｙｈｙｐｅｒｋｉｎｅｓｉａｒｅｓｅａｒｃｈＬＩＡＮＧＷｅｎｐｉｎｇ，ＬＵＯＤａｎｋｕｎ，ＬＩＵＢｏ，ＸＵＥＤｏｎｇｂｏ，ＭＡＢｉａｏ．（ＭｉｎｉｍａｌｌｙＩｎｖａｓｉｖｅＢｉｌｉａｒｙＳｕｒｇｅｒｙ，ＴｈｅＦｉｒｓｔＡｆｆｉｌｉａｔｅｄＨｏｓｐｉｔａｌｏｆＨａｒｂｉｎＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ，Ｈａｒｂｉｎ１５０００１，Ｃｈｉｎａ）Ｃｏｒｒｅｓｐｏｎｄｉｎｇａｕｔｈｏｒ：ＭＡＢｉａｏ，ｍａｂｉａｏ＠ｈｒｂｍｕ．ｅｄｕ．ｃｎ（ＯＲＣＩＤ：００００－０００２－７４２９－９０８ｘ）Ａｂｓｔｒａｃｔ：Ｉｎｒｅｃｅｎｔｙｅａｒｓ，ｔｈｅｉｎｃｉｄｅｎｃｅｏｆｄｉｇｅｓｔｉｖｅｄｉｓｏｒｄｅｒｓｈａｓｒｉｓｅｎｓｔｅａｄｉｌｙ．Ａｍｏｎｇｗｈｉｃｈ，ｂｉｌｉａｒｙｄｙｓｋｉｎｅｓｉａ，ｐａｒｔｉｃｕｌａｒｌｙｂｉｌｉａｒｙｈｙｐｅｒｋｉｎｅｓｉａ，ｈａｓｂｅｃｏｍｅａｇｒｏｗｉｎｇｃｏｎｃｅｒｎ．Ｔｈｅｂａｓｉｃｃｏｎｃｅｐｔ，ｅｐｉｄｅｍｉｏｌｏｇｙ，ｐａｔｈｏｇｅｎｅｓｉｓ，ｐａｔｈｏｌｏｇｙ，ｃｌｉｎｉｃａｌａｎｄｉｍａｇｉｎｇｍａｎｉｆｅｓｔａｔｉｏｎｓ，ｄｉａｇｎｏｓｉｓ，ａｎｄｔｒｅａｔｍｅｎｔｏｆｂｉｌｉａｒｙｈｙｐｅｒｋｉｎｅｓｉａａｒｅｓｙｓｔｅｍａｔｉｃａｌｌｙｒｅｖｉｅｗｅｄｉｎｔｈｉｓｐａｐｅｒｂａｓｅｄｏｎｔｈｅｃｕｒｒｅｎｔｓｔａｔｕｓｏｆｒｅｓｅａｒｃｈｉｎｔｈｉｓｆｉｅｌｄｗｏｒｌｄｗｉｄｅ．Ｏｎｔｈｉｓｂａｓｉｓ，ｐｒｏｓｐｅｃｔｉｖｅｆｕｔｕｒｅｒｅｓｅａｒｃｈｄｉｒｅｃｔｉｏｎｓａｒｅａｌｓｏｐｒｏｖｉｄｅｄ．Ｋｅｙｗｏｒｄｓ：ＢｉｌｉａｒｙＤｙｓｋｉｎｅｓｉａ；ＢｉｌｉａｒｙＴｒａｃｔＤｉｓｅａｓｅｓ；ＧａｌｌｂｌａｄｄｅｒＤｉｓｅａｓｅｓＲｅｓｅａｒｃｈｆｕｎｄｉｎｇ：ＨｅｉｌｏｎｇｊｉａｎｇＰｒｏｖｉｎｃｉｎａｌＮａｔｕｒａｌＳｃｉｅｎｃｅＦｏｕｎｄａｔｉｏｎｏｆＣｈｉｎａ（ＬＨ２０２１Ｈ０５０）ＤＯＩ：１０．３９６９／ｊ．ｉｓｓｎ．１００１－５２５６．２０２２．１０．０４３收稿日期：２０２２－０３－０７；录用日期：２０２２－０６－０２通信作者：马，ｍａｂｉａｏ＠ｈｒｂｍｕ．ｅｄｕ．ｃｎ胆囊运动亢进是一种由胆囊原发性动力改变引发的一类疾病。

胆道疾病 (2)

(二).胆道系统的生理功能其主要生理功能是分泌、储存、浓缩与运送胆汁，且对胆汁排入十二指肠的起着重要的调节作用。 1.胆汁的生成、分泌和代谢胆汁 800～1200ml/天胆汁的成分 97%是水，其他主要成分胆汁酸胆盐、胆固醇、磷脂酰胆碱
胆汁的生理功能：乳化脂肪抑制肠内致病菌的生长和内毒素的形成刺激肠蠕动中和胃酸胆汁分泌的调节：神经调节：迷走神经兴奋，胆汁分泌增加交感神经兴奋，胆汁分泌减少
胆红素结石的形成：胆红素在肝内与葡萄糖醛酸结合，形成可溶性胆红素结合，随胆汁排入肠道。若胆红素在肝内未与葡萄糖醛酸相结合，或当胆道感染时，大肠杆菌所产生的葡萄糖醛酸酶将结合性胆红素水解为非结合性胆红素，易聚结析出与钙结合形成胆红素钙，促进胆色素结石形成。另外，与蛔虫卵、细菌等成为成石的核心有关。
2.胆囊的功能：浓缩储存胆汁：浓缩胆汁5～10倍排出胆汁：受体液因素和神经因素的调节分泌功能：胆囊粘膜每天分泌20ml粘液性物质，起润滑和保护胆囊粘膜的作用。因此胆囊切除后，胆总管可代偿性扩张，起到一定浓缩胆汁的作用。
3.胆囊和胆管的流体力学胆道系统是一个低压、低流量系统。胆道的压力决定胆汁的流向及流速。肝细胞分泌压力为30cmH2O，最高，使毛细胆管的胆汁向肝外胆管流出。胆管运输胆汁至胆囊和十二指肠的这一过程是由胆囊和Oddi括约肌共同协调完成。空腹时或餐间Oddi括约肌收缩，胆管内压升高，达15 ～ 20cmH2O,使胆汁流向压力低的胆囊，直到胆囊内压与胆管内压达到平衡为止，即10cmH2O。
2.肝外胆管： ⑴.左右肝管及肝总管 ⑵.胆囊 ⑶.胆囊管胆囊三角(Calot triangle) ⑷.胆总管(common bile duct)

116例胆道疾病患者阿托品试验的体会

116例胆道疾病患者阿托品试验的体会发表时间：2017-05-16T10:41:54.437Z 来源：《临床医学教育》2017年5月作者：樊玲殷慧张玉红李丽萍[导读] 阿托品试验是鉴别病态窦房结综合征（Sick sinus syndrome, SSS）的常用方法之一，该法操作简便，安全，临床仍在广泛使用,其机制是消除迷走神经对窦房结的抑制作用。

湖南省长沙市第二人民医院湖南长沙 410000摘要目的通过对胆道疾病伴窦性心动过缓患者进行系列检查，寻找安全有效的诊断病窦综合征的方法。

方法对本院116例胆道疾病伴窦性心动过缓患者行阿托品试验，阳性患者进一步行动态心电图检查，并分析结果。

结果 1. 阿托品试验结果示86例阴性，30例阳性；2.动态心电图结果示30例阿托品试验阳性患者中有11例排除病窦综合征，19例患者诊断病窦综合征。

结论阿托品试验-动态心电图序贯检查,可准确诊断病窦综合征。

关键词胆道疾病阿托品试验动态心电图[Abstract] According to the physical education for patient the man who is having biliary tract diseases and sinus bradycardia (SB), to discuss the most efficiency and safest way to diagnosis and treatment this project.Methods: make atropine test to 116 patients in our hospital the one has same problems, moreover, using observed and measured ECG research to cases with positive, then analysis the performance when finish this experiment. In conclusion：the results demonstrate 88 number of negative, and 33 persons is positive. However, ECG test gives the un-similar results, only for 19 people having that issue in 30 total amount people. Then gettheconclusion using ECG test could get a correct method to test sick sinus node syndrome.[Key words] biliary disease Atropine test of dynamic electrocardiogram (ECG)阿托品试验是鉴别病态窦房结综合征（Sick sinus syndrome, SSS）的常用方法之一，该法操作简便，安全，临床仍在广泛使用,其机制是消除迷走神经对窦房结的抑制作用。

胆汁淀粉酶升高的影响因素及意义研究进展

胆汁由肝脏持续性分泌，胆汁中除水分外，含有胆盐、卵磷脂、胆固醇、甘油三酯、胆色素等有机物以及钠、钾、钙、碳酸氢根等无机物，胆汁是唯一不含消化酶的消化液。事实上胆汁中含有少量的淀粉酶，但并不是由肝脏分泌的，有研究表明胆汁淀粉酶热稳定性与血清相似，这表明胆汁中的淀粉酶是通过肝循环进入胆汁的，即胆汁淀粉酶是由血中淀粉酶通过肝脏过滤而来。胆汁淀粉酶含量尚无正常标准，但根据一些学者既往所做的一些观察，以及从解剖生理角度分析，胆汁淀粉酶含量应低于血清淀粉酶，因此，若胆汁淀粉酶含量高于血浆淀粉酶应视为异常。
Research Progress on Influencing Factors and Significance of Bile Amylase Elevation
ZHU Gan, LI Bin
(Affiliated Hospital of Guilin Medical College, Guilin Guangxi 541000)
ABSTRACT: Under normal physiological conditions, human bile contains a certain amount of amylase. The abnormal amylase content in bile can be regarded as a pathological state and a high risk factor for some biliary tract diseases. This paper summarizes the factors affecting the amylase content in bile and its significance. KEY WORDS: bile amylase; plasma amylase; pancreatic bile duct reflux

MRCP在胆道疾病中的应用

MRCP在胆道疾病中的应用陈筛扣;华星;黄震萍;钱秋平;沈长兵【期刊名称】《中外医学研究》【年(卷),期】2015(013)035【摘要】目的:探讨MRCP在胆道疾病诊断中的应用价值.方法:选择笔者所在医院收治的96例确诊为胆道疾病的患者为研究对象,对其进行磁共振胰胆管水成像扫描(MRCP).根据检查结果分析MRCP在胆道疾病诊断中的应用价值.结果:本组96例患者中胆系结石86例,胆管炎性狭窄4例,恶性梗阻6例;MRCP诊断出胆系结石83例(96.51%),胆管炎性狭窄4例(100%),恶性梗阻5例(83.33%).结论:MCRP诊断技术可以准确反映胰胆管的正常及异常情况,并能对胰胆管梗阻的部位及程度进行准确判断,因此在临床诊断胆道疾病方面具有较高的应用价值.%Objective:To study the application value of MRCP in diagnosis of biliary tract diseases.Method:96 cases of patients with biliary tract disease were selected as the research object,magnetic resonance imaging and scanning of the bile duct(MRCP) was performed.The value of MRCP in diagnosis of biliary tract diseases was analyzed according to the results of the examination.Result:96 patients in this group,86 cases of biliary calculi and 4 cases for cholangitis stenosis,6 cases of malignant obstruction;83 patients with biliary stones of MRCP diagnosis,the accuracy rate was 96.51%;diagnosed 4 patients with cholangitic stenosis,the accuracy rate was 100%;5 patients of malignant obstruction,the diagnostic accuracy rate was 83.33%.Conclusion:MCRP diagnosis technology can accurately reflectthe normal and abnormal conditions of the pancreatic duct,and can accurately judge the site and extent of bile and pancreatic duct obstruction,so it is with high application value in the clinical diagnosis of biliary tract diseases.【总页数】2页(P147-148)【作者】陈筛扣;华星;黄震萍;钱秋平;沈长兵【作者单位】泰州市第二人民医院江苏泰州 225500;泰州市第二人民医院江苏泰州 225500;泰州市第二人民医院江苏泰州 225500;泰州市第二人民医院江苏泰州 225500;泰州市第二人民医院江苏泰州 225500【正文语种】中文【中图分类】R657.4【相关文献】1.MSCT、MRCP、MRI结合MRCP在诊断胆道梗阻性疾病中的应用比较 [J], 周文珍;顾建平;殷信道;王丽萍2.多层螺旋CT扫描与1.5T磁共振MRCP技术在诊断胆道梗阻性疾病中的应用效果分析 [J], 姜波3.MSCT、MRI结合MRCP在诊断胆道梗阻性疾病中的应用比较 [J], 吴冬; 赵志清; 郑锐标; 钟金兰; 专庆春; 吕永革; 余深平4.饮水低张MRCP结合MRI在低位胆道梗阻性疾病中的临床应用价值 [J], 李巨春; 李兴权; 陈乔坤5.MRCP与ERCP在胆道疾病中的应用 [J], 王姣;卢海燕因版权原因，仅展示原文概要，查看原文内容请购买。

关于“异类”的

篇一:《关于几个异类异议词的翻译错误分析》医学英语中几个异类异义词的翻译探讨张林（遵义医学院外语系,贵州，遵义，563003）[关键词] 医学英语异类异义词翻译探讨这里所说的异类异义词指是这几个词不是当常用词类来用。

它们是but, once, since和otherwise, 这几个词在医学英语翻译中的错误非常常见；有的译文涩味难懂；有的译文牵强附会；更有甚者是有的翻译文理不通；笔者对此进行了大量的研究，归纳和总结，以供从事医学翻译的同志参考。

1. but一词的误译but一词的用法相当复杂。

最常见的用法是作为表示反意的并列连词（可连接两个并列成分或分句），译为“但是”、“而”等。

除此以外，它还有下列几种主要的用法：（一）用作副词，相当于only,译为“仅”、“不过”(二)用作介词，相当于except, 译为“除了……外”，常于all连用；（三）用作关系代词，引导定语从句，本身带有否定意义，相当于who ……not或that ……not ,它往往与表示否定意义的先行词连用，所以全句意思还是肯定的；（四）用作从属连词，可引导条件状语从句（常与that连用），可译为“假如不”、“要不是”。

也可引导结果状语从句（主句中常有否定词＋so或such a）,可译为“如此……以致”。

[1]1．1. but用作副词的误译Most microorganims are composed of but one cell in which arecarried on all the processes of life-nutrition, growth, reproduction and so on.【误译】但是大多数微生物由一个细胞组成，一切生命过程（营养、生产、繁殖等）都在此细胞中进行。

【评析】本例的but为副词（意为“仅”、“只”）而并非并列连词，病句把它当作并列连词，误译成了“但是”。

【正译】大多数微生物仅单细胞组成，一切生命过程（营养、生产、繁殖等）都在此细胞中进行。