胆道疾病

Diseases of the Biliary tract

● Anatomy and Physiology

● Examinations for biliary system disease

● Cholelithiasis

● Infection of the biliary tract system

● Biliary ascariasis

● Biliary tract tumor

第一节 解剖和生理

Anatomy and Physiology

第一节 解剖和生理概要（ 1 ）

1. Intrahepatic bile ducts ● gradation 2. Extrahepatic bile ducts ● segment ● Vater’s ampulla ● oddi’s sphincter 3. Gallbladder ● Heister’s valve ● Hartmann’s pouch ● Calot’s triangle

第一节 解剖和生理概要（ 2 ） Physiology ● Storage bile ● Condense bile ● Regulate biliary tract pressure ● Secrete mucus: “White bile”

第二节 胆道疾病检查方法

Examination methods for biliary system disease

第二节 胆道疾病检查方法（ 1 ）

1. Laboratory findings2. Ultrasonography3. X-ray examinations ●plain radiography ●percutaneous transhepatic cholangiography (PTC) ●endoscopic retrograde cholangiopancreatography (ERCP) ●during or post operative cholangiogram

第二节 胆道疾病检查方法（ 2 ）

● computed tomography (CT) ●oral cholecystography ●intravenous cholangiography ●hypotonic duodenographyRadionuclide scansDuodenal drainageCholangioscopyMagnetic resonance imaging (MRI,MRCP)

附：先天性胆总管扩张症congenital cystic dilatation of bile duct

第三节 胆石病

Cholelithiasis

第三节 胆石病—概述（ 1 ）

1. Prevalence2. Classification ●cholesterol ●pigment ●mixed type ●black3. Position ●gallbladder ●extrahepatic ●intrahepatic

第三节 胆石病—概述（ 2 ）

4. Mechanism for gallstone formation ●bile stasis ●abnormal metabolization ●infection ●other factors: age, sex, weight, diet Cholesterol stones: Admirand-Small triangular coordinate grapy Pigment stones:

咖啡与预防胆结石 　　 香喷喷的咖啡，是提神醒脑的饮品，而最新研究还发现，每喝几杯咖啡可以预防胆结石。最新一期美国医学协会期刊报道，美国哈佛大学研究人员发现，每喝两杯三杯咖啡的男性，得到胆结石的几率比不喝咖啡的人低了 40% ，而每天喝咖啡达四杯以上的话，得胆结石的几更降为 45% 。不过，无咖啡因的咖啡可就没有这种效果了，只有含咖啡因的咖啡，才能刺激胆囊收缩，并减少胆汁内容易形成胆石的胆固醇。而同样含有咖啡因的茶、可乐等其他饮料，由于咖啡因含量低于咖啡，因此无法达到同样效果。

第三节 胆石病—胆囊结石（ 1 ）

1. Gallbladder stones (1) Clinical manifestations: ●biliary colic, radiation of the pain, neusea, vomiting ●tenderness in right upper quadrant, rebound tenderness, muscle rigidity, palpable distended gallbladder, or Murphy’s sign (+) ●bile duct stones, cholangitis

重点掌握内容

第三节 胆石病—胆囊结石（ 2 ）

● Mirizzi’s syndrome:

(2) Diagnosis: ●clinical manifestations: symptoms and signs ●assistant examinations: B-US, CT, MRI

  第三节 胆石病—胆囊结石（ 3 ） (3) Treatment: ● no need for treatment: asymptomatic stones ● drug therapies: seldom attack or unsuitable for operation ● operative management: cholecystectomy: open and laparoscopic ● other treatments: oral dissolution therapy contact dissolution therapy extracorporeal shock wave lithotripsy

第三节 胆石病—肝外胆管结石（ 1 ）

2. Extrahepatic bile duct stones(1)   Clinical manifestations: ● Charcot’s triad: abdominal pain, chills and fever, jaundice ● deep tenderness with or without rebound tenderness, muscle rigidity or palpable enlarged gallbladder

重点掌握内容

第三节 胆石病—肝外胆管结石（ 2 ）

(2) Diagnosis: ● previous biliary tract disease ● clinical manifestations: Charcot’s triad ● laboratory examinations: ● assistant examinations: B-US, CT, PTC, ERCP, MRCP

第三节 胆石病—肝外胆管结石（ 3 ）

Differential diagnosis: ● viral hepatitis ● carcinoma of pancreas ● biliary ascariasis ● benign stricture ● renal colic, enterospasm

第三节 胆石病—肝外胆管结石（ 4 ）

(3) Treatment: ● Chinese medicine: dissolution, discharge ● drug therapy: antispastic, analgesic ● EST ● operative management: exploratory choledochostomy and T-tube drainage choledocho-jejunostomy sphincteroplasty of Oddi

第三节 胆石病—肝内胆管结石（ 1 ）

3. Intrahepatic duct stones (1) Clinical manifestations and diagnosis ● Symptoms: ● Physical findings: ● B-US, CT, PTC, ERCP, MRCP

第三节 胆石病—肝内胆管结石（ 2 ）

(2) Treatment ● Nonoperative treatment: anti-inflammatory and cholagogic ● Operative treatment: hepatobiliary exploration cholangio-jejunostomy partial hepatectomy

本次课重点内容

胆囊结石肝外胆管结石

临床表现、诊断、治疗

第四节 胆道感染

Infection of the biliary tract system

第四节 胆道感染—急性胆囊炎（ 1）

1. Acute cholecystitis (1)   Pathogenesis: · bile stasis: obstruction, dysfunction · bacteria · other factors: bile salt, pancreatic juice

重点掌握内容

第四节 胆道感染—急性胆囊炎（ 2） (2) Pathology: simple, suppurative, gangrenous (3) Complications: · pericholecystic or cholecystic abscess · perforation: bile peritonitis, fistulization (external or internal ), gallstone ileus · liver abscess, cholangitis, pancreatitis · pylephlebitis, sepsis

第四节 胆道感染—急性胆囊炎（ 3）

(4) Clinical manifestations and diagnosis · symptoms: pain, radiated pain, nausea, vomiting, fever · signs: tenderness, rebound tenderness, muscle rigidity, distended gallbladder with tenderness or Murphy’s sign(+) · complications: · assistant examinations: laboratory WBC↑, B-US

第四节 胆道感染—急性胆囊炎（ 4）

Differential diagnosis · acute perforated duodenal or gastric ulcers · acute pancreatitis · acute appendicitis · acute ileus

第四节 胆道感染—急性胆囊炎（ 5） (5) Treatment · nonoperative management: fasting, nasogastric suction; antispastic, analgisia; control of infection · operative intervention: indication: acute calculous cholecystitis, recurrent chole-cystitis, no response to conservative treatment timing: early, delayed methods: cholecystectomy, cholecystostomy

第四节 胆道感染—慢性胆囊炎（ 1）

2. Chronic cholecystitis (1) Pathogenesis and pathology: (2) Clinical manifestations and diagnosis · the history of recurrent cholecystitis · symptoms: untold bitterness, discomfort, indigestion · signs: deep tenderness in the right upper quadrant · B-US (3) Treatment · operative: cholecystetomy · nonoperative: anti-inflammatory, cholagogic, low-fat meals

第四节 胆道感染—胆管炎（ 1）

3. Cholangitis Pathologic type: · acute obstructive suppurative cholangitis · chronic simple cholangitis · primary sclerosing cholangitis

附：原发性硬化性胆管炎 primary sclerosing cholangitis

第四节 胆道感染—胆管炎（ 2）

Acute obstructive suppurativecholangitis

(1) Pathogenesis · Complete bile duct obstruction: stones, benign strictures, malignant tumor, parasites · Bacterial infections: E. Coli, Klebsiella, proteus, and anaerobic bacteria

重点掌握内容

第四节 胆道感染—胆管炎（ 3）

(2) Pathophysiology · completely obstruction, dilatation, high intraductal pressure · bacteria invasion, multiplication, pus bile · retrograde enter the liver, acute liver infection · systemic sepsis, infective shock, MSOF

第四节 胆道感染—胆管炎（ 4）

(3) Clinical manifestations · Abdominal pain · chills and fever · jaundice · shock · central nervous system depression: apathy, drowsiness, coma

Charcot’striad

Reynold’spentad

· tenderness with or without rebound tenderness, muscle rigidity; enlarged liver with tenderness, percussion pain

第四节 胆道感染—胆管炎（ 5）

(4) Diagnosis · recurrent previous biliary tract disease · Charcot’s triad + CNS + shock (Reynold’s pentad) · physical examination results: · assistant examinations: laboratory findings (WBC↑, hyperbilirubinemia), B-US

第四节 胆道感染—胆管炎（ 6）

(5) Treatment · principle: immediate removal of the obstruction emergency bile duct decompression · methods: preoperative preparation: exploratory choledochostomy and T- tube drainage PTBD, ENBD

第五节 胆道蛔虫病

biliary ascariasis

第五节 胆道蛔虫病（ 1）

1. Pathogenesis: 2. Pathophysiology · colic · obstructive jaundice · complicated infection · stone formation · pancreatitis · cirrhosis

第五节 胆道蛔虫病（ 2）

3. Clinical manifestations and diagnosis · paroxysmal epigastric pain · suddenly attack and suddenly stop · serious symptoms but slight signs · complicated infection: cholangitis · fecal examination, B-US, CT

第五节 胆道蛔虫病（ 3）

4. Treatment · nonoperative: antispastic, analgisia; cholagogic, expel parasites; control of infection · operative: exploratory choledochostomy and T-tube drainage

第六节 胆道肿瘤

biliary tract tumors

第六节 胆道肿瘤—胆囊息肉（ 1）

1. Gallbladder polyps (1) Classification: · non-neoplastic polyps: inflammatory, cholesterol, hyperplastic · neoplastic polyps: adenoma

第六节 胆道肿瘤—胆囊息肉（ 2）

(2) Clinical manifestations and diagnosis:(3) Treatment · follow-up · operative: cholecystectomy

第六节 胆道肿瘤—胆囊癌（ 1）

2. Carcinoma of the gallbladder (1) Pathogenesis: unclear (2) Clinical manifestations and diagnosis · early: no specific · advanced: jaundice, ascites, mass · B-US, CT, MRI

第六节 胆道肿瘤—胆囊癌（ 2）

(3) Treatment · operative: located in gallbladder wall: cholecystectomy protrude serosa or liver invasion: radical cholecystectomy unresectable: decompression and drainage · nonoperative: PTBD, ENBD

第六节 胆道肿瘤—胆管癌（ 1）

3. Bile duct cancer (1) Pathogenesis: unclear (2) Clinical manifestations and diagnosis · advancing jaundice · pain, nausea, vomiting · ascites, portal hypertension · B-US, CT, PTC, ERCP, MRCP

第六节 胆道肿瘤—胆管癌（ 2）

(3) Treatment · operative resection: Whipple’s operation · nonoperative: PTBD, ENBD, prosthesis

胆道疾病重点内容

1. 胆囊结石的诊断和治疗。2. 肝外胆管结石的临床表现、诊断和治疗。3. 胆囊炎的病因、病理变化、临床表现、 并发症、诊断、治疗。4. 急性梗阻性化脓性胆管炎的诊断和治疗。