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。
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