4胆道疾病

2020/2/3胆道疾病青海大学附属医院普外二科2020/2/3BiliaryDisease2胆道解剖anatomyoftheBiliaryTract2020/2/3BiliaryDisease3ANATOMYIntrahepaticBiliaryTractExtrahepaticBiliaryTractThegallbladderOddi’ssphincter2020/2/3BiliaryDisease4ANATOMY1．肝内胆管2．肝外胆道⑴肝管和肝总管⑵胆囊⑶胆囊管⑷胆总管2020/2/3BiliaryDisease5ANATOMYIntrahepaticBiliaryTract毛细胆管小叶间胆管肝段胆管肝叶胆管左右肝管三级二级一级2020/2/3BiliaryDisease6AnatomyoftheBiliarySystemanditsRelationshiptoSurroundingStructures•左右肝管Theleftandrighthepaticducts左：2.5-4cm,右：1-3cm•肝总管Thecommonhepaticduct长：2-4cm,直径：0.4-0.6cm副肝管：•胆总管（Thecommonbileduct）长：7-9cm，直径：0.6-0.8cm，1cm病理分段：十二指肠上段、后段、胰腺段、十二指肠壁内段胆管、门静脉和肝动脉的关系2020/2/3BiliaryDisease7AnatomyoftheBiliarySystemanditsRelationshiptoSurroundingStructures胆囊（Thegallbladder）分底、体、颈三部（fundus,body,andneck）。胆囊管（Thecysticduct）•SheathofGlisson•PouchofHartmann•ValvesofHeister•TriangleofCalot•PapillaofVater•SphincterofOddi2020/2/3BiliaryDisease8胆汁生理BiliaryPhysiology2020/2/3BiliaryDisease9BiliaryPhysiology胆汁的分泌、成分和功能：分泌：肝细胞、胆管细胞,量?成分：97%为水，胆汁酸、胆盐、胆固醇、卵磷脂(phospholipid)……功能：?800-1200ml/日乳化脂肪、抑制细菌、刺激肠蠕动、中和胃酸。2020/2/3BiliaryDisease10BiliaryPhysiologyRegulationofbilesecretion促胰液素、CCK：胃酸、脂肪、蛋白质的刺激。Metabolismofbile：胆固醇的溶解：–胆盐、磷酯酰胆碱微胶粒(micelles)–胆固醇磷脂泡：磷酯+胆固醇–胆盐池的稳定：肠肝循环2020/2/3BiliaryDisease11肠肝循环2020/2/3BiliaryDisease12AdmirandandSmallTriangle2020/2/3BiliaryDisease13BiliaryPhysiologyMetabolismofbilirubin胆红素的溶解：胆红素+葡萄糖醛酸——结合胆红素肝脏代谢异常胆道细菌感染2020/2/3BiliaryDisease142020/2/3BiliaryDisease15BiliaryPhysiologyPhysiologicalfunctionofbileduct---regulationofbiledischarge1.18kPa0.98kPa3.83kPa0.79kPa1.18kPa2020/2/3BiliaryDisease16解剖生理概要重点内容胆管、门静脉和肝动脉的关系胆总管:直径：0.6-0.8cm，1cm病理TriangleofCalot胆汁的功能：胆固醇、胆红素的溶解2020/2/3BiliaryDisease17胆道特殊检查2020/2/3BiliaryDisease18B型超声扫描(一)诊断胆系结石：胆囊内95%肝外胆管70%左右肝内胆管60%(二)鉴别诊断：诊断阻塞性黄疸90%(三)诊断其他胆道疾病(四)术中B超：引导穿刺、取石2020/2/3BiliaryDisease19X线检查(一)腹部平片：10-15%胆囊结石(二)口服胆囊造影：碘普酸→肠吸收→胆汁排泄→胆囊浓缩(三)静脉胆管造影造影剂→静脉经肝→胆汁排泄→胆管2020/2/3BiliaryDisease20(四)经皮肝穿刺胆道造影术（PercutaneousTranshepaticCholangiography,PTC）及置管引流术(PercutaneousTranshepaticCholangiographyDrainage,PTCD)诊断：用于肝内胆管扩张时，了解肝内外胆道情况。注意并发症：出血、胆漏。治疗：PTCD可解除胆道梗阻，可置入内支架，治疗胆管狭窄。2020/2/3BiliaryDisease21(五)内窥镜逆行胰胆管造影（EndoscopicRetrogradCholangiopancreatography,ERCP）自下而上了解胆道及胰管情况治疗：1.Oddi括约肌切开取石，治疗狭窄和胆道残余结石。2.经鼻行胆管内引流，治疗胆管炎和胰腺炎。并发症：急性胰腺炎、急性胆管炎2020/2/3BiliaryDisease22(六)术中、术后直接胆管造影术术中：经胆囊管插管行胆总管造影经T管行胆道造影术后：经T管行胆道造影(七)CT：为无创检查：2020/2/3BiliaryDisease23纤维胆道镜检查术中术后直接进行检查、取石、活检等•核磁共振可三维显示胆道内情况2020/2/3BiliaryDisease24胆石超声图像2020/2/3BiliaryDisease252020/2/3BiliaryDisease26PTC影像2020/2/3BiliaryDisease272020/2/3BiliaryDisease282020/2/3BiliaryDisease292020/2/3BiliaryDisease302020/2/3BiliaryDisease312020/2/3BiliaryDisease322020/2/3BiliaryDisease332020/2/3BiliaryDisease34DiagnosticApproachesEndoscopicExaminations胆道镜检查术中、术后–诊断、治疗十二指肠引流2020/2/3BiliaryDisease352020/2/3BiliaryDisease362020/2/3BiliaryDisease37本节重点内容胆道疾病的首选检查方法BUS、CT、PTC、PTCD、ERCP、MRI、MRCP2020/2/3BiliaryDisease38胆石症Cholelithiasis2020/2/3BiliaryDisease39胆石病Cholelithiasis常见病、多发病结石分类–胆固醇结石(CholesterolGallstones)：80%位于胆囊–胆色素结石(PigmentGallstones)：主要发生于胆管–混合性结石：胆囊60%、胆管40%2020/2/3BiliaryDisease40胆石分类2020/2/3BiliaryDisease412020/2/3BiliaryDisease422020/2/3BiliaryDisease432020/2/3BiliaryDisease44胆囊结石Cholecystolithiasis、Gallstone结石性质发病年龄、性别(4F:Forty,Female,Fatty,Fertility)发病机制：–胆汁胆固醇过饱和–促成核因子：均相成核、异相成核–胆囊功能2020/2/3BiliaryDisease45胆囊结石Cholecystolithiasis、GallstoneClinicalpresentations：静止性结石（silentstone,asymptomatic)有症状性结石–胃肠道症状–胆绞痛–Mirrizisyndrome–胆囊积液–其他：继发性胆管结石、胰腺炎、胆石性肠梗阻、癌变。2020/2/3BiliaryDisease46胆囊结石Cholecystolithiasis、GallstoneDiagnosis病史体征影像学确诊:首选BUS诊断率96%以上强回声光团+声影+移动性.CT、MRI、胆囊造影2020/2/3BiliaryDisease472020/2/3BiliaryDisease48胆囊结石Cholecystolithiasis、GallstoneTreatment首选胆囊切除指征：有症状、有并发症无症状者，可观察，其手术指征为：–胆囊无功能、结石较大、老年人心肺功能不良、合并糖尿病2020/2/3BiliaryDisease49胆囊结石Cholecystolithiasis、GallstoneTreatment手术方法开腹手术(OpenCholecystectomy)腹腔镜手术(Laparoscopiccholecystectomy)胆管探查指征术前术中发现胆管结石或其他病变有黄疸或胆管炎、胰腺炎表现胆管扩张1.0cm非手术治疗：碎石、溶石、排石。2020/2/3BiliaryDisease50胆囊切除术2020/2/3BiliaryDisease512020/2/3BiliaryDisease52LaparoscopicCholecystectomy2020/2/3BiliaryDisease53LaparoscopicCholecystectomy2020/2/3BiliaryDisease542020/2/3BiliaryDisease552020/2/3BiliaryDisease562020/2/3BiliaryDisease57胆管结石Choledocholithiasis原发性：胆色素或混合性结石继发性：胆固醇结石肝外胆管结石：CBD远端肝内胆管结石：左外叶、右后叶多见2020/2/3BiliaryDisease58肝外胆管结石Pathology：梗阻+感染胆管梗阻：不全性、完全性近端扩张、壁增厚、胆汁淤滞继发感染：组织充血、水肿、化脓、糜烂、溃破，脓毒症肝细胞坏死、胆源性肝脓肿、胆汁性肝硬化胆源性胰腺炎2020/2/3BiliaryDisease59肝外胆管结石ClinicalpresentationsCharcot三联症（ClinicaltriadofCharcot）–腹痛：部位、性质–寒战高热：–黄疸：间歇性、波动性影响因素：梗阻程度、感染、有无胆囊体征：胆囊肿大、腹膜刺激征2020/2/3BiliaryDisease60肝外胆管结石Labexaminations：–WBC、Bilirubin、SGPT、AKPRadiologyFindings：–BUS首选–CT、MRI–PTC–ERCP2020/2/3BiliaryDisease612020/2/3BiliaryDisease62肝外胆管结石Diagnosis–Charcot三联症+影像学检查Differentiation–壶腹癌和胰头癌–肾绞痛–肠绞痛2020/2/3BiliaryDisease63肝外胆管结石Management手术治疗为主手术原则–取尽结石–解除梗阻–去除病灶–通畅引流2020/2/3BiliaryDisease64肝外胆管结石--手术方法CBD切开取石+T管引流术适应症：胆管无狭窄术中检查：造影、BUS、胆道镜术后注意事项–妥善固定–引流通畅–拔管指征：时间、临床症状、引流情况、造影、夹管试验2020/2/3BiliaryDisease65T型管、Y型管2020/2/3BiliaryDisease66肝外胆管结石--手术方法胆肠吻合术适应症：CBD扩张、远端狭窄、泥沙样结石不易取尽–Roux-en-Y吻合术（+抗返流措施）–CBD十二指肠吻合术202