膽道疾病雙語幻燈培訓(xùn)課件

1、ANATOMYIntrahepatic Biliary Tract Extrahepatic Biliary Tract The gallbladderOddis sphincterANATOMYIntrahepatic Biliary TrANATOMYIntrahepatic Biliary Tract 毛細膽管小葉間膽管肝段膽管肝葉膽管左右肝管三級 二級 一級ANATOMYIntrahepatic Biliary TAnatomy of the Biliary System and its Relationship to Surrounding Structures左右肝管 The le

2、ft and right hepatic ducts左：2.5-4cm, 右：1-3cm肝總管 The common hepatic duct長：2-4cm, 直徑：0.4-0.6cm副肝管：膽總管（The common bile duct）長：7-9cm，直徑：0.6-0.8cm，1cm病理分段：十二指腸上段、后段、胰腺段、十二指腸壁內(nèi)段膽管、門靜脈和肝動脈的關(guān)系 Anatomy of the Biliary System Anatomy of the Biliary System and its Relationship to Surrounding Structures膽囊（The ga

3、llbladder）分底、體、頸三部（fundus, body, and neck）。膽囊管 （The cystic duct）Sheath of GlissonPouch of HartmannValves of HeisterTriangle of Calot Papilla of VaterSphincter of OddiAnatomy of the Biliary System ANATOMYArtery術(shù)中注意：膽囊A、膽管A走行與分布VeinLymph腫瘤轉(zhuǎn)移Nerve膽心反射ANATOMYArtery術(shù)中注意：膽囊A、膽管A走行與分Biliary Physiology膽汁的分泌

4、、成分和功能：分泌：肝細胞、膽管細胞, 量?成分：97%為水，膽汁酸、膽鹽、膽固醇、卵磷脂(phospholipid) 功能：?800-1200ml/ 日乳化脂肪、抑制細菌、刺激腸蠕動、中和胃酸。Biliary Physiology膽汁的分泌、成分和功能：Biliary PhysiologyRegulation of bile secretion 促胰液素、CCK：胃酸、脂肪、蛋白質(zhì)的刺激。Metabolism of bile：膽固醇的溶解：膽鹽、磷酯酰膽堿微膠粒(micelles)膽固醇磷脂泡：磷酯+膽固醇膽鹽池的穩(wěn)定：腸肝循環(huán)Biliary PhysiologyRegulation o腸肝

5、循環(huán)腸肝循環(huán)Admirand and Small TriangleAdmirand and Small TriangleBiliary PhysiologyMetabolism of bilirubin 膽紅素的溶解：膽紅素+葡萄糖醛酸結(jié)合膽紅素肝臟代謝異常膽道細菌感染Biliary PhysiologyMetabolism o膽道疾病雙語幻燈培訓(xùn)課件Biliary PhysiologyPhysiological function of bile duct-regulation of bile discharge1.18kPa0.98kPa3.83kPa0.79kPa1.18kPaBiliar

6、y PhysiologyPhysiologicaBiliary PhysiologyPhysiological function of gall bladderConcentration and storage of bileDischarge bileSecretion Biliary PhysiologyPhysiologica解剖生理概要重點內(nèi)容膽管、門靜脈和肝動脈的關(guān)系膽總管: 直徑：0.6-0.8cm，1cm病理Triangle of Calot 膽汁的功能：膽固醇、膽紅素的溶解解剖生理概要重點內(nèi)容膽管、門靜脈和肝動脈的關(guān)系Diagnostic ApproachesUS：B-type

7、 Ultrasonography 首選Diagnosis of gallstone：強回聲光團+聲影Differentiation of joundic：膽管擴張Detection of gallbladder functionOther biliary illnessIntraoperative US：干擾小 Diagnostic ApproachesUS：B-type膽石超聲圖像膽石超聲圖像膽道疾病雙語幻燈培訓(xùn)課件Diagnostic ApproachesConventional RadiologyKUB film：鈣化結(jié)石15%，瓷化膽囊，膽道積氣Oral cholecystograph

8、y：功能測定、充盈缺損Veinal cholangiography：膽管顯影Diagnostic ApproachesConventioDiagnostic ApproachesSpecial RadiologyPTC：黃疸鑒別、PTCD ERCP：乳頭部病變、定性診斷、造影CT、MRI（MRCP）Intra- or postoprative cholangiographyDiagnostic ApproachesSpecial RPTC影像PTC影像膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件

9、膽道疾病雙語幻燈培訓(xùn)課件Diagnostic ApproachesEndoscopic Examinations 膽道鏡檢查術(shù)中、術(shù)后診斷、治療十二指腸引流Diagnostic ApproachesEndoscopi膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件本節(jié)重點內(nèi)容膽道疾病的首選檢查方法BUS、CT、PTC、PTCD、ERCP、MRI、MRCP本節(jié)重點內(nèi)容膽道疾病的首選檢查方法Liu BinSurgeon in Chief and Vice-Chairman Division of General Surgery膽石病 CholelithiasisLiu Bin膽石病 Choleli

10、thiasis膽石病 Cholelithiasis常見病、多發(fā)病結(jié)石分類膽固醇結(jié)石(Cholesterol Gallstones) ：80%位于膽囊膽色素結(jié)石(Pigment Gallstones) ：主要發(fā)生于膽管混合性結(jié)石：膽囊60%、膽管40%膽石病 Cholelithiasis常見病、多發(fā)病膽石分類膽石分類膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽囊結(jié)石Cholecystolithiasis、Gall stone結(jié)石性質(zhì)發(fā)病年齡、性別 (4F: Forty, Female, Fatty, Fertility)發(fā)病機制：膽汁膽固醇過飽和促成核因子：均相成核

11、、異相成核膽囊功能膽囊結(jié)石Cholecystolithiasis、Gall 膽囊結(jié)石Cholecystolithiasis、Gall stoneClinical presentations：靜止性結(jié)石（silent stone , asymptomatic )有癥狀性結(jié)石胃腸道癥狀膽絞痛Mirrizi syndrome膽囊積液其他：繼發(fā)性膽管結(jié)石、胰腺炎、膽石性腸梗阻、癌變。膽囊結(jié)石Cholecystolithiasis、Gall 膽囊結(jié)石Cholecystolithiasis、Gall stoneDiagnosis病史體征影像學(xué)確診:首選BUS 診斷率96%以上強回聲光團+聲影+移動性.CT

12、、MRI、膽囊造影膽囊結(jié)石Cholecystolithiasis、Gall 膽道疾病雙語幻燈培訓(xùn)課件膽囊結(jié)石Cholecystolithiasis、Gall stoneTreatment 首選膽囊切除指征：有癥狀、有并發(fā)癥無癥狀者，可觀察，其手術(shù)指征為：膽囊無功能、結(jié)石較大、老年人心肺功能不良、合并糖尿病膽囊結(jié)石Cholecystolithiasis、Gall 膽囊結(jié)石Cholecystolithiasis、Gall stoneTreatment 手術(shù)方法開腹手術(shù)(Open Cholecystectomy) 腹腔鏡手術(shù)(Laparoscopic cholecystectomy)膽管探查指征術(shù)前

13、術(shù)中發(fā)現(xiàn)膽管結(jié)石或其他病變有黃疸或膽管炎、胰腺炎表現(xiàn)膽管擴張1.0cm非手術(shù)治療：碎石、溶石、排石。膽囊結(jié)石Cholecystolithiasis、Gall 膽囊切除術(shù)膽囊切除術(shù)膽道疾病雙語幻燈培訓(xùn)課件Laparoscopic CholecystectomyLaparoscopic CholecystectomyLaparoscopic CholecystectomyLaparoscopic Cholecystectomy膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽管結(jié)石Choledocholithiasis 原發(fā)性：膽色素或混合性結(jié)石繼發(fā)性：膽固醇結(jié)石肝外膽管結(jié)

14、石：CBD遠端肝內(nèi)膽管結(jié)石：左外葉、右后葉多見膽管結(jié)石Choledocholithiasis 原發(fā)性：肝外膽管結(jié)石Pathology：梗阻+感染膽管梗阻：不全性、完全性近端擴張、壁增厚、膽汁淤滯繼發(fā)感染：組織充血、水腫、化膿、糜爛、潰破，膿毒癥肝細胞壞死、膽源性肝膿腫、膽汁性肝硬化膽源性胰腺炎肝外膽管結(jié)石Pathology：梗阻+感染肝外膽管結(jié)石Clinical presentationsCharcot 三聯(lián)癥（Clinical triad of Charcot）腹痛：部位、性質(zhì)寒戰(zhàn)高熱：黃疸：間歇性、波動性影響因素：梗阻程度、感染、有無膽囊體征：膽囊腫大、腹膜刺激征肝外膽管結(jié)石Clinica

15、l presentations肝外膽管結(jié)石Lab examinations：WBC、Bilirubin、SGPT、AKPRadiology Findings：BUS 首選CT、MRIPTCERCP肝外膽管結(jié)石Lab examinations：膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件肝外膽管結(jié)石DiagnosisCharcot三聯(lián)癥+影像學(xué)檢查Differentiation壺腹癌和胰頭癌腎絞痛腸絞痛肝外膽管結(jié)石Diagnosis肝外膽管結(jié)石Management 手術(shù)治療為主手術(shù)原則取盡結(jié)石解除梗阻去除病灶通暢引流肝外膽管結(jié)石Management 肝外膽管結(jié)石-手術(shù)方法CBD切開取石+T管

16、引流術(shù)適應(yīng)癥：膽管無狹窄術(shù)中檢查：造影、BUS、膽道鏡術(shù)后注意事項妥善固定引流通暢拔管指征：時間、臨床癥狀、引流情況、造影、夾管試驗 肝外膽管結(jié)石-手術(shù)方法CBD切開取石+T管引流術(shù)T 型管、Y型管T 型管、Y型管肝外膽管結(jié)石-手術(shù)方法膽腸吻合術(shù)適應(yīng)癥：CBD擴張、遠端狹窄、泥沙樣結(jié)石不易取盡Roux-en-Y吻合術(shù)（+抗返流措施）CBD十二指腸吻合術(shù)肝外膽管結(jié)石-手術(shù)方法膽腸吻合術(shù)肝外膽管結(jié)石-手術(shù)方法Oddi 括約肌成型術(shù)：CBD擴張輕經(jīng)內(nèi)鏡下括約肌切開取石術(shù)：肝外膽管結(jié)石-手術(shù)方法Oddi 括約肌成型術(shù)：CBD擴張輕肝內(nèi)膽管結(jié)石Hepatolithiasis Etiology 感染、膽汁

17、淤滯、膽道蛔蟲Pathology部位：左葉、右后葉多見肝內(nèi)膽管狹窄、狹窄近端擴張膽管炎：慢性增生、肉芽腫、化膿性肝膽管癌肝內(nèi)膽管結(jié)石Hepatolithiasis Etiolog膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件肝內(nèi)膽管結(jié)石HepatolithiasisClinical presentations合并肝外膽管結(jié)石表現(xiàn)無癥狀或肝區(qū)不適AOSC、黃疸不顯膽源性肝膿腫膽管支氣管瘺膽汁性肝硬化、膽管癌肝內(nèi)膽管結(jié)石HepatolithiasisClinical肝內(nèi)膽管結(jié)石HepatolithiasisDiagnosisBUSCTPTC 特征狹窄、擴張、結(jié)石影部分膽管不顯影肝內(nèi)膽管結(jié)石Hep

18、atolithiasisDiagnosi膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件肝內(nèi)膽管結(jié)石 HepatolithiasisManagement：手術(shù)為主原則：取盡結(jié)石、解除梗阻、去除病灶、通暢引流高位膽管切開及取石術(shù)膽腸內(nèi)引流術(shù)肝葉切除術(shù)中西結(jié)合治療殘石的處理：膽道鏡、激光、微爆破、溶石肝內(nèi)膽管結(jié)石 HepatolithiasisManagem本節(jié)重點內(nèi)容膽石分類及部位膽囊結(jié)石的臨床表現(xiàn)、典型表現(xiàn)膽囊結(jié)石手術(shù)指征及膽總管探查指征肝外膽管結(jié)石的典型表現(xiàn)：Charcot三聯(lián)癥肝內(nèi)外膽管結(jié)石的手術(shù)原則及方法、適應(yīng)癥T型管的觀察及拔除指征。本節(jié)重點內(nèi)容膽石分類及部位膽

19、道感染Infection of biliary tractLiu BinDivision of HPB Surgery膽道感染Infection of biliary trac膽道感染Infection of biliary tract膽囊炎 Cholecystitis 、膽管炎 Cholangitis急性、亞急性、慢性，常與膽石合并存在、互為因果急性膽囊炎 Cholecystitis Acute calculous cholecystitis 95%Acute acalculous cholecystitis 5%膽道感染Infection of biliary tracAcute Calc

20、ulous Cholecystitis Etiology膽囊管梗阻、結(jié)石損傷、膽鹽刺激細菌感染：G-、厭氧菌Pathology急性單純性膽囊炎急性化膿性膽囊炎壞疽性膽囊炎膽囊穿孔并發(fā)膽管炎、胰腺炎、消化道內(nèi)瘺、膽石性腸梗阻Acute Calculous Cholecystitis Acute Calculous CholecystitisClinical presentations女性多見典型表現(xiàn)：疼痛：突發(fā)性、誘因、陣發(fā)性-持續(xù)性、放射性痛、夜間痛寒戰(zhàn)高熱（黃疸）體征：腹膜刺激征、Murphy sign(+)、腫大的膽囊Acute Calculous CholecystitisCAcute

21、Calculous CholecystitisLaboratory examinationWBC、SGPT、AKP、Bilirubin、amylaseRadiological examination BUS: 膽囊增大、壁增厚（雙邊、夾層）膽囊內(nèi)結(jié)石光團CT、MRIAcute Calculous CholecystitisL膽道疾病雙語幻燈培訓(xùn)課件Acute Calculous CholecystitisDiagnosis and differentiation胃十二指腸穿孔急性胰腺炎高位闌尾炎肝膿腫結(jié)腸肝曲癌右側(cè)肺炎、胸膜炎Acute Calculous CholecystitisDAcut

22、e Calculous CholecystitisTreatment非手術(shù)治療禁食輸液、糾正水、電解質(zhì)及酸堿平衡抗生素：廣譜、聯(lián)合解痙止痛：并存病處理、術(shù)前準(zhǔn)備Acute Calculous CholecystitisTAcute Calculous CholecystitisOperative treatment時機：發(fā)病72小時內(nèi)非手術(shù)治療無效且病情惡化有并發(fā)癥：膽囊穿孔、彌漫性腹膜炎、化膿性膽管炎、急性壞死性胰腺炎手術(shù)方法：膽囊切除、膽囊造口手術(shù)指征：局部、全身情況、術(shù)者技術(shù)Acute Calculous CholecystitisOAcute Acalculus Cholecystit

23、isIncidence :4-8%Etiology嚴重創(chuàng)傷、燒傷、手術(shù)后：低血壓危重病人：膿毒癥長時間的TPN：CCK下降，膽汁淤積Pathology同結(jié)石性膽囊炎，壞死、穿孔率高Acute Acalculus CholecystitisIAcute Acalculus CholecystitisClinical manifestations男：女=1.5：1表現(xiàn)同結(jié)石性膽囊炎易被原發(fā)病掩蓋，提高認識和警惕Management一經(jīng)診斷、早期手術(shù)：切除或造口難以耐受手術(shù)者：經(jīng)皮穿刺引流病情較輕者：嚴密觀察下非手術(shù)治療Acute Acalculus CholecystitisCChronic ch

24、olecystitisEtiology急性膽囊炎的結(jié)果結(jié)石的反復(fù)刺激Pathology炎性細胞浸潤纖維組織增生增厚、萎縮、瘢痕Chronic cholecystitisEtiologyChronic cholecystitisClinical presentations不典型膽絞痛史消化道癥狀右上腹和肩背部隱痛Signs: 膽囊區(qū)輕壓痛Chronic cholecystitisClinical Chronic cholecystitisDiagnosisBUS:膽囊縮小、壁增厚，排空功能減退或消失。膽囊內(nèi)結(jié)石?？诜懩以煊埃猴@影差、收縮功能降低Differentiations胃十二指腸潰瘍胃炎

25、肝病Chronic cholecystitisDiagnosisAcute Obstructive Suppurative Cholangitis, AOSCAcute Cholangitis of Severe Type，ACSTEtiology最常見原因：膽管結(jié)石，76-88.5%膽管狹窄，8.7-11%膽管、壺腹部腫瘤原發(fā)性硬化性膽管炎膽腸吻合術(shù)后、經(jīng)T管造影、PTC術(shù)后Acute Obstructive Suppurative Acute Obstructive Suppurative Cholangitis, AOSCPathology基本病理改變：膽道梗阻+膽管內(nèi)化膿性感染 膽管：

26、內(nèi)壓升高、膽管擴張、管壁增厚、炎性細胞浸潤、糜爛、潰瘍肝臟：充血腫大、細胞腫脹變性、淤膽、肝細胞壞死、多發(fā)性肝膿腫全身性化膿性感染、多器官功能損害 膽血反流：膽內(nèi)壓1.96kPa(20cmH2O) Acute Obstructive Suppurative Acute Obstructive Suppurative Cholangitis, AOSCClinical presentationsReynolds 五聯(lián)癥：Charcot三聯(lián)癥+休克、中樞神經(jīng)系統(tǒng)受抑制表現(xiàn)畏寒、發(fā)熱：39-40C或以上疼痛：依梗阻部位而異黃疸：肝內(nèi)膽管一側(cè)梗阻可不出現(xiàn)神經(jīng)系統(tǒng)癥狀：淡漠、嗜睡、神智不清、昏迷休克：A

27、cute Obstructive Suppurative Acute Obstructive Suppurative Cholangitis, AOSCClinical presentationsT39-40 C 、P120次/分、BP下降腹膜刺激征、肝腫大、壓痛WBC20109/L、PL降低、PT延長、肝腎功能損害、體液失衡BUS：梗阻部位、性質(zhì)CT、MRI（MRCP）Acute Obstructive Suppurative Acute Obstructive Suppurative Cholangitis, AOSCTreatment原則：緊急手術(shù)解除膽道梗阻并引流、及早而有效地降低膽管

28、內(nèi)壓力非手術(shù)治療：治療手段（觀察6h) 及術(shù)前準(zhǔn)備抗生素：足量、有效、廣譜糾正水、電解質(zhì)紊亂糾正休克、低氧血癥對癥治療Acute Obstructive Suppurative Acute Obstructive Suppurative Cholangitis, AOSCTreatment手術(shù)治療：簡單、有效膽總管切開減壓、T管引流肝膿腫處理單純膽囊造口不宜采用非手術(shù)方法置減壓引流PTCDERCP-ENBD（endoscopic nasobiliary drainage)Acute Obstructive Suppurative 膽道疾病雙語幻燈培訓(xùn)課件本節(jié)重點內(nèi)容急性膽囊炎的診斷及鑒別診斷急

29、性膽囊炎的手術(shù)時機及方法選擇AOSC的典型表現(xiàn)及治療原則本節(jié)重點內(nèi)容急性膽囊炎的診斷及鑒別診斷Biliary ascariasis多發(fā)于青少年和兒童農(nóng)村多見Etiology and pathology蛔蟲喜堿厭酸，胃腸功能紊亂時上行鉆孔習(xí)性機械刺激-膽絞痛、胰腺炎細菌逆行感染細菌殘骸-膽結(jié)石Biliary ascariasis多發(fā)于青少年和兒童Biliary ascariasisClinical manifestations突發(fā)性、劍突下、陣發(fā)性、鉆頂樣、劇烈絞痛，右肩部放射痛可突然緩解、間歇期正常（膽管炎表現(xiàn)）體征輕微BUS：平行強光帶。ERCP：Biliary ascariasisClin

30、ical manBiliary ascariasisDiagnosis特點：癥狀與體征不相稱+ BUSBiliary ascariasisDiagnosisBiliary ascariasisTreatment非手術(shù)療法：解痙止痛利膽驅(qū)蛔：烏梅湯、食醋、30%硫酸鎂 驅(qū)蟲劑：驅(qū)蛔靈、左旋咪唑 消炎利膽：抗感染內(nèi)鏡治療Biliary ascariasisTreatmentBiliary ascariasisTreatment手術(shù)治療手術(shù)指征積極治療3-5天無緩解蛔蟲較多或合并結(jié)石進入膽囊合并嚴重并發(fā)癥手術(shù)方式：CBD切開取蟲+T管引流Biliary ascariasisTreatment膽道腫瘤

31、Tumor of biliary tract膽囊息肉樣病變(polypoid lesions of gallbladder)- 微小隆起性病變腫瘤性：腺瘤、腺癌，其他少見非腫瘤性；炎性、膽固醇性、腺肌性增生診斷：BUS手術(shù)指征：疑為惡性或有明顯臨床癥狀膽道腫瘤Tumor of biliary tract膽囊息膽道腫瘤Tumor of biliary tractDifferentiation of benign and malignant tumor 良性 惡性大小 小于1cm 大于1cm增長速度 慢 快數(shù)目 多發(fā) 單發(fā)形狀 乳頭狀、蒂細長 不規(guī)則、基底寬BUS 強回聲 低回聲膽道腫瘤Tumor

32、 of biliary tract膽道疾病雙語幻燈培訓(xùn)課件膽固醇息肉聲像圖特征為：1，呈球形、桑葚狀或乳頭狀，有蒂或基底較窄；2，一般多發(fā)，可見于膽囊任何部位；3，體積小，通常內(nèi)徑小于10mm，4，多為強回聲表現(xiàn)，不隨體位而移動。膽固醇息肉聲像圖特征為：1，呈球形、桑葚狀或乳頭狀，有蒂或基膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽道疾病雙語幻燈培訓(xùn)課件膽囊腺肌瘤樣增生（adenomyomatous hyperplasia） 膽囊粘膜上皮及其平滑肌層增生，肌肉間可見多數(shù)由柱狀細胞構(gòu)成的大小腺腔，細胞無異型性。HE100膽囊腺肌瘤樣增生（adenomyomatous hyperpCarci

33、noma of Gallbladder膽道系統(tǒng)常見的惡性腫瘤，占肝外膽道癌的25%，膽囊切除的1%左右女性多見，男：女=1:1.98發(fā)病高峰年齡60-70歲Etiology70-98%合并膽囊結(jié)石腺瘤惡變腺肌性增生、黃色肉芽腫性膽囊炎、瓷化膽囊Carcinoma of Gallbladder膽道系統(tǒng)常見Carcinoma of GallbladderPathology體、底部多見80%為腺癌，其他：未分化癌、鱗狀細胞癌、混合性癌轉(zhuǎn)移途徑：淋巴、靜脈、種植、神經(jīng)、膽管Carcinoma of GallbladderPatholCarcinoma of GallbladderClassificationNevin分期I 期： 粘膜內(nèi)原位癌II 期： 侵犯粘膜和肌層III期： 侵犯膽囊壁全層IV期： 侵犯膽囊壁全層并周圍淋巴結(jié)轉(zhuǎn)移V 期： 侵犯肝和（或）轉(zhuǎn)移至其他臟器Carcinoma of GallbladderClassiCarcinoma of GallbladderClassification of