Hemobilia--evolution of current diagnosis and treatment.

"Hemobilia," upper gastrointestinal tract bleeding that originates from within the biliary tract, has become widely recognized due to an increased clinical awareness of the disorder and to improvements in diagnostic techniques. In addition, the growing use of percutaneous liver puncture for the diagnosis of and therapy for hepatobiliary diseases and the increased incidence of both blunt and penetrating hepatic trauma have contributed to a rising incidence of hemobilia. We review the history, pathophysiology, and current approaches to the diagnosis and treatment of this disease.     

Radiodiagnosis of patients with primary sclerosing cholangitis

Among diseases of the hepatobiliary system, primary sclerosing cholangitis is an undetectable disorder of the biliary tract rather than a rare nosological entity, complex radiation study is of great importance in its preoperative diagnosis. Among direct methods for contrasting the biliary tract, the authors gave preference to percutaneous transhepatic cholangiography that allows the dilated biliary tract to be contrasted virtually in 100% of cases. The specific features of X-ray semiotics of primary sclerosing cholangitis were identified in 17 patients.     

老年人急性胆道感染(附68例临床分析)

目的:探讨老年人急性胆道感染的临床特点及诊疗经验。方法:回顾性分析68例老年人急性胆道感染的诊断和治疗的临床资料。结果:老年人急性胆道感染病人并发症多,使病情危重复杂,影响手术的安全性和术后的恢复。甚至手术效果良好的病人术后死于并发症的严重发作,多数患者预后不佳。结论:老年人具有特殊的生理特点与临床特点,急性胆道感染时临床表现多不典型。年龄不是手术禁忌证,应在积极抗感染、抗休克的同时,尽早采取恰当的手术治疗,做好围手术期的处理才能提高治疗效果,降低病死率。     

恶性胆道梗阻患者所行经皮穿刺肝内胆管引流术中成功置入金属支架的术前影响因素分析

目的:探讨恶性胆道梗阻患者行PTBD(Percutaneous Transhepatic Biliary Drainage)术中金属支架置入成功率的影响因素。方法:回顾性搜集2010年10月-2017年1月上海市第一人民医院收治的因患有近端恶性胆道梗阻行PTBD术患者的相关临床资料。比较不同原发病因患者支架置入情况。根据患者支架置入是否成功将其分为支架组和非支架组,比较患者的一般临床特征。结果:胰腺癌、胃癌和胆囊癌为本研究中数量上前3位的肿瘤,将以上3组分别按照支架置入数行x~2检验,其中胰腺癌(n=18,支架=6)和胃癌(n=14,支架=11)有统计学意义。将50例患者分为支架组(n=28)和非支架组(n=22),组间比较差异有统计学意义的因素包括:白细胞计数(支架组=6.40±3.40×10~9/L,非支架组=10.74±6.41×10~9/L),中性粒细胞计数(支架组=4.90±3.06×10~9/L,非支架组=8.92±6.25×10~9/L),胆道感染(支架组=9,非支架组=15)。进一步将该50例患者分为6组:胰腺癌-胆道感染组、胃癌-胆道感染组、其他肿瘤-胆道感染组、胰腺癌+胆道感染组、胃癌+胆道感染组、其他肿瘤+胆道感染组。将以上6组分别按照支架置入数行x~2检验,胰腺癌+胆道感染组(n=11,支架=1,P=0.001)有统计学意义。结论:PTBD术对于恶性胆道梗阻是一种有效的姑息治疗手段。胆道感染是PTBD术中支架置入成功的不利因素,胰腺癌合并胆道感染会显著降低PTBD术中支架置入成功率。     

胆囊切除术医源性胆管损伤的处理

目的:探讨开腹胆囊切除术医源性胆道损伤的诊断、手术时机和手术方式的选择。方法:对18例胆道损伤进行分析总结:分别施行了胆管修补、T管引流术10例,保守治疗2例,Roux-en-Y胆肠吻合术6例。结果:3例术后过早拔管发生吻合口狭窄,再次手术。1例因梗阻性胆管炎并发肝功能衰竭、多器官功能衰竭死亡。1例因胆肠吻合术后并发消化道出血、肝昏迷死亡。余术后良好。结论:尽早发现及正确处理对提高疗效和预防术后胆管狭窄起着决定性的作用。术中发现胆管损伤立即行端端吻合加T管引流;术后数天发现或多次胆道修补术失败者,则宜行规范的Roux-en-Y胆肠吻合术。     

胆道梗阻合并胆道感染的病原学特征和危险因素及与肝脏损伤的关系研究

目的:探讨胆道梗阻合并胆道感染的病原学特征和危险因素,并分析胆道感染与肝脏损伤的关系。方法:回顾性分析250例胆道梗阻患者的临床资料,分析胆道梗阻合并胆道感染的病原菌分布和主要病原菌的耐药性,分析胆道梗阻合并胆道感染的危险因素,比较各组的肝功能指标[天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、谷氨酰转移酶(GGT)、直接胆红素(DBIL)]和肝纤维化指标[层黏蛋白(LN)、透明质酸(HA)、Ⅲ型前胶原(PCⅢ)、Ⅳ型胶原(Ⅳ-C)]。结果:250例胆道梗阻中共有132例合并胆道感染,感染率为52.80%,共分离出病原菌150株,以革兰阴性菌和革兰阳性菌为主。粪肠球菌对红霉素的耐药率最高,屎肠球菌对林可霉素的耐药率最高,均对万古霉素的耐药率最低;大肠埃希菌和肺炎克雷伯菌均对氨苄西林的耐药率最高,对妥布霉素的耐药率最低。年龄≥60岁、有胆道手术史、肝功能Child-Pugh评分≥11分是胆道梗阻合并胆道感染的危险因素(P<0.05)。胆道感染组的AST、ALT、GGT、DBIL、LN、HA、PCⅢ、Ⅳ-C水平高于无胆道感染组和对照组,且无胆道感染组高于对照组(P<0.05)。结论:胆道梗阻患者胆道感染的发生率较高,并且胆道感染会进一步加重胆道梗阻患者的肝脏损伤,临床应根据其病原学特征和危险因素做好相应的防治工作。     

Mirizzi症合症 32 例临床分析

目的：探讨Mirizzi综合症的诊治。方法：将32例经手术证实的Mirizzi综合症的诊断与治疗加以归纳分析。结果：31例均一期手术治愈,7例并发胆管狭窄,2例出现漏胆。另有一例反复发作胆管炎12年。结论：术前诊断以胆道造影学检查为主,其中确诊是正确手术的关键。     

胆道系统恶性肿瘤的内科治疗新进展

胆道系统恶性肿瘤是一种发病率低、预后差的肿瘤,包括胆管癌、胆囊癌及壶腹部癌.在西方国家胆道系统恶性肿瘤大约占胃肠道肿瘤的4％,东南亚发病率相对较高.在我国,胆道系统恶性肿瘤的发病率并没有明确数字,约占消化道肿瘤的第6位.胆系肿瘤生存率低,预后差,至今尚无有效的化疗方案.目前,关于进展期胆系肿瘤化疗的Ⅱ、Ⅲ期临床试验研究以逐渐开展,化疗方案以吉西他滨为主,单药或联合铂类等药物,得到了明显提高的有效率及生存期.本文就目前胆系肿瘤化疗方面新的进展及成果做综述.     

An elderly man with cholestatic jaundice due to biliary hydatidosis

Hydatid disease is found throughout the world, with a higher prevalence in the Mediterranean area. In Spain, the most endemic regions are Rioja and Aragon, with rates above 10 cases/100,000 inhabitants, followed by Castilla-La Mancha and Castilla y Leon (5-10 cases/100,000 inhabitants). This parasitic disease is caused by the larval stage of Echinococcus granulosus (EG) and the main organs affected are the liver and the lung (85 % cases). We present a case of obstructive jaundice and secondary cholangitis due to a biliary hydatidosis. Abdominal computed tomography scan showed dilatation of the entire biliary tract. The technique used for diagnosis and treatment was endoscopic retrograde cholangiopancreatography.     

8例胆道周围感染与小儿亚急性重症肝炎关系的临床分析

对8例小儿亚急性重症肝炎合并胆道周围感染进行了临床分析。其结果,8例胆道周围感染的B型超声图像均有特征性显示,其中以壁厚、呈双边征,胆囊水肿显示率最高;8例胆道周围感染中,血象仅有1例在正常范围内,余均超过正常范围,白细胞升高者占87.5%,8例血象75%以中性粒细胞升高为主。认为,(1)胆道周围感染与肝脏病变互为因果。感染是小儿重型病毒性肝炎致死的重要原因之一;(2)继发感染在重症肝炎时易被忽视,感染灶不易被发现,临床表现多不典型。B超图像特征性显示,对胆道周围感染的诊断有很大的临床实用价值。     

Value of endoscopic retrograde cholangiopancreatography-guided brushings in preoperative assessment of pancreaticobiliary strictures: what's new?

Brush cytology plays a prominent role in confirming the presence of extrahepatic biliary tract malignancy. However, its value is limited by its relatively low and widely variable sensitivity values. Various factors seem to influence the accuracy of cytologic diagnosis and are attributed to sampling, technical and interpretation errors. Ancillary methods, such as immunocytochemistry, flow cytometry, image analysis, fluorescence in situ hybridization (FISH) and the newly discovered method of global analysis of gene expression are helpful in resolving cases with inconclusive cytology and are vigorously investigated for their value in assessing the expression of novel tumor markers for the diagnosis and prognosis of pancreatic and bile duct carcinomas. However, their routine use in clinical practice remains in doubt. To increase the sensitivity of brush cytology and strengthen its role in the preoperative assessment of patients with pancreaticobiliary malignancies, the following are of the utmost importance: improvement of current sampling and cytopreparation techniques, introduction of a uniform system for reporting epithelial abnormalities based on strict and clearly distinct morphologic criteria for each pathologic entity and incorporation of experience and knowledge derived from standard cytologic methods and novel diagnostic technologies in clinical practice without compromising the high specificity associated with brush cytology.     

Actue Cholecystitis Following Unrelated Surgery

In a series of 26 cases of acute cholecystitis occurring after an operation for an unrelated condition, 88% of the patients were over 50 years of age and males outnumbered females by 2 to 1. In some of the cases diagnosis was difficult and delay was responsible for the death of one patient. Acalculous cholecystitis occurred in 20% of the cases and in these gangrene or perforation supervened early in the course of the disease.Efforts should be directed to ensuring adequate hydration after operation; resumption of a diet low in fat may be important. Even in the absence of a history of biliary disease, there is a place for the radiological study of the biliary tract before major elective operations are performed. If gallstones are discovered on the occasion of the initial surgery, cholecystectomy should be performed whenever it is feasible. In any patient with postoperative cholecystitis early operation is generally indicated.     

梗阻性黄疸患者经内镜逆行胰胆管造影术后胆道感染的病原菌分布、耐药性及影响因素分析

目的:探讨梗阻性黄疸患者经内镜逆行胰胆管造影(ERCP)术后胆道感染病原菌分布、耐药性以及导致术后胆道感染的影响因素。方法:选择2016年3月至2019年10月我院收治的310例行ERCP治疗的梗阻性黄疸患者,根据ERCP术后是否发生胆道感染将其分为感染组(50例)和未感染组(260例)。检测胆道感染患者病原菌种类及其耐药性,多元Logistic回归分析影响梗阻性黄疸患者ERCP术后胆道感染的影响因素。结果:ERCP术后胆道感染发生率为16.13%,大肠埃希菌、铜绿假单胞菌、粪肠球菌、屎肠球菌是主要致病菌,检出率分别为40.79%、13.16%、9.21%、6.58%。大肠埃希菌、铜绿假单胞菌对头孢类、氨基糖苷类抗生素耐药率高,粪肠球菌、屎肠球菌对利福平、喹诺酮类抗生素耐药率高,大肠埃希菌、铜绿假单胞菌、粪肠球菌、屎肠球菌均对利奈唑胺、亚胺培南敏感。多元Logistic回归分析结果显示,恶性病变、ERCP2次及以上、胆胰管汇流异常、术后胆管引流不畅是梗阻性黄疸患者ERCP术后胆道感染的危险因素(P0.05),术后预防性使用抗生素是保护因素(P0.05)。结论:梗阻性黄疸患者ERCP术后存在一定胆道感染风险,革兰氏阴性菌是主要致病菌,临床应注重对高危因素预防,有必要术后选择敏感抗生素预防性治疗。     

Influence of the Biliary System on Biliary Bacteria Revealed by Bacterial Communities of the Human Biliary and Upper Digestive Tracts

Biliary bacteria have been implicated in gallstone pathogenesis, though a clear understanding of their composition and source is lacking. Moreover, the effects of the biliary environment, which is known to be generally hostile to most bacteria, on biliary bacteria are unclear. Here, we investigated the bacterial communities of the biliary tract, duodenum, stomach, and oral cavity from six gallstone patients by using 16S rRNA amplicon sequencing. We found that all observed biliary bacteria were detectable in the upper digestive tract. The biliary microbiota had a comparatively higher similarity with the duodenal microbiota, versus those of the other regions, but with a reduced diversity. Although the majority of identified bacteria were greatly diminished in bile samples, three Enterobacteriaceae genera (Escherichia, Klebsiella, and an unclassified genus) and Pyramidobacter were abundant in bile. Predictive functional analysis indicated enhanced abilities of environmental information processing and cell motility of biliary bacteria. Our study provides evidence for the potential source of biliary bacteria, and illustrates the influence of the biliary system on biliary bacterial communities.     

Purification and properties of gamma-glutamyl transferase from normal rat liver

gamma-Glutamyl transferase ((5-glutamyl)-peptide: amino-acid 5-glutamyltransferase, ED 2.3.2.2) has been partially purified from both whole rat liver (600-fold) and from isolated biliary tract (1200-fold). The most highly purified fraction gave two protein bands on polyacrylamide gel electrophoresis, the major band alone having enzyme activity. The enzyme purified from biliary tract appears identical to that from whole liver preparation according to molecular weight, kinetic parameters and the effects of various inhibitors. Three liver cell-types; parenchymal, Kupffer and biliary tract were isolated by perfusion of the rat liver in situ with collagenase, followed by selective cell isolation. Approx. 80-90% of the total recovered enzyme activity was found in the biliary tract. Nearly 50% of the apparent enzyme activity in the parenchymal cell was attributable to a nonspecific hydrolase.     

Bile acids and their nuclear receptor FXR: Relevance for hepatobiliary and gastrointestinal disease

The nuclear receptor Farnesoid X Receptor (FXR) critically regulates nascent bile formation and bile acid enterohepatic circulation. Bile acids and FXR play a pivotal role in regulating hepatic inflammation and regeneration as well as in regulating extent of inflammatory responses, barrier function and prevention of bacterial translocation in the intestinal tract. Recent evidence suggests, that the bile acid–FXR interaction is involved in the pathophysiology of a wide range of diseases of the liver, biliary and gastrointestinal tract, such as cholestatic and inflammatory liver diseases and hepatocellular carcinoma, inflammatory bowel disease and inflammation-associated cancer of the colon and esophagus. In this review we discuss current knowledge of the role the bile acid–FXR interaction has in (patho)physiology of the liver, biliary and gastrointestinal tract, and proposed underlying mechanisms, based on in vitro data and experimental animal models. Given the availability of highly potent synthetic FXR agonists, we focus particularly on potential relevance for human disease.     

Usefulness of bile cytology in the diagnostic management of patients with biliary tract obstruction

Eighteen patients with evidence of biliary tract obstruction had a total of 29 satisfactory bile samples submitted for diagnostic cytology during a two-year period. These 29 specimens were reviewed in order to determine if bile cytology is useful in the diagnostic management of patients with obstructive biliary tract disease. Twenty-one of the bile specimens were from patients with malignant biliary stricture, and eight were from patients with benign biliary obstruction. Bile cytology was positive for carcinoma in eight samples from patients with malignant stricture and was inconclusive for malignancy in two. There were no false positives. The diagnostic specificity of bile cytology was 100%, the diagnostic sensitivity was 48%, and the diagnostic accuracy was 62%. When carefully collected and promptly processed, bile proved an excellent specimen for cytologic evaluation and was a valuable adjunct to other diagnostic procedures for the detection of carcinoma causing biliary tract obstruction.     

肝部分切除治疗肝内胆管结石患者术后并发症及影响因素分析

目的:分析肝部分切除术治疗肝内胆管结石患者术后并发症及影响因素。方法:选取我院收治的肝内胆管结石患者117例,均采取肝部分切除术治疗,对其临床资料进行回顾性分析,研究术后并发症的发生情况,并对影响因素进行分析。结果:本组117例患者,并发症发生率35.04%,其中肝功能衰竭1例,胆道出血2例,消化道出血6例,腹腔感染6例,胆瘘6例,胸腔积液8例,切口感染12例。并发症组患者术前白蛋白、手术时间、既往胆道手术史水平与非并发症组比较,差异均有统计学意义(P0.05)。肝部分切除术后的并发症多因素Logistic回归分析结果显示,手术时间、既往胆道手术史均是术后并发症独立风险因素。结论:肝部分切除术治疗肝内胆管结石患者术后并发症发生率较高,以切口感染和胸腔积液为最,患者的既往手术史以及手术时间均是影响并发症发生的重要危险因素,做好针对性预防可预防并发症的发生。     

Acute cholecystitis and biliary tract infections due to Candida

Candida biliary tract infection is a rare disease. Most of the reported cases have been diagnosed in patients with surgery or invasive procedures of the biliary tract, critical illness, immunosuppression or antibiotic treatment. This report deals with an 85 years old female patient with Candida albicans cholecystitis without previous risk factors and with a literature review on the subject. Only four patients without risk factors have been so far reported.