胆道疾病 ppt课件

胆道疾病 教学专用肝内胆管:一、二、三级……肝外胆管:胆总管,直径<1cm,分为4段胆囊及胆囊管胆囊三角(Calot三角)胆道血管与淋巴胆道神经生理功能胆道解剖与生理胆道疾病 Bus,X-ray(平片,上腹,静脉造影) PTC(percutaneoustranshepaticCholangiography) PTCD,ERCP(endoscopicretrograde Cholangiopancreatography). CT,MRI Cholangiographyinoperation Choledochoscopy常用的辅助检查方法胆道疾病胆囊结石肝外胆管结石肝内胆管结石(肝石) 胆固醇性 胆色素性 混合性胆石病(症)(Cholithiasis)分类:部位:概述:流行病学胆道疾病-胆囊结石胆固醇性和混合性结石多见女多于男综合性因素致病胆道疾病-胆囊结石临床现:无症状(SilentStone20%~40%)胆绞痛,消化道症状,Mirizzisyndrome,黄疸.转归:无症状,终身无致病,胆囊癌变,速发性胆囊管结石,胆源性胰腺炎胆道疾病-胆囊结石B超无症状的胆囊结石的治疗问题:有争议胆囊切除(OC.MC.LC)胆总管探查指征:CBD扩张,CBD结石,肿瘤?黄疸与胰腺炎病史诊断和治疗:胆囊结石*Withthedevelopmentofeconomyandtheimprovementofmedicalscienceandtechnology,livertransplantationwillundoubtedlybefacingapromisingfutureinMainlandChina.Fromourexperiences,therecurrenceoftumor,thereinfectionofHBVaswellasthebiliaryandvascularcomplicationsarethemainobstacles.Weneeda“braindeath”ordinancetofacilitatecadavericlivertransplantation.Weshouldestablishanefficientsystemfororgansharingandallocation.SpecialattentionshouldbegiventoLRLT,splitlivertransplantationandxenotransplantation,whichcouldbethehopeinthefuture. Carcinoma, Severestricture Severeadhesion Severeperitonitis ImpariedofCoagulationfunction MainorgandisfunctionLaparoscopicCholecystectomy(LC)禁忌症胆道疾病-胆管结石原发性与继发性肝外与肝内分类:胆道疾病-肝外胆管结石病理:梗阻继发感染梗阻性化脓性胆管炎,肝脓肿,胰腺炎(急,慢)临床表现:腹痛,发热,黄疸(Charcot三联症)体检:剑突下,右上腹压痛,肿大胆囊.实验室检查:血常规、肝功能、B超等鉴别诊断:肾绞痛、肠痉挛、胆道恶性梗阻.胆道疾病-肝外胆管结石的治疗手术原则:取尽结石,解除狭窄,通畅引流方法:胆总管探查引流:适应症,“T”管放置于拔除的指征胆肠吻合:适应症及方法(Roux-y)Oddi’s扩约肌成形及EST.胆道疾病-肝内胆管结石(Hepatolithiasis)病因病理:感染,狭窄,胆汁代谢异常临床表现:与肝外胆管结石相似,可无黄疸,病史长者易合并胆管细胞癌治疗:手术原则同肝外胆管结石HCJ(高位胆管空肠Roux-y吻合),肝叶切除残余结石反复胆道镜取石左肝内胆管结石胆囊结石和肝内外胆管结石胆总管下端结石和左肝内多发结石左肝外叶切除、胆道镜取石左肝外叶切除胆道疾病-胆道感染急性结石性胆囊炎:胆囊粘膜机械性损伤病因:细菌感染,其他因素病理:单纯性,化脓性,坏疽性鉴别诊断:消化道穿孔,急性胰腺炎,高位阑尾炎.治疗:保守,手术:切除,切开急症手术指征:保守无效,胆囊明显大,张力高,WBC>15000/mm3,结石嵌顿,穿孔胆道疾病-胆道感染急性非结石性胆囊炎病因:不明,危重病人,长期TPN,感染病人病理:与结石性相同,但坏死穿孔率高.诊断:易误诊治疗:切除造瘘手术胆道疾病-急性梗阻性化脓性胆管炎 Acuteobstructivesuppurativecholangitis-AOSC AcuteCholangitisofSeveretype-ACST 病因病理:结石,蛔虫,肿瘤肝总管结石和胆道蛔虫症胆囊蛔虫症胆道疾病-急性梗阻性化脓性胆管炎梗阻胆汁中细菌繁殖胆管上皮炎症溃疡肝细胞损害胆管门静脉瘘肝脏小脓肿胆汁血液返流全身炎性反应综合症（SIRS)多器官功能不全或衰竭 细菌、胆盐入血病理：常见菌：G-(大肠肝菌、克雷伯菌、变形、假单孢）G+(肠球菌、粪链球菌）厌氧菌、混合感染胆道疾病-急性梗阻性化脓性胆管炎 Charcot三联症 Charcot五联症（Reynolds五联症) （+休克，中枢神经系统抑制表现）临床表现： WBCPlateLF受损 酸碱平衡失调，肾功能受损实验室检查：胆道疾病-急性梗阻性化脓性胆管炎原则：紧急解除梗阻，有效引流胆道方法：非手术治疗：抗炎，抗休克，皮质激素应用，PTCD、ENAD、EST手术治疗：力求简单，尽量避免一期内引流治疗胆道肿瘤-胆囊息肉（PLG)肿瘤性：腺瘤、腺癌…非肿瘤性：炎性、胆固醇性、腺肌症分类恶性可能：单发、无蒂、广基、直径>1cm.短期内迅速增大者影像学结果与病理的关系：治疗随诊观察、手术胆囊息肉样病变*Withthedevelopmentofeconomyandtheimprovementofmedicalscienceandtechnology,livertransplantationwillundoubtedlybefacingapromisingfutureinMainlandChina.Fromourexperiences,therecurrenceoftumor,thereinfectionofHBVaswellasthebiliaryandvascularcomplicationsarethemainobstacles.Weneeda“braindeath”ordinancetofacilitatecadavericlivertransplantation.Weshouldestablishanefficientsystemfororgansharingandallocation.SpecialattentionshouldbegiventoLRLT,splitlivertransplantationandxenotransplantation,whichcouldbethehopeinthefuture.胆道肿瘤-胆囊癌流行病学：占胆道疾病的0.4%~3.8%女>男，年龄60岁病因：不明，诱因胆囊结石，腺瘤息肉，肉芽肿，腺肌症等分期：Nevin分期I粘摸原位癌II粘膜和肌层（无淋巴结转移）III胆囊壁全层（无淋巴结转移）IV胆囊壁全层（有淋巴结转移）V侵犯肝或邻近脏器治疗：单纯胆囊切除胆囊癌根治术（范围）姑息手术疗效：五年生存率<5%我院（1992.1-2000.7）110例根治术后五年：13%胆道肿瘤-胆囊癌病理：腺癌（80%）、未分化癌、鳞癌转移途径：淋巴转移直接侵犯胆囊腺癌胆道肿瘤-胆管癌定义：左右肝管至胆总管下端相关疾病：结石，硬化性胆管癌，先天性胆管囊肿类型:乳头状、结节状、弥漫性腺癌（高分化、乳头状、低分化、未分化）典型症状：无痛性黄疸进行性加重Courvoisier’ssign治疗：手术上段癌同胆囊癌下段癌同胰头癌（Wipple）疗效：>胆囊癌与胰腺癌我院（1992-2000）90例根治术后五年生存率23%肝门部胆管肿瘤右肝管胆管癌右肝管胆管癌行半肝切除术Thanks!*Thisisourhospitalbuildingandyouarewelcome.*Withthedevelopmentofeconomyandtheimprovementofmedicalscienceandtechnology,livertransplantationwillundoubtedlybefacingapromisingfutureinMainlandChina.Fromourexperiences,therecurrenceoftumor,thereinfectionofHBVaswellasthebiliaryandvascularcomplicationsarethemainobstacles.Weneeda“braindeath”ordinancetofacilitatecadavericlivertransplantation.Weshouldestablishanefficientsystemfororgansharingandallocation.SpecialattentionshouldbegiventoLRLT,splitlivertransplantationandxenotransplantation,whichcouldbethehopeinthefuture.*Withthedevelopmentofeconomyandtheimprovementofmedicalscienceandtechnology,livertransplantationwillundoubtedlybefacingapromisingfutureinMainlandChina.Fromourexperiences,therecurrenceoftumor,thereinfectionofHBVaswellasthebiliaryandvascularcomplicationsarethemainobstacles.Weneeda“braindeath”ordinancetofacilitatecadavericlivertransplantation.Weshouldestablishanefficientsystemfororgansharingandallocation.SpecialattentionshouldbegiventoLRLT,splitlivertransplantationandxenotransplantation,whichcouldbethehopeinthefuture.*Thisisourhospitalbuildingandyouarewelcome.