晚期恶性梗阻性黄疸并发消化道出血高危因素分析

目的探讨晚期恶性梗阻性黄疸并发消化道出血的高危因素,提出预防及治疗措施。方法回顾分析我科2008年12月至2010年12月我科收治晚期恶性梗阻性黄疸并发消化道出血患者35例,分析引起消化道出血的相关因素、出血表现和治疗结果。结果晚期恶性梗阻性黄疸并发消化道出血的高危因素是内毒素血症、低蛋白血症、肾功能损害、凝血功能障碍。晚期恶性梗阻性黄疸引起消化道出血病情危重,临床止血率低,本组成功止血率42.9%。结论积极加强营养、预防和控制内毒素血症是预防晚期恶性梗阻性黄疸上消出血的关键;抑制胃酸、静脉输注止血药及生长抑素是治疗上消出血的重点。     

梗阻性黄疸与肠道菌群失调

梗阻性黄疸是临床上常见的病理状态,梗阻性黄疸患者术后高并发症发生率及死亡率一直是术后恢复过程中一大难题。目前,肠源性内毒素血症被认为是梗阻性黄疸预后不良的主要原因,而梗阻性黄疸时,致病菌大量繁殖,肠道菌群失调,内毒素移位是肠源性内毒素血症发生的主要机制。因此如何有效地控制梗阻性黄疸时的肠道菌群失调成为现今研究的热点。本文就梗阻性黄疸时肠道菌群的变化,如何进行干预,降低患者术后并发症的发生率及死亡率的最新进展进行综述,希望对梗阻性黄疸的治疗提供新的思路及对策。     

梗阻性黄疸并急性肾衰死亡危险因素

黄疸肾是指由于胆道梗阻、高胆红素血症所致的肾损害[1 ] 。我院 1 987～ 1 996年间梗阻性黄疸术后死亡 51例 ,其中急性肾衰 1 8例 ,现就其危险因素分析如下。1　临床资料肾衰死亡患者 1 8例中男 1 6例 ,女 2例 ,平均年龄 56 4岁 ,血浆尿素氮及肌酐水平分别为1 1 1 7～ 30 35μｍｏｌ/Ｌ及 2 65 2～ 72 4 88μｍｏｌ/Ｌ ,术后 2 4ｈ尿量 <40 0ｍｌ,甚至无尿。肝外胆管结石 1 4例 ,肝内胆管结石 2例 ,术后胆管狭窄 1例 ,壶腹癌 1例。其它死亡 33例 ,男性 2 1例 ,女性1 2例 ,平均 52 7岁 ,术后尿量正常 ,血浆尿素氮小于 7 1 μｍｏｌ/Ｌ ,…     

大鼠梗阻性黄疸对红细胞变形能力影响的研究

将 ５６只雄性大鼠分组制成梗阻性黄疸及假手术模型，术后１ｄ、３ｄ、７ｄ连续股静脉穿刺采血进行血流变和生化检测，与０时间的正常鼠作比较，发现术后梗阻性黄疸组有明显血流变性改变，主要为全血粘度升高红细胞变形能力下降，并出现肝、肾功能损害。认为阻黄后红细胞变形能力的下降导致了微循环灌注不足，并影响血液流动性，是引起脏器功能损害的原因之一。而阻黄后高胆汁酸血症、内毒素血症及氧自由基是引起红细胞变形能力下降的重要因素。     

思美泰对梗阻性黄疸患者免疫功能影响的临床研究

感染、胃肠道出血、肾功能衰竭、营养不良、伤口不愈合和脓毒血症等是梗阻性黄疸病人围手术期常见的致死性并发症,梗阻性黄疸除引起肝组织损害为主的全身各器官系统的病理变化外,还可引起机体免疫防御功能的抑制,它是导致机体各种感染等诸多严重致死性并发症产生的原因[1]。因此,围手术期改善梗阻性黄疸病人的免疫功能,可减少术后并发症的发生,同时对于提高患者术后生存率具有重要意义。笔者在临床运用思美泰治疗68例梗阻     

内皮素与梗阻性黄疸时内毒素血症的相关研究

梗阻性黄疸时发生的肠源性内毒素学症可导致围手术期患者死亡率增高。肝网状内皮系统是清除内毒素的主要场所，梗阻性黄疸时其功能下降是主要原因。内皮素作为体内最强的缩血管因子，对维持肝网状内皮系统血运起重要作用。本实验通过观察梗阻性黄疸模型大鼠内皮素（ET）、内毒素（LPS）含量的变化，初步探讨梗阻性黄疸时肝网状内皮系统血液动力学变化对肠源性内毒素含量的影响机制。     

消化道吻合器行胆肠吻合术的严重并发症原因分析与处理

目的:探讨应用消化道吻合器行胆肠吻合术治疗肝外梗阻性黄疸患者的严重并发症发生原因及处理方法.方法:回顾我们在1999年3月至2008年10月间收治的77例应用消化道吻合器行胆肠吻合术治疗肝外梗阻性黄疸患者的临床资料.结果:77例肝外梗阻性黄疸患者中,术后发生并生症共7例(9.1%),其中胆道出血2例(2.6%),胆道逆行感染1例(1.3%),胆汁漏1例(1.3%),胆道梗阻2例(2.6%),胰腺假性囊肿1例(1.3%).结论:严格把握手术适应证,熟练掌握消化道吻合器操作要点以及细致的手术操作,是避免或减少在应用消化道吻合器行胆肠吻合(胆总管与空肠Roux-en-Y吻合)治疗肝外梗阻性黄疸中并发症发生的关键.     

术后急性肾功能衰竭的治疗

术后急性肾衰死亡率高达50％以上,术后急性肾衰的预防和治疗,对提高治愈率具有重大意义。 1 术后急性肾衰的预防 对术后容易发生少尿、无尿的患者,在其真正的肾衰症状出现之前,给予甘露醇或速尿等利尿剂,以维持肾血流量及尿量是很重要的,对弥漫性腹膜炎、化脓性胆管炎、梗阻性黄疸等术后患者尤为重要,避免使用具有肾毒性的麻醉药和抗生素,对各种原因引起的休克患者,通过输液,呼吸和循环的管理,使循环状态很快得到恢复。     

梗阻性黄疸病人手术并发症和死亡原因分析

目的:通过对梗阻性黄疸手术病例的统计,分析引起手术并发症及死亡的原因。方法:回顾性分析1995~2010年150例梗阻性黄疸手术病例,对其手术并发症发生率及术后死亡因素进行分析统计。结果:梗阻性黄疸病人手术并发症发生率为34.7%、死亡率为13.3%,死亡率与其胆红素水平关系密切,术前胆红素≥342μmol/L时,死亡率达47.4%,急性肾功能衰竭是其主要死亡原因。结论:术前纠正营养不良,保护肝、肾功能,预防和控制感染,监测尿量及肾功能,对降低梗阻性黄疸病人手术并发症和死亡率有重要意义。     

胆道出血9例治疗体会与预防

胆道出血多由于损伤或其他原因，导致肝内或肝外的血管与胆道相通，血经胆道流入十二指肠而发生的消化道出血，其典型症状为右上腹或中上腹疼痛、黄疸、周期性消化道出血的三联征。随着肝胆手术的普及胆道出血已成为一个不可忽视的问题。本文就我院自１９８６年３月～１９９８年８月收治的９例患者，对胆道出血的诊断，治疗及预防讨论于后。１ 临床资料 本组男６例，女３例；年龄最小１８岁，最大６３岁．术前胆道出血１例，术中胆道出血２例，术后出血６例。肝内胆管结石引起者最多共７例，其中４例伴梗阻性化脓性胆管炎，胆囊出血１例，外…     

医院获得性急性肾功能衰竭的病死危险因素分析调查及临床对策

目的调查医院获得性急性肾功能衰竭(肾衰)的病死率及死亡危险因素。方法回顾性调查1991～1996年的1056例危重病患者,利用队列研究方法对医院获得性急性肾衰患者死亡危险因素进行分析。结果1　056例危重病患者中,143例发生急性肾衰,病死率64.34%。患者平均APACHEⅡ评分(24.20±8.53)分,而Liano急性肾衰预后评分(ATNISS)为(72.46±25.58)%。单纯急性肾衰的住院病死率为0,而急性肾衰合并肾外器官衰竭数目越多,患者的病死率越高。合并1个肾外器官衰竭者病死率25.00%,2个肾外器官衰竭者为47.62%,3个肾外器官衰竭者为81.58%,而发生4个肾外器官功能衰竭者病死率达90.20%。22个因素参与急性肾衰死亡危险因素的单因素分析,结果显示年龄(>60岁)、免疫功能低下、APACHEⅡ评分(>20分)、非手术、全身性炎症反应的程度、严重全身性感染、感染性休克、器官衰竭数目、机械通气、昏迷、低血压、黄疸及少尿等因素均与急性肾衰死亡关系显著(P均<0.05)。急性肾衰患者的最常见的直接病死原因是顽固性感染性休克(46.74%)。结论充分认识急性肾衰死亡的危险因素,并积极控制机体炎症反应,防治多器官功能衰竭,可能是降低急性肾衰病死率的关键。     

Renal function in jaundiced patients: a prospective analysis

A prospective analysis was undertaken to assess renal function in patients with obstructive jaundice. A total of 59 jaundiced patients (serum bilirubin > 100 mumol/l) undergoing biliary decompression by surgical, endoscopic or radiological means received prophylactic fluid volume expansion (3 litres crystalloid fluid intravenously) during the 24 hours before intervention. Renal function (urea and electrolytes, creatinine, creatinine clearance, urinary output) was assessed preoperatively and on days 1-7 and on day 28 postoperatively. Two jaundiced patients (3.4%) developed renal failure (urinary output < 400 ml in 24 hours in the presence of an increased serum urea and/or creatinine) and subsequently died. The overall incidence of post-procedural renal impairment (urinary output < 800 ml in 24 hours) was 10.2%. It is concluded that, with vigilant control of fluid and electrolyte balance and pre-procedural intravenous volume expansion, the incidence of renal dysfunction in patients with obstructive jaundice is not as high as previously reported.     

Endoscopic placement of expandable metal stents for biliary strictures--a preliminary report on experience with 33 patients

The main problem with palliative treatment of extrahepatic cholestasis with an endoscopic biliary endoprosthesis is clogging. One of the factors thought to be of importance is the diameter of the stent. In order to avoid being limited by the size of the instrumentation channel of the endoscope, expandable stents have been developed. In this article we report on our preliminary clinical experience with an endoscopically placed expandable metal stent ("Wallstent") in 33 patients with extrahepatic bile duct stenoses. When fully expanded, the stent has a diameter of 30 F and a length of 6.7 cm. It was possible to successfully place a stent in every patient. Clinical improvement was achieved in all patients except one. Two patients underwent elective surgery, while one died of renal failure. Another died of septic shock after 5 weeks, but no autopsy was performed. In conclusion, our initial experience with this stent shows that at least in the short term biliary drainage was excellent, with no complications of pancreatitis or hemorrhage. Longer follow-up than our 4 weeks is necessary to establish the position of this stent in comparison with the conventional endoprosthesis in the management of obstructive jaundice.     

超声引导下穿刺置管治疗继发性肾功能衰竭72例

目的 分析超声引导下肾造瘘术对肾功能衰竭患者肾功改善的临床意义。方法 72例因肿瘤原因致肾功能衰竭患者经肾造瘘术后,观察治疗前、后血肌酐（Cr）和尿素氮（BUN)变化。 结果 72例均一次穿刺成功,穿刺成功率100%。随访4周,其中一周内肾功能明显改善69例,有效率95.8%,其余3例两周内肾功能明显改善。Cr下降范围120-270umol/L,BUN下降范围3.9-8.1mmol/L。 本组发生轻微并发症5例,发生率为6.9% 。结论 超声引导下肾造瘘能够明显改善肾功能,短期内治疗肾功能衰竭效果满意。     

超声引导下经皮肝胆管穿刺置管引流术治疗恶性阻塞性黄疸的临床价值

目的探讨在超声引导下经皮肝胆管穿刺置管引流术(PTCD)对恶性阻塞性黄疸的临床价值。方法回顾性分析13例恶性肿瘤所致的阻塞性黄疸患者,在普通彩超仪3．5MHz凸阵探头引导下行PTCD术。结果13例患者共行14次PTCD,其中1例左叶置管后滑出改行右前支穿刺置管,1例因肝内胆管内径小于4mm,穿刺失败后选用经皮肝胆囊穿刺置管,手术成功率92．8%(13／14),术后观察黄疸明显消退。结论在超声引导下行PTCD对不宜手术的恶性阻塞性黄疸病人是较好的选择,它具有灵活、简便、创伤小、疗效确切,值得临床推广应用。     

Acute Reversible Renal Failure in Patients with Acute Cholecystitis and Cholangitis

Although acute renal failure is a well recognized complicationof several extra-hepatic biliary tract diseases especially biliarytract surgery in the presence of obstructive jaundice, thereis little information concerning renal failure in acute cholecystitis.Renal function was assessed in 14 patients with acute cholecystitisand two with acute cholangitis. Six patients had no evidenceof renal impairment, four had modest elevations of plasma ureaand creatinine concentrations and six had acute reversible renalfailure of whom three required peritoneal dialysis. Only onepatient was hypovolaemic and in the remainder there was evidencethat intravascular coagulation was responsible for the renalfailure. It is suggested that bacteraemia was the initiatingfactor. The therapeutic implications of these findings are discussed. ^*Present address: Wessex Regional Renal Unit, St. Mary's GeneralHospital, Portsmouth     

Severe imported malaria: clinical presentation at the time of hospital admission and outcome in 42 cases diagnosed from 1996 to 2002

The objectives of this retrospective study were to describe initial clinical profiles and subsequent outcome of adult patients in France who were diagnosed with severe imported malaria, as defined by the World Health Organization (WHO). Forty-two patients diagnosed from 1996 to 2002 were included (median age: 30 years, men: 78%, non-immune persons: 74%, return from Africa: 100%, inappropriate antimalarial chemoprophylaxis: 95%). At the time of hospital admission, jaundice (62%), hyperparasitemia (56%), and prostration (52%) were the most frequent findings, followed by acute renal failure (31%). Other findings, as described by the WHO criteria, were less common. Twenty-three patients presented only with jaundice, hyperparasitemia, or prostration in isolation, or in combination. Of these 23, five non-immune persons subsequently developed coma, shock, acute respiratory distress syndrome or acute renal failure; this led to death in 2 of these cases. This suggests that non-immune persons with imported malaria who present with jaundice, hyperparasitemia, or prostration should be admitted to the intensive care unit for close monitoring.     

Obstructive jaundice blunts myocardial contractile response to isoprenaline in the dog: a clue to the susceptibility of jaundiced patients to shock?

Patients with obstructive jaundice are susceptible to postoperative shock. To clarify the mechanism of this phenomenon, we compared the contractile response to isoprenaline of isolated ventricular preparations from three groups of dogs: (a) dogs with chronic bile-duct ligation (CBDL), (b) dogs with choledochocaval anastomosis (CDCA) and (c) sham-operated dogs (SO). Isolated ventricular muscles from CBDL and CDCA dogs showed a depressed contractile response to isoprenaline as compared with SO dogs. Mechanical performance was spared in the CBDL and CDCA dogs. There were no differences in the contractile responses of SO and CBDL dogs, either to ouabain or to changes in the rates of stimulation (force-frequency relationships). These data demonstrate that, in the dog, obstructive jaundice and/or cholaemia are associated with blunted contractile response to beta-adrenoreceptor stimulation in the face of intact basic mechanical performance. Similar inotropic refractoriness to beta-adrenoreceptor stimulation could contribute to the susceptibility to postoperative shock in patients with obstructive jaundice.     

Endotoxemia after abdominal surgery

The blood level of endotoxin after operations in patients with digestive diseases, mainly liver cirrhosis and obstructive jaundice, and the complications most likely related to the presence of endotoxemia were investigated. Twenty-seven patients without either liver cirrhosis or obstructive jaundice showed a minimal elevation of the endotoxin level in blood, as shown by 6.1 +/- 3.9 (mean +/- S.E.) pg/ml at the first postoperative day and there was only one anastomotic leakage. On the other hand, 18 patients with liver cirrhosis showed a notable and persistent endotoxemia after surgery. The cirrhotic patients who especially underwent splenectomy and hepatectomy showed marked elevations of endotoxin level at the first postoperative day, with values of 151.0 +/- 46.1 pg/ml and 101.3 +/- 36.2 pg/ml, respectively, and one of these patients died of hepatic failure. Thirteen patients with obstructive jaundice developed endotoxemia evidenced by the value of 21.6 +/- 4.8 pg/ml at the first day after surgery. Among these patients, two had gastrointestinal bleeding and one developed disseminated intravascular coagulation (DIC). The markedly high and persistent levels of endotoxin in patients with liver cirrhosis or obstructive jaundice may be possibly related with the development of multiple organ failure (MOF).     

Serum xanthine oxidase in jaundice.

Serum xanthine oxidase activity was measured by a radiochemical method in 137 consecutive patients with jaundice of varying etiology and in 40 non-jaundiced patients with liver or other disease. Serum xanthine oxidase was markedly increased, up to 50 times the upper normal limit (mean + 2 S.D.), in 32 out of 34 patients with infectious hepatitis. A slight elevation of serum xanthine oxidase, up to twice the upper normal limit, was found in 2 out of 49 patients with extrahepatic obstructive jaundice and in 4 out of 20 patients with chronic renal failure. In comparison to serum glutamic-oxaloacetic transaminase and lactate dehydrogenase serum xanthine oxidase appeared to be the more sensitive and specific indicator of acute hepatocellular damage.