经皮经肝穿刺胆道超声造影的方法及临床意义

目的 建立经皮经肝穿刺胆道超声造影(percutaneous transhepatic contrast-enhanced cholangio-ultrasonography,PTCECUS)的方法,探讨其可行性、安全性及临床价值.方法 对21例梗阻性黄疸患者行经皮经肝胆管(17例)、胆囊(4例)穿刺引流术,术中经引流管向胆管/胆囊内注射浓度为0.94%的SonoVue水溶液50 ml,在对比脉冲序列模式下观察胆管、胆囊及十二指肠内SonoVue微泡的流动和充填情况,判断胆管的梗阻程度.部分病例与常规超声、胰管胆管磁共振成像(MRCP)、经皮经肝穿刺胆道X线造影(PTC)进行对照.结果 ①PTCECUS生成对比良好的胆管树造影声像图;②PTCECUS判断胆管梗阻程度比常规超声准确,与MRCP和PTC一致,可指导正确实施胆汁引流方案;③PTCECUS克服了PTC穿刺与造影异地实施的烦琐,减少环节,提高效率;④全部患者穿刺及造影过程中均无并发症,14例经1～8个月肝胆超声随访未见不良反应.结论 PTCECUS过程安全,能突出显示胆道系统的走行及其管腔通畅度,对梗阻性黄疸的引流方案具有指导意义.     

MR versus multislice CT cholangiography in evaluating patients with obstruction of the biliary tract

Background We compared magnetic resonance cholangiography (MRC) with multislice computed tomographic (MSCT) cholangiography in the assessment of patients with bile duct obstruction. Methods Thirty-six patients with clinical or biochemical signs of biliary obstruction were prospectively studied. MRC was performed with fast spin-echo and single-shot fast spin-echo sequences. Source images, maximum intensity projection, and multiplanar reconstruction were evaluated. MSCT cholangiography was performed without biliary contrast agent, with intravenous injection of 150 mL of iodinated contrast material at 4 mL/s, 2.5-mm slice thickness, 7.5-mm/s table speed, and 1.25-mm reconstruction interval. Axial, multiplanar, and minimum intensity projection reformatted images were evaluated. MRC and MSCT findings were compared with endoscopic retrograde cholangiopancreatography (ERCP; 20 patients), percutaneous cholangiography (eight patients), intraoperative cholangiography (two patients), surgery (11 patients), and cytology (11 patients) with respect to cause and site of obstruction. Results With regard to presence and site of obstruction, agreement was observed across MRC, MSCT cholangiography, and reference investigations in all cases. Concerning cause, the correct diagnosis was made by MSCT cholangiography in 34 of 36 patients. Two cases of common bile duct lithiasis, diagnosed on MRC and ERCP, were missed by MSCT cholangiography. Conciusion MSCT cholangiography can be considered a possible noninvasive alternative to MRC.     

Revision of the common bile duct in a combined PTCD/ERC approach – A case report

Introduction and importanceThe endoscopic retrograde cholangiography (ERC) represents the standard treatment for choledocholithiasis. However, ERC in patients with previous gastrectomy and anastomosis is difficult due to altered access.Case presentationIn our case, we report on a patient with previous gastrectomy and Y-Roux-anastomosis suffering from choledocholithiasis. Operative revision with simultaneous cholecystectomy failed. In a combined procedure of percutaneous transhepatic cholangiodrainage (PTCD) and endoscopic cholangiography the stone removal of the common bile duct was finally successful.Clinical discussionThere are some approaches for treatment of choledocholithiasis in pre-operated patients. However, prospective multi-center studies for complication and success rates are not available due to the rarity of such cases.ConclusionInterdisciplinary procedures seem to be the safest and most promising way to succeed in the treatment of choledocholithiasis in challenging cases.     

The evaluation of infant stool color card combined with laparoscopy-assisted cholangiography in diagnosis of prolonged jaundice in infants

目的 探讨大便比色卡联合腹腔镜胆管造影在婴儿延迟性黄疸诊断中的价值.方法 72例延迟性黄疸患儿(男34例,女38例,平均日龄64 d),由父母连续7d以上进行大便颜色观察并与比色卡对照:大便颜色持续异常者,以及大便颜色波动在正常与异常之间经内科治疗无效的患儿直接行腹腔镜探查和胆管造影、肝脏组织病理检查;大便颜色持续正常者,以及大便颜色波动在正常与异常之间经内科治疗转为正常的患儿则行内科治疗.所有患儿均行B超、MRCP、ECT检查并随访6～12个月.结果 48例患儿大便颜色连续7d以上为异常,腹腔镜探查及胆管造影结果示:43例为胆道闭锁(BA),5例为非BA.14例患儿大便颜色持续至少7d正常,诊断为婴肝综合征(IHS),内科治疗并随访6～12个月全部治愈.10例患儿大便颜色波动在正常和异常之间,4例经内科治疗后大便颜色转为正常,排除BA行内科治疗,随访3例治愈,1例为漏诊BA;6例内科治疗后无变化,腹腔镜检查诊断1例为IHS,3例为BA,2例为胆道发育不良(CBDH).72例患儿中8例(11.1％)非BA接受了腹腔镜胆管造影,大便比色卡诊断BA的灵敏度、特异度和准确率分别为97.9％、73.9％和90.0％.结论 大便比色卡筛查延迟性黄疸患儿,有选择地行腹腔镜检查,显著降低了IHS患儿行腹腔镜检查比率,提高了BA的早期诊断准确性.     

经皮肝穿刺胆管造影诊断单发巨大肝内胆管囊肿1例

患者男,71岁。10天前发现右上腹肿物,自觉逐渐长大,伴恶心、腹痛。查体:皮肤、巩膜黄染,右肋下缘可触及约15cm×10cm质软肿物,压痛(+),界清,无活动。实验室检查:白细胞计数8.78×109/L,谷丙转氨酶218U/L,谷草转氨酶223U/L,总胆红素709.5μmol/L,直接胆红素491.6μmol/L,间接胆红素217.9μmol/L,碱性磷酸酶587U/L,γ谷氨酰转肽酶403U/L,总胆汁酸127.1μmol/L,尿素11.61mmol/L。     

Oriental cholangiohepatitis: Preoperative radiographic and ultrasonographic diagnosis

The recent influx of immigrants from Southeast Asia into the United States has increased the likelihood of encountering unusual diseases heretofore rarely seen in this country. Among these disorders is Oriental cholangiohepatitis, a potentially life-threatening process whose early diagnosis is facilitated by roentgenographic findings. Ultrasonography can also provide useful information, although potential pitfalls in diagnosis should be recognized.     

经T形管造影及胆道镜检查136例评价分析

目的：对胆道术后经T形管造影检查结果评价分析。方法收集2010年7月~2012年8月间行胆道术后T形管造影147例次结果,与同期行纤维胆道镜检查结果进行回顾性对比分析。结果全组136例患者行T形管造影摄片检查共147例次,报告阳性病例63例次（42.9%）,阴性病例84例次（57.1%）。与同期行胆道镜检查结果对比,本组X线检查假阳性2例（3.3%）,假阴性19例（22.6%）。结论胆道术后经T管造影检查有较高的误诊及漏诊率,不能成为拔除T管,终止临床治疗的可靠指征。其可作为在接受胆道镜检查治疗过程中的辅助检查方法,两者联合应用,可获得较理想的临床治疗效果。     

胆道闭锁的家系报道

一、患者资料 先征者女,2月龄,因“皮肤黄染2月”于2010年12月20日收住江苏省淮安市妇女儿童医院小儿外科.患儿出生后解正常胎便,短期解黄色大便后一直解白陶土样便.入院后查体:全身皮肤、巩膜中度黄染,心前区闻及Ⅲ级收缩期杂音,肝肋下2 cm,质地Ⅰ °.实验室检查:甲型肝炎、丙型肝炎、乙型肝炎均为阴性.肝功能检查结果显示:总胆红素(TBil)136.2 μ mol/L,直接胆红素(DBil) 88.8μmol/L,γ-谷氨酰基转移酶(GGT) 147U/L.彩色多普勒超声显示:房间隔缺损0.24 cm,动脉导管未闭,胆囊约1.2cm×0.2cm,胆总管未显示.腹部CT:胆囊显示欠佳.入院诊断:(1)黄疸原因待查,胆道闭锁?(2)先天性心脏病.     

Endoscopic retrograde cholangiopancreatography

Indications for endoscopic retrograde cholangiography (ERCP) have been poorly defined. We studied the symptoms in 161 patients who underwent ERCP and evaluated the results from four groups of indications: cholestasis, pancreatitis, suspected carcinoma of the pancreas, and pain of unknown etiology. The likelihood of finding abnormalities is discussed.     

Percutaneous transhepatic cholangiography and biliary drainage after liver transplantation: A five-year experience

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis.Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents.Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.