经皮穿肝胆管支架置入术治疗恶性梗阻黄疸发生早期胆道感染的风险及对策

目的  研究恶性梗阻黄疸患者接受经皮穿肝胆管支架置入后发生早期胆道感染的危险因素,探讨可行治疗方案。方法  观察128例恶性梗阻黄疸患者行支架置入术后1个月内发生胆道感染情况。应用单因素及多因素分析法针对相关危险因素进行统计学分析。结果  128例患者引流成功率71.1%（91/128）,早期胆道感染发生率30.4%（39/128）。年龄、致胆管狭窄类型、梗阻部位、黄疸持续时间、支架位置及术后胆红素下降比为差异具有统计学意义的危险因素,后3者为独立危险因素。支架跨过十二指肠大乳头患者引流成功率高82.5%（47/57）,早期胆道感染发生率19.2%（11/57）低于未跨过组38.0%（28/71）,差异有统计学意义（χ2=6.053,P =0.014）。结论  经皮穿肝胆管支架置入术针对恶性梗阻黄疸患者减黄效果稳定、操作安全。支架跨过十二指肠大乳头能够迅速减黄从而降低早期胆道感染发生率。

     

经皮经肝胆道引流术治疗梗阻性黄疸

目的：探讨经皮经肝胆道引流术（PTCD）治疗梗阻性黄疸的临床意义。方法：在B超或X线引导下,对22例梗阻性黄疸患者采用PTCD治疗。结果：22例中,21例成功,成功率为95%。死亡2例,死亡率为9%。单纯胆道造影（PTC）1例,放置引流管引流17例,置入金属胆道支架9例。治疗后黄疸和皮肤瘙痒减轻,总胆红素明显下降,肝功能改善,效果满意。结论：此方法创伤小,并发症少,操作简单,引流可靠有效,是梗阻性黄疸较好的引流方法,值得推广。     

PTCD在恶性梗阻性黄疸治疗中的临床应用

目的探讨经皮经肝穿刺胆道造影及引流术(PTCD)在恶性梗阻性黄疸治疗中的临床应用价值。方法对22例(男15例,女7例)行PTCD治疗的恶性梗阻性黄疸患者的临床资料进行回顾性分析,其中胆管癌9例、胆囊癌4例、肝癌及肝转移癌6例、胰头癌3例。结果21例患者成功实施PTCD,其中3例行胆道内支架置入,1例患者PTCD未成功。全组技术成功率95.5%,术后患者黄疸、皮肤瘙痒等临床症状明显缓解,并发症有胆道少量出血、发热、肝区疼痛,经对症治疗后症状消失,未见严重的并发症发生。结论PTCD姑息治疗恶性梗阻性黄疸是一种安全、有效的介入治疗方法。     

The Endoscopic Retrograde Cholangiopancreatographic Manifestations of Histopathologically Diagnosed Hepatocellular Carcinoma with Obstructive Jaundice

To study the manifestation of endoscopic retrograde cholangiopancreatography(ERCP) in patients of obstructive jaundice associated with HCC ,32 cases of histopathologically diagnosed HCC with obstructive jaundice were successfully examined with routine ERCP.31 patients were demonstrated by ERCP as having malignant obstructive jaundice.Among them,19 were hepatic perihilar bile duct stricture,7 bile ductile tumorous thrombus,3 perihilar bile duct stricture complicated with thrombus,2 metastasis to hilar lymph node,and 1 common bile duct stone as proven by sphincterotomy.The maliganant perihilar stricture was all of type Ⅲ and IV by Bismuth standard of Klastin tumor.In patients identified as having bile duct tumor thrombus,by the Ueda classification,none was of type I and Ⅱ;1 type Ⅲa;4Ⅲa;2 type Ⅳ.HCC with obstructive jaundice was mainly caused by the malignant infiltration of tumor,and most stricture was of serious nature.When major extra-hepatic bile duct was involved by tumor thrombus,obstructive jaundice might develop.Malignant perihilar stricture and tumor thrombus might coexist in some patients.Jaundice was rarely caused by hepatic hilar lymph node metastasis.Jandice was not necessarily caused by tumors and sometimes,it might be caused by common bile stones.Care should be exercised in differentiation diagnosis in such patients.     

实时超声弹性成像技术诊疗梗阻性黄疸的应用价值研究

  摘要 目的  探讨实时超声弹性成像技术在诊断梗阻性黄疸及减黄治疗效果评价中的价值。方法  选取2015年1月-2016年6月在浙江省绍兴市人民医院轻度梗阻性黄疸患者40例作为轻度黄疸组，中度梗阻性黄疸患者40例作为中度黄疸组，重度梗阻性黄疸患者40例作为重度黄疸组，同期住院的无黄疸患者40例作为对照组。所有患者进行实时超声弹性成像检查。结果  梗阻性黄疸患者的实时超声弹性成像中颜色分布出现不均匀性，蓝色分布随黄疸程度的加重而增多，绿色分布随着黄疸程度的加重而相对减少；黄疸组总胆红素水平、蓝色领域百分比高于对照组（P <0.05），黄疸组应变均值低于对照组（P <0.05）；重度黄疸组总胆红素水平和蓝色领域百分比高于中度黄疸组和轻度黄疸组（P <0.05），中度黄疸组总胆红素水平和蓝色领域百分比高于轻度黄疸组（P <0.05），重度黄疸组应变均值低于中度黄疸组和轻度黄疸组（P <0.05），中度黄疸组应变均值低于轻度黄疸组（P <0.05）；梗阻性黄疸患者实时超声弹性成像的蓝色领域百分比与总胆红素水平呈正相关（P <0.05），应变均值与总胆红素水平呈负相关（P <0.05）；减黄治疗后总胆红素水平、蓝色领域百分比均低于治疗前（P <0.05），减黄治疗后应变均值高于治疗前（P <0.05）。结论  实时超声弹性成像技术在梗阻性黄疸的诊断、严重程度评估及减黄治疗效果评价中具有一定价值。

     

胆管支架放置术治疗恶性梗阻性黄疸5例

目的探讨胆管支架放置术治疗恶性胆管梗阻性黄疸的疗效和安全性，探讨其更有效的治疗方法。方法对5例恶性胆管梗阻性黄疸患者行胆管支架放置术治疗。结果所有病人在治疗过程中均安全，胆管支架放置术疗效显著，黄疸均有明显下降，平均支架维持通畅时间为9mo，6mo和1a生存率达100％-60％。结论胆管支架放置术对恶性胆管梗阻性黄疸有较好的疗效，绝大多数患者均能耐受，是治疗恶性胆管梗阻性黄疸的一种有效方法。     

Cardioversion of atrial fibrillation does not affect obstructive sleep apnea

Background: Sleep apnea is common in patients with atrial fibrillation, but the effect of the cardioversion of atrial fibrillation to sinus rhythm on central and obstructive apneas is mainly unknown. The primary aim of the study was to analyze the association between cardioversion of atrial fibrillation and sleep apneas, to investigate whether obstructive or central sleep apneas are reduced following cardioversion. A secondary objective was to study the effect on sleep quality.

Methods: Twenty-three patients with atrial fibrillation were investigated using overnight polysomnography, including esophagus pressure monitoring and ECG, before and after the cardioversion of persistent atrial fibrillation.

Results: Obstructive sleep apnea occurred in 17/23 patients (74%), and central sleep apnea in 6/23 patients (26%). Five patients had both obstructive and central sleep apnea. Sinus rhythm at follow-up was achieved in 16 patients. The obstructive apnea-hypopnea index, central apnea-hypopnea index, and the number of patients with obstructive or central sleep apnea did not differ before and after restoration of sinus rhythm. Sleep time, sleep efficiency, time in different sleep stages, and subjective daytime sleepiness were normal and unaffected by cardioversion.

Conclusions: Both obstructive and central sleep apneas are highly prevalent in patients with persistent atrial fibrillation. Obstructive sleep apneas are unaffected by the cardioversion of atrial fibrillation to sinus rhythm. The sleep pattern is normal and unaffected by cardioversion in patients with atrial fibrillation.

Clinical Trial Registration: Trial number NCT00429884.     

Idiopathic Neonatal Hepatitis: Discordance in Monozygotic Twins

Idiopathic neonatal hepatitis is the uncommon syndrome of prolonged obstructive jaundice associated with giant cell transformation in the liver and patent bile ducts. Either hepatitis virus or an inherited abnormality has been suggested as a likely pathogenic agent for the syndrome.

Recent observation of discordance for idiopathic neonatal hepatitis in monozygotic twins is felt to be inconsistent with either an infectious or a simple genetic etiology. Immaturity of the hepatic parenchymal cell bilirubin excretory pathway is postulated as a cause of jaundice in some of these babies.

     

The changes of protein kinase C activity in peripheral blood lymphocytes in the patients with obstructive jaundice and the implication

It hasbeen suggested thatlymphocytescould in-fluence the cell immune function in the patients withobstructive jaundice and mightplay an importantrolein the initiation and developmentof the inflammatoryprocess.But the mechanism of transfer of intracellu-lar signal pathway for lymphocytic function changesin the developmentof obstructive jaundice hasnotyetbeen clearly determined. Protein kinase C (PKC) isaubiquitous phosphorylating enzyme that is capable ofmembrane translocation and plays an imp…     

磁共振胰胆管成像对梗阻性黄疸的诊断价值

目的：研究磁共振胰胆管成像（MRCP）在梗阻性黄疸诊断中的应用价值。方法：对87例梗阻性黄疸病人采用常规磁共振芨MRCP方法检查的结果进行分析比较。结果：87例病人全部成功地进行了MRCP检查。其中胰胆管肿瘤28例中26例阳性，胆管结石58例中54例阳性，1例为慢性胰腺炎。结论：MRCP是一种简单，安全，无创的影像学技术，在对梗阻性黄疸的诊断中具有较高价值，其图像质量及诊断价值均不低于逆行胰胆管造影。     

肝损伤患者血清肝活素水平测定的临床意义

目的 探究肝活素(HPS)在阻塞性黄疸所致肝损伤的诊断以及慢性肝病肝功能评估中的作用.方法 ELISA法检测60例阻塞性黄疸患者、68例慢性肝病患者及30例健康体检者血清HPS水平.分析肝损伤患者与正常人血清HPS水平有无差异;对阻塞性黄疸患者血清HPS和丙氨酸氨基转移酶(ALT)进行相关性分析;绘制受试者工作特征曲线,观察HPS对阻塞性黄疸所致肝损伤的诊断价值;分析慢性肝病患者HPS与Child-Pugh分级(CPC)以及肝衰竭之间的关系.结果 阻塞性黄疸和慢性肝病患者血清HPS水平均显著高于对照组(P<0.01).阻塞性黄疸患者血清中HPS与ALT呈正相关性(rs=0.914,P<0.01);HPS在阻塞性黄疸肝损伤诊断中的曲线下面积达到0.938,最佳节点是141.87 μg/L;慢性肝病中非衰竭者Child A、Child B、Child C与慢加急性肝衰竭、慢性肝衰竭5组之间两两比较,非肝衰竭组中,随着CPC升高,HPS水平也逐渐升高(P<0.05),两组肝衰竭血清HPS水平均高于非衰竭各组(P<0.05),两组肝衰竭之间HPS水平差异无统计学意义.结论 血清HPS水平测定能够对阻塞性黄疸患者有无肝损伤作出诊断,也能够辅助CPC评估慢性肝病患者肝功能.     

Experience with endoscopic biliary drainage in Singapore

In several overseas centres endoscopic biliary drainage is now a standard procedure in the initial or definitive management of biliary tract obstruction. We report the first nine patients in whom this procedure was carried out in our unit. Four patients presented with acute cholangitis due to cholelithiasis. Urgent endoscopic biliary drainage improved the general condition in three patients prior to subsequent elective surgery. In one other patient with huge common bile duct calculi a biliary stent prevented recurrent episodes of cholangitis. Endoscopic endoprostheses were used in three patients with malignant biliary tract obstruction. Two had terminal metastatic disease and endoscopic drainage provided adequate palliation of jaundice and pruritus in one. Endoprosthesis blockage necessitated percutaneous drainage in the other patient. The third patient with carcinoma of the head of the pancreas was improved by endoscopic drainage prior to an open surgical bypass procedure. Another patient with obstructive jaundice due to terminal gall bladder carcinoma experienced relief of jaundice and pruritus following endoscopic insertion of a nasobiliary drain. We anticipate that endoscopic biliary drainage will become increasingly used in Singapore.     

68例阻塞性黄疸的B超诊断与手术结果分析

目的 :探讨 B超对阻塞性黄疸的诊断价值。方法 :总结回顾 6 8例阻塞性黄疸的病人 ,结合临床手术结果对照。结果 :胆总管疾病引起的阻塞性黄疸占 4 7.0 % ,诊断正确率为 93.75 % ;胰腺疾病占 2 3.5 % ,诊断正确率为 91.6 % ;十二指肠疾病占 13.2 % ,诊断正确率为 77.7% ;肝门占位 7.3% ,诊断正确率为 10 0 %。结论 :B超对阻塞性黄疸的病因诊断及部位定位是很好的影像方法 ,结合临床可以提高诊断准确性。     

介入治疗在恶性梗阻性黄疸中的临床应用

目的探讨经皮肝穿刺胆道引流术(PTCD)在恶性梗阻性黄疸治疗中的治疗效果;比较各种引流方法及有无后续治疗,生存期有无差别。方法对60例行PTCD治疗的恶性梗阻性黄疸患者的临床资料进行回顾性分析,其中胆管癌20例,胆囊癌8例,肝癌8例,肝转移癌7例,胰头癌17例。结果 60例患者成功实施PTCD。术后患者黄疸、皮肤瘙痒等临床症状明显缓解,血清胆红素和转氨酶较术前显著下降。胆道支架组平均生存时间较单纯胆道外引流组平均生存时间延长。行后续治疗组[行动脉插管化疗灌注(TACE)或栓塞术(TAI)]平均生存时间明显延长。结论 PTCD姑息治疗恶性梗阻性黄疸是一种安全、有效的介入治疗方法。     

The Diagnostic Value of Serum Leucine Aminopeptidase

Experience with serum leucine aminopeptidase determination in 61 patients led to the following conclusions. The test is no more sensitive than the alkaline phosphatase test in cases of carcinoma of the pancreas. It is elevated in all cases of obstructive and hepatogenous jaundice and serves no useful function in their differentiation. It was a valuable test in cases of calculous biliary tract disease, being more sensitive than either bilirubin or alkaline phosphatase determinations. In three instances of elevated leucine aminopeptidase in disorders apparently not related to the liver or pancreas, laparotomy and autopsy showed involvement of these organs in two.     

THERAPEUTIC BILIARY ENDOSCOPY: EXPERIENCE AT A SERVICE HOSPITAL

Therapeutic Biliary Endoscopy (TBE) is becoming a popular mode of treatment for patients with obstructive jaundice. This paper highlights our early experience of TBE at Armed Forces Medical College and Command Hospital (SC), Pune with this mode of treatment. TBE was used as a primary therapeutic option in 46 patients with obstructive jaundice. The age of the patients ranged from 11 to 80 (mean and SD:45.5 ± 16) years and majority 29 (63%) were males. The cause of obstructive jaundice in these patients was choledocholithiasis (n=31), benign biliary stricture (n=8), post cholecystectomy recurrent stones (n=3), carcinoma of pancreas (n=3) and papillary stenosis (n-1). Endoscopic Sphincterotomy (ES) was technically successful in all the 46 patients and brought prompt symptomatic relief in 43 patients. Sixteen patients (34.8%) required additional drainage such as stenting or nasobiliary drain. In patients with choledocholithiasis, bile duct could be cleared of stones in 29 (93.5%) patients and in two surgical removal was required. Of the remaining patients, surgery was required in 4 (50%) patients with benign biliary structure, in 1 (33.3%) of those with malignant stricture and none of the patients presenting with papillary stenosis or recurrent bile duct stones after cholecystectomy. Complications were seen in only two patients (4.4%): one had mild acute pancreatitis and another had GI bleed, which did not require blood transfusion. Both the complications were self-limiting. No procedure related deaths were noted. Endoscopic therapy, thus, a simple, effective and safe method of treatment in patients with choledocholithiasis and selected patients with malignant biliary obstruction.KEY WORDS: Biliary obstruction, Endoscopic sphincterotomy, Endotherapy, Gall stones, Obstructive jaundice, Therapeutic endoscopy     

恶性阻塞性黄疸术前减黄手术的必要性

本文通过对51例乏特氏壶腹周围癌致恶性阻塞性黄疸病例的分析,探讨了术前减黄的必要性和减黄方法的合理选择。结果表明:术前减黄可以降低手术死亡率(术前减黄组手术死亡率9％,未减黄组手术死亡率17.3％)。作为术前减黄方法胆囊造瘘、空肠造瘘体外架桥连管内引流术,简便、有效、易行。     

经皮肝穿刺胆管引流术联合胆道支架植入治疗34例恶性梗阻性黄疸护理体会

目的 考察经皮肝穿刺胆管引流术(PTCD)联合胆道金属支架植入术治疗恶性梗阻性黄疸患者的护理疗效,归纳并探究治疗前后并发症的护理体会。 方法 回顾性分析肝胆外科2008年4月—2014年3月行PTCD联合胆道支架植入术的34例恶性梗阻性黄疸患者的护理。 结果 34例经皮肝穿刺胆管引流术(PTCD)联合胆道金属支架植入术全部成功,黄疸5 d内退净6例,黄疸2周内退净18例,2周内黄疸明显减轻7例。皮肤、巩膜黄染及皮肤瘙痒症状3～7 d消失,大小便颜色2～5 d恢复正常;血尿淀粉酶明显升高5例,经4～7 d应用生长抑素后治愈;局限性胆汁性腹膜炎4例,重新放置PTCD引流管后症状消失;引流管脱出2例,经及时处理后好转出院;夹管带管出院1例。所有患者均未出现穿孔、腹膜炎等其他严重并发症。 结论 PTCD结合胆道金属支架置入治疗恶性梗阻性黄疸患者效果良好、创伤小;合理、有效、优质的围手术期护理可促进手术成功及为良好预后提供重要保证。系统的个性化的护理方案以及切实有效的措施可为支架植入患者的恢复提供重要保障。同时,在临床护理过程中仍然需要不断探索及总结经验,使患者能更好地配合治疗并增加战胜疾病的信心,积极的心理状态可以促进患者康复。      

肝性糖尿病临床特点浅析

目的 探讨肝硬化并发肝性糖尿病患者的临床特点、治疗及预后。方法 回顾性研究42例肝硬化患者，详细记录病史并随访，实验室检查评价肝功能、血糖和糖尿病并发症。比较肝功能损害程度与血糖的关系。结果 肝硬化患者中有32％有糖尿病表现，12％有糖耐量异常，56％糖耐量正常，大部分无临床症状。肝性糖尿病患者中1例（9％）有糖尿病家族史，1例并发糖尿病视网膜病变。肝功能C级患者的血糖比B级明显升高，其中白蛋白水平差异更显著（P〈0.05）。在诊断肝硬化5年内，23％肝性糖尿病患者因肝硬化并发症而死亡。结论 肝性糖尿病临床表现不典型，其降糖治疗应根据患者具体情况而定，发生心血管和视网膜病变的危险性较低，预后受肝病并发症影响更大。     

The Diagnosis and Management of Jaundice

Although the problems of at least 80% of patients presenting with jaundice lend themselves to accurate diagnosis by conventional clinical and laboratory findings, the remainder present an ever-increasing problem. The widespread and often indiscriminate use of many drugs has made the diagnosis of jaundice more difficult. It is now well established that many of these substances may effect liver function in a very selective fashion, resulting in a pattern of laboratory findings similar to those usually associated with surgical lesions of the biliary tree.

By reviewing the newer concepts of bilirubin metabolism, the physician is in a better position to avoid these pitfalls. Since 1953, when the role of the liver in conjugation of bilirubin with glucuronic acid was defined, considerable revision in our previous concepts of bilirubin metabolism has taken place. The enzymatic activity of glucuronyl transferase and the conditions which arise in the presence of a deficiency of this enzyme have now defined a whole series of previously poorly understood jaundiced states.

The problem presented by the jaundiced newborn is discussed at some length. Similarly, jaundice of long standing in the elderly debilitated adult is also discussed. The author feels that laparotomy with liver biopsy and/or cholangiography are of definite value in the management of these problems.