胆囊十二指肠瘘的诊断与治疗

目的：探讨胆囊十二指肠瘘的病因、诊断与治疗。方法：回顾性分析我院1996～2002年收治的43例经手术治疗的胆囊十二指肠瘘的临床资料。结果：胆石症是引起胆囊十二指肠瘘的主要原因，消化性溃疡、胆囊癌、外伤等为少见病因。本组术前诊断率为13．9％（6／43），其余均在术中或行其它手术时发现的。全部经手术治愈。术后出现十二指肠漏，切口感染1例，经保守治疗后治愈。结论：胆囊十二指肠瘘术前诊断较为困难，长期胆囊结石患者尤其发现胆囊萎缩，囊区内胆汁暗区消失或肝内胆管系统积气应高度怀疑。对胆道疾病的及时诊断与治疗是减少胆囊十二指肠瘘发生率和改善其预后的关键。     

39例老年胆石症的手术治疗体会

目的：探讨老年人胆石症的手术治疗时机、术式及并发症。方法：对39例老年人胆石症患者的手术治疗情况进行总结分析。其中20例行单纯胆囊切除术、15例行胆囊切除一胆总管切开取石“T”管引流术、2例行胆总管十二指肠吻合术，2例行胆囊造瘘术。结果：治愈33例（占84．6％），好转4例（占10．2％）。结论：对老年人胆石症行手术治疗要在明确诊断的基础上选择合理术式、掌握手术时机并积极治疗伴随疾病和并发症。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石56例临床观察

目的探讨腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石的临床疗效。方法选取胆囊结石合并胆总管结石的患者96例,分为两组,治疗组56例行内镜Oddi括约肌切开取石术及腹腔镜胆囊切除术,并联合内镜逆行胆胰管造影检查;对照组40例行开腹胆囊切除、胆总管探查取石。对比两组的术中出血量、手术时间、住院时间、胃肠功能恢复时间和术后疼痛等情况。结果治疗组的出血量、手术时间、住院时间、胃肠功能恢复时间和术后疼痛均优于对照组(P<0.05)。结论腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石具有手术创伤小、恢复快、术后疼痛轻等特点,值得临床推广应用。     

36例胆内瘘的诊断与治疗

目的 探讨胆内瘘的诊断及治疗方法。方法 对1990年1月至2006年6月收治的36例胆内瘘患者进行回顾性分析。结果 术前明确诊断7例,占19.4%;胆内瘘类型：胆囊十二指肠瘘19例,胆囊结肠瘘10例,胆囊胃瘘2例,胆囊肝总管瘘4例,胆总管十二指肠瘘1例;所有病人均行手术治疗,痊愈出院。结论 胆内瘘术前诊断困难,漏诊率高;胆内瘘手术原则为切除胆囊、修补瘘口、通畅引流。     

胆囊十二指肠瘘43例诊疗分析

目的探讨胆囊十二指肠瘘的诊断要点和治疗方法。方法回顾性分析郧西县人民医院1998-02-2010-04 43例胆囊十二指肠瘘患者的临床资料。结果术前确诊11例,术中确诊32例;所有患者均行手术治疗,术中损伤胆总管2例,术后出现十二指肠漏及胆漏各1例,经保守治疗后痊愈。结论结合B超、上消化道钡剂造影、胃镜及CT等检查,可提高术前确诊率;选择合适的手术方式及术后支持治疗可有效减少并发症的发生。     

胆囊十二指肠瘘临床分析

目的 在一般人群中,胆囊十二指肠瘘发生率低,术前诊断困难.胆囊十二指肠瘘在治疗方面有一定争议,该文就胆囊十二指肠瘘的诊断和治疗作一分析.方法 回顾性分析20例胆囊十二指肠瘘患者的临床资料,该组患者平均年龄55岁（25～72岁）.所有患者术前分别行B超、胃镜、PTC、ERCP和CT检查,均开腹手术.结果 17例既往有胆道疾病史,10例发现胆结石,3例为十二指肠球部溃疡.PTC或胃镜发现异常造影剂分流或胆汁流,术前通过PTC或胃镜分别诊断1例.18例行胆囊切除、胆总管切开和引流并关闭瘘口.所有患者均治愈.结论 B超示胆道积气时,患者术前应行胃镜、PTC、ERCP等检查.术中探查在诊断胆囊十二指肠瘘时起重要作用,可避免漏诊.选择合适的手术时机和正确的处理方法,有利于提高胆囊十二指肠瘘的治疗水平.     

胆内瘘6例诊治分析

目的探讨胆内瘘的临床诊治方法。方法回顾性分析我院2002年以来收治的6例胆内瘘病人的诊治情况。结果6例病人术前均诊为萎缩性结石性胆囊炎，术中发现为胆囊十二指肠瘘3例，胆囊结肠瘘3例，瘘口直径在1．0cm以内。行胆囊切除、瘘口修补。无手术死亡，均临床治愈出院。结论胆内瘘是胆石症的一种少见且复杂的并发症，诊治过程复杂，误诊率高，手术风险大，术后并发症多。瘘口直径在1．0cm以内行胆囊切除、瘘口修补是安全的。     

三镜联合治疗胆囊及胆总管结石并发症的护理

目的探讨三镜联合治疗胆囊及胆总管结石的术后并发症及护理措施。方法对25例胆囊合并胆总管结石的患者行三镜（十二指肠镜、胆道镜及腹腔镜）联合胆总管探查术，并对术后并发症资料作护理分析。结果本组25例病人中术后并发急性胰腺炎1例，内镜术后出血1例，肩背部酸痛2例，伤口疼痛4例。结论三镜联合胆总管探查术治疗胆囊合并胆总管结石是一安全有效的微创手术方法。     

Foley尿管治疗十二指肠瘘的护理2例

肠外瘘是腹部外科较为多见的严重并发症 ,尤其是高流量的十二指肠瘘 ,并发症和病死率高。为了加速瘘口的愈合 ,缩短治疗时间 ,我科应用Foley尿管堵塞瘘口治疗十二指肠瘘 2例 ,效果理想 ,现将护理体会报告如下。1　临床资料1.1　一般资料。例 1:患者 ,男 ,70岁。因“胆囊、胆总管结石”行“胆囊切除、胆总管取石、胆总管十二指肠吻合术”。术后第 5天出现肠瘘 ,有 2 0 0 0ml/d的黄绿色液体自腹腔引流管引出。经T管、腹腔引流管造影确诊为“胆管—十二指肠吻合口瘘”。术后第4 5天 ,经腹腔引流管造影证实瘘道已完全形成 ,在X线下拔除腹腔引…     

胆内瘘31例诊治分析

目的：总结胆内瘘的临床特征和诊治经验。方法：回顾分析31例自发性胆内瘘患者的临床资料。结果：术前经B超、CT、消化道造影、磁共振胰胆管造影（magnetic resnancect cholangiopancreatography,MRCP）等检查确诊胆内瘘8例,术前疑诊胆内瘘7例。术中证实胆囊十二指肠瘘23例,胆囊结肠瘘4例,胆囊胆总管瘘4例。除2例胆囊癌晚期外均切除胆囊后,行十二指肠瘘修补术18例,胆总管切开T管外引流＋胃空肠吻合术2例,结肠瘘修补术3例,横结肠癌根治术1例,胆总管修补＋T管引流术4例,另有3例行回肠切开取石。结论：胆内瘘患者常无特殊临床症状,结合B超、CT、消化道造影、MRCP等检查有助于术前诊断胆内瘘,治疗原则仍是切除病变胆囊和瘘管、修补瘘口、解除消化道梗阻。     

Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report

BACKGROUNDCholecystoduodenal fistula is a rare complication of cholelithiasis. Symptoms are usually non-specific and often indistinguishable from those of etiologic diseases, but it rarely presents as severe gastrointestinal bleeding. Bleeding associated with cholecystoduodenal fistula usually requires surgery because significant bleeding from the cystic artery is unlikely to be resolved by conservative management or endoscopic hemostasis.CASE SUMMARYWe report a case of cholecystoduodenal fistula that presented with hematemesis which was diagnosed by endoscopy and computed tomography. Endoscopic hemostasis could not be achieved, but surgical treatment was successful. Additionally, we have presented a literature review.CONCLUSIONCholecystoduodenal fistula should be considered as differential diagnosis when a patient with history of gallstone disease presents with gastrointestinal bleeding.     

螺旋CT低张增强在胆囊十二指肠瘘诊断中的价值

目的：探讨螺旋CT低张增强扫描对胆囊十二指肠瘘的诊断价值，以便为临床治疗提供更为准确的依据。方法：对9例CT平扫高度怀疑胆囊十二指肠瘘的病人，进行螺旋CT低张增强扫描，然后利用软件进行后处理，得出诊断，并与手术结果进行比较。结果：9例病人中，螺旋CT能直接发现瘘口者6例，未发现瘘口者3例中，2例发现结石掉入肠道；1例高度怀疑胆囊十二指肠瘘，经手术确诊。结论：螺旋CT能较好的发现胆囊十二指肠瘘，低张增强扫描能很好地显示瘘口。     

自发性胆囊内瘘43例分析

目的：总结自发性胆囊内瘘的诊治经验。方法：对43例胆囊内瘘的病例进行回顾性病例分析。结果：43例中胆囊十二指肠瘘28例，胆囊结肠瘘8例，胆囊胆总管、肝总管瘘9例，胆囊胃瘘3例，其中同时有两处瘘7例。术前B超检查41例，9例提示胆囊积气；1例提示胆囊壁腹腔面消失，右下腹探得结石影。7例术前行腹部平片检查，4例提示小肠梗阻；6例见结石影；2例显示胆道积气。8例行CT检查，其中2例显示胆囊、胆管气体。3例行ERCP，其中1例见十二指肠有异常造影剂溢出。术前仅9例考虑到胆囊内瘘的诊断，其余均在术中发现。43例均行胆囊切除或部分切除，37例胆囊胃肠瘘行瘘口修补，其中5例因瘘口过大利用部分胆囊壁来修补；4例胆囊胆管瘘在取尽结石后，经瘘口置T管引流，瘘口较大者亦利用胆囊壁修补。术后1例因感染性休克死亡；1例有少量胆漏，经引流治愈，其余均恢复良好。结论：萎缩性胆囊炎、胆囊结石应警惕合并胆囊内瘘。出现以下情况提示胆囊内瘘：(1)B超、CT、腹部平片发现胆道积气。(2)CT、腹部平片提示肠梗阻。有下列情况可确诊胆囊内瘘：(1)B超发现胆囊腹腔面消失。(2)B超、CT、腹部平片提示原有明确的胆囊结石消失或在异位出现。(3)ERCP、PTC等发现非胆管开口有胆汁或造影剂溢出。(4)口服造影剂或钡剂灌肠见造影剂进入胆囊。治疗应修补瘘口，瘘口过大可利用部分胆囊壁来修补。     

Unusual cause of gastric outlet obstruction: CT findings in Bouveret's syndrome

We have described an 81-year-old woman with symptoms of gastric outlet obstruction in whom upper gastrointestinal endoscopy showed an extrinsic mass compressing the superior aspect of the postbulbar duodenum. This was confirmed by an upper gastrointestinal series, and CT revealed migration of a known, previously asymptomatic gallstone through the duodenal wall, forming a cholecystoduodenal fistula.     

黄色肉芽肿性胆囊炎的临床诊断及治疗

目的探讨黄色肉芽肿性胆囊炎（XGC）的诊断与治疗。方法回顾性分析近五年来我科收治的9例XGC病人的临床资料。结果术前B超检查9例，CT检查4例，MRI检查3例，行ERCP检查1例，术前均误诊，术中冰冻病理确诊7例，术后石蜡病理确诊9例。5例行胆囊切除术，1例行胆囊切除加胆总管探查T管引流术，1例行胆囊大部切除加十二指肠瘘修补术，2例行胆囊切除加胆囊床部肝组织切除。术后并发胆瘘1例，切口感染1例。本组无死亡病例。结论XGC是一种少见特殊类型的胆囊慢性炎性疾病，术前难与胆囊癌相鉴别，目前认为XGC与胆囊癌可能有关。因此，XGC一经诊断应积极手术治疗，术中冰冻切片检查、术后病理检查是关键，XGC仅需行胆囊切除，不宜盲目扩大切除的范围。     

Duodenal obstruction by gallstones (Bouveret's syndrome): a review of the literature

Bouveret's syndrome, first described in 1896, is gastric obstruction by a gallstone following a cholecystoduodenal fistula. Endoscopy is the mainstay of diagnosis, but radiographic examination such as upper gastrointestinal contrast series and abdominal radiography can also contribute to the diagnosis. Diagnosis by computed tomography and ultrasonography has also been described. The syndrome can be diagnosed and treated endoscopically, with stone extraction or mechanical lithotripsy. Extracorporeal shockwave lithotripsy has also been used successfully. Surgery is required in over 90% of cases, with mortality rates ranging from 19% to 24%. One-stage and two-stage procedures have been described, including enterolithotomy, cholecystectomy, and fistula repair, no convincing data are available to show which of these two approaches provides a better outcome. Although the condition is rare, Bouveret's syndrome should be considered in elderly patients with a history of chronic cholecystitis who present with pain, vomiting or haematemesis.     

Spontaneous biliary enteric fistulas

Biliary enteric fistulas usually occur as a complication of chronic cholelithiasis, may be difficult to document preoperatively, and often pose problems in surgical management. We reviewed 13 cases of spontaneous biliary enteric fistulas to identify methods of diagnosis, management, and complications. There was no specific set of clinical symptoms or signs that led to the diagnosis of a fistula. In six cases the diagnosis was made preoperatively by x-ray films showing pneumobilia, gallstone in the small bowel, or fistula. Initial surgical treatment included cholecystectomy in six cases, small bowel enterotomy and removal of gallstones in four, and vagotomy and antrectomy in one case. Two patients initially treated without operation were lost to follow-up. Eight complications occurred in six patients, and there were three deaths due to underlying cardiac disease. The morbidity and mortality of biliary enteric fistulas associated with chronic cholecystitis may be avoided by performing elective cholecystectomy when the patient is in optimal condition.     

口服胃肠道造影剂超声造影诊断胆囊十二指肠瘘

目的 探讨超声检查对胆囊十二指肠瘘的诊断价值.方法 23例结石性胆囊炎患者术前常规超声检查怀疑并发胆囊十二指肠瘘,在常规超声检查的基础上进一步接受超声造影检查.口服胃肠道造影剂动态观察有无胆囊十二指肠瘘,并与手术结果对照.超声造影诊断胆囊十二指肠瘘的标准是动态观察可见造影剂经瘘口进入胆囊.结果 23例患者中,口服胃肠道超声造影剂动态观察可见18例患者十二指肠内造影剂经瘘口进入胆囊,手术证实均有胆囊十二指肠瘘;未见造影剂进入胆囊者5例,手术证实有胆囊十二指肠瘘的2例、无胆囊十二指肠瘘的3例.结论 在常规超声检查的基础上,口服胃肠道超声造影剂动态观察的方法简易可行、无创、准确性较高,是诊断胆囊十二指肠瘘的有效方法.