Association ofStomatococcus mucilaginosus with cholangitis

The first case of cholangitis in whichStomatococcus mucilaginosus was cultured from bile is reported. A 64-year-old male became icteric and was shown to have gallstones in the gallbladder and a common bile duct stone which was removed endoscopically. As the patient remained icteric for a month thereafter the gallbladder with stones was removed. No common bile duct stone was shown by cholangiography perioperatively. The liver biopsy revealed cholangitis andStomatococcus mucilaginosus was grown from the bile. The patient was cured by cholecystectomy without any antimicrobial therapy.     

A quadriplegic patient's cholescintigraphic findings: delayed gallbladder visualization and common bile duct dilation.

A Tc-99m DISIDA cholescintigraphic study of a 37-year-old patient with a 20-year history of quadriplegia demonstrated dilation of the common bile duct and delayed gallbladder visualization. A concurrent sonographic study showed an enlarged gallbladder with stones and dilation of the common bile duct. These findings were proved by autopsy. Quadriplegia secondary to a high level of spinal cord injury may result in gallbladder dysfunction.     

急性胆源性胰腺炎的个体化治疗分析

目的 探讨急性胆源性胰腺炎（ABP）临床个体化治疗方法及效果。方法 回顾性分析34 例ABP患者的临床资料。其中原发病为胆囊结石18例,胆总管结石7例,胆囊结石合并胆总管结石 5 例,未见胆囊及胆管结石但有胆总管扩张表现 4例;轻型急性胰腺炎11 例,重症急性胰腺炎23例。34例均在采用保守治疗的同时实施早期微创治疗,其中经皮肝穿刺胆管引流术（PTCD）15例;胆囊穿刺引流术10例;经内镜逆行胰胆管造影术（ERCP）4例;经皮穿刺胰周引流术＋胆囊穿刺1例,经皮穿刺胰周引流术＋PTCD 4例,其中3例（8.82%）经上述治疗后无缓解施行急诊手术（胆囊切除＋胆总管切开取石＋T管引流术＋胰腺坏死组织清除术＋胰周引流术1例,以及加腹腔减压术2例）。结果 3例急诊手术患者中,2例治愈出院后无ABP再次发作,1例死亡;26例（76.47%）择期手术（胆囊切除术22例、胆囊切除＋胆总管切开＋T管引流术 4例）,随访期间,无ABP再次发作;4例（ 11.76%）患者暂未行手术治疗,随访期间4例中均无ABP再次发作;1例患者微创介入治疗（PTCD）后,住院期间死亡未行手术治疗。全组并发心功能损害15 例（44.12%）,肾功能损害 11 例（32.35%）,肝损害 12例（35.29%）,急性肺部感染9例（26.47%）。治愈32例（94.12%）,死亡2例（5.88%）。结论 对于ABP的治疗应按不同病因和病期采取个体化治疗方案,早期ERCP、超声引导下经皮经肝胆管或胆囊穿刺引流或胰周引流能显著提高疗效。     

The relationship between serum lipids,nucleation time,and biliary lipids in patients with gallstones

Summary The relationship between biliary lipids, cholesterol saturation index, nucleation time, and serum lipids was studied in a group of 45 gallstone patients (10 male, 35 female; age 50.1 ±14.5 years). Bile was obtained by direct fine-needle puncture of the gallbladder under local anesthesia and sonographic monitoring. No significant correlation between the serum lipids and either the cholesterol saturation index or total biliary cholesterol levels was observed. We found a positive correlation between the nucleation time and serum triglycerides content (r = 0.45, p = 0.0018) and a negative correlation between nucleation time and biliary cholesterol level (r = –0.38, p = 0.009). The fatty acids derived from the triglycerides are primarily resynthesized to phospholipids in the liver. When the supply of free fatty acids exhausts the metabolic capacity of the liver as, for example, in fat-rich diets, triglycerides accumulate in the liver cells and may possibly be excreted in the bile. Free fatty acids stimulate mucin hypersecretion in the gallbladder. This mucosal hypersecretion has been assigned a significant role in the formation of gallbladder stones. We also found a positive correlation between the total biliary bile acids and serum high density lipoprotein (HDL)-cholesterol in patients with a rapid nucleation time (r = 0.50, p = 0.0128). This supports the findings of other researchers, which suggests that HDL-cholesterol is devoted primarily to bile acid synthesis. In patients with a short nucleation time, the cholesterol saturation index, total lipid concentration, biliary cholesterol, mean age, and biliary bile acids were statistically different in comparison with patients with a prolonged nucleation time.Abbreviations CSI cholesterol saturation index - CT computer tomography - HU Hounsfield units - NT nucleation time - TLC total lipid concentration - LDL/HDL low/high density lipoproteins - VLDL very low density lipoproteins     

Chronology of cholelithiasis. Dating gallstones from atmospheric radiocarbon produced by nuclear bomb explosions

We investigated the natural history of cholelithiasis in 59 samples of stones from the gallbladder or common bile duct in 15 patients, using as a tracer for the timing of stone formation the 14C released into the environment during nuclear weapons testing. The ages of the stones were correlated with the dates of onset of symptoms and with other clinical data. None of 11 symptomatic patients had symptoms or complications until at least two years (mean +/- SD, 8.0 +/- 5.1 years) after stone formation began. There was a lag time of 11.7 +/- 4.6 years between initial stone formation and cholecystectomy. The growth rates of stones from 11 symptomatic patients and 4 asymptomatic patients were similar (2.6 +/- 1.4 and 2.6 +/- 1.1 mm per year). Studies of two stones retrieved from the common bile duct showed that one had the same age as a cholecystic stone; the other, removed two years after cholecystectomy, apparently grew in the common bile duct. The long latency period between the formation of gallstones and the onset of symptoms indicates that interruption of the natural progression of gallstone disease is potentially possible with medical therapy.     

肝外胆道动力学因素在胆囊结石形成中的作用

目的：探讨肝外胆道动力学因素在胆囊结石形成中的作用。方法：选用家兔４７只随机分为４组。对照组（ｎ＝１３），成石组（ｎ＝１４），消炎痛组（ｎ＝１０），红霉素组（ｎ＝１０）。饲养４周后检测成石情况、胆总管压力等指标。结果：成石组１２／１４只形成结石，消炎痛组４／１０只形成结石，红霉素组无一只形成结石。成石组胆汁中胆固醇和粘蛋白含量显著增高，胆囊管阻力和胆总管压力显著增高，胆囊排空率显著降低。消炎痛组较成石组胆汁中粘蛋白浓度降低，胆囊管阻力下降，胆总管压力下降，胆囊排空率无显著改善。红霉素组较成石组胆汁粘蛋白含量下降，胆囊管阻力下降，胆囊排空率增加而胆总管压力无显著变化。结论：除胆汁成分异常外，肝外胆道动力学因素参与了胆囊结石形成，改变肝外胆道动力学因素以促进胆囊排空，能有效地防止胆囊结石形成     

175例胆系恶性肿瘤的外科处理

总结了本院1976年～1995年间收治的129例胆管癌和46例胆囊癌.胆囊癌与同期良性胆囊疾病(2597例)的比例为1:56.46,后10年比前10年增加1.83倍.27例(59%)并胆囊结石,B超对胆囊癌的诊断准确率为73.9%,高于CT确诊率,129例胆管癌中高位胆管癌68例.中位37例和低位24例.与同期良性胆管疾病(5605例)的比例为1:43.45,后10年比前10年增长1.49倍,59例(46%)并胆管结石.19例曾行胆道手术的病例中12例属胆管空肠Roux—Y吻合术,且癌肿发生部位位于吻合口上10厘米以内.CT对胆管癌的诊断准确率高于B超,且在术前分期中有一定价值.前10年本组所有胆道癌病例行根治术仅16.3%,而后10年上升至38.95%.     

Primary papillary hyperplasia of the gallbladder and cystic and common bile ducts

A unique case of primary papillary hyperplasia of the gallbladder and cystic and common bile ducts occurring in a young female without calculi, ulcerative colitis, or primary sclerosing cholangitis is reported. The papillary lesion involved the mucosa of the entire gallbladder and of the cystic and common bile ducts. Histologically, the gallbladder mucosal folds were close to one another and taller than normal. They were lined by normal-appearing columnar cells and pencil-like cells. The papillary projections of the common bile duct were lined only by columnar cells with prominent subnuclear vacuoles. No endocrine cells or cytologic atypia were noted. The differential diagnoses, including secondary hyperplasia, multiple adenomas, and papillomatosis of the gallbladder, are discussed.     

Microscopic Examination of Gallbladder Stones Improves Rate of Detection of Clonorchis sinensis Infection

To improve the rate of detection of Clonorchis sinensis infection, we compared different specimens from patients with cholecystolithiasis. Feces, gallbladder bile, and gallbladder stones collected from 179 consecutive patients with cholecystolithiasis underwent microscopic examination, and according to the results, 30 egg-positive and 30 egg-negative fecal, gallbladder bile, and gallbladder stone specimens, respectively, underwent real-time fluorescent PCR. The detection rates of eggs in feces, bile, and gallbladder stones were 30.7%, 44.7%, and 69.8%, respectively, and the differences were statistically significant (P < 0.01). The PCR results confirmed that the eggs in the specimens were C. sinensis eggs. Eggs in the feces were “fresh” and in the gallbladder stones were “old.” Microscopic examination of gallbladder stones may improve the detection rates of C. sinensis infection, which is important for developing individualized treatments to prevent the recurrence of gallbladder stones and to prevent the occurrence of severe liver damage and cholangiocarcinoma.     

两种微创方案治疗胆囊结石并胆总管结石的疗效对比

目的 比较腹腔镜胆囊切除术（LC）+胆道镜胆总管探查取石术（LCBDE）与LC+内镜下十二指肠乳头括约肌切开取石术（EST）治疗胆囊结石并胆总管结石的临床疗效。方法 收集我院2013年1月~2017年12月收治的胆囊结石合并胆总管结石患者104例作为研究对象,按照手术方法分为LC+LCBDE组和LC+EST组,各52例。比较两组患者手术时间、术中出血量、住院时间、并发症发生率以及Oddis括约肌损伤发生率。结果 LC+LCBDE组患者的手术时间（131.52±25.71）min、住院时间（8.13±2.35）d、并发症发生率（15.38%）、Oddis括约肌损伤发生率（3.85%）均低于LC+EST组的（167.12±35.24）min、（10.37±3.25）d、48.07%、25.00%,差异均有统计学意义（P＜0.05）;两组术中出血量比较,差异无统计学意义（P＞0.05）。结论 LC+LCBDE和LC+EST均是治疗胆囊结石并胆总管结石的有效微创手段,LC+LCBDE方案具有手术时间短、住院时间短、并发症发生率低的优点,同时能保护Oddis括约肌的正常功能,具有一定的优越性。     

Dissolution of bile duct stones by a hydrophilized glyceromonooctanoin-bile-acid-EDTA emulsion

Summary The clinical suitability of conventional glyceromonooctanoin (GMOC) and ethylenediaminetetraacetic acid (EDTA) containing solvents for the dissolution of common bile duct stones is questionable. To improve the solvent-stone contact and the miscibility with bile, GMOC was hydrophilized by the addition of polyethyleneglycol-caprylglyceride, polyethyleneglycol-sorbitan-etheroleyl-ester, and polyethyleneglycol-sorbitanlaurylester (PEG-GMOC). This product was mixed with a bile acid-EDTA (BA-EDTA) solution in a ratio of 12 (v/v) for cholesterol solubilizing and calcium complexing capacities. To determine clinical efficiency, the new solvent was infused via a nasobiliary tube in 16 patients with endoscopically nonextractable common bile duct stones and compared with a group of 16 patients treated with an alternating GMOC/BA-EDTA regimen. Continuous perfusion with PEG-GMOC-BA-EDTA led to a total (12 patients) or partial (3 patients) disappearance of the stones within 2–15 days. Similarly, alternating GMOC and BA-EDTA treatment dissolved the stones in 12 patients.The average volume of PEG-GMOC-BAEDTA infused contained only 27% of the GMOC applied during the alternating therapeutic regime. This reduction of the GMOC dose was associated with a significant reduction of adverse effects such as emesis, diarrhea and biliary pain. We concluded that GMOC is equally efficient in the new hydrophilized form but it is clearly superior as far as side effects are concerned. In all, this supports its clinical suitability for the dissolution treatment of common bile duct stones.Abkürzungsverzeichnis GMOC Glyceromonooctanoin - EDTA Ethylenediaminetetraacetic acid - PEG-GMOC Polyethyleneglycol-sorbitanlauryl-ester - BA-EDTA Bile acid ethylenediaminetetraacetic acid - EPT (EST) Endoscopic papillotomy (Endoscopie spincterotomy) - CBS Common Bile Duct Stones - MTBE Methyl-tert-Butyl Ether - CCE Cholecystectomy In memoriam Heinrich Baumgaertel     

Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

Purpose

Cholecystectomy in patients with an intact gallbladder after endoscopic removal of stones from the common bile duct (CBD) remains controversial. We conducted a case-control study to determine the risk of recurrent CBD stones and the benefit of cholecystectomy for prevention of recurrence after endoscopic removal of stones from the CBD in Korean patients.

Materials and Methods

A total of 317 patients who underwent endoscopic CBD stone extraction between 2006 and 2012 were included. Possible risk factors for the recurrence of CBD stones including previous cholecystectomy history, bile duct diameter, stone size, number of stones, stone composition, and the presence of a periampullary diverticulum were analyzed.

Results

The mean duration of follow-up after CBD stone extraction was 25.4±22.0 months. A CBD diameter of 15 mm or larger [odds ratio (OR), 1.930; 95% confidence interval (CI), 1.098 to 3.391; p=0.022] and the presence of a periampullary diverticulum (OR, 1.859; 95% CI, 1.014 to 3.408; p=0.045) were independent predictive factors for CBD stone recurrence. Seventeen patients (26.6%) in the recurrence group underwent elective cholecystectomy soon after endoscopic extraction of CBD stones, compared to 88 (34.8%) in the non-recurrence group; the difference was not statistically significant (p=0.212).

Conclusion

A CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were found to be potential predictive factors for recurrence after endoscopic extraction of CBD stones. Elective cholecystectomy after clearance of CBD stones did not reduce the incidence of recurrent CBD stones in Korean patients.     

Mucosal alkaline phosphatase and bile lipids in the gallbladder in cholecystitis

Histochemically, alkaline phosphatase was localised in epithelial brush-border and capillary endothelium of the lamina propria in 41 gallbladders studied. Three distinct patterns of the brush-border enzyme distribution were observed, namely, complete delineation, patchy localisation and a brush-border totally devoid of enzyme activity. Where no histochemical activity was found, biliary chenodeoxycholate was 50 per cent. higher than in cases of patchy distribution and twice as high as in cases with complete staining of the brush-border. Conversely, biliary cholate levels were significantly higher in completely stained cases. Biliary cholesterol was higher in the cases with no histochemical activity and this was reflected in a significantly higher lithogenic index. Significant quantities of cholesterol esters were found in bile from the focal activity group only. Total alkaline phosphatase activity assayed in gallbladders from 112 patients with cholecystitis and/or lithiasis showed that activity was significantly lower in patients with pigment stones than patients with cholecystitis and/or cholesterol stones. This activity was not related to biliary lipid composition in the 77 bile samples analysed. This evidence indicates that biliary lipid composition is associated with the histochemical distribution of alkaline phosphatase in gallbladder mucosa.     

Cytological findings in a sample of peritoneal aspirate from a case of bile peritonitis

Bile peritonitis (BP) is a rare and serious condition warranting urgent surgical intervention to prevent the high incidence of mortality. BP is ascribed to the leakage of bile into the peritoneal cavity usually due to a perforation of the gallbladder or common bile duct caused by stones or a trauma. The radiological studies are useful in suggesting the diagnosis. The cytological findings of BP have been reported rarely in the literature characterised by the presence of lakes of stringy bile material admixed with variable numbers of histiocytes, mesothelial cells, and some inflammatory cells. Recently, we have examined an aspirate sample of peritoneal fluid (PF) obtained under ultrasound guidance in a case of BP ascribed to the perforation of the gallbladder in a 19-yr-old female patient in which apart from occasional bile pigment-laden macrophages admixed with a few mesothelial cells and inflammatory cells, numerous crystalline structures of varying shapes, sizes, and colour with birefringence along with some microspheroliths were found. At operation, the abdominal cavity showed a large amount of bile and the gallbladder specimen showed two perforations and gangrenous cholecystitis with numerous yellow-brown somewhat friable stones. The foregoing findings in the aspirate appeared to be of interest because to the best of our knowledge, numerous crystalline structures along with the cytological features of BP have not been described in the English literature.     

Bulldog夹在三孔法腹腔镜保胆取石术中的应用分析

目的 探讨Bulldog夹在三孔法腹腔镜保胆石取石术中的应用价值。方法 回顾2014年7月~2016年 8月华中科技大学同济医学院附属中西医结合医院接受三孔法腹腔镜保胆取石术病例36例,术中均于胆道镜取石操作前采用Bulldog夹临时阻断胆囊管,观察并记录结石标本的性状、分布和数量,检测术后肝功能及炎症反应情况,并对手术前后胆囊声像学表现进行评估。结果 所有36例患者均顺利完成手术操作,其中小胆石者（<0.3 cm）占22.22%,胆色素结石者占52.78%,胆道镜证实胆囊管结石者为13.89%。术后第3天,观察组平均TBIL、DBIL、ALP均处于正常范围内,PCT及CRP水平亦未超过正常值上限;与术前相比,术后2月彩超复查胆囊壁厚度（2.37±1.42 mm vs 2.25±0.72 mm）,无统计学差异(P>0.05),且未发现胆囊腔内残石及胆管扩张病例。结论 Bulldog钳可以作为安全有效的胆囊管暂时阻断器械应用于GPLC术中,在提高胆囊管结石清除率的同时,有效防止胆石溢入胆总管,且不会增加术后胆囊炎、胆囊动脉损伤风险。     

Morphology of the prairie dog gallbladder: Normal characteristics and changes during early lithogenesis

Studies were undertaken to describe the normal structure of the prairie dog gallbladder and adjacent cystic duct, and then to determine sequential changes that occurred as abnormalities in bile composition developed during high cholesterol feeding. Control animals were fed a diet with trace cholesterol, while experimental animals were fed a diet enriched with 1.2% cholesterol for 1, 2, 3, or 4 weeks. Light microscopy and scanning and transmission electron microscopy were used to characterize morphologic changes at each time interval. Biliary lipid composition was altered in all experimental groups, evidenced by significant decreases in bile-acid-to-cholesterol ratios. Cholesterol crystals appeared in experimental bile at 1 and 2 weeks, while stones formed at 3 and 4 weeks. The cystic duct and neck of the gallbladder occasionally displayed goblet cells. Little mucus was demonstrable in principal cells of the gallbladder, but much more in those lining the cystic duct. After 2 weeks of lithogenic diet, there was an increase in mucus content and secretion from all areas, as well as an influx of polymorphonuclear and mononuclear leukocytes. Accumulation of plasma cells in the lamina propria was an especially prominent feature of experimental tissues. These results suggest that (1) there is regional heterogeneity in the mucus content of the gallbladder and cystic duct of the prairie dog, and (2) both regions respond to lithogenesis with mucus hypersecretion and acute and chronic inflammatory changes prior to the appearance of cholesterol gallstones.     

Bile acid analysis in biliary tract cancer

The etiology of biliary tract cancer is obscure, but there are evidences that bile acid plays a role in carcinogenesis. To find the association between biliary tract cancer and bile acid, this study compared the bile acid concentration and composition among patients with biliary cancer, biliary tract stones, and no biliary disease. Bile was compared among patients with biliary tract cancer (n = 26), biliary tract stones (n = 29), and disease free controls (n = 9). Samples were obtained by percutaneous transhepatic biliary drainage, endoscopic nasobiliary drainage, or gallbladder puncture, and analyzed for cholic, deoxycholic, chenodeoxycholic, lithocholic, and ursodeoxycholic acid composition. Total bile acid concentration was lower in the cancer group than the biliary stone and control groups; the proportions of deoxycholic (2.2% vs. 10.2% and 23.6%, p < 0.001 and p < 0.001, respectively) and lithocholic acid (0.3% vs. 0.6% and 1.0%, p = 0.065 and p < 0.001, respectively) were also lower. This result was similar when disease site was limited to bile duct or gallbladder. Analysis of cases with bilirubin 相似文献   

Extrahepatic biliary schwannomas: a case report

Benign schwannomas arise in neural crest-derived Schwann cells. They can occur almost anywhere in the body, but their most common locations are the central nervous system, extremities, neck, mediastinum, and retroperitoneum. Schwannomas occurring in the biliary tract are extremely rare and mostly present with obstructive jaundice. We recently experienced a case of extrahepatic biliary schwannomas in a 64-yr-old female patient who presented with intra- and extrahepatic bile duct and gallbladder stones during a screening program. To the best of our knowledge, extrahepatic biliary schwannomas associated with bile duct stones have not been reported previously in the literature.     

Expression of the extracellular matrix protein periostin in liver tumours and bile duct carcinomas

Riener M‐O, Fritzsche F R, Soll C, Pestalozzi B C, Probst‐Hensch N, Clavien P‐Alain, Jochum W, Soltermann A, Moch H & Kristiansen G
(2010) Histopathology 56 , 600–606 Expression of the extracellular matrix protein periostin in liver tumours and bile duct carcinomas Aims: To study the relevance of periostin, known to be involved in epithelial–mesenchymal transition (EMT), in hepatocellular and bile duct cancer. Methods and results: Immunohistochemical periostin expression was semiquantitatively analysed in normal liver tissue (n = 20), hepatocellular carcinoma (HCC; n = 91), liver‐cell adenoma (n = 9), focal nodular hyperplasia (n = 13) and bile duct carcinomas (BDC; n = 116) using tissue microarrays. Normal bile ducts, gallbladder epithelium and hepatocytes showed weak cytoplasmic periostin expression. In HCC, there was strong epithelial periostin expression in 19/91 (20.9%) and strong stromal periostin expression in 10/91 cases (11%). Epithelial expression in tumour cells was significantly associated with a higher tumour grade (P < 0.05) and hepatitis B virus infection (P = 0.007). Importantly, there was no strong periostin expression in benign liver tumours. Strong stromal periostin expression was detected in 78/116 (67.2%) BDC and strong epithelial expression in 39/116 (33.6%) BDC. pT stage, differentiation grade and proliferation rate in primary BDC were independent of periostin expression. Epithelial periostin expression was associated with reduced overall survival on univariate and multivariate analysis. Conclusions: The EMT protein periostin is expressed in the stroma and epithelium of a subset of BDC and HCC. Epithelial periostin expression is a marker for malignant transformation of hepatocytes and a novel prognostic marker in BDC.     

腹腔镜联合胆道镜一期手术与十二指肠镜联合腹腔镜分期手术治疗细径胆总管结石合并胆囊结石的疗效比较

目的:比较腹腔镜和胆道镜双镜联合一期手术与经典的十二指肠镜和腹腔镜分期手术治疗细径胆总管结石合并胆囊结石的临床疗效。方法:回顾性队列研究。纳入2016年4月—2020年8月天津市第五中心医院肝胆外科收治的细径胆总管（直径≤0.8 cm）结石合并胆囊结石患者121例,其中男80例、女41例,年龄18~84岁。根据治疗方法...