用非高渗透压培养基从慢性胆囊炎胆囊分离细菌L型

用非高渗透压培养基从１１０例慢性胆囊炎患者的胆囊壁组织和胆汁中分离培养细菌Ｌ型。结果表明常规细菌学检查有菌和无菌的慢性胆囊炎胆囊中均可检出细胞Ｌ型，其中胆囊壁组织检出率为９４．５４％，胆汁检出率为８６．０２％。胆囊细菌Ｌ型检出率２７．２７％，其中革兰阴性细菌占６１％，革兰阳性细菌占３９％。     

从胆汁中分离出一株阿莱塔葡萄球菌

阿莱塔葡萄球菌（Ｓ．ａｒｌｅｔｔａｅ）引起人类感染比较少见，我们于１９９８年３月从一胆石性胆囊炎患者胆汁中分离出１株该菌，现报道如下。患者，女，６４岁，因胆石症合并胆囊炎入院。体温３８６℃，血常规ＷＢＣ１１×１０９／Ｌ，Ｎ０８５，Ｌ０１５，Ｂ超显示胆囊壁增厚，内有泥沙样结石合并胆囊炎。行胆囊摘除术，术中留取胆汁４ｍｌ做细菌培养。直接涂片有革兰阳性球菌，呈葡萄状排列。培养后，鉴定为阿莱塔葡萄球菌。细菌鉴定：将胆汁注入肉汤增菌，作者单位：７３００００兰州，甘肃省临床检验中心３５℃、２４小时孵育…     

急性胆囊炎的超声诊断分析及治疗中的应用

目的：探讨急性胆囊炎的超声诊断及治疗中的应用。方法：回顾分析858例急性胆囊炎的超声表现，并追踪观察752例非手术治疗效果。结果：858例中胆囊肿大占93．9％，胆囊壁厚呈“双层”结构占61．3％，超声Murphy征阳性占96．6％，胆囊壁内膜粗糙占71．7％，胆汁透声差占62．7％，有胆囊结石占66．3％，有胆囊蛔虫占13．5％。其中106例手术病理证实，非手术组自觉症状消失中，427例超声显像未恢复正常而停药，378例（88.5%)复发，另325例超声显像正常后停药无复发。结论：胆囊肿大、超声Murphy征阳性是诊断急性胆囊炎的重要指标；B超在观察治疗效果中起着重要作用。     

厚壁型胆囊癌与慢性胆囊炎CT鉴别诊断

目的：着重探讨CT对厚壁型胆囊癌与慢性胆囊炎的鉴别诊断价值。材料和方法：回顾性分析15例厚壁型胆囊癌和30例慢性胆囊炎的CT表现特征,并作鉴别诊断。结果：①厚壁型胆囊癌15例中,CT显示为胆囊肿大且壁不均增厚9例（33．3％）,胆囊壁僵硬且边界不清8例（53．3％）,胆囊壁连续性中断5例（33．3％）,胆囊壁均匀强化13例（86．0％）,肝门淋巴结肿大5例（33．3％）,②慢性胆囊炎30例中,CT显示胆囊壁均匀增厚5例（16．7％）,胆囊边缘模糊不清25例（83．3％）,胆囊壁轻度强化30例（100．0％）,胆囊周围积液、积气4例（13．0％）,胆囊炎合并结石9例（30．0％）。结论：螺旋CT双期增强扫描在显示厚壁型胆囊癌与慢性胆囊炎CT表现特征及其鉴别诊断上,具有重要价值。     

B型超声观察长期禁食患者的胆囊改变

目的探讨长期禁食(3天-7天或以上)患者的胆囊表现。方法对63例由于各种原因导致长期禁食患者,观察其胆囊壁的厚度,胆囊内胆汁透声情况,进行综合分析。结果63例中显示淤胆型胆囊炎者55例,占87％;胆囊壁增厚并少量沉积物者8例,占 12．7％。结论提高认识,可预防淤胆型胆囊炎的形成,降低胆囊结石及胆囊癌的发病率。     

对急性胆囊炎超声诊断指标的再认识

目的：评价现行急性胆囊炎的某些超声诊断指标的实用价值。方法：对１０５例急性胆囊炎行术前声像图与手术标本对照,同时１０５例手术组及４３８例非手术组急性胆囊炎声像图与４１例正常胆囊对照。结果：超声诊断准确率达９８．１％,手术组胆囊大小超声测平均为８．７ｃｍ×３．８ｃｍ,手术测平均为１１．０ｃｍ×４．６ｃｍ。囊壁厚超声测０．２８±０．０７ｃｍ,手术测０．４３±０．１ｃｍ,两者间有显著性差异（Ｐ＜０．０５）。超声见胆汁透声好占７９．０％,术中见胆汁清亮占８４．６％。椭圆形胆囊手术组、非手术组、正常对照组分别占７１．４％、６１．２％及５２．０％。超声莫非氏征阳性手术组为９３．３％,非手术组为８９．７％。“双环”征本组占１５．９％,囊壁粗糙不光滑占１８．７％。胆囊轮廓模糊占６．８％。结论：胆囊壁增厚并出现“双环”征、胆汁透声差、胆囊轮廓模糊不能作为诊断急性胆囊炎的常见或主要超声诊断指征。     

胆道感染患者胆汁和血培养主要病原菌一致性研究

目的　探讨胆道感染患者胆汁培养和血培养主要病原菌的一致性。方法　回顾性分析2016 年1 月~ 2019 年6 月江苏大学附属人民医院胆汁和血培养同时阳性的114 例胆道感染患者的资料，比较胆汁和血液两种类型标本中病原菌的分布，采用Kappa 检验分析其一致性。结果　116 份胆汁标本共检出148 株菌，革兰阴性菌占71.62%，革兰阳性菌占27.03%，真菌占1.35%。126 份血液标本共检出129 株菌，革兰阴性菌占82.95%，革兰阳性菌占16.28%，真菌占0.78%。有45 例患者（39.47%）的胆汁和血标本分别只检出一种菌，且相同；28 例（24.56%）的胆汁和血标本检出病原菌至少一种相同；41 例（35.96%）的胆汁和血标本检出病原菌完全不同。胆汁和血培养检出大肠埃希菌的总符合率为61.40%。胆汁和血标本检出菌至少一种相同的患者中，大肠埃希菌检出率在两种标本类型中表现出较高的一致性（Kappa 值=0.784），符合率为89.3%。结论　胆道感染患者的胆汁和血培养病原菌以革兰阴性杆菌为主，其中大肠埃希菌占比最高。两种标本类型在大肠埃希菌检出率上具有较高一致性。     

壁厚型胆囊癌与慢性胆囊炎CT表现的研究

目的：探讨壁厚型胆囊癌与慢性胆囊炎的鉴别诊断。方法：收集经手术和病理证实的14例壁厚型胆囊癌与14例慢性胆囊炎，分成良、恶两组，对它们的CT表现进行对比分析，结果：两组间的CT征象有许多不同。14例壁厚型胆囊癌胆囊壁均不规则增厚，壁僵硬9例(64．2％)，胆囊腔变小和形态失常8例(57.1％)，胆囊边界不清10例(71．4％)，9例(64.2％)见有不同程度的胆管扩张；而14例慢性胆囊炎中2例(14．3％)壁厚薄不均，2例(14．3％)壁显僵硬，2例(14．3％)胆囊挛缩变小，胆囊边界不请2例(14.3％)，恶性组增强后见胆囊壁连续性中断5例(37．5％)，7例(50．0％)见淋巴结肿大；而良性组均未见两征象。结论：螺旋CT在胆囊癌与慢性胆囊炎的鉴别诊断中有重要价值，上述征象出现率高的病例有助于胆囊癌的诊断。     

老年人胆道感染85例临床分析

目的：探讨老年人胆道感染的临床病原学特点及细菌耐药状况，指导临床合理用药。方法：回顾性分析1999年1月-2003年5月85例老年胆道感染胆汁标本中病原学的检出。结果：85份标本中有58份胆汁培养有细菌生长，阳性率为68．2％(58／85)，其中混合感染标本占17．2％(10／58)，分离细菌70株，革兰阴性杆菌57株占81．4％，主要为大肠埃希菌、肺炎克雷伯菌、铜绿假单胞菌。革兰阳性球菌13株占18．6％，主要为肠球菌属和金黄色葡萄球菌。分离的革兰阴性杆菌对亚胺培南、头孢吡肟、头孢他啶等敏感性较高，可作为老年重症胆道感染的首选用药，而对庆大霉素、环丙沙星有较高的耐药性．不宜作为老年胆道感染患者的经验性治疗用药。结论：对老年胆道感染病原学的监测，有利于选择有效的抗菌药物．减少治疗的盲目性。     

胆系感染时抗生素的选择

健康人的胆道系统没有致病菌存在,无临床症状的慢性胆囊炎患者的胆汁也是无菌的,尤其在B超检查中发现胆囊壁厚、毛糙、胆囊收缩功能差的胆囊炎,其胆囊常无细菌存在,多为胆囊收缩功能降低,胆固醇结晶析出,胆囊壁水肿等引起,因而不需抗生素治疗.但慢性胆囊炎急性发作或有胆道结石、胆道蛔虫、肠道急慢性炎症时,患者的胆汁是有菌的,这就需要抗生素治疗.一旦出现寒战、发热、黄疸、右上腹部疼痛或慢性胆囊炎患者长期反复的无其他原因的白细胞增高,应立即应用抗生素.抗生素的选择要注意以下三个方面:①可能感染的病原菌;②药物在胆汁和血液中的浓度;③药物的抗菌谱及其对机体的毒副作用.     

血平板分离培养细菌L型的生物学特性

目的了解血平板分离培养细菌L型的特性及其漏检原因。方法201份标本直接接种于血平板培养,盲刮盲扩后取针尖样或云雾状菌落,干片固定观察菌落特征;常规法鉴定L型及其生化特性。结果分离出102株L型（50.7%）,针尖样菌落57份,云雾状菌落45份,L型多为颗粒型（G型）菌落（81%）,易回复（88%）;超薄切片细胞壁缺失;生化反应减弱;金黄色葡萄球菌L型居首位（50%）。结论血平板可直接用于分离培养L型,能保持传统培养L型的多种特性,有利于临床标本同时检出细菌型和L型,可提高L型的检出率。     

Effects of cholecystectomy on the kinetics of primary and secondary bile acids.

Removal of the gallbladder is thought to increase formation and pool size of secondary bile acids, mainly deoxycholic acid (DCA), by increased exposure of primary bile acids (cholic acid [CA], chenodeoxycholic acid [CDCA]) to bacterial dehydroxylation in the intestine. We have tested this hypothesis by simultaneous determination of pool size and turnover of DCA, CA, and CDCA in nine women before and at various intervals after removal of a functioning gallbladder. An isotope dilution technique using marker bile acids labeled with stable isotopes (2H4-DCA, 13C-CA, 13C-CDCA) was used. After cholecystectomy, concentration and output of bile acids relative to bilirubin increased (P less than 0.02) in fasting duodenal bile and cholesterol saturation decreased by 27% (P less than 0.05) consistent with enhanced enterohepatic cycling of bile acids. Three months after removal of the gallbladder bile acid kinetics were in a new steady state: pool size and turnover of CDCA were unchanged. Synthesis of CA, the precursor of DCA, was diminished by 37% (P = 0.05), probably resulting from feedback inhibition by continuous transhepatic flux of bile acids. The fraction of CA transferred after 7 alpha-dehydroxylation to the DCA pool increased from 46 +/- 16 to 66 +/- 32% (P less than 0.05). However, this enhanced transfer did not lead to increased input or size of the DCA pool, because synthesis of the precursor CA had decreased.     

Piperacillin distribution into bile, gallbladder wall, abdominal skeletal muscle, and adipose tissue in surgical patients.

The concentrations of piperacillin in serum, bile, gallbladder wall, abdominal skeletal muscle, and adipose tissue were measured simultaneously at various times after the intravenous administration of a single 5-g dose to each of 14 patients undergoing biliary tract surgery. Piperacillin concentrated in the bile with peak levels exceeding 4,000 micrograms/ml. In a single patient with cystic duct obstruction, trace gallbladder bile piperacillin levels were measured. Gallbladder wall concentrations of piperacillin tended to be higher than corresponding serum concentrations, with a correlation observed between tissue values and the degree of acute gallbladder inflammation and gallbladder bile piperacillin concentrations. Mean peak muscle and adipose tissue piperacillin concentrations of 31 and 27 micrograms/g, respectively, were reached at between 2 and 3 h after the start of infusion. These concentrations exceeded the minimum inhibitory concentration for a majority of susceptible organisms. A single 5-g dose of piperacillin achieved therapeutic levels in gallbladder wall, intraabdominal skeletal muscle, and adipose tissue and concentrated in the bile of patients with patent biliary tracts.     

Concentration of norfloxacin in human gallbladder tissue and bile after single-dose oral administration.

Concomitant concentrations of norfloxacin in serum and in gallbladder tissue and bile were determined in 10 patients after a single oral dose of 400 mg given before cholecystectomy. Concentrations in gallbladder bile ranged from 0.6 to 15.6 micrograms/ml, with a mean bile/serum ratio of 7.0. The mean concentration in gallbladder tissue was 1.8 +/- 0.8 (standard error) micrograms/g.     

Bile-based detection of extrahepatic cholangiocarcinoma with quantitative DNA methylation markers and its high sensitivity

Extrahepatic cholangiocarcinoma (EHC) is usually difficult to diagnose by bile cytology because of cellular disintegration. However, DNA samples from bile fluid can provide sufficient materials to screen for the presence of EHC. We developed DNA methylation marker panels that can be used for MethyLight assay-based detection of EHC in bile fluid specimens. The methylation status of 59 DNA methylation markers was investigated in 20 EHC and 20 non-neoplastic gallbladder tissue samples with MethyLight assay to determine cancer-specific DNA methylation markers. Through assaying cancer-specific DNA methylation markers in a training set (n = 40) and validation set (n = 45) of bile fluid specimens from patients with EHC or those without cancer, we selected suitable marker panels that were assessed for their performance in a third set (test set; n = 40). Four marker panels showed a sensitivity of 60% or more and a specificity of 100% in both the training and validation sets, whereas bile cytology displayed a sensitivity of 40% to 46% and a specificity of 100%. In an independent test set of bile fluid samples, a five-gene panel (CCND2, CDH13, GRIN2B, RUNX3, and TWIST1) detected EHC at a sensitivity of 83%, which was far higher than that of bile cytology (46%, P = 0.004). Using bile fluids, a methylation assay consisting of a five-gene panel may be useful for detecting EHC and in helping to increase the sensitivity of preoperative diagnoses.     

自然组织谐波成像在胆道疾患中的应用价值

目的：通过与常规超声即基波成像的对比观察,探讨自然组织谐波成像在胆道疾患中的应用价值。方法：采用数字式超声诊断仪基波成像和自然组织谐波成像分别对60例各种胆道疾患患者和60例正常人进行胆道系统超声检查对比分析。结果：1、自然组织谐波成像的60例各种胆道疾患中胆囊隆起性病变、胆囊结石、胆总管结石、胆总管下端占位清晰显示率分别为100％、100％、93％、80％;而基波成像清晰显示率则分别为80％、90％、60％、40％,二者呈显著差异（P＜0．05）。总显示率自然组织谐波成像均在100％,而基波成像分别为100％、100％、87％、60％,后二者也呈显性差异;2、在超声检查的60例正常人对照组中,自然组织谐波成像的胆囊轮廓、胆囊壁层次显示清晰者为99％胆总管显示率为98％;而基波成像者则分别为90％和93％。二者有一定差异,但无统计学意义（P＞0．05）。结论：自然组织谐波成像对胆道系统疾患的超声图像能明显地改善信噪比和分辨率,提高二维图像质量。尤其是对胆总管疾患的声像图改善更为突出。自然组织谐波成像在检查胆道疾患中有极高的应用价值。     

Role of Gallbladder Mucus Hypersecretion in the Evolution of Cholesterol Gallstones: STUDIES IN THE PRAIRIE DOG

Because mucin glycoproteins may be important in the pathophysiology of gallstones, we studied the relationship among biliary lipids, gallbladder mucin secretion, and gallstone formation in cholesterol-fed prairie dogs. Organ culture studies of gallbladder explants revealed that the incorporation of [³H]glucosamine into tissue and secretory gallbladder glycoproteins was significantly increased at 3, 5, 8, and 14 d of feeding. Peak secretion of labeled mucin occurred at 5 d, when total tissue and secreted glycoprotein production was fivefold greater than control. Gel filtration of the secreted glycoprotein on Sepharose 4B indicated that the majority of radioactivity was present in a macromolecule of > 1 million molecular weight. The increased secretion of gallbladder mucin was organ specific, in that [³H]glucosamine incorporation into glycoproteins of stomach and colon was unaffected by cholesterol feeding. Similarly, the incorporation of [³H]mannose into gallbladder membrane glycoproteins was not altered by cholesterol feeding. The rate of glycoprotein synthesis and secretion returned to normal upon withdrawal of the cholesterol diet, and ligation of the cystic duct before cholesterol feeding prevented gallbladder mucin hypersecretion. Both results indicate that the stimulus to mucin secretion was a constituent of bile. Gallbladder bile after 5 d contained cholesterol in micelles, liquid crystals, and crystals, whereas hepatic bile remained a single micellar phase throughout cholesterol feeding. For this reason the cholesterol-saturation indices of gallbladder bile were compared in both homogenized and centrifuged samples. The micellar phase of gallbladder bile was appreciably less saturated than homogenized bile at 5 and 8 d, which reflects the continuous nucleation of cholesterol in the gallbladder. Purified human gallbladder mucin gels were shown to induce nucleation of lecithin-cholesterol liquid crystals from supersaturated hepatic bile. These in turn gave rise to cholesterol monohydrate crystals within 18 h. Control supersaturated hepatic bile could not be nucleated by the addition of other proteins, and was stable for days upon standing. These results suggest that the increase in cholesterol content of bile in cholesterolfed prairie dogs stimulates gallbladder mucus hypersecretion, and that gallbladder mucus gel is a nucleating agent for biliary cholesterol.     

Gallbladder and Small Intestinal Regulation of Biliary Lipid Secretion during Intraduodenal Infusion of Standard Stimuli

The gallbladder and small intestine are reservoirs for the bile acid pool during its enterohepatic circulation and, as such, may regulate biliary secretion of bile acid. During studies of biliary bile acid secretion, a stimulus to gallbladder contraction is continuously infused into the duodenum. Under these conditions, it is assumed that the gallbladder is tonically contracted and that the rate of bile acid secretion into the duodenum equals the hepatic bile acid secretion rate. However, secretion rates vary by as much as 100%, depending upon which of two standard stimuli is used. Therefore, we studied the role of gallbladder emptying and small intestinal transit in determining biliary lipid secretion rate and composition during infusion of these stimuli in five healthy subjects. Each subject was studied with a liquid formula containing 40% of calories as fat, and with an amino acid solution for 10 h. Bile acid, phospholipid, cholesterol, and markers were measured in duodenal bile and hourly secretion rates were calculated by marker dilution technique. Real-time gallbladder sonographs and serum pancreatic polypeptide levels were obtained every 30 min. Small bowel transit time was estimated levels were obtained every 30 min. Small bowel transit time was estimated by the breath hydrogen response after giving lactulose intraduodenally.     

Impact of gallbladder status on the outcome in patients with retained bile duct stones treated with extracorporeal shockwave lithotripsy

BACKGROUND AND STUDY AIMS: The use of endoscopic therapy in combination with lithotripsy techniques has become increasingly common in patients with complicated common bile duct stones. In many units, although this is controversial, cholecystectomy is then performed, because of possible subsequent cholecystitis and recurrence of choledocholithiasis. The aim of this study was to investigate whether gallbladder status influences the long-term outcome in patients after extracorporeal shockwave lithotripsy (ESWL) of common bile duct stones. PATIENTS AND METHODS: Recruited for the study were 120 patients with an average age of 68 years (range 28 - 86). They were selected from 137 consecutive patients who presented to our department between January 1989 and June 1996 with complicated common bile duct stones, and in whom ESWL was necessary to achieve complete clearance of stones. Follow-up data were obtained from the patients and their general practitioners. RESULTS: The mean duration of follow-up was 4 years (range 3 - 9). A total of 37 patients had their gallbladder in situ (group A), while 83 had undergone cholecystectomy. Of these 83 patients, 27 had had a cholecystectomy after ESWL (group B), whereas 56 patients had already had the gallbladder removed when choledocholithiasis was diagnosed (group C). During follow-up, 36 patients (30 %) experienced some biliary symptoms. There were no significant differences in the incidence of recurrent biliary symptoms between the three groups. Re-exploration of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) revealed 28 cases of recurrent bile duct stones. Recurrence developed more often in groups B and C, who had undergone cholecystectomy, without reaching statistical significance ( P = 0.077). In patients with an intact gallbladder (group A), there was no difference in the rate of recurrent biliary symptoms or stones between the patients with or without cholecystolithiasis. Operations were necessary in 28 patients; in only ten was this for biliary reasons. CONCLUSION: The intact gallbladder is not a risk factor for recurrent biliary complications after ESWL of common bile duct stones; therefore, as far as patients with complicated bile duct stones which require additional lithotripsy techniques are concerned, elective cholecystectomy after endoscopic clearance of the bile duct no longer seems appropriate.     

婴儿先天性肝门部囊性占位的超声鉴别

目的 探讨超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值。 方法 随机选取2016年6月~2017年6月我院收治的肝门区囊肿患儿31例,所有患儿均接受超声检查及手术治疗,依据手术结果将这些患儿分为囊肿型胆道闭锁组（n=15）和胆总管囊肿组（n=16）,对两组患儿的肝内胆管扩张、肝门部纤维块、胆囊内胆泥沉积、胆囊形态异常、胆囊收缩不良发生情况、肝动脉内径、胆囊大小、囊肿体积进行统计分析。 结果 囊肿型胆道闭锁组患儿的肝内胆管扩张、胆囊内胆泥沉积发生率0%、6.7%（1/15）均显著低于胆总管囊肿组75.0%（12/16）、50.0%（8/16）（P<0.05）,肝门部纤维块、胆囊形态异常、胆囊收缩不良发生率80.0%（12/15）、86.7%（13/15）、73.3%（11/15）均显著高于胆总管囊肿组0%、6.3%（1/16）、12.5%（2/16）（P<0.05）,肝动脉内径长于胆总管囊肿组（P<0.05）,囊肿体积小于胆总管囊肿组（P<0.05）,胆囊宽径短于胆总管囊肿组（P<0.05）,但两组患儿的胆囊长径之间的差异无统计学意义（P>0.05）。 结论 超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值高。