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。     

Pulmonary bile emboli. Sequelae of iatrogenic trauma

A 58-year-old man manifested obstructive jaundice secondary to adenocarcinoma of the common hepatic duct. The markedly icteric patient underwent multiple diagnostic and therapeutic procedures, including percutaneous needle biopsy of the liver, curettage, catheterization and washing of the hepatic ducts, and percutaneous transhepatic cholangiography. Three months later the patient died of a bleeding gastric ulcer. Autopsy confirmed the presence of adenocarcinoma of the common hepatic duct. Microscopic examination of the lungs disclosed numerous bile emboli in the smaller arteries, arterioles, and in a few alveolar capillaries. Histochemical reaction of the emboli was positive for bilirubin. Organizing fibrin was seen around occasional bile emboli, but most were without microscopic reaction. Review of the literature disclosed nine cases of pulmonary bile embolism, six of which had a history of marked cholestasis and trauma to the liver, like the present patient. Bile reaches the systemic circulation through a biliary-venous fistula that, in our case, was probably iatrogenic.     

慢性胰腺炎CT影像解剖学分型及其临床意义

目的 根据慢性胰腺炎CT表现的不同,探讨慢性胰腺炎的CT影像解剖学分型及分型的意义.方法收集1996年1月至2009年1月入住我院经临床或手术证实的213例慢性胰腺炎患者,其中男性156例,女性57例,平均年龄为(48.0±11.5)岁;平均住院天数(18.4±9.2)d;胆系疾病68例(32%),反复发作急性胰腺炎3...     

A case of idiopathic fibrosing pancreatitis

We experienced a case of chronic fibrosing pancreatitis in an 18/12-year-old girl, which was idiopathic because there were no familial back ground, no cystic fibrosis of pancrease, no ductal anomalies and obstruction. The patient presented intermittent colicky abdominal pain and progressive obstructive jaundice, but T-tube drainage and removal of the lymph nodes around the common bile duct relieved her symptoms and disease process. This seems to be the first case reported in a Korean child. Idiopathic fibrosing pancreatitis should be considered in the differential diagnosis of abdominal pain with obstructive jaundice in children.     

THE CHOLEDOCHO-PANCREATICO-DUCTAL JUNCTION IN INFANTILE OBSTRUCTIVE JAUNDICE DISEASES

A histopathological study on how the common bile duct and main pancreatic duct open into the duodenum was performed on autopsied cases of infantile obstructive jaundice diseases, and control cases. The so-called "common channel" formation type (Type III) was divided into two types; the junction of the common bile duct and the pancreatic duct was situated in the mucosal or submucosal layer of the duodenum in type IIIa and the junction below the propria muscularis of the duodenum in type IIIb. Type IIIb was identified in 17 out of 28 cases in congenital biliary atresia and in 2 cases of congenital choledochal cyst, while the control cases all belonged to type IIIa. In cases of type IIIb the well-developed sphincter muscle was located in the submucosal layer and it surrounded the common channel after joining of both ducts suggesting the possibility of free communication of both ducts. As the intraductal pressure of pancreatic duct is normally higher than that of the bile duct, reflux of pancreatic juice may occur into the bile duct. Abnormal choledocho-pancreaticoductal junction was suggested to be a pathogenic factor which causes infantile obstructive jaundice diseases.     

A case of complete resolution of mediastinal pseudocyst and pleural effusion by endoscopic stenting of pancreatic duct

We report a case of a mediastinal pseudocyst with a pleural effusion that developed in a patient suffering from alcohol- related chronic pancreatitis. A 53-year-old man was admitted to another institution complaining of pleuritic chest pain and coughing. A chest X-ray revealed a pleural effusion with a collapse of the right middle and lower lobes. Pleural fluid taken by thoracentesis was exudative, and the patient was transferred to our institution. A CT scan showed a loculated cystic lesion in the mediastinum and pancreatic changes that were consistent with chronic pancreatitis. The endoscopic retrograde cholangiopancreatography (ERCP) findings were compatible with chronic pancreatitis showing severe pancreatic ductal stricture at the head with an upstream dilation and distal bile duct stricture. After a one week of treatment with fasting and octreotide without improvement, both pancreatic and biliary stents were placed endoscopically. After stenting, the pleural effusion and pseudocyst rapidly resolved. The stents were changed 3 months later, at which time a repeated CT demonstrated a complete resolution of the pseudocyst. Since the initial stenting, he has been followed up for 7 months and is doing well with no recurrence of the symptoms, but he will need to undergo regular stent changes. Overall, endoscopic pancreatic stenting appears to be a good option for managing selected cases of mediastinal pancreatic pseudocysts.     

Pancreatic cancer initially presenting with a pseudocyst at the splenic flexure

Pancreatic cancer and pancreatitis associated pseudocyst are not uncommon disorders. However, occurrence of the cancer with an initial manifestation of pseudocyst has been rarely reported. Surgery was performed on a 44-year-old male patient for an abscess-like cavity situated at the mesenteric side of the colon and extending from the splenic flexure to the descending colon. The lesion was verified as a pseudocyst with fat necrosis due to leakage of pancreatic fluid. When further surgery was carried out 1 month later in order to manage the drainage site of the pancreatic fluid, cancer of the pancreas body was detected proximal to the drainage site. The cancer was a moderately differentiated ductal adenocarcinoma with wide peripancreatic infiltration. It is thought that the cancer-associated duct obstruction caused a local pancreatitis resulting in a large communicating pseudocyst, although the exact mechanism remains unresolved. The present case may be instructive in showing physicians that a pseudocyst may obscure the presence of pancreatic cancer.     

Two cases of common bile duct stone after liver transplantation

Biliary complications after orthotopic liver transplants are a continuing cause of morbidity and mortality. Biliary stones and sludge are less well known complications of hepatic transplantation, although they have long been recognized. Recently we experienced two cases of biliary stones developed after liver transplantation. One 32-year-old male, who frequently admitted due to recurrent cholangitis, was treated with percutaneous transhepatic biliary drainage and choledochojejunostomy with cholecystectomy. The other 58-year-old male, who had stones in commone bile duct, was treated by endoscopic manipulation. They are in good condition without recurrent bile duct stones or its accompanying complications. Although stones and sludge are relatively infrequent after liver transplantation, surgical or interventional radiologic treatments are usually performed for treatment.     

136例重症急性胰腺炎的治疗方法与疗效评估

目的探讨重症急性胰腺炎（SAP）的治疗方法与疗效。方法总结分析2001年3月至2008年3月间收治的136例重症急性胰腺炎的临床病例资料。结果102例行非手术治疗,死亡8例（7．8％）,并发假性囊肿12例（11．8％）。34例行手术治疗,术后死亡8例（23．5％）,并发假性囊肿4例（11．8％）,腹腔内出血6例（17．6％）,胰瘘8例（23．5％）,肠瘘2例（5．9％）。结论重症急性胰腺炎以非手术治疗为主的个体化原则,综合治疗效果明显优于早期手术治疗。如果病情加重合并脏器功能障碍、黄染加重、胰周大量积液、高热、疑有胰周或胆道感染者应正确把握重症胰腺炎的外科手术时机,合理选择手术方式对决定重症胰腺炎的预后很重要。     

Lymphoplasmacytic sclerosing pancreatitis with cholangitis: a variant of primary sclerosing cholangitis extensively involving pancreas

Pancreatic involvement in primary sclerosing cholangitis (PSC) is an extremely rare condition, and its pathologic features are poorly documented. We report two cases of an unusual lymphoplasmacytic sclerosing inflammatory disease involving the total pancreas, common bile duct, gallbladder, and, in one patient, the lip. Two elderly men presented with waxing and waning obstructive jaundice, and exhibited radiologic and ultrasonographic findings highly suggestive of pancreatic carcinoma. Gross appearance of the pancreas showed firm and mass-like enlargement with regional lymph node swelling. Histologic findings were characterized by diffuse lymphoplasmacytic infiltration with marked interstitial fibrosis and acinar atrophy, obliterated phlebitis of the pancreatic veins, and involvement of the portal vein. Similar inflammatory processes involved the bile duct and the gallbladder. Lymphoplasmacytic sclerosing pancreatitis with cholangitis is thought to be a more appropriate term for this condition, of which a similar lesion has been previously noted in a single case of "PSC involving pancreas". Differences in age, radiologic appearance, and the negative history of ulcerative colitis exist, but the two cases in this study could be considered as a variant of PSC extensively involving pancreas, which can readily be mistaken for pancreatic carcinoma.     

急性胆源性胰腺炎的临床治疗探讨

目的:探讨提高急性胆源性胰腺炎(acute biliary pancreatitis,ABP)疗效的治疗方法.方法:本组共48例ABP患者,其中胆道梗阻性11例、非梗阻性37例.对梗阻性ABP患者采取早期急诊手术治疗,手术方式为胆囊切除、胆总管切开取石、T管引流,胰腺包膜切开引流、胰腺坏死组织和感染灶清除;对非梗阻性ABP患者早期采取非手术治疗.结果:非梗阻性ABP 37例,其中34例经非手术治疗痊愈;3例出现体温升高、病情恶化者急诊手术,2例痊愈,1例死于多器官功能衰竭.11例梗阻性ABP行急诊手术治疗,发生并发症5例,均治愈.结论:急性胆源性胰腺炎的治疗应遵循个体化原则,对伴有胆道梗阻者早期宜行急诊手术,其它类型的急性胆源性胰腺炎早期宜非手术治疗.选择正确的治疗方法,把握恰当的手术时机,可提高治愈率,降低病死率.     

Obstructive jaundice caused by Clonorchiasis-associated duodenal papillitis: a case report

We describe an unusual presentation of Clonorchis sinensis infection with obstructive jaundice due to duodenal papillitis which was relieved dramatically by endoscopic sphincterotomy. A 26-yr-old male presented with complaints of fatigue, weight loss and painless jaundice. The history was significant for frequent ingestion of raw freshwater fish. The patient underwent endoscopic retrograde cholangiopancreatography for evaluation of obstructive jaundice. The duodenal papilla was markedly edematous with a bulging configuration and hyperemic changes at the orifice. Cholangiography revealed mild bile duct dilatation and irregular wall changes with multiple indentations. However, there were no biliary stricture or stones noted as the cause of obstructive jaundice. We performed an endoscopic sphincterotomy for effective bile drainage through the duodenal papilla. After the sphincterotomy, the patient's jaundice was dramatically improved. Pathology of the duodenal papilla showed eosinophilic infiltration of the mucosa. Parasitic eggs, consistent with the diagnosis of C. sinensis, were found in the bile sample.     

Non-alcoholic duct-destructive chronic pancreatitis: recognition before definitive treatment

Non-alcoholic duct-destructive chronic pancreatitis is a new entity that differs morphologically and pathogenetically from alcoholic chronic pancreatitis. Some clinical and imaging features of this entity resemble those of pancreatic cancer, and hence most of the reported cases underwent pancreatic resections including an invasive pancreaticoduodenectomy. Recognition of this new entity before a definitive treatment is therefore important to avoid an unnecessary pancreatic resection. Recently, we experienced a case of non-alcoholic duct-destructive chronic pancreatitis in an 80-year-old man presenting with obstructive jaundice and whose radiologic features were characteristic as originally described. Recognition of this new entity before definitive treatment enabled us to manage this patient optimally. In addition, the relation between non-alcoholic duct-destructive chronic pancreatitis and chronic pancreatitis with diffuse irregular narrowing of the main pancreatic duct is discussed.     

Cholestasis caused by a choledochal botryoid rhabdomyosarcoma in a 22-month-old boy

Botrioid rhabdomyosarcoma of the extrahepatic bile ducts is a rare cause of jaundice in children. It has a very poor prognosis and is rarely diagnosed preoperatively. We report a choledochal botrioid rhabdomyosarcoma in a 22-month-old boy who developed an obstructive jaundice. Radiographic explorations suggested cystic lymphangioma. The gallbladder, the cystic duct, the common bile duct and the pancreatic head were resected. The diagnosis was made on pathological examination; adjuvant chemotherapy followed. The patient was disease free 20 months following treatment.     

恶性梗阻性黄疸的介入治疗

目的探讨恶性梗阻性黄疸的介入治疗方法及其疗效。方法对256例恶性梗阻性黄疸患者,施用经皮经肝穿刺胆道引流术(PTCD)加金属内支架置入术或结合局部动脉化疗术,共使用256条外引流管和256枚金属内支架。结果 256例患者采用经皮经肝穿刺置入外引流管及支架置入术,均一次置入成功。术后总胆红素、直接胆红素、碱性磷酸酶均明显下降。术后256例患者黄疸消退满意;112例黄疸消退,并于术后4周行局部灌注化疗术。结论经皮经肝穿刺胆道外引流加内支架置入术是姑息性治疗恶性梗阻性黄疸的安全、有效方法,结合局部动脉灌注化疗,能提高患者的生命质量及延长生存期。     

Type I Choledochal Cyst Complicated With Acute Hemorrhagic Pancreatitis: A Case Report

Choledochal cysts rarely present with acute pancreatitis. We report a patient with type I choledochal cyst(s) who had concomitant acute frank hemorrhagic pancreatitis.A 14-year-old male noted with a history of recurrent abdominal pain, fever and jaundice. Ultrasonography (US) of abdomen at the Emergency Department depicted distended gall bladder with wall thickening. Apparently dilated intrahepatic ducts (IHDs) and fusiform dilatation of the common bile duct (CBD), and mild dilatation of the pancreatic duct were also noted, suggesting a type I choledochal cyst( ). Computed tomography (CT) demonstrated calcifications in the uncinate process of the pancreas in addition to the similar findings on US. He subsequently underwent choledochal cyst excision with a Roux-en-Y hepaticojejunostomy. After surgical treatment, he has been doing well for 3 years.     

Fibrolamellar carcinoma as a cause of bile duct obstruction

Obstructive jaundice due to growth within bile ducts of hepatocellular carcinoma is uncommon and usually a manifestation of advanced, lethal tumour. We report a case of fibrolamellar carcinoma of the liver presenting with obstructive jaundice, caused by tumorous permeation of the left hepatic duct with migration of tumour fragments into the common bile duct. Immunocytochemical and ultrastructural features are described. Two and a half years after complete surgical resection the patient is free of tumour. The importance of accurate diagnosis of such tumours is emphasized.     

肝细胞癌胆管转移的超声诊断

目的：总结18例肝细胞癌胆管转移的影像学特征，探讨超声诊断本病的依据及与胆管癌的鉴别诊断。方法：回顾性收集749例阻塞性黄疸的临床资料，对其中18例经手术、病理证实为肝细胞癌胆管转移的影像资料进行分析。结果：18例肝细胞癌胆管转移约占全部阻塞性黄疸病例的2.4％，超声诊断本病的符合率约66.7％（12/18）。主要超声表现为：肝实质回声增强增粗，分布欠均匀，部分（10/18）肝内可见边界模糊、形态不规则的强回声斑块；胆总管上段及肝内胆管明显扩张，在扩张的胆管下端可见较规则的实性肿块，以椭园形等回声居多（11/18）；肿块与胆管壁的界限大多清楚（15/18），胆管壁无增厚及回声增强，胆管腔无鼠尾状狭窄。结论：肝细胞癌胆管转移有其特征性图像，有别于胆管癌，若结合CDFI或介入穿刺细胞学检查可提高诊断的符合率。     

Small cell carcinoma of the extrahepatic bile duct: case report and immunohistochemical analysis

A small cell carcinoma of the extrahepatic bile duct in a 75-year-old Japanese man is reported. The patient suffered from obstructive jaundice, and percutaneous transhepatic cholangiography-drainage (PTCD) revealed a massive lesion in the lower common bile duct. Because it was diagnosed as a malignant tumor, pancreaticoduodenectomy was performed. A nodular infiltrating tumor measuring 4.5 x 3.0 x 2.0 cm was located in the intrapancreatic portion of the extrahepatic bile duct. Histologically, the tumor was composed of a dense proliferation of small atypical cells with a little region of high-grade dysplasia in the adjacent epithelium of the common bile duct. Tumor cells were immunoreactive to neuroendocrine markers such as chromogranin A, synaptophysin, CD56, and Leu7. Although carcinoma cells invaded into pancreas and duodenum, there were no histological findings that indicated the carcinoma arose from the mucosa of either the pancreatic duct or duodenum. These results indicated that the tumor was a small cell carcinoma derived from the epithelium of the extrahepatic bile duct; a rare neoplasm with only a few cases reported. A few neuroendocrine cells were recognized in the adjacent epithelium of the extrahepatic bile duct, suggesting that the tumor cells might be derived from them. Using immunohistochemical examination, no p53 abnormality was found. Tumor cells showed positive nuclear staining for p16, while negative for cyclin D1, suggesting that functional retinoblastoma protein (pRB) might be lost in the p16/pRB pathway, as in small cell lung cancer.     

Percutaneous transhepatic biliary biopsy using gastrofiberscopic biopsy forceps.

To obtain a histopathologic diagnosis at the site of a biliary obstruction, we recently have performed 24 cases of biliary biopsy using gastrofiberscopic biopsy forceps (Olympus, Tokyo, Japan) via transhepatic tracts provided in the course of the procedure of percutaneous biliary drainage. Histopathologic diagnosis was successfully made at the first attempt of biopsy procedure but a second trial was made a week later in 6 cases who were negative for malignant cells on the first attempt. The histological results from the biopsy specimens were 18 adenocarcinomas, 5 chronic inflammations and one normal epithelium. Of 6 cases who were negative for malignant cells on forceps biopsy specimen, three cases were confirmed as adenocarcinoma of the ampulla of Vater, adenocarcinoma of the pancreas and chronic pancreatitis by surgical biopsy. The latter was a true negative result, which was diagnosed as chronic inflammation on forceps biopsy and verified as chronic pancreatitis by surgery. The remaining two cases were diagnosed as malignant obstructive jaundice by clinical and radiological follow-up findings. Major complications (bile peritonitis, bleeding, and hemopneumothorax) occurred in 3 patients, which mainly arose in the earlier period of study. This procedure can be performed at the same time as percutaneous transhepatic biliary drainage with low morbidity or mortality, and although the potential for perforation of bile ducts and injury to adjacent blood vessels is considered it is a useful addition to existing biopsy techniques for yielding material sufficient for histologic analysis.