胆管支气管瘘的诊断和治疗

探讨胆管支气管瘘的诊断和治疗方法.结合2例胆管支气管瘘病人的诊治经过,结合文献资料探讨胆管支气管瘘病因、症状、诊断、治疗方法及预后.胆管支气管瘘病因众多,肝或肺包虫病、阿米巴肝脓肿、细菌性肝脓肿、膈下脓肿及胆道结石均是重要原发病,医源性胆管支气管瘘值得注意;胆管支气管瘘最重要症状是胆汁样痰;结合原发病、影像学及临床表现诊断一般不难;内镜或介入方法胆管引流可治疗胆管支气管瘘,反复发作或经久不愈者需行手术治疗.胆汁样痰是胆管支气管瘘的特征症状,发生胆管支气管瘘处理需迅速及时.     

胆管支气管瘘

胆管支气管瘘在临床上虽较少见,但病理变化复杂,诊断与治疗上亦甚困难。胆管支气管瘘是肝胆疾病的严重并发症,最常见的病因是:①胆道梗阻并发化脓性胆管炎,可由胆道蛔虫、胆管结石、狭窄或肿瘤引起;②肝脏疾病,如细菌性肝脓肿、阿米巴肝脓肿、肝包虫病等;③继发于上腹部的膈下感染;④外伤,继发于胸腹贯通伤后。我院1955～1984年间共收治胆管胸膜、胆管心包及胆管支气管瘘11例,除2例因阿米巴性肝脓肿引起外,余均因胆道蛔虫、胆管结石或胆管狭窄引起的化脓性胆管炎引起。其中3例死亡,1例未治,现就8例由化脓性胆管炎引起的胆管支气管瘘作一介绍并予讨论。临床资料(见表1)     

高龄坏疽性胆囊炎56例临床分析

回顾性分析l2年来收治的56例65岁以上坏疽性胆囊炎患者的临床资料，治愈55例，治愈率为98．2％；死亡l例。提示早期诊断、争取一期切除胆囊，或取净结石、胆囊造瘘；对合并胆管梗阻者，应解除梗阻、充分引流胆管。积极地选择合适的术式和细致的手术操作及术后有效抗感染措施是提高治愈率的关键。     

肝胆管结石合并支气管胆瘘35例诊治经验

目的 探讨肝胆管结石合并支气管胆瘘的诊治方法.方法 回顾性分析10年来35例患者的临床资料.结果 全组均行手术治疗,修补膈肌瘘口.其中行肝叶切除22例,胆管梗阻狭窄切开整形13例.胆总管T管支撑引流19例,肝断面胆管空肠内引流3例,肝胆管盆式Roux-en-Y内引流术13例.术后支气管胆瘘均无复发,肝内胆管结石残留4例.结论 患者咯出极苦的黄色脓痰是较为典型的临床特征.解除胆管梗阻,建立通畅引流是手术治疗的关键.     

胆管支气管瘘29例临床分析

目的 总结胆管支气管瘘(bronchobiliary fistula,BBF)的病因、病理及诊治经验.方法 回顾性分析1976-2009年收治的29例BBF患者的临床资料.结果 29例患者均有腹痛、寒战发热、黄疸、肝肿大;胸闷、咳嗽并咯血及咯胆汁痰,量为100～200 ml/d;右下肺闻及湿性啰音或呼吸音减弱或消失.29例患者先后选择胸部X线片或腹部X线片、A型超声、BUS、CT或PTC、MRCP、ERCP等诊断措施.29例患者均采用手术治疗,术式分别为胆总管切开取石、T型管引流术及膈下或肝脓肿引流、瘘管切除或膈肌瘘口修补术19例(其中2例同时行肝右后叶不规则切除术);胆囊切除、胆总管切开取蛔虫及取结石、T型管引流、膈下脓肿引流及膈肌瘘口修补术3例;胆囊切除、胆总管切开取蛔虫及取结石,胆管空肠Roux-en-Y型吻合术1例;肝外伤性膈下脓肿引流术,胆总管切开、T型管引流术3例;单纯行膈下脓肿引流及胆总管切开及T型管引流术2例;Oddi括约肌狭窄行肝脓肿切开引流及膈肌瘘口修补术并行胆管空肠Roux-en-Y型吻合术1例.手术治愈26例;死亡3例.结论BBF来自肝胆管梗阻和感染导致胆源性肝脓肿及肺脓肿,手术解除梗阻、去除病灶、通畅引流是治愈BBF的关键措施.     

胆管支气管瘘29例临床分析

目的 总结胆管支气管瘘(bronchobiliary fistula,BBF)的病因、病理及诊治经验.方法 回顾性分析1976-2009年收治的29例BBF患者的临床资料.结果 29例患者均有腹痛、寒战发热、黄疸、肝肿大;胸闷、咳嗽并咯血及咯胆汁痰,量为100～200 ml/d;右下肺闻及湿性啰音或呼吸音减弱或消失.29例患者先后选择胸部X线片或腹部X线片、A型超声、BUS、CT或PTC、MRCP、ERCP等诊断措施.29例患者均采用手术治疗,术式分别为胆总管切开取石、T型管引流术及膈下或肝脓肿引流、瘘管切除或膈肌瘘口修补术19例(其中2例同时行肝右后叶不规则切除术);胆囊切除、胆总管切开取蛔虫及取结石、T型管引流、膈下脓肿引流及膈肌瘘口修补术3例;胆囊切除、胆总管切开取蛔虫及取结石,胆管空肠Roux-en-Y型吻合术1例;肝外伤性膈下脓肿引流术,胆总管切开、T型管引流术3例;单纯行膈下脓肿引流及胆总管切开及T型管引流术2例;Oddi括约肌狭窄行肝脓肿切开引流及膈肌瘘口修补术并行胆管空肠Roux-en-Y型吻合术1例.手术治愈26例;死亡3例.结论BBF来自肝胆管梗阻和感染导致胆源性肝脓肿及肺脓肿,手术解除梗阻、去除病灶、通畅引流是治愈BBF的关键措施.     

重症急性胰腺炎15例诊治体会

回顾性分析10年间15例重症急性胰腺炎患者的手术与非手术治疗情况。非手术治疗3例，无并发症及死亡；手术治疗12例中，并发腹腔脓肿2例，胆瘘及肠瘘1例，死亡3例。手术死亡率25．0％，全组死亡率20．0％。提示重症急性胰腺炎早期，如无胆道梗阻，无并发感染和休克情况，应采用非手术综合治疗；如出现感染，休克和胆道梗阻症状，应积极手术探查，有望挽救病人生命，提高治愈率。     

胆管支气管瘘伴胆囊肝内胆管瘘1例

胆管支气管瘘伴胆囊肝内胆管瘘１例蒋江营胆管支气管瘘临床少见，迄今国内仅报告１１例［１－４］近来作者治疗１例。效果良好，特予报道。临床资料患者，女，５８岁，１９９０年１０月２４日入院。自１９８７年冬反复中上腹疼痛，寒战高热，伴有黄疸，诊断为“胆囊炎胆石...     

不同部位消化道梗阻的内支架治疗特点与对策

目的探讨不同部位消化道梗阻的内支架治疗特点与对策。方法消化道恶性梗阻63例采用71枚内支架治疗，全部使用永久性部分带膜镍钛合金支架，均在数字减影血管造影（digital subtraction angiography，DSA）监视下经口或肛门将支架置于梗阻部位，预扩张和后扩张分别为6例和3例，术前术后均做造影对照，根据进食和排便情况评价疗效，并做临床随访3～24个月，平均11个月。结果单次成功放置支架60例；胃窦部、十二指肠空肠曲及乙状结肠首次操作失败再次置入支架各1例。56例上消化道支架置入后恢复饮食47例，7例乙状结肠和直肠支架置入后肠梗阻症状即刻解除；8例食管-支气管瘘置入食管支架后瘘管完全封堵；1例残胃-纵隔-支气管瘘置入支气管支架后轻度呛咳，3周后瘘口基本闭塞。出现剧烈疼痛1例，轻度疼痛12例，大出血1例，支架移位2例，术后再狭窄2例，声音嘶哑1例。结论部分带膜镍钛合金支架置入术是消化道恶性梗阻和食管一支气管瘘的有效治疗方法。但对不同部位消化道恶性梗阻均应区别对待，必须使用相应的材料和操作方法，以提高其有效性和安全性。     

胆囊结石合并胆囊内瘘的诊治体会

目的分析总结胆囊结石合并胆囊内瘘的临床特征和诊治经验。方法回顾性分析20例胆囊结石合并胆囊内瘘患者的临床资料。结果20例患者临床症状无明显特殊，其中胆囊十二指肠瘘9例，胆囊结肠瘘5例，胆囊胃瘘4例，胆囊胆总管瘘2例。B超是目前首选的检查手段，其中16例提示胆囊呈萎缩状。本组仅有5例术前疑诊为胆囊内瘘（25％），其中1例行钡灌肠诊断为胆囊结肠瘘，2例B超示胆囊内积气，1例行腹部平片示胆管内积气，诊断胆囊结肠、胃瘘，1例行CT检查诊断胆囊十二指肠瘘。治疗均切除胆囊后，行十二指肠瘘修补术5例，十二指肠瘘修补术＋胃大部切除术4例；横结肠癌根治性切除1例，结肠瘘修补4例，胃瘘修补4例，胆总管修补＋T管引流1例，胆总管空肠Roux-en-Y吻合术1例。结论胆囊内瘘治疗原则仍然是切除病变的胆囊、切断瘘管、修补瘘口、酌情胆道探查、T管引流、解除消化道梗阻。     

Bronchobiliary fistulas in adults.

Reported herein are 16 cases of nontraumatic bronchobiliary fistula in adults observed over 32 years. The fistulas were due to either biliary obstruction or infectious diseases involving the liver. All patients had biloptysis and other respiratory symptoms, and most had cholangitis, jaundice, and/or sepsis. The diagnosis was established by fistulography or cholangiography. All patients except one were treated surgically by relief of biliary obstruction and drainage of intra-abdominal abscesses. All 15 surgically treated patients had a successful outcome. Rapid diagnosis and early treatment of septic complications are necessary, but careful assessment and surgical relief of the biliary obstruction are essential in successfully treating this condition.     

Ureteropelvic junction obstruction in the newborn

Ureteropelvic junction (UPJ) obstruction is a common cause of hydronephrosis in infants. Newborns with severe obstruction often have marked improvement following correction; therefore early diagnosis and operation is important. From 1973 to 1983, 21 patients were operated on for UPJ obstruction diagnosed under 6 weeks of age. Six patients (29%) had antenatal ultrasonographic diagnosis. The remaining patients were diagnosed by IVP or radionuclide scan for palpable renal enlargment or for associated anomalies. Seventeen had unilateral and four had bilateral obstruction. Twenty-three pyeloplasties, one primary nephrectomy, and one cutaneous pyelostomy with subsequent nephrectomy were done. All pyeloplasties were dismembered, with tailoring of the renal pelvis. Postoperative renal function was followed with radionuclide scan or IVP. Postoperative complications included a single urinary tract infection in three patients and two bowel obstructions. One early postoperative death occurred in an infant with bilateral obstruction who developed congestive heart failure secondary to severe uncontrollable hypertension. There were two other unrelated late deaths. Documented functional improvement with minimal complications follow unilateral or simultaneous bilateral pyeloplasty in newborns with UPJ obstruction.     

Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy.

Measurement of urinary flow rate was carried out on 39 male patients with bladder outlet obstruction due to benign prostatic hypertrophy. All patients were over 50 years of age. Ten subjects, by clinical evaluation, had doubtful bladder outlet obstruction, nine had mild obstruction and 20 patients had moderate or severe obstruction. Four criteria were used for clinical diagnosis: obstructive symptoms, size of prostate by rectal digital exploration, volume of postmicturition residual urine and degree of bladder trabeculation seen on cystourethroscopy. Considerable inaccuracy results from basing the degree of impairment of urinary flow on the patient's obstructive symptoms, degree of prostatic enlargement, postmicturition residual urine or degree of bladder trabeculation. Severe obstruction symptoms generally indicate impaired urinary flow but the absence of obstructive symptoms does not exclude impaired flow.     

缺血性急性肠梗阻的诊断与治疗

目的　探讨缺血性肠梗阻的病因及其诊断与治疗。方法　总结 6例缺血性肠梗阻的诊治经验 ,并从病因、诊断和治疗等方面进行分析。结果　 6例均经手术证实。全部进行手术治疗 ,均治愈。结论　缺血性肠梗阻少见。临床表现无特异性 ,术前难以诊断。及早剖腹探查及后续治疗是防止复发、降低死亡率的关键     

腹茧症16例诊治体会

目的 探讨腹茧症的诊断及治疗方法。方法 回顾性分析l6例腹茧症的临床资料及随访结果。结果 16例腹茧症均经手术治疗并确诊。术前11例误诊为机械性肠梗阻2～l0年，4例为误诊慢性阑尾炎，l例误诊为腹部肿块。术后并发症2例，全部患者均临床治愈。并获随访1～l0年，2例分别因反复发作肠梗阻于1年和5年死亡，2例反复发作不完全性肠梗阻合并营养不良，12例情况良好。结论 腹茧症术前诊断困难，上消化道造影和B超及CT对诊断可能有帮助；包膜切除，肠粘连松解是治疗本病的有效方法。     

粘连性肠梗阻的多层螺旋CT诊断及其临床应用价值

目的:探讨多层螺旋CT对粘连性肠梗阻的诊断作用。方法:对35例手术证实为粘连性肠梗阻患者的术前全腹多层螺旋CT征象进行回顾性分析，并以手术、病理结果为标准，评价CT诊断的准确性。结果:35例患者CT均确定了梗阻的存在。31例单发梗阻CT均准确确定了梗阻部位，4例多发梗阻者CT确定了11处梗阻中的9处。26例非癌性粘连中23例在CT上均有相应的CT征象支持粘连性肠梗阻的诊断;9例癌性粘连中5例CT发现癌性粘连的直接征象，2例提示癌灶复发或淋巴结转移。根据CT征象判断绞窄性肠梗阻的敏感性93.3％，特异性87.5％，准确性为91.4％。结论:多层螺旋CT可较为全面地评价粘连性肠梗阻，对于指导临床诊疗有较大帮助。     

Spontaneous sternal fractures in four patients with chronic airflow obstruction taking corticosteroids.

Four patients with chronic airflow obstruction developed spontaneous sternal fractures. All had received repeated courses of high dose corticosteroids and three were receiving long term treatment with low dose corticosteroids. It is important to consider sternal fracture in the differential diagnosis when patients with chronic airflow obstruction present with chest pain.     

Surgical management of congenital vascular rings.

Case histories of 53 patients with surgically treated vascular rings are presented. The diagnosis was strongly suggested in all patients by symptoms of tracheosophageal obstruction and was confirmed by barium esophagogram, which showed typical bilateral and posterior indentations in the esophagus. Angiography was rarely used although it is helpful in doubtful cases. Endoscopic studies were considered unnecessary and potentially harmful. A left posterolateral thoractomy afforded ample access for division of the ring in all patients. Two patients died who were operated upon during the early experience. There were no postoperative deaths among the last 45 consecutive patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. The importance of early diagnosis and prompt surgical division is emphasized.     

经皮肝穿胆道引流术治疗梗阻性黄疸

目的 评价经皮肝穿胆道引流术治疗梗阻性黄疸的临床价值。方法 １２例梗阻性黄疸,其中９例恶性梗阻（胆管癌４例,肝门淋巴结转移压迫胆管５例０采用ＰＴＣＤ姑息性引流,３例高危良性梗阻采用ＰＴＣＤ进行术前胆道减压。结果 ４例患者行内外引流术,８例行外引流术。经１－３周引流,８例血清总胆红素降至近正常,３例下降不满意,１你无效。３例高危良性梗阻者于引流减压后安全地进行了手术,７例恶性梗阻者于ＰＴＣＤ后１周１     

Duodenal tuberculosis: A review of the clinicopathologic features and management of twelve cases

A retrospective analysis of twelve cases of duodenal tuberculosis is presented herein. The average age of the patients was 31.4 years with a male to female ratio of 2:1. The presenting complaints were duodenal obstruction in six patients and subacute intestinal obstruction in three. None of the patients had associated pulmonary tuberculosis. Eight patients had isolated duodenal tuberculosis, two of whom were successfully treated with antitubercular drugs. In four patients, the diagnosis was established at laparotomy by the presence of tubercles over the duodenum. Five patients required a bypass procedure for obstruction caused by the duodenal tuberculosis and one patient was operated on for uncontrollable bleeding from a tubercular duodenal ulcer. All patients remained symptom free after treatment, whether medical or surgical. Thus, in areas where tuberculosis is endemic, even in the absence of pulmonary tuberculosis, duodenal tuberculosis should be suspected in patients with upper gastrointestinal obstruction or in patients with peptic ulcer like symptoms not responding to medical therapy