胆汁,胆酸和胆石：新知识将会提供新能力吗？

胆酸的生物合成:消除胆固醇的方法胆酸为胆固醇代谢的最终产物。其最主要的“目的”是能够变成一种水溶性的生物转运产物,以能在胆汁中被清除。因此,胆酸的生物合成与胆固醇解毒为同义语。在较低等的脊椎动物不形成胆酸,胆固醇侧链上的变化仅限于一个或多个羟基化,因此其最终的生物转运产物为胆汁醇。可能大多数胆汁醇都不溶于水,因此在其形成以后必须转化成水溶性形式。在原始的脊椎动物通过硫酸盐对胆汁醇的酯化来完成。相反在较高等脊椎动物则形成在硷性pH值环境中可溶性的胆酸。Haslewood花费了一生的精力提取各种脊椎动物的胆醇和胆酸,提出应将所有这些化合物统称为“胆盐”。     

胆石成分与胆石症的诊断和防治

胆石症是胆道系统最常见的一种胆道疾病；在世界范围内，其发病率达1％-10％，该病在中年肥胖女性中尤为多见，有高发和年轻化的趋势。近年来，随着对胆石症研究的不断深入，对胆结石的成因及其防治等都有了进一步的认识。现就临床工作中经常遇到的两个问题，结合文献作一介绍。     

烧伤病人血清铁,铜,锌含量和转运蛋白的变化

对１５例严重烧伤病人（烧伤面积≥３０％）血清锌、铜、铁及其转运蛋白的同步动态观察发现，烧伤后血清微量元素和转运蛋白均显著降低，锌、铜和铁分别于伤后１周、３周左右恢复正常，而白蛋白、铜蓝蛋白和转铁蛋白的降低持续较久。烧伤后血清锌、铜和铜蓝蛋白的变化之间呈显著性正相关。本文着重讨论了微量元素与转运蛋白之间的关系及其创面修复、造血功能、菌血症发生的作用，提示临床上应重视两者的补充。     

西宁地区血清中微量元素（镉,锌,铜,铅）与冠心病关系的研究

目的：探讨西宁地区人群血清中微量元素（镉、锌、铜、铅）与冠心病的关系；方法：使用ＭＰ－１型溶出分析仪采用电位溶出法测定之；结果：与健康人组对照，冠心病患者血清中Ｃｄ、Ｚｎ含量明显增高（Ｐ〈０．０１），Ｃｕ含量明显降低（Ｐ〈０．０１），导致Ｃｕ／Ｚｎ比值显著失调（Ｐ〈０．０１）；西宁地区健康人群中血清中Ｃｄ、Ｚｎ含量低于平原地区（山东济宁市）的健康人群，Ｃｕ、Ｐｂ含量则反之，四者均有显著性差异（Ｐ〉     

体外胆石的CT分类和化学成分关系的研究

目的：探讨体外胆石的ＣＴ分类和化学成分的关系。材料和方法：６０例胆石标本进行体外ＣＴ扫描，以红外光谱仪定量分析所有结石的四种主要化学成分。结果：胆石分成５类；胆石的ＣＴ类型与其化学成分及形态特点密切相关；胆石的ＣＴ值与其胆固醇含量成显著负相关（ｒ＝－０．６３），而与碳酸钙的含量成显著正相关（ｒ＝０．６５）；胆固醇和非胆固醇性结石的ＣＴ值有显著差异，以ＣＴ值－５０Ｈｕ为两者的判断界值，其敏感性和特异性分别为９０％及９７．５％。结论：ＣＴ能准确预测胆石的化学性质和形态特点。     

肝癌、胆管癌患者血清微量元素及酶活性水平的研究

对23例肝癌,11例胆管癌患者血清Zn、Cu、Mn、Cd含量进行测定分析,同时测定丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、碱性磷酸酶(ALP)、γ-谷氨酰转肽酶(GGT)活性,并同36例健康人作对照比较。结果显示:肝癌、胆管癌血清Cu、Mn、Cd含量明显高于对照组(P<0.01),血清Zn低于对照组(PO.05),而ALT与正常对照组无显著性差异(P>0.05)。以上结果提示血清Cu、Mn、Cd、Zn含量及AKP、GGT、AST、ALT活性的联合检测可作为肝癌、胆管癌诊断、疗效观察及预后的参考指标。     

原发性胆汁性肝硬化患者63例血清内毒素的变化

目的 探讨原发性胆汁性肝硬化(PBC)患者病程进展中血清内毒素(LPS)变化的意义及其与血生化之间的关系.方法 对63例经肝穿病理确诊为PBC患者的临床特征、血生化指标和血清自身抗体指标进行分析,将检查组织分为早期组(相当于Ⅰ、Ⅱ期)和晚期组(相当于Ⅲ、Ⅳ期),并与30例健康成人作比较.应用鲎试剂微量基质法对63例PBC患者血清进行内毒素水平检测.结果 63例PBC患者中男女比例为1∶8,平均年龄为43.5岁,黄疸、乏力症状明显,抗线粒体抗体(AMA)阳性率为70.3%,血清γ-GGT、ALP和胆红素显著升高,与早期组比较,晚期组血清AST、ALT水平有所降低,差异有显著性(P＜0.05),但总胆红素和直接胆红素均明显升高(P＜0.01);PBC患者血清内毒素水平明显升高,与正常对照组比较差异显著(P＜0.05),且随疾病进展而增加;在早期组及晚期组LPS水平与ALP、TB、DB呈正相关,早期组r值分别为0.543,.568,.533(P均＜0.01),晚期组r值分别为0.614,.502,.513(P＜0.01或0.05).结论 血清LPS水平与PBC的发病及疾病进展有一定的相关性;对于血清AMA阴性的PBC病例,肝穿刺病理确诊是必要的.     

胆石症患者血清胃泌素、胰岛素及血糖变化的临床研究

测定了胆石症患者和非胆石症患者血清胃泌素、胰岛素和血糖浓度,并行纤维胃镜检查。结果发现,胆石症患者血清胃泌素、胰岛素水平明显高于非胆石症患者(P<0.01)。胆石症组胃炎、胃溃疡发病率亦高于非胆石症组。认为胆石症容易引起胃部疾病,也是糖尿病重要的病因之一。     

内镜对胆石症术后患者的诊断和治疗价值

目的：探讨内镜对胆石症术后患者的诊治价值。方法：对185例胆石症术后患者行ERCP明确病因后,胆管结石行内镜乳头括约肌切开术后取石;怀疑Oddi括约肌功能障碍（SOD）者行乳头小切开;胆漏患者行ENBD（鼻胆管引流）或ERBD（胆道塑料支架置入）。确诊胆总管占位行ERBD或EMBE（胆道金属支架置入）。结果：182例（98%）ERCP成功。135例胆道结石成功取石。胆漏7例,5例行ENBD,2例行ERBD,SOD15例予乳头括约肌小切开。胆囊管结石3例,行ENBD。10例胆管肿瘤行EMBE 8例及ERBD 2例。胆总管截断2例转外科治疗。胆道系统正常10例。术后3例并发急性胰腺炎,4例并发上消化道出血,总的并发症发生率4.3%。结论：内镜下ERCP能明确胆石症术后患者的病因,同时可给予相应的内镜治疗。     

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p = 0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p = 0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.     

原发性肝癌介入化疗栓塞治疗术前后血清总胆汁酸测定的价值

目的　探讨血清总胆汁酸(TBA)检测在原发性肝癌介入治疗围手术期肝功能储备及预后评价的价值。方法　分析1 6 0例接受动脉介入化疗栓塞的原发性肝癌患者围手术期血清TBA水平与肝功能损伤程度、肝硬化、介入治疗方式及术后肝功能衰竭的关系。结果　1 6 0例肝癌患者术前血清TBA值较正常对照组明显升高(P <0 .0 1 ) ,ChildA级相似文献   

Preoperative evaluation of common bile duct stones in patients with gallstone disease

OBJECTIVE: Our objective was to suggest criteria for selection of a preoperative diagnostic technique for patients with gallstone disease. CONCLUSION: Use of MR cholangiography preferentially before laparoscopic cholecystectomy, on patients who have a moderate or high risk of common bile duct stones, can significantly reduce purely diagnostic endoscopic retrograde cholangiography.     

Causes, clinical features and non-operative management of bile leaks

This paper evaluates the management of 31 patients with bile leaks identified over a 7-year period. Leaks complicated cholecystectomy in 19 patients (11 laparoscopic, 8 open), interventional procedures in 10 (including surgery in 1), trauma in one and was spontaneous in one case. Confirmation of the diagnosis typically lagged behind the onset of symptoms (mean for the group 4.2 days), indicating that a high index of suspicion is required in at-risk patients with typical symptoms. These include abdominal pain or distension, fever, bile leaking along a drain, jaundice, abnormal liver function tests and elevated white cell count. Two post-surgical bile leaks required surgical drainage of abdominal cellections. The remainder were successfully managed by non-operative methods including percutaneous drainage, endoscopic retrograde cholangiography with or without sphincterotomy or stent placement and percutaneous stenting. The spontaneous leak and all bile leaks complicating interventional procedures were managed non-operatively, although six patients in this group died due to the underlying malignant pathology. Only the patient with self-inflicted transection of the bile duct died directly from the complications of the bile leak. Although this is a varied, small series, we conclude that the majority of bile leaks can be managed by non-operative techniques. Whilst endoscopy is the primary modality for treatment, percutaneous techniques are crucially important for the management of complex cases and endoscopic failure. Received 3 September 1997; Revision received 2 February 1998; Accepted 20 March 1998     

血液透析患者血清钙磷控制与继发性甲状旁腺功能亢进症的横断面研究

目的分析长期血液透析患者血清钙、磷控制与继发性甲状旁腺功能亢进症的发生情况,指导临床治疗。方法选择我院2012年12月之前血液透析时间大于6个月的患者79例,回顾性分析记录患者血清钙、磷、钙磷乘积、甲状旁腺素浓度、年龄、透析龄、Kt/V等指标并进行统计分析。结果 79例血透患者平均校正血清钙（1.97±0.21）mmol/L,平均血磷（1.93±0.52）mmol/L,平均钙磷乘积（47.82±12.98）mg^2/dl2,平均甲状旁腺素（iPTH）浓度（398.32±282.34）pg/ml;血清磷达标率为30.4%,血清校正钙达标率为20.5%;血清iPTH达标率为32.9%,血清Ca×P达标率为75.9%;高磷血症发生率为63.3%,继发甲状旁腺功能亢进发生率为55.7%,低钙血症发生率为76.9%。单因素分析显示血清磷浓度、年龄、透析龄与iPTH控制水平相关;多元Logistic回归分析显示透析龄和血磷与甲状旁腺水平呈正相关,是继发甲状旁腺功能亢进的独立危险因素。结论血磷、透析龄是影响继发甲状旁腺素异常代谢独立危险因素。长期血液透析患者需要将血磷、校正血清钙维持在KDOQI指南建议的目标范围内,发生继发甲状腺旁腺功能亢进的危险才能降低。     

MR cholangiopancreaticography and endoscopic retrograde cholangiopancreaticography in patients with suspected common bile duct stones

Purpose: To prospectively compare MR cholangiopancreaticography (MRCP) vs. endoscopic retrograde pancreaticography (ERCP) in patients with suspected common bile duct (CBD) stone disease.Material and Methods: Fifty consecutive patients with suspected CBD disease underwent MRCP and then ERCP within 12 h of each other. The result of the MRCP was blinded to the reader of the ERCP. The MRCP was done using a superconducting 1.0 T unit with a heavily T2-weighted breath-hold technique. The ERCP was done in the fluoroscopy suite by one of the clinicians and was evaluated by one of the radiologists who had not read the MRCP examinations.Results: There were 28 true-positives, 17 true-negatives, 1 false-positive, and 4 false-negatives. The sensitivity was 87.5% and the specificity 94.4%, respectively. The positive predictive value was 96.6% and the negative predictive value was 81.1%.Conclusion: MRCP was shown to be good enough to replace ERCP as a diagnostic method in patients with suspected CBD disease. MRCP is now our modality of choice after ultrasound in the diagnostic evaluation of these patients.     

腹腔镜下胆道镜胆总管探查取石135例临床应用

目的：总结腹腔镜联合纤维胆道镜治疗胆囊结石合并胆总管结石的临床疗效。方法：回顾性总结我科2011-07-2013-12收治的135例胆囊结石合并胆总管结石患者经腹腔镜联合纤维胆道镜取石的＂一步＂微创治疗临床资料。结果：135例患者均安全出院,无围手术期死亡;中转开腹率5.2%（7/135）。128例腹腔镜下顺利完成胆道镜探查胆总管取石术,平均手术时间115min,术中平均出血量120ml,其中13例（10.2%）经胆囊管完成胆道镜探查胆总管取石,115例（89.8%）经胆总管切开完成手术。术后主要并发症：胆漏,均为一过性,发生率为8.6%（11/128）,经腹腔引流管引流痊愈;结石残余,发生率为7.0%（9/128）,均采用胆道镜经窦道成功取出;另有2例术后发生急性肾功能衰竭,经连续性肾脏替代治疗（CRRT）等治愈;1例胆道出血,经保守治疗治愈;1例Oddi括约肌狭窄,经内镜括约肌切开（EST）治愈。结论：对于胆囊结石合并胆总管结石的患者,采用腹腔镜联合术中胆道镜取石,可以＂一步＂解决胆囊和胆管结石,充分发挥微创外科安全、有效、恢复快的优势。     

急性胆石性胰腺炎的CT和ERCP相关性分析

目的：探讨急性胰腺炎与胆石症的相关性。方法：对46例胆石性胰腺炎的资料进行回顾性分析，对其CT表现和经内镜逆行胰胆管造影(endoscopic rctrograde cholangiopancreatography，ERCP)表现进行比较。结果：46例中39例为轻度胰腺炎，7例为坏死性胰腺炎。15例CT显示胆囊结石，24例ERCP可见胆囊结石。2例CT显示总胆管结石，16例ERCP可见总胆管结石。结石的大小与胰腺炎的严重程度无明显的相关性。结论：胆石症是引起急性胰腺炎的原因之一，其他致病因子在疾病的进展和预后中可能起更为重要的作用。胆石性胰腺炎应强调综合治疗，并提出胆石性胰腺炎治疗的设想。