金石穿胶囊对致石豚鼠胆汁主要成分的影响

目的 :研究金石穿对致石豚鼠胆汁中几种主要化学成分的影响 ,以确定其防治胆石症的疗效。方法 :随机将 6 0只实验豚鼠分为正常组、模型对照组、胆石通组、金石穿组 ,用致石饲料诱发豚鼠胆囊结石模型 ,喂养一段时间后处死豚鼠 ,取胆汁 ,测定其胆汁中胆红素 (Bi L)、胆固醇 (Cho)、钙离子 (Ca2 )的含量。结果 :金石穿组胆汁中Cho、Bi L、Ca2 浓度均降低。结论 :金石穿能有效降低致石豚鼠成石率 ,具有明显的防治胆石症的作用     

碎石溶石排石三联疗法治疗胆石症临床疗效观察

目的：探讨碎石溶石排石三联疗法治疗胆囊结石的疗效。方法：根据胆石直径，个数将146例患者分为2组，胆石直径＜1．3cm2-3个和1．3－2．0cm单个结石为治疗组（107例），胆石直径＞1．3cm的多发结石和＞2．1cm的单发结石为试验组（39例），用三联疗法：B超监测定位碎石，口服熊去氧胆酸溶石，胆道排石汤和利胆剂，排胆剂，胆石治疗仪治疗，观察两组患者的疗效，副作用和复发率，结果：146例坚持三联疗法治疗3个月以上者，胆结石排净者88例，排净率60．3％，治疗组3个月结石排净率52．3％（56／107），试验组6个月结石排净率43．3％（17／39），治愈后，胆囊收缩功能增进率达63．3％，安全，无副作用，1年复发率为5．4％，累计4年复发率为17．3％，结论：碎石溶石排石三联疗法治疗胆石症是安全有效的。     

胆石症的中药治疗

胆石症分胆囊结石和胆管结石,对总胆管结石一般采用溶石、碎石和内镜下取石法,我国对肝內胆管结石的研究取得重大突破,我国学者1957年提出肝叶切除已成为治疗肝胆管结石的常用方法,中医药治疗本病在我国更具独特优势,通过临床研究对中药排石、溶石、防石机制有进一步的认识.本刊十分重视介绍本病的研究成果,创刊以来发表大批文章,主要涉及胆石症的临床、诊断进展(B 超、ERCP、PTC、磁共振胆胰管成象)、治疗进展(胆石介入性溶解、体外振波碎石、腹腔镜胆囊切除、内镜下括约肌切开取石、胆叶切除治肝胆管结石和狭管)以及中医、中西医结合研究进展.本次焦点论坛主要讨论胆石症的诊断和治疗,着重介绍中医和中西医结合研究本病的现状,以期引起国內同道对本病的重视。从而开展更为深入的研究.     

中西医结合治疗胆石症

胆石症分胆囊结石和胆管结石,对总胆管结石一般采用溶石、碎石和内镜下取石法,我国对肝內胆管结石的研究取得重大突破,我国学者1957年提出肝叶切除已成为治疗肝胆管结石的常用方法,中医药治疗本病在我国更具独特优势,通过临床研究对中药排石、溶石、防石机制有进一步的认识.本刊十分重视介绍本病的研究成果,创刊以来发表大批文章,主要涉及胆石症的临床、诊断进展(B 超、ERCP、PTC、磁共振胆胰管成象)、治疗进展(胆石介入性溶解、体外振波碎石、腹腔镜胆囊切除、内镜下括约肌切开取石、胆叶切除治肝胆管结石和狭管)以及中医、中西医结合研究进展.本次焦点论坛主要讨论胆石症的诊断和治疗,着重介绍中医和中西医结合研究本病的现状,以期引起国內同道对本病的重视。从而开展更为深入的研究.     

胆石症的治疗

胆石症分胆囊结石和胆管结石,对总胆管结石一般采用溶石、碎石和内镜下取石法,我国对肝內胆管结石的研究取得重大突破,我国学者1957年提出肝叶切除已成为治疗肝胆管结石的常用方法,中医药治疗本病在我国更具独特优势,通过临床研究对中药排石、溶石、防石机制有进一步的认识.本刊十分重视介绍本病的研究成果,创刊以来发表大批文章,主要涉及胆石症的临床、诊断进展(B 超、ERCP、PTC、磁共振胆胰管成象)、治疗进展(胆石介入性溶解、体外振波碎石、腹腔镜胆囊切除、内镜下括约肌切开取石、胆叶切除治肝胆管结石和狭管)以及中医、中西医结合研究进展.本次焦点论坛主要讨论胆石症的诊断和治疗,着重介绍中医和中西医结合研究本病的现状,以期引起国內同道对本病的重视。从而开展更为深入的研究.     

胆石症的诊断

胆石症分胆囊结石和胆管结石,对总胆管结石一般采用溶石、碎石和内镜下取石法,我国对肝內胆管结石的研究取得重大突破,我国学者1957年提出肝叶切除已成为治疗肝胆管结石的常用方法,中医药治疗本病在我国更具独特优势,通过临床研究对中药排石、溶石、防石机制有进一步的认识.本刊十分重视介绍本病的研究成果,创刊以来发表大批文章,主要涉及胆石症的临床、诊断进展(B 超、ERCP、PTC、磁共振胆胰管成象)、治疗进展(胆石介入性溶解、体外振波碎石、腹腔镜胆囊切除、内镜下括约肌切开取石、胆叶切除治肝胆管结石和狭管)以及中医、中西医结合研究进展.本次焦点论坛主要讨论胆石症的诊断和治疗,着重介绍中医和中西医结合研究本病的现状,以期引起国內同道对本病的重视。从而开展更为深入的研究.     

胆石症的中医病因病机

胆石症分胆囊结石和胆管结石,对总胆管结石一般采用溶石、碎石和内镜下取石法,我国对肝內胆管结石的研究取得重大突破,我国学者1957年提出肝叶切除已成为治疗肝胆管结石的常用方法,中医药治疗本病在我国更具独特优势,通过临床研究对中药排石、溶石、防石机制有进一步的认识.本刊十分重视介绍本病的研究成果,创刊以来发表大批文章,主要涉及胆石症的临床、诊断进展(B 超、ERCP、PTC、磁共振胆胰管成象)、治疗进展(胆石介入性溶解、体外振波碎石、腹腔镜胆囊切除、内镜下括约肌切开取石、胆叶切除治肝胆管结石和狭管)以及中医、中西医结合研究进展.本次焦点论坛主要讨论胆石症的诊断和治疗,着重介绍中医和中西医结合研究本病的现状,以期引起国內同道对本病的重视。从而开展更为深入的研究.     

计算机辅助控制胆囊结石自动灌注溶石仪体内外溶石的实验研究

胆石症是我国的常见病。目前的治疗方法均属于有创性手段，且均有禁忌证或相对禁忌证。因此，胆石病的非手术疗法是当前临床研究的热点。本研究采用我科研制的计算机辅助控制胆囊结石自动灌注溶石仪（DRY-03A胆石溶解仪）进行体内外溶石试验，为进一步研发和应用提供依据。     

金属元素和糖蛋白在胆石形成中作用的实验研究

为了探讨金属元素和糖蛋白与胆石形成的关系。本实验动态观测了豚鼠胆囊结石形成时，胆囊胆汁内钙、镁、铜、锌、铁元素浓度变化和胆囊分泌糖蛋白的变化，测定了胆石内金属元素含量。结果提示：炎性胆囊分泌的酸性糖蛋白和成石胆汁内高浓度的钙、镁、铜元素可能参与了胆石形成的初始机制。其中钙是与游离胆红素和糖蛋白结合形成胆石的主要金属元素。成石胆汁内金属元素浓度变化除有促进胆石形成的作用外，也可能有抑制胆石形成的作用。     

胆石症辨治经验浅议

目的动用中医中药，采用胆石“总攻”或“缓攻”疗法治疗胆石症．方法胆石“总攻”或“缓攻”疗法是根据“以通为用”的原则，有机地组合中医治疗措施，集中力量，以攻下结石．其排石原理主要可分为三个步骤．首先以中药使胆汁分泌增加；其次应用药物将胆管下端括约肌收缩，使胆汁暂时贮留，增加胆压；然后利用药物、电针等开放括约肌、收缩胆囊，大量排胆．将胆系内结石一举攻下或加速排出．胆石症的病位以肝胆为主，且常波及脾胃，病邪为气郁、血瘀、湿热，三者互为因果，互相转化．又胆为“中清之腑”，以通降下行为顺．故治疗原则以“理气活血，通里攻下，清热燥湿”为主因此排石汤主要由：茵陈、郁金、枳壳、木香、大黄、芒硝、栀子等药味组成．临证时根据病情而选用“总攻”疗法或“缓攻”疗法．具体如下：①胆石“总攻”疗法：胆石“总攻”疗法，不论是症状缓解期，还是症状发作期，均可应用．一般每周宜“总攻”2～3次，6～7次为一个疗程．治疗具体程序如下：中药排石汤一副，口服；吗啡，皮下注射；硫酸镁，口服；脂肪餐（油煎鸡蛋2～3个）；电针30min（右胆俞、日月或梁门、大冲）．②胆石“缓攻”疗法：胆石症症状缓解期或发作期均可应用“缓攻”疗法，此法对泥砂样小结石更为适用．具体治疗     

Perioperative fluorocholangiography with routine indication versus selective indication in laparoscopic cholecystectomy

BACKGROUND: The use of routine or selective peroperatory cholangiography in cholecystectomy is a matter of controversy in literature. AIM: To compare the efficacy of selective or routine fluorocholangiography in diagnostic of common bile duct stone in patients underwent to laparoscopic cholecystectomy based on selective indication criteria. METHOD: Two hundred and fifty four patients with cholelithiasis were prospectively studied. The patients were divided in two groups: to the first 127 patients perioperative fluorocholangiography was indicated as routine (group 1), and to the other 127 patients perioperative fluorocholangiography indication followed clinical criteria (jaundice, choluria, fecal acholia and history of pancreatitis), laboratory criteria (increase in seric alkaline phosphatase, bilirubins, amylase) or ultra-sonographyc criteria (less than 6 mm diameter calculi, common bile duct stone, common bile duct diameter more than 6 mm). A comparative assessment of the difference in common bile duct stone diagnosis, fluorocholangiography success index and reliability of the selective criteria of indication for perioperative fluorocholangiography was compared between the two groups. RESULTS: Perioperative fluorocholangiography was successfully performed in 102 of the 127 patients from group 1 (a rate of 80.3%), and in 59 of the 71 patients from group 2 (a rate of 83.1%). In the 102 patients of group 1 who underwent perioperative fluorocholangiography, 11 (10.8%) presented common bile duct stone, 4 (3.9%) presented common bile duct dilatation, and 1 (1%) had a false-positive image. In the 59 patients from group 2, 7 (11.7%) presented common bile duct stone and one (1.7%) presented a common bile duct diatation. In another situation, when application of selective indication criteria to perioperative fluorocholangiography was simulated in group 1 patients, we observed that only in one patient with common bile duct stone the diagnostic would not have been made. Fluorocholangiography selective indication criteria presented sensitivity of 90.9% and specificity of 46.2%. The main causes of fluorocholangiography failure were biliary pedicle inflammation and cystic duct size and caliber variations. CONCLUSION: There was not a significant difference in common bile duct stone diagnostic through perioperative fluorocholangiography between the groups of patients with selective and routine indication, validating the examination selective indication criteria, with a sensitivity of 90.9%, despite the specificity of 46.2%--43 patients were selected to the flourocholangiography and common bile duct stone was not diagnosed.     

Gall stone disease without gall stones--bile acid and bile lipid metabolism after complete gall stone dissolution.

Although bile acid and bile lipid metabolism have been studied in established cholelithiasis, little is known about them in patients destined to develop gall stones, but in whom the stones have not yet appeared (prestone gall stone disease). After confirmed complete gall stone dissolution and withdrawal of treatment, gall stones recur frequently. Before the stones reappear, these patients have 'poststone gall stone disease'. In 13 such patients we confirmed complete gall stone dissolution with two normal cholecystograms and in 11 of the 13 by normal ultrasonography, measured bile acid and bile lipid composition in fasting duodenal bile, bile acid synthesis from marker corrected three day faecal bile acid excretion, bile acid pool size using an abbreviated isotope dilution technique, 'steady-state' bile lipid secretion using a duodenal amino acid perfusion system and then calculated the enterohepatic cycling frequency of the bile acid pool and the relationship between pool size and body weight. The results confirm that after withdrawal of treatment the biliary cholesterol saturation index reverts to levels (1.6 +/- SEM 0.4) comparable with those before dissolution therapy first began (1.6 +/- 0.2; NS). The mean bile acid pool size in the 13 patients of 4.4 +/- 0.5 mmol was comparable with that in untreated gall stone patients. Pool size was significantly smaller in the nine non-obese patients (3.5 +/- 0.3), than in the four obese (6.0 +/- 0.8; p less than 0.05). It also correlated significantly with body weight (r = 0.72) and with %IBW (r = 0.79). The coefficients of variation for biliary bile acid, phospholipid and cholesterol secretion were high, but the mean hourly secretion rates were of the same order as those seen in untreated gall stone patients studied with the amino acid duodenal perfusion stimulus. These results provide a baseline for assessing the response to postdissolution treatment and may indicate metabolic events leading to gall stone formation.     

Pathogenesis of cholelithiasis in chronic pancreatitis]

The prevalence and the pathogenesis of gallstones in patients with chronic pancreatitis have never been studied prospectively. The aim of this study was to evaluate prospectively the prevalence of gallstones with ultrasonography and to look for markers of pigment or cholesterol stone formation in gallbladder bile. Ultrasonography was performed in 39 patients and detected gallstones in 7 patients and sludge in 3. Common bile duct and intrahepatic bile duct dilatation were observed in 16 and 13 patients, respectively. Liver biopsies were obtained in 31 patients and cirrhosis was found in 4. There were calcium bilirubinate granules in 7 of the 27 bile samples examined. Cholesterol crystals were not found in any case. The nucleation time (median: 21 days) was higher in patients with chronic pancreatitis than in patients with cholesterol stones (median: 2 days) (P < 0.001) but was not different from nucleation time in patients either free of stones (median: 21 days) or with pigment stones (median: 21 days). The cholesterol saturation index was similar in patients with chronic pancreatitis and in controls. The 2 patients with chronic pancreatitis who underwent cholecystectomy had pigment stones. Calcium bilirubinate granules were more frequent in patients with intrahepatic bile ducts dilatation (P < 0.02). In conclusion, this study demonstrates a high prevalence of cholelithiasis in chronic pancreatitis patients. Pigment stone formation could be favored by cholestasis.     

Quantitative study of metals in bile from patients with cholelithiasis.

OBJECTIVE: Biliary lithiasis is a multifactorial phenomenon that is decisively influenced by the composition of bile. We analyzed the presence of eight metals in bile and compared their concentrations in healthy persons and patients with cholelithiasis. METHODS: We studied bile from 119 patients who underwent cholecystectomy because of symptomatic cholelithiasis, and from 25 control subjects in whom the gallbladder was removed for reasons other than cholelithiasis. Metal concentrations were analyzed by atomic absorption spectrophotometry. The subjects were divided into subgroups according to age, sex and type of stone. RESULTS: Bile from patients with cholelithiasis contained significantly less of the essential element magnesium (Mg) and the toxic element lead (Pb) than bile from control subjects. Calcium (Ca) and strontium (Sr) concentrations were also lower in patients with gallstones than in the control group, although the differences were not significant. CONCLUSIONS: Biliary concentrations of Mg and Pb were significantly lower in patients with cholelithiasis than in the control group. The biliary excretion of Ca and Sr was lower in patients than in controls, although the differences were not statistically significant.     

南宁市健康体检老年人胆石症患病情况调查及其与性别和年龄关系的分析

目的调查南宁市健康体检老年人胆石症患病情况及其与性别、年龄的关系,为临床诊治策略的制定提供依据。方法统计2011年全年在广西壮族自治区人民医院健康体检中心进行健康体检的本市60岁及以上老年人2 257名（男1 294名,女963名）的胆石症患病率,按年龄分为三组：A组60~69岁,B组70~79岁,C组≥80岁,采用SPSS for windows 17.0统计学软件对数据进行分析。结果 （1）该组老年人群中胆石症总的患病率为12.5%,除肝内胆管结石和胆总管结石各1例外,其余全部为胆囊结石。（2）男性和女性胆石症患病率分别为8.2%和18.2%,女性胆石症患病率显著高于男性,差异有统计学意义（P〈0.01）。女性各年龄组胆石症患病率均高于同年龄组男性,差异有统计学意义（P〈0.01）;女性各年龄组间胆石症患病率比较差异有统计学意义（P〈0.05）,女性胆石症患病率随年龄增长而升高,80~93岁组患病率最高。男性各年龄组间胆石症患病率差异无统计学意义（P〉0.05）。结论南宁市健康体检老年人胆石症以胆囊结石为主,胆管结石所占比例小。女性老年人胆石症患病率显著高于男性,女性老年人胆石症患病率随年龄增长而升高。     

The effect of polyunsaturated fats on bile acid metabolism and cholelithiasis in squirrel monkeys.

Squirrel monkeys (Saimiri sciureus) were fed diets containing safflower oil, butter, or coconut oil and 1 mg cholesterol/cal for 15--17 mo to examine the effect of type of fat on cholelithiasis and bile acid metabolism. Controls were fed low cholesterol diets containing an isocaloric mixture of the three fats. Cholic acid fractional catabolic rate, pool size, chenodeoxycholic acid pool size, and total bile acid pool size and excretion rate were estimated using a modification of Lindstedt's isotopic turnover procedure. The animals fed the safflower oil diet had the highest incidence of cholelithiasis (9/10) when compared to those fed butter (3/7) and coconut oil (1/7). Animals consuming the low cholesterol control diet did not develop gallstones. The butter- and coconut oil-fed groups had significantly (p less than 0.05) expanded bile acid pools when compared to controls, and the butter-fed group had a significantly increased (p less than 0.05) cholic acid fractional catabolic rate. The safflower oil group had the smallest mean bile acid pool and the highest mean lithogenic index of the cholesterol-fed groups. It was concluded that the safflower oil-fed animals had a higher incidence of cholelithiasis than the butter group because, unlike the latter group, they did not compensate for a high cholesterol intake by stimulating bile acid synthesis. The animals consuming coconut oil apparently did not absorb cholesterol to the extent of the other groups and as a result their bile did not become saturated with cholesterol.     

三维可视化指导不同手术方法联合硬胆道镜治疗复杂性肝胆管结石临床研究

目的 探讨三维可视化指导下不同手术方法联合硬胆道镜治疗复杂性肝胆管结石患者的效果。方法 2014年3月~2016年3月我院诊治的58例复杂性肝胆管结石患者,在三维可视化系统行三维重建和术前仿真,采用不同手术方法联合硬胆道镜取石治疗。结果 所有患者术前三维可视化重建情况与术中所见大致相符,实际手术方案与仿真手术方案符合率为100%。31例因存在萎缩肝叶或肝段和难以取净的多发结石,行肝部分切除术,预切除体积为（241.6±26.2） mm³,与实际切除体积相符;27例行经胆总管切开探查取石。36例行胆管狭窄扩张术,并予以置入胆管支撑管重建胆道;在行经胆总管切开探查取石患者中,均一期术中经硬胆道镜取尽结石,经T管造影检查无结石残留,其中2例因化脓性胆囊炎不能一期处理,1例因高龄和结石过多,先行部分取石。后3例患者均行二期三维可视化指导下经T管窦道硬胆道镜靶向碎石、取石,均取尽结石;随访9~31个月,无1例结石复发。结论 三维可视化指导个性化手术联合硬胆道镜取石治疗复杂性肝胆管结石患者安全有效,可提高结石清除率,降低远期复发率。     

Kinetics of cholesterol and bile acids in patients with cholesterol cholelithiasis.

The kinetics of cholesterol and bile acid was determined from a 10-week analysis of the biliary lipids after a single injection of labeled cholesterol in parallel with a conventional 1-week study of primary bile acid kinetics. Six healthy controls and 6 patients with cholesterol cholelithiasis were studied. Two of the 6 cholesterol cholelithiasis subjects had kinetic values that were very similar to the controls and the other 4 were significantly different. These 4 patients had significantly smaller primary bile acid pools and significantly lower fractional conversions of cholesterol to both primary bile acids, with concomitantly lower bile acid flux. No significant differences were obtained for the size of the rapidly miscible cholesterol pool, the fractional rate of loss and flux of biliary neutral sterol, and the fractional turnover of the primary bile acid pools. These kinetic data support the hypothesis that in some patients with cholesterol cholelithiasis there is defective conversion of cholesterol to bile acids.     

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.     

Microscopic examination of bile directly collected during endoscopic cannulation of the papilla

The usefulness of microscopic examination of pure bile directly collected from the biliary tract during endoscopic retrograde cholangiography and without hormonal simulation was prospectively evaluated in 72 patients. According to clinical, biochemical, ultrasonographic, and radiographic data, the patients were separated into two groups: group 1, patients with proven stones (N = 50), and group 2, patients with suspected microlithiasis presenting symptoms suggestive of cholelithiasis but without evidence of macroscopic stones at echography or cholangiography (N = 22). Cholesterol crystals and/or bilirubinate granules were observed (eg, positive examination) in the bile of 41 of the 50 patients of group 1 (82%). Among patients of group 2, seven (32%) had a positive bile examination: cholecystectomy (N = 2) or endoscopic sphincterotomy (N = 5) disclosed minute stones in all cases. In the 15 patients of group 2 with a negative bile examination, cholecystectomy (N = 3), sphincterotomy (N = 2), and clinical (and/or echographic) 20-month follow-up (N = 9) revealed biliary lithiasis in only one patient, in whom recurrent cholangitis led to disclosure of one bile duct stone. According to these results, microscopic examination of bile samples collected during endoscopic retrograde cholangiography exhibited a sensitivity and a specificity for cholelithiasis recognition of 82.7% and 100%, respectively, with a positive predictive value of 88%. We conclude that the accuracy of this method makes it useful to investigate and manage patients with suspected microlithiasis.