急性胆道梗阻大鼠肝细胞的死亡方式

目的:通过建立大鼠急性胆道梗阻模型研究梗阻性黄疸时肝细胞死亡方式.方法:♂ Wistar大鼠随机分为胆道结扎(BDL)组和对照(C)组.BDL组采用Yoshidome法建立急性胆道梗阻模型,7 d后取材,应用流式细胞仪检测肝细胞胀亡和凋亡的百分比,HE染色和电镜观察肝组织病理组织学改变以及肝细胞凋亡、胀亡,并检测血清总胆红素TBIL,DBIL,ALP,γ-GT,ALT,AST和LDH水平.结果:BDL组胀亡和坏死细胞百分比均显著高于C组(胀亡:25.41%±2.18% vs 6.12%±1.69%:坏死:3.99%±1.24% vs 0.79%±0.29%;均P＜0.05),而凋亡百分比显著低于C组(2.79%±1.43% vs 5.18%±1.87%,P＜0.05).BDL组胀亡细胞百分比显著高于凋亡(25.41%±2.18% vs 2.79%±1.43%,P＜0.05).肝病理组织学检查发现BDL组胆管增生,纤维结缔组织明显增生,肝细胞索排列紊乱,胀亡增加.BDL组血清TBIL,DBIL,ALP,γ-GT,AST,ALT和LDH水平均显著高于C组(P＜0.05).结论:急性胆道梗阻时大鼠肝细胞死亡以胀亡为主,其肝功能损伤程度与肝细胞胀亡、凋亡有密切关系.     

ERCP联合PTCD治疗肝门部胆管恶性梗阻1例

1例48岁男性患者,因胃癌浸润肝门胆管导致梗阻性黄疸。ERCP治疗失败后行PTCD术,随后行ERCP联合PTCD在左右肝管放置双塑料支架成功。     

Resected cystadenoma of the common bile duct

Biliary cystadenoma in the extrahepatic bile ducts is a very rare tumor. A 62-year-old woman with jaundice was admitted to our hospital. Imaging studies revealed a 4-cm cystic lesion around the hepatic hilum, compressing the common bile duct (CBD). When laparotomy was performed, a cystic tumor was detected in the hepatic hilum, filling the lumen of the CBD. Bile duct resection that included the tumor was performed, followed by biliary reconstruction. Microscopically, the cyst wall was lined by a single layer of cuboidal epithelial cells, covering an ovarian-like stroma. The degree of atypia was low and warranted the diagnosis of cystadenoma.     

Diffuse intrahepatic bile duct dilation caused by a very small hepatic cyst

A 72-year-old woman presented to our hospital with diffuse dilation of the intrahepatic bile ducts. Imaging studies revealed a solitary hepatic cyst, 3?cm in diameter, in segment 4 of Couinaud's category of the liver, riding on the hilar hepatic duct. Deroofing of the hepatic cyst was performed, and the dilation of the intrahepatic bile ducts was attenuated. We concluded that even a very small solitary hepatic cyst might cause stenosis of the common hepatic duct, if it is located just above the hepatic hilum.     

Effect of ZVAD-fmk on hepatocyte apoptosis after bile duct ligation in rat

AIM: Retention and accumulation of toxic hydrophobic bile salts within hepatocyte may cause hepatocyte toxicity by inducing apoptosis. Apoptosis is a pathway of cell death orchestrated by a family of proteases called caspases. Z-Val-Ala-Asp (OMe)-fluoromethyl ketone (ZVAD-fmk) is a cell-permeable irreversible inhibitor of caspase. The purpose of this study was to evaluate the possible effect of ZVAD-fmk on hepatocyte apoptosis after bile duct ligation in the rat. METHODS: Male Sprague-Dawley rats, weighing 250-300 g, were randomized to five groups of five rats each. Group 1 underwent common bile duct ligation and simultaneous treatment with ZVAD-fmk (dissolved in dimethylsulfoxide (DMSO)). Group 2 underwent common bile duct ligation and simultaneous treatment with Z-Phe-Ala-fluoromethyl ketone (ZFA-fmk, dissolved in DMSO). Group 3 underwent sham operation and simultaneous treatment with the same amount of DMSO. Group 4 underwent sham operation and simultaneous treatment with the same amount of normal saline. Group 5 underwent common bile duct ligation without other manipulation. After three days, liver tissue was harvested for histopathologic analysis and measurements of apoptosis. RESULTS: When compared with sham operation, common bile duct ligation significantly increased hepatocyte apoptosis (P= 0.008) and ductular proliferation (P= 0.007). ZVAD-fmk significantly diminished the increased hepatocyte apoptosis and ductular proliferation after common bile duct ligation (P= 0.008 and P= 0.007, respectively). ZFA did not show the same effects. CONCLUSION: Hepatocyte apoptosis and ductular proliferation significantly increased after common bile duct ligation. ZVAD-fmk effectively diminished the increased hepatocyte apoptosis and ductular proliferation after common bile duct ligation, whereas ZFA-fmk did not.     

一氧化氮和内毒素在梗阻性黄疸致病机制方面的作用

梗阻性黄疸（obstructive jaundice，OJ）是临床常见的症状。梗阻性黄疸患者术后并发症和死亡率较高，常死于感染和败血症，提示机体术前的免疫功能受到了抑制。梗阻性黄疸可使网状内皮系统功能降低，细菌清除能力减弱。肠道来源的细菌和内毒素逃脱肝脏枯否细胞的监视，进入血液循环。有研究发现梗阻性黄疸常并发肠源性内毒素血症，内毒素激活枯否细胞，产生大量炎性介质，如一氧化氮（NO）、肿瘤坏死因子α（TNFα）及氧自由基等。     

术前胆道引流对低位恶性胆道梗阻患者行胰十二指肠切除术后的影响

目的 评价术前胆道引流(PBD)对低位恶性胆道梗阻性黄接受胰十二指肠切除术(PD)后的并发症、死亡率及住院时间的影响.方法 回顾性总结分析2001年1月至2010年12月期间接受PD术的71例低位恶性胆道梗阻患者的临床资料.术前胆道引流方法包括经皮肝穿刺胆道引流(PTCD)、逆行胰胆管造影术(ERCP)及胆囊造瘘术,71例中行PBD患者19例(26.8%),未行PBD患者52例(73.2%).结果 PBD组总胆红素(TBIL)在引流前为(424.9±129.9)μmol/L,引流后下降为(77.7±48.6)μmol/L,差异具有统计学意义(t=11.1,P＜0.001).PBD组直接胆红素(DBIL)在引流前为(300.7±98.1)μmol/L,引流后下降为(60.0±34.5)μmol/L,差异具有统计学意义(t=10.7,P＜0.001).PBD组谷丙转氨酶(ALT)在引流前为(227.9±275.8)U/L,引流后下降为(90.3±66.5)U/L,差异具有统计学意义(t=2.5,P=0.023).PBD组术中输血量为(589±93)ml,非PBD组为(603±71)ml,差异无统计学意义(t=-110,P=0.913).PBD组术后并发症发生率为52.6%(10/19),非PBD组为55.8%(29/52),差异无统计学意义(P＞0.05).PBD组术后住院时间为(33±3)d,非PBD组为(25±2)d,差异无统计学意义(P＞0.05).结论 对黄疸较重、肝功能严重受损的患者,行PBD可有效改善患者的一般状况,但并未降低PD术后并发症发生率及死亡率,也未减少术后的住院时间.     

对阻塞性黄疸行胆道活检的临床研究

目的探索一条胆道活检新途径，依据病理指导临床治疗阻塞性黄疸。方法在经皮肝穿刺胆管引流术(PTCD)过程中，82例阻塞性黄疸经经皮肝穿刺胆道造影术(PTC)途径向胆道内送入8F鞘管，引入活检钳和毛刷对梗阻段胆道钳夹活检和毛刷刷取获得标本，行组织学和细胞学检查。并进行x^2检验。结果82例胆道钳夹组织块的技术成功率为97．6％，活检中未发生严重并发症。82例钳夹活检中72例获得组织学诊断，钳夹病理学敏感率为87．8％。胆管癌钳夹活检敏感率较非胆管恶性肿瘤高(x^2=4．067，P=0．044)。74例毛刷刷取中56例获得细胞学诊断，诊断敏感率为75．7％；钳夹病理学敏感率较毛刷高，差异有显著性(x^2=3．886，P=0．049)，毛刷活检可作为钳夹活检的一种补充。结论PTC下胆道钳夹活检操作简单，技术成功率高，创伤小且并发症少，病理学诊断敏感性高，是值得推广的胆道病理学诊断新途径。     

Combined hepatocellular carcinoma and cholangiocarcinoma growing into the common bile duct

Received: August 7, 2000 / Accepted: December 22, 2000     

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass

AIM:To study the diagnosis of hepatocellular carcinoma(HCC)presenting as bile duct tumor thrombus with no detectable intrahepatic mass.METHODS:Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration,were collected.Their clinical and imaging data were retrospectively analyzed.The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings.RESULTS:Jaundice was the major clinical symptom of the patients.The elevated serum total bilirubin,direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease.Of the 6 patients showing evidence of viral hepatitis,5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9,and 1 was positive for serum carcinoembryonic antigen.No patient was correctly diagnosed by ultrasound.The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct,with large filling defects presenting as casting moulds in the expanded bile duct,hypervascular intraluminal nodules,debris or blood clots in the bile duct.No obvious circular thickening of the bile duct walls was observed.CONCLUSION:Even with no detectable intrahepatic tumor,bile duct HCC thrombus should be considered in patients predisposed to HCC,and some imaging signs are indicative of its diagnosis.     

RKIP在胆总管结扎肝纤维化大鼠肝脏组织的表达

目的 研究RKIP在胆总管结扎肝纤维化大鼠肝脏组织中的表达.方法 SD大鼠60只,随机分为模型组(48只)、对照组(12只).运用胆总管结扎方法 制作大鼠肝纤维化模型,模型组分别于结扎后1、2,3、4 w麻醉动物,假手术组与4 w模型组同批麻醉,留取肝脏标本.组织切片经HE和Masson三色染色检测病理变化,westem印迹和免疫组织化学方法 检测RKlP在肝组织的表达,用westem印迹方法 检测RKIP和ERK的磷酸化水平.结果 HE和Masson三色染色结果 证明胆总管结扎大鼠肝纤维化模型制作成功.随着肝纤维化程度增高RKIP表达下降,RKIP和ERK的磷酸化水平则相应增加.结论 胆总管结扎大鼠肝纤维化过程中肝脏组织Raf-1/MEK/ERKl,2信号转导途径的激活与RKIP的蛋白表达下降和磷酸化增加有关.     

Common bile duct injury by fibrin glue: Report of a rare complication

Fibrin glue is widely used in clinical practice and plays an important role in reducing postoperative complications.We report a case of a 65-year-old man, whose common bile duct was injured by fibrin glue, with a history of failed laparoscopic cholecystectomy and open operation for uncontrolled laparoscopic bleeding.In view of thepersistent liver dysfunction, xanthochromia and skin itching, the patient was admitted to us for further management.Ultrasound, computed tomography, and magnetic resonance cholangiopancreatography(MRCP) revealed multiple stones in the common bile duct, and liver function tests confirmed the presence of obstructive jaundice and liver damage.Endoscopic retrograde cholangiopancreatography was unsuccessfully performed to remove choledocholithiasis, but a small amount of tissue was removed and pathologically confirmed as calcified biliary mucosa.This was followed by open surgery for suspicious cholangiocarcinoma.There was no evidence of cholangiocarcinoma, but the common bile duct wall had a defect of 8 mm × 10 mm at Calot’s triangle.A hard, grid-like foreign body was removed, which proved to be solid fibrin glue.Subsequently, the residual choledocholithiasis was removed by a choledochoscopic procedure, and the common bile duct deletion was repaired by liver round ligament with T-tube drainage.Six months later, endoscopy was performed through the T-tube fistula and showed a well-repaired bile duct wall.Eight months later, MRCP confirmed no bile duct stenosis.A review of reported cases showed that fibrin glue is widely used in surgery, but it can also cause organ damage.Its mechanism may be related to discharge reactions.     

Diagnostic dilemma in an unusual case of common bile duct obstruction

Biliary obstructions are rarely caused by a foreign body and have received sparse attention. We present an unusual case with pruritis and abdominal pain caused by impacted full length surgical gauze within the common bile duct. The patient had previously undergone an open cholecystectomy. Radiological investigations were inconclusive and suggestive of either a calculus or a cholangiocarcinoma. Surgical exploration revealed full length surgical gauze within the common bile duct. Because imaging modalities are often non-determinant, the possibility of biliary tract obstruction from a foreign body should be borne in mind for patients with unusual presentations, especially those who have previously undergone surgery.     

比较影像学在胆总管阻塞性病变诊断中的应用价值

依据比较影像学的优选线路原则 ,对 6 6例胆总管阻塞患者的术前影像学诊断与术后病理诊断进行对照观察。结果证实超声可作为首选 ,疑恶性梗阻或诊断不清时可选做 CT、MRI,疑难病例加做 B- PTC或 ERCP认为是切实可行的。比较影像学的临床应用避免了不必要的撒网式检查和影像学资源的浪费 ,有助于尽早诊断、尽快治疗 ,具有明显的社会效益和经济效益 ,有一定的推广价值     

胆总管结扎诱导大鼠肝肺综合征模型的建立初步研究

目的 探讨胆总管结扎术诱导大鼠肝肺综合征(HPS)模型的建立.方法 40只SD大鼠被随机分为实验组30只和对照组(假手术组)10只,采用胆总管结扎术建立肝硬化和HPS模型.使用血气分析仪测定PaO2、PaCO2和pH.结果 在术后1 w,腹部超声检查显示实验组肝脏回声增粗,胆总管轻度扩张.在术后2 w,肝脏被膜不平整,...     

Echinococcal cysts in the common bile duct: an uncommon cause of obstruction

Obstruction of the biliary system due to intraductal echinococcal cysts is a rare but serious presentation of hepatic echinococcal disease. Four cases are described. There was a 50% mortality rate and morbidity was high. The clinical presentation is difficult to differentiate from other disease processes. Careful preoperative sonograms should be taken to detect echogenic cyst material in the biliary system in all patients with hepatic echinococcal cysts. If biliary pigments are seen in the cyst during surgical removal, or if the patient has a recent history of jaundice or cholangitis, intraoperative cholangiography should be done to rule out intraductal cysts, which may cause obstruction.