治疗性内镜逆行胰胆管造影术后并发胆道出血的客观危险因素分析*

目的探讨治疗性内镜逆行胰胆管造影术(ERCP)后并发胆道出血的客观危险因素。方法回顾性分析该院收治的285例患者术后行治疗性ERCP的临床资料。根据术后是否出现胆道出血,分为出血组和非出血组,并对发生胆道出血的客观危险因素进行分析。结果 285例患者中共23例患者出现ERCP术后胆道出血,发生率为8.07%。出血组患者胆管癌、壶腹部癌及胰头癌所占比例明显高于非出血组(P 0.05)。出血组患者合并胆道感染及十二指肠乳头憩室,发生率明显高于非出血组(P 0.05)。亚组分析显示,出血组与非出血组相比,结石直径≥2 cm、结石嵌顿和十二指肠乳头内憩室所占比例均明显升高(P 0.05)。结论胆道出血是治疗性ERCP术后常见并发症,恶性胆胰肿瘤、胆总管结石直径≥2 cm、结石嵌顿和十二指肠乳头内憩室均是术后胆道出血的危险因素,针对上述因素加强围手术期管理可降低术后胆道出血风险。     

治疗性内镜逆行胰胆管造影术后十二指肠乳头出血的客观危险因素分析

目的探讨治疗性内镜逆行胰胆管造影(ERCP)术后十二指肠乳头出血的客观危险因素及处理方法。方法回顾性分析遵义医学院第三附属医院收治的890例行治疗性ERCP术患者的临床资料。根据是否发生ERCP术后十二指肠乳头出血,分为出血组和未出血组,探讨出血的客观危险因素及处理方法。结果共51例患者发生ERCP术后十二指肠乳头出血,发生率为5.7%。出血组患者胆总管结石所占比例明显低于未出血组,胆管癌、胰头癌所占比例明显高于未出血组(P0.05)。出血组患者合并高血压病及十二指肠乳头旁憩室发生率明显高于未出血组(P0.05)。亚组分析显示出血组患者结石直径2 cm、结石嵌顿及憩室内十二指肠乳头所占比例明显高于未出血组(P0.05)。结论胆总管结石嵌顿或直径2 cm、恶性胆胰肿瘤、合并高血压病或憩室内十二指肠乳头均是ERCP术后十二指肠乳头出血的客观危险因素,重在预防出血,内镜止血安全有效。     

老年患者治疗性内镜逆行胰胆管造影的临床分析

目的 研究治疗性内镜逆行胰胆管造影(ERCP)对老年患者的临床治疗有效性和安全性.方法 回顾性分析2009年4月至2011年12月我科123例行ERCP治疗的老年胆胰疾病患者,观察ERCP治疗成功率及并发症发生情况.结果 123例患者,年龄为75～91岁,胆总管结石91例(74.0％),胆管良性狭窄3例(2.4％),胆管恶性狭窄29例(23.6％),伴有合并症83例(67.5％).ERCP治疗成功119例(96.7％).术后发生并发症9例(7.3％),胰腺炎6例,胆管感染2例,其中急性胰腺炎合并胆管感染1例,十二指肠乳头括约肌切开(EST)后迟发出血1例.除急性重症胰腺炎合并胆管感染1例死亡外,余均经治疗后痊愈出院.结论 老年患者不应该作为治疗性ERCP的禁忌证,即使合并有心肺系统疾病,经过充分的术前准备,采用简洁有效的手术方式,减少操作时间,并没有增加严重并发症的发生.老年患者ERCP的并发症发生率较高可能与恶性肿瘤所占比例高有关,与合并其他系统疾病未必有关联.     

内镜下逆行胰胆管造影及相关治疗的护理

经十二指肠镜逆行胰胆管造影(ERCP)术是一种诊断和治疗胰胆疾病的有效方法。江苏省苏北人民医院消化内科2005年8月~2006年5月行ERCP及相关治疗50例次,疗效良好,现将护理体会报告如下。1资料与方法本组资料为本院消化科住院患者,男性20例,女性30例,年龄29~73岁,平均50岁。胆总管结石30例,黄疸原因待查10例,胰头癌6例,胆管癌3例,壶腹癌1例。治疗方法:均行ER-CP,其中行鼻胆管引流(ENBD)10例,行胆管内支架10例,行十二指肠乳头括约肌切开术(EST)30例。本组病例中有3例并发急性胰腺炎,经有效治疗和精心护理,患者均痊愈。2护理心理护理:由…     

十二指肠镜、腹腔镜和胆道镜联合治疗胆道结石

目的 探讨胆囊结石合并胆总管结石、乳头狭窄、结石性胰腺炎等的微创外科治疗。方法 先行十二指肠镜逆行胰胆管造影（ERCP）＋乳头括约肌切开（EST）＋网篮取石（ESR）＋内镜鼻胆管外引流术（ENBD），术后3—7d再行腹腔镜胆囊切除术（LC）及术中胆道镜取石治疗胆囊结石合并胆总管结石、乳头狭窄、结石性胰腺炎286例，其中胆囊结石合并肝外胆管结石214例、肝外胆管结石＋乳头炎性狭窄39例、单纯乳头炎性狭窄22例、结石性胰腺炎28例。结果 ERCP成功率100％，EST成功率96．2％，tc（除外2例中转开腹）及术中胆道镜全部成功，无严重并发症发生。结论 十二指肠镜、腹腔镜和术中胆道镜联合治疗复杂性胆道结石，达到了治疗该类疾病的最小创伤，是目前治疗复杂性胆道结石的理想选择。     

内镜逆行胰胆管造影和十二指肠乳头切开取石术治疗胆外胆管结石临床研究

目的 探讨内镜逆行胰胆管造影(EKCP)和内镜十二指肠乳头括约肌切开(EST)取石治疗胆外胆管结石的临床治疗经验和价值.方法 对45例肝外胆管结石患者行ERCP和EST取石术治疗,同时设立开腹手术肝外胆管探查取石治疗组为对照组.观察术后病情及并发症情况.结果 内镜治疗组有效率97.8%,开腹手术组有效率为90.9%(P＞0.05).残余结石发生率:内镜组为2.22%,开腹手术组为20.00%(P＜0.05).并发症发生卒:内镜组为4.44%,开腹手术组为18.18%(P＜0.05).结论 ERCP和EST取石术治疗肝外胆管结石优于开腹手术,是治疗胆外胆管结石安全、有效、简便的方法.     

经内镜诊治老年胆胰疾病387例分析

目的 探讨内镜逆行胰胆管造影(ERCP)对老年胆胰疾病的诊断和治疗中的临床应用价值。方法 对387例老年胆胰疾病患者行ERCP检查，其中胆总管结石、黄疸、胆道术后综合征占检查患者63．6％，肿瘤占17．3％，对180例患者进一步行治疗性ERCP。结果 387例患者中造影成功379例，成功率97．4％，检查结果胆总管结石、蛔虫占50．4％，肿瘤29．8％，肿瘤所占比例较检查前明显高。治疗性ERCP中乳头括约肌切开术(EST)143例，胆道取石、取蛔虫93例，成功90例，成功率96．8％，鼻胆管引流(ENBD)76例，成功72例，成功率94．7％，胆管内引流5例。出现出血、穿孔、胰腺炎的并发症共13例，发生率3．3％，死亡1例，死亡率0．3％。结论 对老年胆胰疾病行ERCP诊断及治疗具有简单、快速、创伤小、生理干扰小，并发症少，效果确切等优点，具有非常广阔的临床应用前景。     

无痛性梗阻性黄疸病因分析(附136例)

目的：探讨无痛性梗阻性黄疸的病因；方法：回顾性分析1994-2001年收治的136例无痛性黄疸，经B超，CT、PTC，ERCP或肝组织穿刺活检等检查及手术探查证实。结果：136例中恶性肿瘤引起的梗阻89例，其中胰头癌49例，十二指肠乳头癌15例。胆管癌18例，肝细胞性肝癌7例；胆总管下段结石32例，硬化性胆管炎6例；胆汁郁积性肝炎5例；慢性胰腺炎4例。结论：无痛性梗阻性黄疸以恶性肿瘤所致为主，占65%，但良性疾病引起也占35%。其中胆管下段嵌顿性结石23%，硬化性胆管炎，胆汁郁积性肝炎占12%，因此，在鉴别诊断中要引起重视。     

内镜下胆管支架植入术治疗胆道梗阻的临床价值

目的分析应用内镜逆行胰胆管造影术(ERCP)联合十二指肠乳头括约肌切开术(EST)、内镜下胆管金属支架引流术(EMBD)/内镜下胆管塑料支架引流术(ERBD)治疗胆道梗阻的临床价值。方法回顾性分析65例胆道梗阻患者,其中胆总管结石29例,肝门、肝总管及胆总管癌14例,胰头癌伴/不伴十二指肠浸润5例,壶腹周围癌3例,胆总管炎性狭窄、乳头口缩窄5例,乳头结石嵌顿伴瘘口形成4例,胆道金属支架置入术后支架堵塞3例,胆道出血2例。均行EST并取石、EMBD或ERBD治疗,观察其临床效果以及并发症。结果 63例获得成功,成功率96.9%。1例肝门部肿瘤、1例胆管上段肿瘤治疗失败后转外科行经皮肝穿刺胆道引流术(PTCD),胆管肿瘤患者因多器官功能衰竭死亡,死亡率为1.5%。术后6例轻微发热,发热率为9.6%,11例上腹隐痛,隐痛发生率为17.7%,均经对症处理后缓解。所有63例患者术后3d后复查肝功均有不同程度好转,于术后7～10d出院,平均住院日为8.7d。结论 ERCP联合EST、EMBD/ERBD治疗胆道梗阻具有安全有效、创伤小、痛苦小、住院时间短、并发症少、死亡率低、患者恢复快的优点,是目前治疗胆道梗阻的理想方法,值得推广应用。     

十二指肠乳头区肿瘤71例超声诊断价值

目的 总结十二指肠乳头区肿瘤的超声特点,探讨超声对十二指肠乳头区肿瘤的诊断价值。方法 回顾性分析了1991－2001年经手术和病理证实的71例十二指肠乳头区肿瘤。结果 术前超声诊断为十二指肠乳头肿瘤51例（71．8％）,误诊胰头癌4例,误诊胆管末端癌5例,误诊为胆总管结石2例,误诊为壶腹部结石1例,诊断胃扩张2例,提示胰胆管扩张,胆囊增大6例。超声在十二指肠乳头区肿瘤定位诊断中的准确性与检查的手法及经验密切相关,本组超声定位准确率88．7％,高于CT（84％）,低于ERCP（96％）。超声为目前诊断十二指肠乳头区肿瘤首选的最佳方法。结论 超声和ERCP联合检查可提高十二指肠乳头区肿瘤检出率。     

ERCP在胆囊切除术后黄疸诊治中的应用

目的：探讨经内镜逆行胆胰管造影（endoscopicretrogradecholangiopancreatograp11y,ERCP）在胆囊切除术后黄疸患者的诊断和治疗中的应用价值。方法：对53例胆囊切除术后不明原因或考虑为外科原因的黄疸患者行ERCP检查,明确黄疸的原因并在内镜下采取相应的治疗措施。对于胆总管结石的患者行乳头括约肌切开（endoscopicsphincterotomy,EST）或乳头球囊扩张（endoscopicpapillaryballoondilation,EPBD）取石,对胆漏和胆道狭窄患者行内镜引流术,对乳头狭窄或括约肌功能异常的患者行EST或EPBD。结果：53例患者均成功行ERCP检查,结果显示胆总管结石38例、胆道损伤8例、乳头狭窄或括约肌功能异常3例、乳头癌1例、肝门胆管癌1例、未见异常2例。经相应治疗后,所有患者均未出现严重并发症。结论：对于胆囊切除术后出现黄疸的患者,ERCP是理想的诊断方法,同时还可以进行内镜下治疗。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石

目的:探讨腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石的临床疗效.方法:回顾分析2009年1月-2010年12月腹腔镜胆囊切除术(LC)联合十二指肠镜治疗35例胆囊结石合并胆总管结石患者的临床资料.所有患者均采取经十二指肠镜逆行胰胆管造影(ERCP),内镜下十二指肠乳头括约肌切开术(EST),取出胆总管结石,放置胆道塑料支架引流(ERBD).ERCP后3d内行LC,术后4d出院.出院后1～2周内再次行十二指肠镜取出胆道支架并行ERCP了解胆管有无残余结石.结果:35例患者均1次取净胆总管结石,1例EST术中出血,34例成功行LC,1例中转开腹行胆囊切除术.术后并发急性胰腺炎2例,所有患者均无胆漏、十二指肠穿孔、黄疸等并发症.结论:腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石具有疗效确切、创伤小、恢复快等优点.     

Astuce pour cath��t��riser une ? papille invisible ? intradiverticulaire

An 83-year-old man was admitted to hospital with suspected calculi in the common bile duct (CBD) a few days after cholecystectomy. Additional investigation including MRI of the biliary system showed widening of the biliary tract with no visible obstruction. Endoscopic ultrasound performed just prior to endoscopic retrograde cholangiopancreatography (ERCP) demonstrated the presence of several biliary duct stones of less than a centimeter in diameter. On duodenoscopy, in the short scope position, we noticed a large duodenal diverticulum, within which the papilla could not be seen. A paediatric biopsy forceps was used to apply traction to the para-diverticular duodenal mucosa and the papilla was then revealed. The common bile duct (CBD) was cannulated by a catheter mounted on a guide wire inserted into the operating channel in parallel with the biopsy forceps, which maintained traction on the mucosa. A 10 mm sphincteroplasty facilitated the extraction of the bile duct stones and ensured that the CBD was evacuated completely.     

ERCP后CT及MPR诊断肝外梗阻性黄疸病因(附24例分析)

目的:探讨ERCP后加做肝胆胰CT对肝外胆道梗阻病因的诊断价值。材料和方法:24例肝外胆道梗阻病人,经ERCP造影后立即进行CT扫描,应用MPR技术充分显示胆道及其周围情况。结果:24例中,胆管癌5例,胰头癌7例,壶腹癌1例,胆总管下端结石9例,胆总管炎2例,均经手术证实,无假阳性及假阴性。结论:ERCP后加做肝胆胰CT及MPR是诊断肝外梗阻性黄疸的一种可靠手段。     

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.     

Clinical success of ERCP procedures in nonagenarian patients with bile duct stones

Abstract

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) procedures are the gold standard in the treatment of bile duct stones. However, repeat endoscopic procedures and sometimes even open surgery are needed in difficult cases with retaining bile duct stones. The aim of the present study was to determine the clinical success of ERCP procedures in the treatment of bile duct stones in extremely old patients. A retrospective data review comprising prospective data collection and double-entry bookkeeping of 23 therapeutic ERCPs in 20 nonagenarians with bile duct stones was conducted between 1997 and 2007. The primary ERCP procedure was the definitive treatment in 17 out of 20 patients with bile duct stones, giving a clinical success rate of 85 % for the first endoscopic procedure. In the remaining three patients, a repeat ERCP procedure had to be done in the follow-up. After these three repeat procedures with successful outcome, the clinical success of endoscopic treatment was 100%. There was no further recurrent biliary obstruction in any of the patients prior to death which occurred after a mean of 38 months (two patients are still alive), and no open surgery had to be performed in these patients. To be concluded, endoscopic treatment modality seems to be excellent in extremely elderly patients with bile duct stones.     

胆总管结石继发急性梗阻性化脓性胆管炎的急诊内镜治疗

目的：探讨胆总管发急性梗阻性化脓性胆管炎的急诊内镜镜治疗方法,方法：118例胆总管结石继发急性梗阻性化脓性胆管炎患者接受ERCP检查和治疗,112例,人镜括约肌切开（EST）或内镜乳头气囊扩张（EPBD）取石梳 及放置鼻胆管引流（ENBD）,结果：31例经EPBD后取石,39例经EST后取石,或同时放置ENBD,42例单纯放ENBD,105例患者经急诊治疗后症状得到缓解,无严重并发症和死亡,结论：内镜治疗急性胆管炎较传统开腹手术具有操作简单,安全,有效,创伤小和恢复快等优点。     

经内镜胆管引流术对良恶性胆管狭窄的治疗体会

目的探讨经内镜胆管引流术对各种良恶性胆管狭窄的治疗效果。方法67例良恶性胆管狭窄病人先行内镜逆行胰胆管造影(ERCP)检查,确定胆管狭窄病变部位和性质后,再决定使用以下三种治疗中的一种:内镜下鼻胆管引流(ENBD)、内镜下塑料胆道支架引流(ERBD)和内镜下金属胆道支架引流(EMBE)。结果针对良性胆管狭窄行ENBD 21例,主要见于胆总管结石;针对恶性胆管狭窄行ERBD 29例,行EMBE 17例,主要见于胰头癌、胆管癌、壶腹癌、原发性肝癌及肝门及肝内转移压迫胆管,所有病例均在引流后总胆红素及直接胆红素明显下降。结论经内镜下胆管引流术的应用愈来愈广泛,其操作安全而有效,特别是对各种良恶性病变引起的胆管狭窄起了关键性的治疗作用。