46例自发性胆囊内瘘的回顾性分析

目的总结结石引起的自发性胆囊内瘘的诊治经验。方法对46例胆囊内瘘的病例进行回顾性分析。结果46例胆囊内瘘中胆囊十二指肠瘘29例，胆囊结肠瘘9例，胆囊胆总管、肝总管瘘11例，胆囊胃瘘3例，其中同时有两处瘘7例。术前经B超检查44例，9例提示胆囊积气；1例提示胆囊壁腹腔面消失，右下腹探得结石影。术前7例行腹部平片检查，4例提示小肠梗阻；6例见结石影；2例显示胆道积气。8例行CT检查，其中2例显示胆囊、胆管气体。3例行ERCP检查，其中1例见十二指肠有造影剂异常溢出。术前仅9例考虑到胆囊内瘘的诊断，其余均在术中发现。46例均开腹行胆囊切除或部分切除，39例胆囊胃肠瘘行瘘口修补，其中5例瘘口过大则利用部分胆囊壁来修补；10例胆囊胆管瘘在取尽结石后，经瘘口置T管引流，瘘口较大者亦利用胆囊壁修补，1例切除部分胆囊后行胆囊空肠Roux-Y吻合。术后1例因感染性休克死亡；1例有少量胆漏。经引流治愈，其余均恢复良好。结论萎缩性胆囊炎、胆囊结石应警惕合并胆囊内瘘。出现以下情况提示胆囊内瘘：(1)B超、CT、腹部平片发现胆道积气。(2)CT、腹部X线平片提示肠梗阻。有下列情况可确诊胆囊内瘘：(1)B超发现胆囊腹腔面消失。(2)B超、CT、腹部平片提示原有明确的胆囊结石消失或在异位出现。(3)ERCP、PTC等发现非胆管开口有胆汁或造影剂溢出。(4)口服造影剂或钡剂灌肠见造影剂进入胆囊。治疗时应修补瘘口，瘘口过大可利用部分胆囊壁来修补。

Retrospective analysis of 46 cases of spontaneous internal gallbladder fistula

Objective To summarize the experience in diagnosing and treating spontaneous internal gallbladder fistula (SIGF). Methods The clinical data of 46 patients with SIGF treated in our hospital were retrospectively analyzed. Results Only 9 cases were diagnosed to suffer from SIGF before the operation. All the 46 patients received cholecystectomy. Thirty-nine fistulae in the enterogastric tract were repaired directly and another 5 were repaired with part of the gallbladder wall. T tube drainage was conducted in 10 cases of cholangiocholecystic fistula after removing the stones and conduction of Roux-en-Y cholecystenterostomy. Only 1 patient died of infectious shock. Conclusions Internal gallbladder fistula should be reminded if there is atrophic cholelithiasis. B-mode ultrasonograpy, CT scanning, plain X-ray examination, ERCP, PTC and barium meal are helpful for diagnosis of SIGF. Open operations are suitable for its treatment. Fistulae can be repaired directly or with part of the gallbladder wall.