First, intrahepatic bile duct lithiasis of the epidemiology and pathogenesis of hepatolithiasis about is the more than hepatic duct confluence of the branch duct stones.Can stand alone, but also can co-exist extrahepatic bile duct stone.The disease was particularly prevalent in the Far East and Southeast Asia, including China, Japan, Korea, Philippines, Thailand, Indonesia and Malaysia and other countries.In China's coastal areas, the southwest region and Hong Kong, Taiwan and other regions a higher rate of incidence.The reasons for its prevalence of bacteria and biliary tract infections, parasitic infections and related Cholestasis.Infection led to the primary factor in stone formation, infection is a common cause of biliary tract infections and parasitic cholangitis recurrence, almost all of the intrahepatic bile duct stone patients can be detected in bacterial culture; infection is mainly derived from intestinal bacteria Road, commonly Escherichia coli and anaerobic bacteria.Coliform and anaerobic infection is generated when the B-glucuronidase and biliary tract infection when endogenous glucuronidase, can generate a combination of hydrolysis of bilirubin free bilirubin and calm.Intrahepatic Cholestasis is a necessary condition for the formation of bile duct stones, only in the bile under the conditions of detention, to the composition of bile and the formation of sedimentary stone.Stranded there cause bile duct stricture and bile duct malformation inflammatory; in the distal bile duct obstruction with increased pressure, biliary dilatation, slow bile flow is conducive to the formation of stones.In addition, mucin in bile, acid mucopolysaccharide, immunoglobulin molecules, such as substances, inflammatory exudation, loss of epithelial cells, bacteria, parasites, bile, such as the metal ions are involved in the formation of stones.
Second, the diagnosis of intrahepatic bile duct stones (a) intrahepatic bile duct of the clinical characteristics of patients with intrahepatic bile duct stones according to the different course of disease and pathology, the clinical manifestations may be manifold, from the early clinical symptoms had no significant limitations in the intrahepatic bile ducts within a certain period of hepatic duct stones, to the latter both inside and outside the duct system throughout the liver complicated with biliary cirrhosis or liver atrophy, liver abscess, such as the advanced cases, it is very complex clinical manifestations.Its main clinical manifestations of acute cholangitis, including biliary obstruction triad (pain, fever chills, jaundice) with severe cholangitis five of Fallot.Its clinical features are:
1, onset age 30-50 years of age;
2, upper abdominal pain, Biliary Colic might be typical or persistent pain, some patients with obvious pain, fever and chills is very powerful attack cycle;
3, may have a long history of the biliary tract, accompanied by chills or fever, history of jaundice acute cholangitis;
4, under the affected liver and recurrent chest pain does not often radiation to back, shoulder;
5, when the side of common hepatic duct obstruction, jaundice, or jaundice may be very light;
6, combined with severe cholangitis, the body is very serious and acute episode of a slow recovery;
7, inspection, liver tenderness and pain knock obvious asymmetry in the liver was enlarged and tender;
8, the body condition of affected significantly, 90% of patients have hypoproteinemia, 1 / 3 of patients with anemia significantly;
9, late stage liver, splenomegaly and portal hypertension performance.
(B) the diagnostic methods of the diagnosis of hepatolithiasis, in addition to increase in clinical awareness of this disease, the diagnosis mainly depends on imaging examination.The main application of imaging technology has B-, CT and X-ray cholangiography.
1, B ultrasound diagnosis of B-is Hepatolithiasis the preferred method of diagnosis, diagnostic accuracy is generally estimated that 50% -70%.Hepatolithiasis more of the ultrasound image changes, the general requirements in the bile duct calculi are the expansion of the remote to make the diagnosis of hepatolithiasis, intrahepatic pipe systems due to the calcification also has a stone-like image performance.
2, CT diagnosis of hepatolithiasis due mainly containing pigment bilirubin calcium stones, high calcium content, the photos in the CT can clearly show, CT for the diagnosis rate of 50% -60%.CT can show the location of hilar bile duct dilatation and hypertrophy of the liver, atrophic changes in the systematic observation of CT levels photos, you can understand the distribution of intrahepatic bile duct stones in the situation.
3, X-ray X-ray cholangiography cholangiography (including PTC, ERCP, TCG) for the diagnosis of hepatolithiasis classical methods, generally able to make the correct diagnosis, PTC, ERCP, TCG diagnosis in line with the rate of 80% -90%, 70% -80%, 60% -70%.X-ray diagnostic cholangiography and surgery should be to meet the needs of the biliary tract a good film should be able to build a comprehensive understanding of the anatomy of intrahepatic bile duct system variability and the distribution of stones.Cholangiography should pay attention to the following questions:
(1) should be multi-directional X-ray;
(2) a paragraph or liver do not develop liver bile duct, care should be taken to identify, stone obstruction is only one of the reasons for which should be carried out to identify other checks;
(3) Do not meet a particular diagnosis, as misdiagnosis may result;
(4) made in the analysis of biliary movie made as much as possible to obtain the most recent films, there may be a result of the progress of the disease.
(C) the early diagnosis of intrahepatic bile duct lithiasis Currently, the clinical treatment of intrahepatic bile duct lithiasis due to emergence of multi-cholangitis, bile duct stricture, obstruction, liver shrinkage treatment before serious pathological changes, despite the imaging diagnosis of Hepatobiliary Surgery and surgical techniques have made great progress, but the stone recurrence rate after surgery and the high rate of re-operation of the status quo there is no significant improvement, therefore, Hepatolithiasis early diagnosis and treatment may be the key to change the status quo.Early diagnosis of hepatolithiasis include:
(1) chronic right upper quadrant pain, not to exclude other diseases;
(2) B super tips hepatolithiasis (intrahepatic should be consistent with other pipeline systems to identify calcification);
(3) CT prompted multiple intrahepatic calculi shadow, and showed segmental distribution;
(4) ERCP confirmed the possession of certain liver and gallbladder stones were.
Third, the complications of hepatolithiasis with intrahepatic bile duct stones is the main pathological changes of biliary obstruction and infection; as a result of bile duct system and the liver parenchymal cells of the direct relationship between cholangitis is often accompanied by severe liver serious damage to liver cells, and even lead to large areas of necrosis of liver cells, benign biliary tract disease has become the leading cause of death.Hepatolithiasis complications, including complications of acute and chronic complications.
(A) intrahepatic bile duct complications in the acute phase of the acute phase of gallstone disease is biliary tract infection complications, including severe liver cholangitis, liver abscess and biliary infections with complications.Infection stones incentives and inflammatory biliary tract obstruction and narrow on the narrow.Complications in the acute phase is not only a high mortality rate, but also seriously affect the surgical results.
(B) intrahepatic bile duct complications of chronic phase of chronic phase patients with systemic complications such as malnutrition, anemia, hypoproteinemia, chronic biliary cholangitis and liver abscess, multiple bile duct stenosis, liver fibrosis atrophy , biliary cirrhosis, portal hypertension, liver decompensation, and long-term bile duct infection and delayed retention of liver-related cholangiocarcinoma.Intrahepatic bile duct lithiasis complications of the chronic phase is increased by surgery, which has also affected the effect of surgery.
Fourth, intrahepatic bile duct lithiasis of the surgical treatment of (a) intrahepatic bile duct lithiasis of the principles of surgical treatment of intrahepatic bile duct stone Hepatobiliary Surgery treatment is still necessary to examine one of the important issues, the treatment of the disease is the lifting of obstruction, eliminate the lesion and patency of drainage.These three areas are closely linked and one can not lift the stone and / or narrow surgical treatment of obstruction is the key; eliminate the surgical treatment of lesions is the core, while at the same time is often an important means for the lifting of obstruction; and open drainage is to prevent recurrence of infection measures and renewable sources of stone, but must be removed to relieve the obstruction and the premise of lesions.Non-surgical treatment only in the completion of the above three basic requirements in order to be effective.
(B) Surgical treatment of intrahepatic biliary lithiasis basic operation and selection of 1, hepatic lobectomy in 1958 this surgery was first advocated by Professor Huang Zhiqiang used in intrahepatic bile duct lithiasis, after the widely used.Resection of lesions as a result of the liver tissue, eliminate suppurative lesions, an increase of the radical surgery, and will help improve the efficacy of surgery.Curative liver resection, including hepatectomy and auxiliary liver resection.Curative liver resection, including the indication of a liver (above) and a narrow calculus, bile duct stricture with multiple or concurrent with chronic liver abscess, or biliary fistula, or cancer were suspected.Auxiliary liver resection liver resection is the purpose of leaf or liver side above the middle under the intrahepatic bile ducts in liver tissue so fully exposed, an increase to deal with hilar bile duct lesions or cholecystojejunostomy space.
2, choledochojejunostomy choledochojejunostomy the basic procedure is the Roux-Y jejunal bile duct anastomosis, the bridge climb should not be less than 50cm.Choledochojejunostomy eliminate the basic premise of the lesions and the lifting of stones or biliary strictures, or should not be cholecystojejunostomy.I asked cholecystojejunostomy low, large diameter (eg, basin-type anastomosis), and other mucous membrane of the mucosal anastomosis.
3, bile duct drainage drainage only adapted to certain special cases, such as emergency patients, or associated with the transition of portal hypertension surgery, or can not tolerate surgical hepatectomy complex elderly patients, or general condition worse cases.Because of the need for long-term support with tube drainage, it will promote further formation of stones, poor efficacy.
