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胆道疾病 Diseases of the Biliary tract

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胆道疾病 Diseases of the Biliary tract. ● Anatomy and Physiology ● Examinations for biliary system disease ● Cholelithiasis ● Infection of the biliary tract system ● Biliary ascariasis ● Biliary tract tumor. 第一节 解剖和生理 Anatomy and Physiology.

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● Anatomy and Physiology●Examinations for biliary system disease● Cholelithiasis● Infection of the biliary tract system● Biliary ascariasis● Biliary tract tumor

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第一节 解剖和生理概要(1)1. Intrahepatic bile ducts● gradation 2. Extrahepatic bile ducts●segment●Vater’s ampulla● oddi’s sphincter3. Gallbladder●Heister’s valve● Hartmann’s pouch● Calot’s triangle

2 physiology storage bile condense bile regulate biliary tract pressure secrete mucus white bile

第一节 解剖和生理概要(2)Physiology● Storage bile● Condense bile● Regulate biliary tract pressure ● Secrete mucus: “White bile”

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第二节 胆道疾病检查方法(1)1. Laboratory findings2. Ultrasonography3. X-ray examinations ●plain radiography●percutaneous transhepatic cholangiography (PTC)●endoscopic retrograde cholangiopancreatography (ERCP)●during or post operative cholangiogram

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第二节 胆道疾病检查方法(2)●computed tomography (CT)●oral cholecystography●intravenous cholangiography●hypotonic duodenographyRadionuclide scansDuodenal drainageCholangioscopyMagnetic resonance imaging (MRI,MRCP)

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第三节 胆石病—概述(1)1. Prevalence2. Classification●cholesterol●pigment●mixed type●black3. Position●gallbladder●extrahepatic●intrahepatic

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第三节 胆石病—概述(2)4. Mechanism for gallstone formation ●bile stasis●abnormal metabolization●infection●other factors: age, sex, weight, diet Cholesterol stones: Admirand-Small triangular coordinate grapy Pigment stones:

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咖啡与预防胆结石 香喷喷的咖啡,是提神醒脑的饮品,而最新研究还发现,每喝几杯咖啡可以预防胆结石。最新一期美国医学协会期刊报道,美国哈佛大学研究人员发现,每喝两杯三杯咖啡的男性,得到胆结石的几率比不喝咖啡的人低了40%,而每天喝咖啡达四杯以上的话,得胆结石的几更降为45%。不过,无咖啡因的咖啡可就没有这种效果了,只有含咖啡因的咖啡,才能刺激胆囊收缩,并减少胆汁内容易形成胆石的胆固醇。而同样含有咖啡因的茶、可乐等其他饮料,由于咖啡因含量低于咖啡,因此无法达到同样效果。

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重点掌握内容

第三节 胆石病—胆囊结石(1)1. Gallbladder stones(1) Clinical manifestations:●biliary colic, radiation of the pain, neusea, vomiting●tenderness in right upper quadrant, rebound tenderness, muscle rigidity, palpable distended gallbladder, or Murphy’s sign (+)●bile duct stones, cholangitis

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第三节 胆石病—胆囊结石(2)●Mirizzi’s syndrome:(2) Diagnosis:●clinical manifestations: symptoms and signs●assistant examinations: B-US, CT, MRI

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第三节 胆石病—胆囊结石(3)(3) Treatment:● no need for treatment: asymptomatic stones● drug therapies: seldom attack or unsuitable for operation● operative management: cholecystectomy: open and laparoscopic● other treatments: oral dissolution therapy contact dissolution therapy extracorporeal shock wave lithotripsy

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重点掌握内容

第三节 胆石病—肝外胆管结石(1)2. Extrahepatic bile duct stones(1)Clinical manifestations:●Charcot’s triad: abdominal pain, chills and fever, jaundice● deep tenderness with or without rebound tenderness, muscle rigidity or palpable enlarged gallbladder

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第三节 胆石病—肝外胆管结石(2)(2) Diagnosis:● previous biliary tract disease● clinical manifestations: Charcot’s triad● laboratory examinations:● assistant examinations: B-US, CT, PTC, ERCP, MRCP

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第三节 胆石病—肝外胆管结石(3)Differential diagnosis:●viral hepatitis●carcinoma of pancreas●biliary ascariasis●benign stricture● renal colic, enterospasm

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第三节 胆石病—肝外胆管结石(4)(3) Treatment:● Chinese medicine: dissolution, discharge● drug therapy: antispastic, analgesic● EST●operative management: exploratory choledochostomy and T-tube drainage choledocho-jejunostomy sphincteroplasty of Oddi

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第三节 胆石病—肝内胆管结石(1)3. Intrahepatic duct stones(1) Clinical manifestations and diagnosis● Symptoms: ● Physical findings:● B-US, CT, PTC, ERCP, MRCP

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第三节 胆石病—肝内胆管结石(2)(2) Treatment● Nonoperative treatment: anti-inflammatory and cholagogic● Operative treatment: hepatobiliary exploration cholangio-jejunostomy partial hepatectomy

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本次课重点内容胆囊结石肝外胆管结石临床表现、诊断、治疗本次课重点内容胆囊结石肝外胆管结石临床表现、诊断、治疗

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第四节 胆道感染—急性胆囊炎(1)1. Acute cholecystitis(1)Pathogenesis: ·bile stasis:obstruction, dysfunction ·bacteria ·other factors: bile salt, pancreatic juice

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第四节 胆道感染—急性胆囊炎(2)(2) Pathology: simple, suppurative, gangrenous(3) Complications:·pericholecystic or cholecystic abscess · perforation: bile peritonitis, fistulization (external or internal ), gallstone ileus ·liver abscess, cholangitis, pancreatitis ·pylephlebitis, sepsis

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第四节 胆道感染—急性胆囊炎(3)(4) Clinical manifestations and diagnosis·symptoms: pain, radiated pain, nausea, vomiting, fever · signs: tenderness, rebound tenderness, muscle rigidity, distended gallbladder with tenderness or Murphy’s sign(+) ·complications: ·assistant examinations: laboratory WBC↑, B-US

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第四节 胆道感染—急性胆囊炎(4)Differential diagnosis·acute perforated duodenal or gastric ulcers ·acute pancreatitis ·acute appendicitis ·acute ileus

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第四节 胆道感染—急性胆囊炎(5)(5) Treatment·nonoperative management: fasting, nasogastric suction; antispastic, analgisia; control of infection ·operative intervention: indication: acute calculous cholecystitis, recurrent chole-cystitis, no response to conservative treatmenttiming: early, delayedmethods: cholecystectomy, cholecystostomy

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第四节 胆道感染—慢性胆囊炎(1)2. Chronic cholecystitis (1) Pathogenesis and pathology: (2) Clinical manifestations and diagnosis ·the history of recurrent cholecystitis ·symptoms: untold bitterness, discomfort, indigestion ·signs: deep tenderness in the right upper quadrant ·B-US(3) Treatment ·operative: cholecystetomy ·nonoperative: anti-inflammatory, cholagogic, low-fat meals

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第四节 胆道感染—胆管炎(1)3. Cholangitis Pathologic type: ·acute obstructive suppurativecholangitis ·chronic simple cholangitis ·primary sclerosing cholangitis

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第四节 胆道感染—胆管炎(2)Acute obstructive suppurativecholangitis(1) Pathogenesis ·Complete bile duct obstruction: stones, benign strictures, malignant tumor, parasites ·Bacterial infections: E. Coli, Klebsiella, proteus, and anaerobic bacteria

重点掌握内容

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第四节 胆道感染—胆管炎(3)(2) Pathophysiology ·completely obstruction, dilatation, high intraductal pressure·bacteria invasion, multiplication, pus bile ·retrograde enter the liver, acute liver infection ·systemic sepsis, infective shock, MSOF

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第四节 胆道感染—胆管炎(4)(3) Clinical manifestations ·Abdominal pain ·chills and fever ·jaundice ·shock ·central nervous system depression: apathy, drowsiness, coma

Charcot’striad

Reynold’spentad

·tenderness with or without rebound tenderness, muscle rigidity; enlarged liver with tenderness, percussion pain

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第四节 胆道感染—胆管炎(5)(4) Diagnosis ·recurrent previous biliary tract disease ·Charcot’s triad + CNS + shock (Reynold’s pentad) ·physical examination results: ·assistant examinations: laboratory findings (WBC↑, hyperbilirubinemia), B-US

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第四节 胆道感染—胆管炎(6)(5) Treatment · principle: immediate removal of the obstruction emergency bile duct decompression · methods: preoperative preparation: exploratory choledochostomy and T- tube drainage PTBD, ENBD

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第五节胆道蛔虫病(1)1. Pathogenesis:2. Pathophysiology ·colic ·obstructive jaundice ·complicated infection ·stone formation ·pancreatitis ·cirrhosis

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第五节胆道蛔虫病(2)3. Clinical manifestations and diagnosis ·paroxysmal epigastric pain ·suddenly attack and suddenly stop ·serious symptoms but slight signs ·complicated infection: cholangitis ·fecal examination, B-US, CT

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第五节胆道蛔虫病(3)4. Treatment ·nonoperative: antispastic, analgisia; cholagogic, expel parasites; control of infection ·operative: exploratory choledochostomy and T-tube drainage

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第六节胆道肿瘤—胆囊息肉(1)1. Gallbladder polyps (1) Classification: ·non-neoplastic polyps: inflammatory, cholesterol, hyperplastic ·neoplastic polyps: adenoma

2 2 clinical manifestations and diagnosis 3 treatment follow up operative cholecystectomy

第六节胆道肿瘤—胆囊息肉(2)(2) Clinical manifestations and diagnosis:(3) Treatment ·follow-up ·operative: cholecystectomy

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第六节胆道肿瘤—胆囊癌(1)2. Carcinoma of the gallbladder (1) Pathogenesis: unclear (2) Clinical manifestations and diagnosis ·early: no specific ·advanced: jaundice, ascites, mass ·B-US, CT, MRI

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第六节胆道肿瘤—胆囊癌(2)(3) Treatment ·operative: located in gallbladder wall: cholecystectomy protrude serosa or liver invasion: radical cholecystectomy unresectable: decompression and drainage ·nonoperative: PTBD, ENBD

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第六节胆道肿瘤—胆管癌(1)3. Bile duct cancer (1) Pathogenesis: unclear(2) Clinical manifestations and diagnosis ·advancing jaundice ·pain, nausea, vomiting ·ascites, portal hypertension ·B-US, CT, PTC, ERCP, MRCP

2 3 treatment operative resection whipple s operation nonoperative ptbd enbd prosthesis

第六节胆道肿瘤—胆管癌(2)(3) Treatment ·operative resection: Whipple’s operation ·nonoperative: PTBD, ENBD, prosthesis

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