Intrahepatic bile duct stones
Introduction
Introduction to intrahepatic bile duct stones Hepatic calculus, also known as intrahepatic bile duct stones, refers to primary bile duct stones above the bifurcation of the hepatic duct. Most of them are pigmented stones with bilirubin calcium as the main component, although intrahepatic bile duct stones Part of the primary bile duct stones, but with its particularity, if it coexists with extrahepatic bile duct stones, it is often similar to the clinical manifestations of extrahepatic bile duct stones. Because the intrahepatic bile duct is deeply hidden in the liver tissue, its branch and anatomical structure are complex, the location, quantity and size of the stone are uncertain. The diagnosis and treatment are far more difficult than the extrahepatic bile duct stones. It is still difficult to treat the hepatobiliary system, and the curative effect is not satisfactory. The disease. basic knowledge The proportion of illness: the incidence rate is about 0.05% - 0.07% Susceptible people: no specific population Mode of infection: non-infectious Complications: biliary tract infection liver abscess malnutrition anemia chronic cholangitis biliary cirrhosis cholangiocarcinoma
Cause
Causes of intrahepatic bile duct stones
Causes
Dietary factors (15%):
Low protein high carbohydrate diet, -glucuronidase inhibitor glutamate 1-4 lactone content is reduced, which is beneficial to -glucuronidase to hydrolyze bound bilirubin to free bilirubin, insoluble in water It is prone to sedimentation and is the basis for the formation of stones. Dietary structure is associated with the formation of hepatolithiasis, which is a high incidence of hepatolithiasis in developing countries and may be one of the reasons.
Biliary tract infection (25%):
It is generally believed that biliary infections, especially Escherichia coli infection, produce a bacterial source of beta-glucuronidase that hydrolyzes bound bilirubin to free bilirubin. In the biliary tract infection, the biliary inflammatory mucus material increases, the coagulation effect is enhanced, and the metal ions such as calcium ions are involved to form bile duct stones mainly composed of bilirubin calcium. The incidence of biliary tract mites in rural areas is high in China, and the incidence of biliary tract infections and hepatolithiasis is higher in urban areas. Similarly, the amount of bacteria in the liver and gallstones is also higher than that of cholesterol stones. And hepatobiliary stones with acute suppurative cholangitis have many opportunities, from different aspects to illustrate the close relationship between biliary bacterial infection and the development of hepatolithiasis.
Bile stasis (20%):
Due to bile duct stricture, biliary obstruction or cystic dilatation of the bile duct, bile dynamics changes, eddy currents, stasis and bacterial infections. Free bilirubin precipitation, mucus purulent involvement, the formation of brown-yellow bile, further aggravating biliary obstruction, stasis, infection, and promote the formation of gallstones. Clinically common such as congenital biliary cystic dilatation, duodenal papillary diverticulum caused by nipple stenosis, etc., are due to poor bile flow, bile duct stones.
Disease factors (25%):
Hepatobiliary stones often occur on the basis of some diseases, or are closely related to certain diseases, which are called background diseases of hepatolithiasis. For example, in cirrhosis, the level of unconjugated bilirubin in bile is increased, and the bile acid component is abnormal, which has a tendency to become stone. Therefore, bile duct pigment stones are prone to occur in cirrhosis. Nicholas reported from autopsy data that 2,377 patients with cirrhosis with gallstones accounted for 30.8%, 4 to 5 times that of normal people. More than 50% of congenital biliary cysts are accompanied by stones. Patients with hemolytic anemia are also prone to bile pigment stones due to abnormal bilirubin metabolism.
Pathogenesis
The basic pathological changes of hepatolithiasis are due to obstruction of the bile duct system caused by stones, infection, bile duct stricture, dilatation, liver fibrosis, liver cirrhosis, atrophy, and even cancerous pathological changes. Intrahepatic bile duct stones are more than 2/3. The patient was associated with hilar or extrahepatic bile duct stones. According to the national survey data, 78.3% combined with extrahepatic bile duct stones, and 3/4 (75.7%) of the 559 intrahepatic bile duct stones in the Second Hospital of Kunming Medical College were also present outside the liver. Bile duct stones, so 2/3 to 3/4 cases can occur in different degrees of acute or chronic obstruction of the hilar or extrahepatic bile duct, resulting in bile duct dilatation above the obstruction, liver cholestatic, hepatomegaly, liver function damage, and gradually Increase the fibrous tissue hyperplasia in the intrahepatic portal area. After bile duct obstruction, the bile duct pressure rises. When the pressure in the bile duct is as high as 2.94 kPa (300 mm H2O), the hepatocytes stop secreting bile into the capillary bile duct. If the obstruction cannot be relieved for a long time, the bile will inevitably appear. Sexual cirrhosis, portal hypertension, gastrointestinal bleeding, liver function disorders, etc. If the stone obstruction occurs in a certain leaf in the liver, the bile duct, the change caused by obstruction It is necessary to be limited to the corresponding leaf, segmental bile duct and liver tissue, and finally will lead to the corresponding leaf, the liver tissue of the segment is hypertrophied, fibrotic to atrophy, loss of function, and adjacent liver and segmental liver may undergo compensatory growth. If the left liver is atrophy, the right liver is compensatory. Because the right liver accounts for 2/3 of the whole liver and the right liver is severely atrophied, the left liver and the tail leaves often have a significant compensatory increase. This asymmetry Hyperplasia, atrophy, often occurs in the medial vena cava as the central axis of the liver, increasing the difficulty of surgery.
Infection is one of the main concomitant lesions and clinical manifestations that are difficult to avoid with hepatolithiasis. Inflammatory changes involve the liver parenchyma. Gallbladder stones and biliary infections coexist at the same time. Acute and chronic bile duct inflammation often alternates and occurs repeatedly. If the stones are severely blocked Concomitant bile duct infection, that is, obstructive suppurative cholangitis, and can involve capillary bile duct, even complicated with liver abscess, severe obstruction for a long time, inflammation, infected bile, gallbladder sand, tiny stones, can pass the small bile duct through the necrotic liver The cells enter the central hepatic vein, causing severe consequences such as cholestasis, sepsis, liver abscess and systemic sepsis, multiple organ failure, repeated acute and chronic cholangitis, mostly local or segmental bile duct fibrous tissue hyperplasia The wall of the tube is thickened, the fibrous scar tissue shrinks gradually, the lumen shrinks, and the bile duct narrows. This change occurs mostly in the vicinity of the stone site or the liver leaf, the bile duct junction, such as the hilar bile duct, the left and right hepatic duct or the liver. Segmental bile duct and other parts, 4197 cases of intrahepatic bile duct stones in China, combined with bile duct stricture accounted for an average of 24.28%, high The number was 41.96%, and the 1448 cases of the Second Hospital of Kunming Medical College accounted for 43.8% of the patients with biliary stricture. Koga A et al. (1984) 59 cases of intrahepatic bile duct stones complicated with bile duct stricture accounted for 62.7%, showing hepatolithiasis complicated with bile duct stricture. The incidence rate is very high, the upper end of the biliary duct has different degrees of dilatation, bile stagnant, further promote the formation of stones, increase, increase, often in the stenosis, a large number of stones accumulate at the upper end of the obstructive bile duct, increase the degree of bile duct infection and Frequency, the development of hepatic bile duct stones during the development of stones, infection, stenosis and cause and effect, gradually increase the pathological changes of the bile duct and liver, liver function damage, and ultimately lead to fibrosis or atrophy of the liver or liver segment.
Long-term chronic cholangitis or acute inflammation recurrence, in some cases, the entire hepatobiliary system, until the peripheral bile duct wall and its surrounding tissue inflammatory cell infiltration, bile duct intimal hyperplasia, thickened fibrosis of the wall, the lumen is extremely reduced or even occlusion, Pathological changes in the formation of inflammatory sclerosing cholangitis.
Intrahepatic bile duct stones combined with cholangiocarcinoma are a serious complication that has been widely recognized in recent years. The incidence of each report varies widely, ranging from 0.3% to 10%, which may be different from diagnosis and treatment. The length of the disease is related to factors such as the length of the disease.
Prevention
Intrahepatic bile duct stones prevention
The occurrence of stones is due to the stone formation of bile, but the key is the patency of bile drainage. Therefore, regular diet should be taken regularly, and B-ultrasound should be reviewed regularly to understand the compensatory expansion of the intrahepatic and extrahepatic biliary tract. If necessary, you can eat some. The choleretic agent promotes the excretion of bile. These may be helpful for your prevention. Some of the common bile duct stones after cholecystectomy are due to abnormal function of the lower nipple sphincter of the common bile duct, or some small particles falling into the gallbladder stones. The common bile duct, without symptoms, grows up with time, and is discovered. Don't be nervous. Even if these stones appear, they can be taken out through the endoscope as long as they are discovered early.
Complication
Intrahepatic bile duct stones complications Complications biliary infection liver abscess malnutrition anemia chronic cholangitis biliary cirrhosis cholangiocarcinoma
The main pathological changes of intrahepatic bile duct stone disease are biliary obstruction and infection; due to the direct relationship between hepatobiliary system and liver parenchymal cells, severe hepatic cholangitis is often accompanied by severe hepatocyte damage, and even leads to large pieces of hepatocyte necrosis, becoming The main cause of death from benign biliary tract disease, complications of intrahepatic bile duct stones include acute complications and chronic complications.
First, acute complications
The acute complications of intrahepatic bile duct stone disease are mainly biliary tract infections, including severe hepatic cholangitis, biliary hepatic abscess and concomitant infectious complications. The cause of infection is related to the obstruction of stones and the inflammatory narrow stenosis of the biliary tract. Acute complication not only has a high mortality rate, but also seriously affects the surgical outcome.
Second, chronic complications
Chronic complications of intrahepatic bile duct stones include systemic malnutrition, anemia, hypoproteinemia, chronic cholangitis and biliary hepatic abscess, multiple hepatic bile duct stricture, hepatic fibrosis atrophy, biliary cirrhosis, Hypertension, decompensation of liver function, and delayed hepatobiliary carcinoma associated with long-term biliary tract infection and biliary retention, chronic complications of intrahepatic bile duct stone disease both increase the difficulty of surgery and affect the surgical outcome.
Symptom
Intrahepatic bile duct stones symptoms common symptoms biliary colic jaundice intrahepatic calcification bile duct stones upper gastrointestinal bleeding liver tube obstruction ascites relaxation heat chills weight loss
The clinical manifestations of intrahepatic hepatic duct stones are very atypical. During the intermittent period of the disease, it may be asymptomatic or only manifest as mild discomfort in the upper abdomen. However, in the acute phase, symptoms of acute suppurative cholangitis, or different degrees of Charcot triad, may be caused by combined extrahepatic bile duct stones. In patients without extrahepatic bile duct stones, when one or one of the intrahepatic bile duct stones causes hepatic bile duct obstruction in the liver or a certain liver segment, and secondary infection, systemic infections such as chills and fever may occur. Symptoms, even in the presence of acute symptoms of acute cholangitis such as psychosis and shock, patients can still have obvious abdominal pain and jaundice. Physical examination can cause liver asymmetry enlargement and tenderness, often misdiagnosed as liver abscess or hepatitis. This periodic intermittent episode is a characteristic clinical manifestation of intrahepatic bile duct stones.
Examine
Intrahepatic bile duct stones
1, CT diagnosis
Because intrahepatic bile duct stones are mainly pigmented stones containing bilirubin calcium, the content of calcium is high, so it can be clearly shown in CT photos, the diagnostic coincidence rate of CT is 50%-60%. CT can also show the position of the hilar, bile duct dilatation and liver hypertrophy, atrophy changes, systematic observation of CT images of various levels, can understand the distribution of stones in the intrahepatic bile duct.
2, X-ray cholangiography
X-ray cholangiography (including PTC, ERCP, TCG) is a classic method for the diagnosis of intrahepatic bile duct stones. It can generally make a correct diagnosis. The diagnostic compliance rate of PTC, ERCP and TCG is 80%-90%, 70%. -80%, 60%-70%. X-ray cholangiography should meet the needs of diagnosis and surgery. A good choledochogram should be able to fully understand the anatomical variation of the intrahepatic biliary system and the distribution of stones.
3, percutaneous transhepatic cholangiography (PTC, PTCD)
There are three types of PTC and PTCD puncture paths: anterior, posterior and lateral. The success rate of the lateral approach is high, the complications are few, the operation is convenient, and the image is clear during angiography. For patients with intrahepatic bile duct stones diagnosed by B-ultrasound, PTC and PTCD have good differential diagnosis value. In particular, the B-guided PTC has a higher success rate. For those who have not undergone surgery and want to determine intrahepatic bile duct stones, they may be considered.
Auxiliary inspection:
Biliary pressure measurement: It is possible to know whether bile is discharged through the biliary tract through biliary pressure measurement. For a branch of intrahepatic bile duct stones, the clinical significance of biliary manometry is small. However, for the left and right hepatic ducts close to the hepatic hilum with biliary stricture, bile excretion can be found, causing bile duct dilatation, bile retention, and increased biliary pressure above the lesion. Electronic biliary pressure gauges have been used to accurately measure the pressure in the bile duct and should be selected according to the condition.
Radionuclide stimuli scan: commonly used radionuclide 99m Tc, after ingestion through the reticuloendothelial system, excreted into the biliary tract. When scanning, it can be layered and fixed, and a three-dimensional image can be obtained to show the relationship with adjacent structures, which provides a good basis for diagnosis. However, the diagnosis of intrahepatic bile duct stones is not ideal.
Selective celiac angiography: observation of arterial vessels for displacement, compression, interruption, and abnormal vascular shadows. For the differential diagnosis of hepatobiliary and gallbladder cancer, the diagnosis of intrahepatic bile duct stones is not satisfactory. Moreover, arterial angiography requires certain equipment, cumbersome operation, high technical requirements, and is not the preferred method for intrahepatic bile duct stones.
Diagnosis
Diagnosis and diagnosis of intrahepatic bile duct stones
diagnosis
The diagnosis of intrahepatic bile duct stones is complicated. In addition to the above clinical manifestations, the results of previous surgical findings and X-ray angiography are often the main basis for determining the diagnosis. X-ray angiography mainly uses direct cholangiography, such as PTC and ERCP, especially the former, which can clearly show the distribution of intrahepatic bile duct stones, as well as understanding the presence or absence of intrahepatic bile duct stricture, complete obstruction or localized dilatation. And guiding treatment is very important. Although B-ultrasound is not as good as PTC or ERCP, it can not help to understand the details of stone distribution, but it still has 80% accuracy in the diagnosis of intrahepatic bile duct stones. The biggest advantage is that the method is simple and non-invasive. Therefore, it is often used as the first choice for diagnosis of intrahepatic bile duct stones. Because CT is expensive, the diagnostic accuracy of pigmented stones with low calcium content in the intrahepatic bile duct is not higher than that of B-ultrasound, and it is generally less used. In addition, it can be diagnosed by surgical exploration, that is, the intrahepatic bile duct is carefully explored during surgery, which is the most reliable diagnostic method for intrahepatic bile duct stones. In addition to the sequential exploration of extrahepatic bile ducts during surgery, attention should also be paid to the palpation of the liver, especially the examination of the left hepatic lobe, and sometimes the double-checking method is used to check for the presence or absence of stones in the liver. Intrahepatic bile ducts are explored by means of stone tongs and T-tube irrigation. Intraoperative cholangiography is often used to diagnose intrahepatic bile duct stones and can be used to guide and select surgical methods. Intraoperative choledochoscopy can be seen under direct vision. Stones in the branches of the intrahepatic bile ducts can sometimes be removed by choledochoscopy using a stone basket and a balloon catheter.
Differential diagnosis
The strong echo of B-suspicion as "intrahepatic calculi" should be differentiated from intravascular calcification, intrahepatic gas or intrahepatic cavernous hemangioma echo.
Hepatic tissue fibrosis due to recurrent episodes of acute suppurative cholangitis, radionuclide scans may appear radioactive defect areas, and need to be differentiated from tumor-induced space-occupying radioactive defects.
Patients with jaundice without acute cholangitis should be differentiated from viral hepatitis and biliary tract tumors.
