common bile duct stones
Introduction
Introduction to common bile duct stones Common bile duct stones are located in the middle and lower part of the common bile duct, but often with the common hepatic duct, as the stones increase, increase and the common bile duct expands, stones accumulate or move up and down. The meaning of common bile duct stones should actually include the entire extrahepatic bile duct stones including the common hepatic duct. The source of common bile duct stones is divided into primary and secondary, primary choledocholithiasis is a component of primary bile duct stones, which can form in the common bile duct, or the stones that originate in the intrahepatic bile duct Into the common bile duct, secondary bile duct stones refer to stones that originate in the gallbladder descending through the cystic duct to the common bile duct. basic knowledge The proportion of illness: 0.3% Susceptible people: no specific people Mode of infection: non-infectious Complications: acute suppurative cholangitis biliary tract bleeding cholangiocarcinoma
Cause
Common cause of common bile duct stones
(1) Causes of the disease
Secondary choledocholithiasis (28%):
The shape, size, and traits are basically the same as or similar to the co-existing gallstones. The number is different. It can be single or multiple. If the diameter of multiple stones in the gallbladder is small and there is obvious expansion of the cystic duct, the stones can be large. Enter the common bile duct, the common hepatic duct or the left and right hepatic ducts.
Primary common bile duct stones (35%):
It is the primary bile duct stone that occurs in the common bile duct. The etiology and formation mechanism are not fully understood. The current research results suggest that the formation of this stone is closely related to biliary tract infection, bile stasis, and biliary parasitic disease. The appearance of the stone is mostly brownish black. It is soft, brittle, and has various shapes, sizes and numbers. Some are like fine sand or unformed mud. Therefore, it is called "sand-like stone". The composition of this stone is bilirubin. Calcium-based pigmented stones, the main components are bilirubin, biliverdin and a small amount of cholesterol and calcium, sodium, potassium, phosphorus, magnesium and other minerals and various trace elements, calcium in minerals The ion content is the highest and it is easy to combine with bilirubin to form bilirubin calcium. In addition, there are a variety of proteins and mucins to form a reticular scaffold. Some of them can be seen under the microscope, such as the shell of the parasite, eggs and bacteria.
(two) pathogenesis
The pathological changes that may be caused by this disease are basically determined by two factors:
1 Whether the obstruction is complete: depending on the size and location of the stone, it is also related to the functional status of the common bile duct sphincter.
2 Whether there is a continuous infection: the cause and nature of the stones are different, and the extent and severity of the inflammation are also very different.
Common bile duct obstruction caused by stones is usually incomplete or intermittent, because stones can move or slide in the biliary tract; but sometimes it can also cause complete acute obstruction, although the secondary stones from the gallbladder into the common bile duct are volume Smaller, but the resulting obstruction is often acute, especially when the stone is incarcerated in the ampulla, it may cause temporary obstruction. On the contrary, if the primary common bile duct stone, the system gradually grows up, although later Can be to a great extent, but because the common bile duct can have a corresponding compensatory expansion, generally does not cause complete obstruction, and sometimes even no obstruction symptoms, which is related to the location of the stone, if the stone in the middle of the common bile duct There are only incomplete obstructions, but stones that are incarcerated in the ampulla or blocked in the hepatic duct can sometimes cause complete obstruction.
Prevention
Common bile duct stone prevention
1. Maintain the contractile function of the gallbladder to prevent long-term stagnation of bile. For patients who use intravenous nutrition for long-term fasting, such as cholecystokinin.
2, active treatment can cause some primary diseases of gallstones, such as hemolytic anemia and cirrhosis, because these diseases are easy to induce gallbladder bile pigment stones.
Complication
Common bile duct stones complications Complications Acute suppurative cholangitis Biliary tract cholangiocarcinoma
1. Acute suppurative cholangitis is the most common complication of primary bile duct stones, also known as biliary tract infection. The clinical manifestations of primary bile duct stones are mostly related to it. The main manifestations are upper right abdominal pain, chills and high fever and jaundice, causing biliary tract. Common bacteria infected are Gram-negative bacilli or anaerobic bacteria. Escherichia coli is more common, more commonly mixed infection. When the stone is invaded at the lower end of the bile duct, acute suppurative cholangitis appears. Treatment, local inflammation and edema subsided, stones floating, incarceration relieved, the above symptoms and signs subsided, thus manifested as volcanic jaundice, B-ultrasound can be found in intrahepatic bile duct dilatation or bile duct stones; may have leukocytosis and other laboratory findings, generally considered Acute suppurative cholangitis should be treated with anti-inflammatory, phlegm and spleen rehydration. After the symptoms are relieved, elective surgery should be performed. However, it should be closely observed during non-surgical treatment. Once acute obstructive suppurative cholangitis occurs, surgery should be considered.
2. Biliary liver abscess due to hepatic bile duct stones complicated by infection or timely invasive small hepatic duct stones in the invasion of suppurative small cholangitis, inflammation and surrounding tissue formation, more common small abscess, There may be right upper quadrant pain or abdominal pain, which is characterized by chills and high fever. It is a relaxation heat type. The jaundice is optional. The course of the disease is generally long. The disease has not been effective after short-term non-surgical treatment. The biliary tract should be drained. If it is diffuse. Small abscess, drainage of the biliary tract can be, if there is a large abscess in addition to a single large abscess or multiple abscess, in addition to biliary drainage, at the same time abscess drainage.
3. Biliary hemorrhage is a serious complication of primary bile duct stones.
4. Gallbladder cirrhosis is a late complication of primary bile duct stones, which belongs to advanced biliary tract disease. In severe cases, it is accompanied by portal hypertension, splenomegaly and hypersplenism. In addition to the symptoms of hepatolithiasis, there is also cirrhosis. And the performance of portal hypertension, if the patient does not have portal hypertension, biliary exploration should be performed as soon as possible, the intrahepatic stones should be taken as far as possible, and some patients' liver function is expected to recover. If accompanied by portal hypertension, the treatment is more complicated and difficult. The situation allows one-stage biliary exploration for stone removal and splenectomy, and then complete hepatolithiasis operation to deal with complicated intrahepatic lesions. Otherwise, staged surgery should be performed. First, biliary exploration should be performed to remove stones, and portal hypertension should be performed again. Finally, Dealing with complicated hepatobiliary surgery, these patients are seriously ill, difficult to handle, and have a high mortality rate. Sometimes the prognosis is very poor regardless of the operation. Therefore, it is best for the hepatolithiasis to perform surgery without symptoms or symptoms. Reduce liver damage.
5. Cholangiocarcinoma Most scholars believe that the occurrence of cholangiocarcinoma is related to primary bile duct stones, especially intrahepatic bile duct stones and infections. There are more intrahepatic cholangiocarcinomas, also known as cholangiocarcinoma, often referred to as primary bile ducts. The symptoms of stones are covered up, and it is easy to miss the diagnosis before surgery. Patients with primary bile duct stones have recently experienced frequent and exacerbation of upper abdominal pain, and are limited to a certain part. The abdominal examination shows obvious tenderness in the right upper abdomen or under the xiphoid process. The tender mass should be suspected of this disease. Further B-ultrasound and CT examination can simultaneously detect intrahepatic calculi and intrahepatic localized or diffuse space-occupying lesions, which can be clearly diagnosed. These patients are generally negative for AFP due to Due to repeated inflammation and fibrosis of hepatolithiasis, cholangiocarcinoma is mostly hard cancer, and there are more fibrous connective tissues, mainly local invasive growth, intrahepatic jumping metastasis and distant metastasis, Hunan Hepatobiliary Surgery of the Second Affiliated Hospital of Medical University has found 17 cases of cholangiocarcinoma in recent years, all of which are associated with hepatolithiasis, 13 of which are located in the left and left hepatic lobe, and 4 in the right. Anterior or right posterior lobe, biliary exploration and hepatic or hepatic resection, 10 of which have survived for more than 3 years, 2 have survived for 2 years, 3 have been in 1 year, and 2 died in postoperative 6 Months and 14 months, if the mass is too large and involves the surrounding tissue and adjacent organs, most of the masses are removed, that is, volume reduction surgery, also has a good effect.
6. Biliary pancreatitis Primary bile duct stones with acute pancreatitis are much less than secondary bile duct stones, which may be related to the presence of Oddi sphincter relaxation in most patients with primary bile duct stones.
Symptom
Common bile duct stones symptoms Common symptoms biliary colic intrahepatic bile duct stones abdominal muscles strong abdominal pain bile duct stones liver enlargement jaundice bilirubin calcium stones
Determined by the degree of obstruction of the bile duct and the presence or absence of infection, most patients have had one or more urgency in the past, a history of chronic cholecystitis or a history of biliary tract mites, and then jaundice after a severe biliary colic, indicating that the stone has entered the common bile duct , or incarceration and obstruction have occurred after the formation in the common bile duct.
Biliary tract obstruction caused by gallstones is usually incomplete and non-sustainable. Complete obstruction is rare. Therefore, about 20% of patients may not feel right upper quadrant, 40% of patients have colic but no jaundice, and the rest are Most of them have jaundice from a few hours to 1 to 2 days after the onset of abdominal pain, and they will gradually disappear after a few days. If the stones in the common bile duct cannot be discharged to the duodenum, the abdominal pain will reappear and the jaundice will appear again. And the frequency of recurrence tends to be more frequent, and the degree is more serious. However, some cases do not recur after more than 10 years after an episode, and the stones in the common bile duct are as large as l~2cm in diameter or the onset of the next episode. When there is only mild abdominal pain and no jaundice, a few cases can cause complete biliary obstruction after a certain attack, jaundice continues to disappear, the color is deep yellow-green, the skin is itchy, the stool is terracotta, and there is obvious weight loss. Phenomenon, it is difficult to distinguish from pancreatic head cancer. In such patients, large stones are often invaded in the ampulla of the biliary tract; or a large amount of sediment-like stones are blocked in the common bile duct or hepatic duct. In a few cases, no stones are seen in the common bile duct during operation. Most of the stones are excessively placed in the intestine due to excessive pressure in the bile duct or due to relaxation of the sphincter after anesthesia. However, during the movement of the stones, the patient has more There is a history of repeated biliary colic attacks. In addition to obstruction, there are often symptoms of biliary tract infection, and the gallbladder is not swollen. It is generally different from pancreatic head cancer.
There is no abdominal muscle rigidity during the attack, but there may be mild tenderness in the upper abdomen or right upper abdomen. The liver is swollen, the texture is firm, slightly tender, but the gallbladder is generally unsatisfactory, and the spleen can sometimes be swollen. Most patients have obvious jaundice, sickness, depression, and weight loss. When there are complications, there are corresponding signs such as jaundice and shock.
Examine
Common bile duct stones
In acute obstructive cholangitis, bloody images of acute inflammation such as leukocytosis and neutrophil increase, blood bilirubin increase and transaminase increase, and obstructive jaundice and liver function damage, if long-term bile duct Obstruction, jaundice or short-term recurrent cholangitis liver function is significantly impaired, hypoglycemia and anemia may occur.
1. X-ray plain bile duct of the primary stones and secondary stones, respectively, bile pigment and cholesterol-based mixed stones, X-ray film can not be displayed.
2. Oral or venous cholangiography of the bile duct is pale, it is difficult to make an accurate diagnosis.
3. B-type ultrasound examination, although inexpensive and non-invasive, the accuracy rate of gallstones is 98%, but due to the influence of the hollow organs such as the duodenum, the accuracy of the common bile duct stones is only about 50% (Figure 1), especially in the duodenum, the bile duct is difficult to display, false positive and false negative rate are higher.
CT computed tomography CT is superior to B-ultrasound in the diagnosis of common bile duct stones, and the accuracy rate can reach about 80%, but it is difficult to show the pathological changes of bile duct system and the number, size and distribution of stones.
5. ERCP and PTC examination can clearly show the whole appearance of the bile duct system, can accurately provide the size, number, location and intrahepatic bile duct dilatation, stenosis and other pathological changes of the intrahepatic and extrahepatic bile duct stones, which is the most accurate diagnosis before surgery. Important examination methods, ERCP is basically non-invasive, less complications, PTC is invasive, a little more complications, can be selected according to the specific circumstances of patients and lesions, under normal circumstances, more choices of ERCP (Figure 2).
6. Magnetic resonance cholangiopancreatography (MRCP) Non-invasive, no contrast agent, can show the gallbladder, pancreatic duct system, can display the common bile duct stones, but not as clear as ERCP or PTC images.
Diagnosis
Diagnosis and diagnosis of common bile duct stones
Diagnostic criteria
Acute obstruction of common bile duct stones, inflammatory attack, according to the history and typical performance, the general clinical diagnosis is not difficult, but because of the etiology of common bile duct stones, pathology and treatment are inseparable from the entire biliary system, so the diagnosis is in addition to clear bile duct In addition to the stones and pathological conditions, it is necessary to fully understand the pathological condition of the entire biliary system including the gallbladder and the liver, whether there are gallbladder and intrahepatic bile duct stones and their quantitative distribution, the presence or absence of hepatic bile duct stenosis, expansion and anatomical variation, Complicated with liver abscess, cirrhosis, liver tissue atrophy and other changes, in order to choose a reasonable treatment, for the best results, must rely on modern imaging diagnosis.
Differential diagnosis
The following conditions, where right upper quadrant pain and jaundice can occur, should be considered in the differential diagnosis:
1 congenital disorders: such as choledochal cyst, hemolytic jaundice.
2 inflammatory diseases: such as infectious hepatitis, chronic pancreatitis, acute cholecystitis.
3 traumatic lesions: such as stenosis of the common bile duct after surgery.
4 parasitic diseases: such as biliary ascariasis, Chinese branch schistosomiasis.
5 cancer: such as liver cancer, pancreatic head cancer, stomach cancer and so on.
The above-mentioned diseases are more common with infectious hepatitis, biliary ascariasis, pancreatic head cancer, etc., and the identification points are as follows.
1. Patients with infectious hepatitis have a history of contact with infection. Before the occurrence of abdominal pain and jaundice, there are often obvious precursor symptoms such as general malaise, loss of appetite, etc. The abdominal pain is dull pain in the liver area, and it is not released. The jaundice appears quickly and subsides. It is slow, the degree is not fixed, and the Fan Dengbai test is biphasic. The patient has elevated body temperature at the beginning of the onset, but the increase and decrease of white blood cells, and the lymphocytes often increase. The liver function test is obviously reduced at the beginning of the disease. , quite prominent.
2. The age of patients with biliary ascariasis is generally mild, mostly under 30 years old, sudden onset, severe cramps, paroxysmal aggravation and special drilling sensation, often accompanied by nausea and vomiting, often spit out aphids, jaundice It is not obvious, unless there is no chills and fever in the late stage of the disease, and abdominal muscle stiffness and abdominal wall tenderness are not significant.
3. Patients with pancreatic head cancer are generally older, mostly over 50 years old, and the incidence is concealed. The jaundice is often accompanied by abdominal pain (the history of jaundice without similar abdominal pain in the past). The scutellaria is progressive and can be developed to a very deep degree. Without fluctuation, the stool will always be clay-like after lack of bile. The urinary urinary bilirubin is often negative, because the obstruction is often complete, abdominal pain is not common, and those with abdominal pain are mostly upper abdomen. Persistent pain, often involved in the back, even if the disease has been long, usually no symptoms of infection, body temperature and white blood cells will always be normal; but the lesions are progressive, often to the end of the course of the disease often have weight loss and cachexia performance, Fan Dengbai test For direct strong positive reactions, other liver function tests are also consistent with obstructive jaundice without hepatocyte damage.
In short, for a patient with jaundice, the type of jaundice should be determined first, and then the lesions and causes should be determined according to various aspects of the examination. Generally speaking, it is not difficult to determine the type of jaundice in the early stage of the disease combined with medical history and laboratory tests, such as Has been identified as obstructive jaundice, the most common lesions in the bile duct are stones or parasites, sometimes blood clots or mucus; lesions in the bile duct wall are mostly scars after surgery, sometimes can be biliary pancreatic duct sphincter, or sclerosing cholangitis; lesions in the bile duct are mainly pancreatic head cancer, sometimes can be caused by chronic pancreatitis or metastatic lymph node compression due to gastric cancer, liver cancer, such different lesions can cause obstructive jaundice, There are usually indications for surgery, and the exact cause is often clear when exploratory laparotomy. Preoperative identification is not important.
It is necessary to point out that long-term obstruction of the biliary tract can cause damage to the liver cells, and when the liver cells have lesions, it can also cause obstruction of the intrahepatic capillary bile duct. Therefore, both the Fandenbai test can be biphasic, and other liver function tests are also performed. The damage causes the identification of hepatic jaundice and obstructive jaundice. The above two different causes of jaundice are fundamentally different because of the treatment principle. The former requires strict medical treatment, and the latter must be operated in time. The differential diagnosis is particularly important. Clinically, it is clinically important. It is necessary to consider all aspects of the information and make repeated conclusions in order to draw a correct conclusion.
