Intrahepatic bile duct stones
Introduction
Introduction 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 are part of primary bile duct stones, they have their specificity. If they coexist with extrahepatic bile duct stones, they are 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 effect is not satisfactory. The disease.
Cause
Cause
(1) Causes of the disease
The cause of hepatolithiasis has not been elucidated so far. Because it involves multidisciplinary issues such as medical geography, biochemistry, microbiology, pathophysiology, etc. In the past 20 years, with the advancement of medical science and the deepening of basic research, many theories have been put forward for the cause of hepatolithiasis.
1. Low protein and hepatolithiasis
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.
2. Biliary tract infection and hepatolithiasis
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 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.
3. Glycoprotein mucus material is the matrix formed by hepatolithiasis
In 1959, King and Boyce reported that organic stones were contained in gallstones. In 1963, Womack et al. proposed that the organic matter in gallstones is mucopolysaccharide. In 1974, Maki experimental study considered that sulfated glycoprotein is a cohesive shaping factor in the process of stone formation. In 1977, Soloway reported that studies of gallstones confirmed that the matrix is an acidic non-sulfated glycoprotein. Through the study of the gallstone interstitial (Matrix), it is also confirmed that the gallstone interstitial is a glycoprotein-based mucus substance, which is the framework and basis for the formation of gallstones by various components of the gallstone.
The study of gallstone interstitial found that the interstitial content of bile pigment stones was more than 10% in cholesterol stone interstitial and 36% in bile pigment stone interstitial. Under light microscope, the interstitial of hepatolithiasis was layered or stacked. Under the electron microscope, the interstitial was mucous group, and the cholesterol stone was mucus. The difference in the content, morphology and distribution of gallstone interstitial, in addition to the combination of cholesterol crystals and bilirubin particles, mainly reflects the pathological formation process of bile pigment stones and cholesterol stones. Biliary pigment stones are based on the inflammation of the bile duct, and the increase of mucus substances increases the coagulation mechanism of bilirubin and calcium ions and the core of stone formation, which is the basis for promoting the formation of bile pigment stones.
4. Bile stasis, changes in bile dynamics due to bile duct stricture, biliary obstruction or cystic dilatation of the bile duct, followed by changes in bile dynamics, 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.
5. Free radical activity in bile during biliary obstruction, resulting in increased precipitation of bilirubin calcium. Recent studies have shown that oxygen free radicals are involved in the formation of bile pigment stones. Liu Xiangtao and other found that oxygen free radicals (O2-), hydroxyl radicals (OH-), can accelerate the formation of bilirubin calcium in the test tube, the conditional solubility decreases, and the precipitated particles increase. Hale reported that 0H- stimulates the secretion of glycoproteins in the gallbladder epithelium and promotes the formation of bilirubin stones. Shen et al. used electron paramagnetic resonance (EPR) studies to confirm the presence of free radicals in bile pigment stones. Biliary tract infection increases oxygen free radicals, which in turn induce bile duct inflammation and play an important role in the formation of bilirubin ethylene-type polymers.
6. Study of primary hepatic bile duct cholesterol stones Ohta believes that unlike bilirubin calcium stones, it is not associated with bile duct inflammation and excessive inflammatory secretion of bile duct mucus, but a decrease in cholesterol nucleation inhibitor Apo AI activity. May be a disease associated with Apo AI deficiency.
Examine
an examination
Related inspection
Liver, gallbladder, spleen CT examination, intravenous cholangiography, oral cholangiography, cholangiography
1. Combined with extrahepatic bile duct stones
Two-thirds to three-quarters of cases of intrahepatic bile duct stones coexist with hilar or extrahepatic bile duct stones, so the clinical manifestations of most cases are similar to extrahepatic bile duct stones. Often manifested as acute cholangitis, biliary colic and obstructive jaundice. Its typical performance can be based on the severity of the Charcot triad (pain, chills fever, jaundice) or Reynolds five joints (the former plus septic shock and changes in consciousness), liver and so on. Some patients may have no obvious symptoms during the non-acute inflammatory phase, or only different degrees of lower right abdomen pain, occasional irregular fever or mild to moderate jaundice, indigestion and other symptoms.
2. Does not combine extrahepatic bile duct stones
Without hepatic or extrahepatic bile duct stones, or with extrahepatic bile duct stones, and bile duct obstruction, inflammation only occurs in some leaves, segmental bile duct, clinical manifestations are atypical, often not valued, easy to misdiagnose. In the case of simple intrahepatic bile duct stones and no acute inflammation, the patient can be asymptomatic or only mild liver discomfort and dull pain, often found in B-ultrasound, CT and other examinations.
Partial hepatic bile duct stones have partial leaf and segmental bile duct obstruction and acute infection, causing acute pyogenic cholangitis in the corresponding leaf and bile duct area. The clinical manifestations are mild or no jaundice, and the rest are acute. Cholangitis is similar. In severe cases, severe acute cholangitis such as pain, chills, fever, decreased blood pressure, septic shock or mental disorder may occur. Right hepatic lobe, segmental bile duct infection, inflammation, pain in the right upper abdomen or liver area and the right shoulder, back release pain and right liver. Left hepatic lobe, segmental bile duct obstruction, inflammation of the pain is mainly in the upper abdomen or xiphoid pain, multi-left shoulder, back release, left liver. Due to one side of the liver, segmental cholangitis, more jaundice or mild jaundice, or even pain is not obvious, or the pain is not accurate, often overlooked, delay diagnosis, should be vigilant. One side of the intrahepatic bile duct stones and acute infection, failed to diagnose and treat in time, can develop into the corresponding liver lobe, bile duct empyema or liver abscess. Long-term consumptive relaxation heat, gradually weak and thin.
Repeated acute inflammation is bound to occur liver parenchymal damage, liver capsule, perihepatitis and adhesions. After acute inflammation control, chronic biliary inflammation such as long-term pain in the liver area or pain in the shoulders is often left.
3. Abdominal signs
Patients with non-acute hepatic bile duct obstruction and infected intrahepatic bile duct stones have no obvious abdominal signs. Some patients may have sputum pain or liver enlargement in the liver area. There are a large number of multiple stones in the left and right liver, and the authors have repeated acute and chronic inflammation. They may have signs of portal hypertension such as liver, splenomegaly, liver dysfunction, cirrhosis, ascites or upper gastrointestinal bleeding.
Patients with acute obstruction of the intrahepatic bile duct and infected with it may have tenderness, muscle tension or hepatomegaly under the right upper abdomen and right flank. At the same time, there are common bile duct stones and obstruction, sometimes with a swollen gallbladder or Murphy sign positive.
Due to the complex anatomical structure of the intrahepatic bile duct, the stones are often multiple, the distribution is uncertain, and the treatment is difficult. Therefore, the diagnosis of intrahepatic bile duct stones is extremely demanding. The anatomical variation of the intrahepatic bile duct should be fully understood before the surgical treatment. The specific location, number, size, distribution of the stones in the intrahepatic bile duct and the pathological changes of the bile duct and liver should be performed. Such as the location, extent, extent of hepatic bile duct stenosis and expansion, hepatic lobe, segment enlargement, reduction, hardening, atrophy or displacement, etc., in order to rationally select surgical methods and develop surgical plans.
Intrahepatic bile duct stones often fall into the common bile duct, forming common bile duct stones secondary to the intrahepatic bile duct or accompanied by primary common bile duct stones. Therefore, all patients with common bile duct stones may have intrahepatic bile duct stones, and all kinds of imaging examinations should be performed according to the diagnosis requirements of intrahepatic bile duct stones.
In order to systematically understand the condition and correct diagnosis, the diagnosis procedure should be arranged, which is neither cumbersome nor missing.
Diagnosis
Differential diagnosis
The strong echo of B-suspicion as "intrahepatic calculi" should be differentiated from intravascular hepatic calcification, bile duct 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.
1. Combined with extrahepatic bile duct stones
Two-thirds to three-quarters of cases of intrahepatic bile duct stones coexist with hilar or extrahepatic bile duct stones, so the clinical manifestations of most cases are similar to extrahepatic bile duct stones. Often manifested as acute cholangitis, biliary colic and obstructive jaundice. Its typical performance can be based on the severity of the Charcot triad (pain, chills fever, jaundice) or Reynolds five joints (the former plus septic shock and changes in consciousness), liver and so on. Some patients may have no obvious symptoms during the non-acute inflammatory phase, or only different degrees of lower right abdomen pain, occasional irregular fever or mild to moderate jaundice, indigestion and other symptoms.
2. Does not combine extrahepatic bile duct stones
Without hepatic or extrahepatic bile duct stones, or with extrahepatic bile duct stones, and bile duct obstruction, inflammation only occurs in some leaves, segmental bile duct, clinical manifestations are atypical, often not valued, easy to misdiagnose. In the case of simple intrahepatic bile duct stones and no acute inflammation, the patient can be asymptomatic or only mild liver discomfort and dull pain, often found in B-ultrasound, CT and other examinations.
Partial hepatic bile duct stones have partial leaf and segmental bile duct obstruction and acute infection, causing acute pyogenic cholangitis in the corresponding leaf and bile duct area. The clinical manifestations are mild or no jaundice, and the rest are acute. Cholangitis is similar. In severe cases, severe acute cholangitis such as pain, chills, fever, decreased blood pressure, septic shock or mental disorder may occur. Right hepatic lobe, segmental bile duct infection, inflammation, pain in the right upper abdomen or liver area and the right shoulder, back release pain and right liver. Left hepatic lobe, segmental bile duct obstruction, inflammation of the pain is mainly in the upper abdomen or xiphoid pain, multi-left shoulder, back release, left liver. Due to one side of the liver, segmental cholangitis, more jaundice or mild jaundice, or even pain is not obvious, or the pain is not accurate, often overlooked, delay diagnosis, should be vigilant. One side of the intrahepatic bile duct stones and acute infection, failed to diagnose and treat in time, can develop into the corresponding liver lobe, bile duct empyema or liver abscess. Long-term consumptive relaxation heat, gradually weak and thin.
Repeated acute inflammation is bound to occur liver parenchymal damage, liver capsule, perihepatitis and adhesions. After acute inflammation control, chronic biliary inflammation such as long-term pain in the liver area or pain in the shoulders is often left.
3. Abdominal signs
Patients with non-acute hepatic bile duct obstruction and infected intrahepatic bile duct stones have no obvious abdominal signs. Some patients may have sputum pain or liver enlargement in the liver area. There are a large number of multiple stones in the left and right liver, and the authors have repeated acute and chronic inflammation. They may have signs of portal hypertension such as liver, splenomegaly, liver dysfunction, cirrhosis, ascites or upper gastrointestinal bleeding.
Patients with acute obstruction of the intrahepatic bile duct and infected with it may have tenderness, muscle tension or hepatomegaly under the right upper abdomen and right flank. At the same time, there are common bile duct stones and obstruction, sometimes with a swollen gallbladder or Murphy sign positive.
Due to the complex anatomical structure of the intrahepatic bile duct, the stones are often multiple, the distribution is uncertain, and the treatment is difficult. Therefore, the diagnosis of intrahepatic bile duct stones is extremely demanding. The anatomical variation of the intrahepatic bile duct should be fully understood before the surgical treatment. The specific location, number, size, distribution of the stones in the intrahepatic bile duct and the pathological changes of the bile duct and liver should be performed. Such as the location, extent, extent of hepatic bile duct stenosis and expansion, hepatic lobe, segment enlargement, reduction, hardening, atrophy or displacement, etc., in order to rationally select surgical methods and develop surgical plans.
Intrahepatic bile duct stones often fall into the common bile duct, forming common bile duct stones secondary to the intrahepatic bile duct or accompanied by primary common bile duct stones. Therefore, all patients with common bile duct stones may have intrahepatic bile duct stones, and all kinds of imaging examinations should be performed according to the diagnosis requirements of intrahepatic bile duct stones.
In order to systematically understand the condition and correct diagnosis, the diagnosis procedure should be arranged, which is neither cumbersome nor missing.
