Intrahepatic duct obstruction
Introduction
Introduction Intrahepatic bile duct stones and obstruction are caused by internal infection, biliary stasis, and biliary aphids.
Cause
Cause
The cause of the disease may be caused by intrahepatic infection, biliary stasis, biliary aphids and other factors.
Examine
an examination
Related inspection
MRI examination of liver, gallbladder, pancreas and spleen by liver, gallbladder and spleen
In the diagnosis of intrahepatic bile duct stones, in addition to clinically improving the understanding of the disease, the diagnosis depends mainly on imaging examination. The main application of the diagnostic methods are B-ultrasound, biliary X-ray, CT, PTCD, ERCP, biliary tract mother mirror, MRCP, choledochoscopy and so on.
1, B-ultrasound diagnosis
B-ultrasound is a non-invasive examination, which is convenient and easy to perform. It is the first choice for the diagnosis of intrahepatic bile duct stones. It is generally estimated that the diagnostic accuracy is 50%-70%. Ultrasound images of intrahepatic bile duct stones vary more. It is generally required that the bile duct at the distal end of the stone can be expanded to make a diagnosis of intrahepatic bile duct stones. The calcification of the intrahepatic duct system also has a stone-like image.
The diagnosis of intrahepatic bile duct stones is not interfered by intestinal gas, and the accuracy of diagnosis is superior to extrahepatic bile duct stones. The diagnostic accuracy rate is 70% to 80%. However, there are many branches of intrahepatic bile ducts, which are easy to miss without careful scanning, and they are also differentiated from intrahepatic calcification points. B-ultrasound is difficult to distinguish between intrahepatic calcification and intrahepatic bile duct stones. If there is a dot-like or agglomeration echo in the liver, if there is sound shadow afterwards, it is not a typical corrugated echo, and then there is sound and shadow, so relying solely on it. B-ultrasound diagnosis of intrahepatic bile duct stones is more difficult. Comprehensive judgment should be combined with other means.
The typical image of B-ultrasound diagnosis of intrahepatic bile duct stones is a cord-like echo, followed by sound and shadow, and the distal bile duct is obviously dilated, which may be caused by biliary obstruction caused by stones and concurrent bile duct stricture. It has been reported that the application of intraoperative B-ultrasound (intraoperative ultrasound scan of the liver surface and the sacral surface) can improve the diagnosis rate of intrahepatic bile duct stones by 91% and the residual stone rate to 9%.
2, 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.
3, 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 bile duct system and the distribution of stones. The following problems should be noted in cholangiography:
(1) There should be multiple X-rays;
(2) When a certain liver segment or hepatic bile duct is not developed, attention should be paid to the identification. Stone obstruction is only one of the reasons, and other tests should be performed for identification;
(3) Do not satisfy the diagnosis of a certain lesion, as it may cause missed diagnosis;
(4) When analyzing cholangiography, try to obtain the most recent angiogram as possible, and the condition may progress.
4, 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.
5, selective retrograde cholangiopancreatography (ERCP), biliary tract mother mirror, choledochoscopy clinical application of ERCP selective cholangiography, has a high diagnostic value for intrahepatic bile duct stones. The intrahepatic bile duct stones can be clearly displayed, and the location, size, and number of stones, and the narrowing or distal expansion of the intrahepatic bile duct can be determined. However, the following points should be noted: (1) In the case of ERCP, sufficient contrast agent should be injected to fully display the intrahepatic bile duct to clearly diagnose intrahepatic bile duct stones.
(2) After the ERCP bile duct is developed, the head can be lowered into the high position and the prone position, so that the intrahepatic bile duct is fully perfused and developed by the contrast agent.
(3) The catheter with balloon can be used. After the ERCP bile duct is developed, the balloon located in the duodenal nipple is inflated or filled with water to block the nipple, so that the contrast agent does not flow into the intestine, and the intrahepatic bile duct is fully displayed. It is of great value in the diagnosis of intrahepatic bile duct stones.
Recently, some scholars have reported that ERCP dual imaging can improve the diagnosis of gallstones. The method is to inject an appropriate amount of air after the ERCP bile duct is developed. The intrahepatic bile duct and its grade 2 branches are well filled, and it is expected that there should be a good image display for intrahepatic bile duct stones. For patients who have not had the gallbladder removed, inject about 5-10 ml of air. If the gallbladder has been resected, inject about 2 to 3 ml of air.
The biliary tract mirror is placed into the thinner sub-mirror through the biopsy tube of the mother lens. The biopsy tube of the mother mirror has a diameter of 5.5 mm and the outer diameter of the sub-mirror is 4.5 mm. Only use the mother lens to perform ERCP, and then do high-frequency electric cutting (ECT) on the duodenal papilla, usually a small incision of 0.5 ~ 1.0cm or expansion of the duodenal papilla, easy to enter the common bile duct, can be Direct observation of common bile duct, grade 1 to 2 intrahepatic bile duct. Can determine the presence and size, location, number of intrahepatic bile duct stones, whether the intrahepatic bile duct has stenosis, expansion and so on. Has a large diagnostic value. However, because the biliary tract mirror is more expensive, it is easy to wear and is not easy to popularize.
The choledochoscope includes three methods: preoperative, intraoperative and postoperative. The preoperative choledochoscope is a light PTC, which replaces the thicker catheter every week, and the sinus is formed after 5-6 weeks. Then enter the mirror from the sinus, look directly at the intrahepatic bile duct, can diagnose intrahepatic bile duct stones, and take stone treatment. Intraoperative choledochoscopy is to open the common bile duct during operation, and to observe the intrahepatic bile duct stones from the incision. Postoperative choledochoscopy is a sinus approach (usually 6 weeks after surgery) formed by a "T" shaped drainage tube after surgery. The intrahepatic bile duct stones are diagnosed and treated. Choledochoscopic examination is a clear diagnosis and treatment value for intrahepatic bile duct stones.
6, NMR cholangiopancreatography (MRCP)
Unlike the new examination method of ERCP, it is a non-invasive examination, which can diagnose intrahepatic and extrahepatic bile stones without duodenoscopy. However, the MRCP image clarity is slightly inferior to ERCP, which needs to be improved and improved in technology. It has a great diagnostic value for intrahepatic bile duct stones, but it is more expensive and not easy to popularize. In short, B-ultrasound, ERCP, choledochoscopy and other methods are of great value, simple and easy to perform, and are the preferred method for diagnosing intrahepatic bile duct stones. Especially ERCP and choledochoscopy, the accuracy of diagnosis of intrahepatic bile duct stones is higher than that of B-ultrasound. After the B-ultrasound examination of intrahepatic bile duct stones, routine examination of the above methods should be performed to rule out the misdiagnosis of B-ultrasound, and the stones can also be removed under choledochoscopy.
Diagnosis
Differential diagnosis
Intrahepatic tube obstruction needs to be identified as follows:
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 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.
Biliary obstruction: bile duct obstruction refers to any part of the bile duct excretion due to bile duct lesions, tube wall disease, infiltration and compression outside the tube wall, causing bile duct mechanical obstruction due to poor bile excretion or even complete blockage. Normally secreted bile can not be excreted smoothly into the intestines, leading to indigestion, cholestasis, jaundice, abnormal liver function, followed by a series of pathophysiological changes such as various functions of the body, multiple organ failure, and even death. How to deal with this type of disease, we discuss endoscopic treatment and surgical treatment.
Gallstones: Gallstone disease, also known as biliary stone disease or cholelithiasis, is a common disease of the biliary system. It is a general term for gallstones and bile duct stones (also divided into intrahepatic and extrahepatic).
Intrahepatic duct obstruction: intrahepatic bile duct stones and obstruction caused by intrahepatic infection, biliary stasis, and biliary aphids.
In the diagnosis of intrahepatic bile duct stones, in addition to clinically improving the understanding of the disease, the diagnosis depends mainly on imaging examination. The main application of the diagnostic methods are B-ultrasound, biliary X-ray, CT, PTCD, ERCP, biliary tract mother mirror, MRCP, choledochoscopy and so on.
1, B-ultrasound diagnosis
B-ultrasound is a non-invasive examination, which is convenient and easy to perform. It is the first choice for the diagnosis of intrahepatic bile duct stones. It is generally estimated that the diagnostic accuracy is 50%-70%. Ultrasound images of intrahepatic bile duct stones vary more. It is generally required that the bile duct at the distal end of the stone can be expanded to make a diagnosis of intrahepatic bile duct stones. The calcification of the intrahepatic duct system also has a stone-like image.
The diagnosis of intrahepatic bile duct stones is not interfered by intestinal gas, and the accuracy of diagnosis is superior to extrahepatic bile duct stones. The diagnostic accuracy rate is 70% to 80%. However, there are many branches of intrahepatic bile ducts, which are easy to miss without careful scanning, and they are also differentiated from intrahepatic calcification points. B-ultrasound is difficult to distinguish between intrahepatic calcification and intrahepatic bile duct stones. If there is a dot-like or agglomeration echo in the liver, if there is sound shadow afterwards, it is not a typical corrugated echo, and then there is sound and shadow, so relying solely on it. B-ultrasound diagnosis of intrahepatic bile duct stones is more difficult. Comprehensive judgment should be combined with other means.
The typical image of B-ultrasound diagnosis of intrahepatic bile duct stones is a cord-like echo, followed by sound and shadow, and the distal bile duct is obviously dilated, which may be caused by biliary obstruction caused by stones and concurrent bile duct stricture. It has been reported that the application of intraoperative B-ultrasound (intraoperative ultrasound scan of the liver surface and the sacral surface) can improve the diagnosis rate of intrahepatic bile duct stones by 91% and the residual stone rate to 9%.
2, 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.
3, 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 bile duct system and the distribution of stones. The following problems should be noted in cholangiography:
(1) There should be multiple X-rays;
(2) When a certain liver segment or hepatic bile duct is not developed, attention should be paid to the identification. Stone obstruction is only one of the reasons, and other tests should be performed for identification;
(3) Do not satisfy the diagnosis of a certain lesion, as it may cause missed diagnosis;
(4) When analyzing cholangiography, try to obtain the most recent angiogram as possible, and the condition may progress.
4, 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.
5, selective retrograde cholangiopancreatography (ERCP), biliary tract mother mirror, choledochoscopy clinical application of ERCP selective cholangiography, has a high diagnostic value for intrahepatic bile duct stones. The intrahepatic bile duct stones can be clearly displayed, and the location, size, and number of stones, and the narrowing or distal expansion of the intrahepatic bile duct can be determined. However, the following points should be noted: (1) In the case of ERCP, sufficient contrast agent should be injected to fully display the intrahepatic bile duct to clearly diagnose intrahepatic bile duct stones.
(2) After the ERCP bile duct is developed, the head can be lowered into the high position and the prone position, so that the intrahepatic bile duct is fully perfused and developed by the contrast agent.
(3) The catheter with balloon can be used. After the ERCP bile duct is developed, the balloon located in the duodenal nipple is inflated or filled with water to block the nipple, so that the contrast agent does not flow into the intestine, and the intrahepatic bile duct is fully displayed. It is of great value in the diagnosis of intrahepatic bile duct stones.
Recently, some scholars have reported that ERCP dual imaging can improve the diagnosis of gallstones. The method is to inject an appropriate amount of air after the ERCP bile duct is developed. The intrahepatic bile duct and its grade 2 branches are well filled, and it is expected that there should be a good image display for intrahepatic bile duct stones. For patients who have not had the gallbladder removed, inject about 5-10 ml of air. If the gallbladder has been resected, inject about 2 to 3 ml of air.
The biliary tract mirror is placed into the thinner sub-mirror through the biopsy tube of the mother lens. The biopsy tube of the mother mirror has a diameter of 5.5 mm and the outer diameter of the sub-mirror is 4.5 mm. Only use the mother lens to perform ERCP, and then do high-frequency electric cutting (ECT) on the duodenal papilla, usually a small incision of 0.5 ~ 1.0cm or expansion of the duodenal papilla, easy to enter the common bile duct, can be Direct observation of common bile duct, grade 1 to 2 intrahepatic bile duct. Can determine the presence and size, location, number of intrahepatic bile duct stones, whether the intrahepatic bile duct has stenosis, expansion and so on. Has a large diagnostic value. However, because the biliary tract mirror is more expensive, it is easy to wear and is not easy to popularize.
The choledochoscope includes three methods: preoperative, intraoperative and postoperative. The preoperative choledochoscope is a light PTC, which replaces the thicker catheter every week, and the sinus is formed after 5-6 weeks. Then enter the mirror from the sinus, look directly at the intrahepatic bile duct, can diagnose intrahepatic bile duct stones, and take stone treatment. Intraoperative choledochoscopy is to open the common bile duct during operation, and to observe the intrahepatic bile duct stones from the incision. Postoperative choledochoscopy is a sinus approach (usually 6 weeks after surgery) formed by a "T" shaped drainage tube after surgery. The intrahepatic bile duct stones are diagnosed and treated. Choledochoscopic examination is a clear diagnosis and treatment value for intrahepatic bile duct stones.
6, NMR cholangiopancreatography (MRCP)
Unlike the new examination method of ERCP, it is a non-invasive examination, which can diagnose intrahepatic and extrahepatic bile stones without duodenoscopy. However, the MRCP image clarity is slightly inferior to ERCP, which needs to be improved and improved in technology. It has a great diagnostic value for intrahepatic bile duct stones, but it is more expensive and not easy to popularize. In short, B-ultrasound, ERCP, choledochoscopy and other methods are of great value, simple and easy to perform, and are the preferred method for diagnosing intrahepatic bile duct stones. Especially ERCP and choledochoscopy, the accuracy of diagnosis of intrahepatic bile duct stones is higher than that of B-ultrasound. After the B-ultrasound examination of intrahepatic bile duct stones, routine examination of the above methods should be performed to rule out the misdiagnosis of B-ultrasound, and the stones can also be removed under choledochoscopy.
