谈谈“胆结石”

谈谈“胆结石”,山东大学齐鲁医院（青岛）普通外科 姜远辉,1.什么是胆结石？2.哪些人容易长胆结石？（高危因素及如何预防）3.胆结石有哪些症状？4.胆结石的危害5.如何治疗胆结石？,什么是胆结石？,“胆结石”又称胆系结石病或胆石症，是指胆管或胆囊内生成的结石引起剧烈腹痛、黄疸、发热等症状，是胆道系统的常见病。,分类,胆囊结石 肝内胆管结石 胆管结石 肝外胆管结石,得了胆结石会有什么症状？,胆囊结石：大部分无症状，少数病人的胆囊结石的典型症状为胆绞痛，表现为急性或慢性胆囊炎。主要临床表现如下：1.胆绞痛：尤其是饱餐、进食油腻后而引起胆绞痛，疼痛位于右上腹或上腹部，呈阵发性，或者持续疼痛阵发性加剧，可向右肩胛部和背部放射，可伴恶心、呕吐。部分病人因痛剧而不能准确说出疼痛部位。首次胆绞痛出现后，约70%的病人一年内会复发。,2.上腹隐痛多数病人仅在进食过量、吃高脂食物、工作紧张或休息不好时感到上腹部或右上腹隐痛，或者有饱胀不适、嗳气、呃逆等，易被误诊为“胃病”。,诊断,全面要有重点有判断有思路（各判断之间的联系） 具体分类中所属位置具体但要求足够的可信度, 依据动态History, present, development 对策Feedback,全 面 具 体,治疗,Diagnostics,Diagnosis,PancreatitisacuteBiliary or gallstone associated Severe, I,II; Fulminant GallstoneIn Gallbladder: pacted？Strangulated? perforated？In CBD: Pacted? changitis？AOSC?Metabolism高渗，酮症，低血糖；电解质； General condition,Complete,Treatment,Diagnosis about AGP,concrete,Etiology of AP,Treatment Strategy for critical Patients, SAP II , AOSC,对因治疗梗阻，感染灶全身状态的评估与维护氧供，氧输送；循环；糖代谢脏器功能：心、肺、肝、肾、脑手术的时机选择与创造,Effective, but higher risks morbidity Mortalityop within 48h 83 18op after 48h 48 12StrategyDiscriminate those with obstruction and CholangitisEndoscopy delayed operation,The role of emergency operation,Role of ERCP & EST During Severe Attack,Three trial / randomized and control Neoptolemos JP；Fan STregardless of presence of obstructive jaundice and / or cholangitis Folsch URrestricted to the patients with obstructive jaundice and / or cholangitis References：Neoptolemos JP, 6 papers,Ameliorate symptoms and progression,Operation to prevent the relapse,RecommendationCholecystectomy should be performed to avoid the recurrence of Gallstone associated pancreatitis.EvidenceRecurrence in 2963 cases if,Recommendation In mild cases, Cholecystectomy should be performed as soon as the patients has recovered, and ideally during the same hospital admission.In severe cases, Cholecystectomy should be delayed until sufficient resolution of the inflammatory response and clinical recovery.,EST to Prevent Further Attack,建议:对全身条件不适宜手术的病人，为降低胆石性胰腺炎复发的危险，EST是胆囊切除术的替代措施。然而，理论上有导致无菌性胰腺坏死感染的危险（B级） 依据：EST in 5 series with a total of 109 cases: median follow-up time 2239 mo