外科黄疸的诊断与处理2014 -.ppt

1、外科黄疸的诊断与处理diagnosis and treatment of surgical jaundice,张志强 2014-12-05,肝外胆道extrahepatic bile duct,本课内容及要求,胆红素代谢（熟悉） Bilirubin metabolism 黄疸的分类（熟悉） Classification of jaundice 外科黄疸的鉴别（掌握） Differential diagnosis of surgical jaundice 外科黄疸的治疗（掌握） Treatment of surgical jaundice,胆红素代谢Bilirubin metabolism,胆红

2、素代谢Bilirubin metabolism,什么是黄疸？ Definition of jaundice,Yellowish discolor of tissue resulting from the deposition of bilirubin(胆红素) Scleral icterus(巩膜黄染): 2mg/dl,高胡萝卜素血症 carrot and orange,黄疸的分类Classification of jaundice,外科黄疸的分类classification of surgical jaundice,梗阻性黄疸的病理基础pathogenesis of obstructive

3、jaundice,Inside bile duct：lithiasis,lithiasis,外科黄疸的常见病因 Etiology of surgical jaundice,Mirizzi syndrome,Inside bile duct：lithiasis,外科黄疸的常见病因 Etiology of surgical jaundice,Mirizzi syndrome,Inside bile duct：lithiasis,外科黄疸的常见病因 Etiology of surgical jaundice,MRCP,Inside bile duct：lithiasis,外科黄疸的常见病因 Etio

4、logy of surgical jaundice,CT,malignant tumor benign tumor metastasis,tumor,Inside bile duct：tumor,外科黄疸的常见病因 Etiology of surgical jaundice,Inside bile duct：tumor,外科黄疸的常见病因 Etiology of surgical jaundice,Inside bile duct：tumor,外科黄疸的常见病因 Etiology of surgical jaundice,PTC,Inside bile duct：tumor,外科黄疸的常见病因

5、 Etiology of surgical jaundice,Inside bile duct：parasite,外科黄疸的常见病因 Etiology of surgical jaundice,Inside bile duct：parasite,T tube cholangiography,Inside bile duct：parasite,Bile duct：congenital anomaly (Biliary atresia),外科黄疸的常见病因 Etiology of surgical jaundice,Bile duct：congenital anomaly (Choledochal

6、 cysts),外科黄疸的常见病因 Etiology of surgical jaundice,Bile duct ：congenital anomaly (Choledochal cysts),外科黄疸的常见病因 Etiology of surgical jaundice,Bile duct：Primary sclerosing cholangitis,外科黄疸的常见病因 Etiology of surgical jaundice,MRCP,Bile duct：biliary injury （iatrogenic/trauma）,外科黄疸的常见病因 Etiology of surgical

7、jaundice,a,d,c,b,ERCP,Bile duct：biliary injury （iatrogenic/trauma）,外科黄疸的常见病因 Etiology of surgical jaundice,MRCP,Outside bile duct：tumor,a,b,c,外科黄疸的常见病因 Etiology of surgical jaundice,MRCP,Outside bile duct：tumor,外科黄疸的常见病因 Etiology of surgical jaundice,Outside bile duct： Chronic pancreatitis,b,a,c,外科黄

8、疸的常见病因 Etiology of surgical jaundice,ERCP,Outside bile duct： duodenal diverticulum(十二指肠憩室),a,upper gastrointestinal contrast,外科黄疸对机体的影响Effects of surgical jaundice,Liver cirrhosis Endotoxemia: gut barrier ;Kupffer cell Renal function: Hyperbilirubin; bile acid; endotoxin,Gastric mucosa: bile acid Ca

9、rdiovascular system: Hyperbilirubin; bile acid; endotoxin Immunologic function:T cell Skin irritation： bile acid,梗阻性黄疸对机体的影响effects of obstructive jaundice,外科黄疸的鉴别诊断Differential diagnosis of surgical jaundice,medical history： Physical examination： laboratory examination: image data:,History 1,Age: T

10、ravelling: Operation: Trauma:,History 2 fever,History 3 abdominal pain,History 4 pruritus,History 5 weight loss,Physical examination 1 inspection,Physical examination 2 palpation,laboratory examination,Routine blood/urine/stool test TB (total bilirubin) 、CB(conjugated bilirubin) ALP、GGT HBsAg Tumor

11、markers: AFP CEA CA19-9,Image data,Cholangiectasis(胆管扩张) mass(肿块),外科黄疸的诊断思路Method and program to diagnose surgical jaundice,jaundice : yes or no？ obstructive jaundice : yes or no？ Where is obstructive site ？ Etiology of surgical jaundice ？,Jaundice : yes or no？,History：dark urine; pruritus Physical

12、examination ：光线充分 脂肪垫 皮肤抓痕 laboratory examination ：STB2mg/dl,Obstructive jaundice : yes or no？,Obstructive jaundice : yes or no？,Image data ： Non-invasive ： B-ultrasound(必选) 、MRCP Invasive ：PTC ERCP,Where is obstructive site ？,Size of gallbladder：Courvoisier库瓦西耶（梗阻部位和性质）,扪及肿大胆囊,无痛,疼痛,肿瘤可能,结石梗阻于胆囊管可能

13、,Where is obstructive site ？,Imaging data ：胆道开始扩张的部位 B ultrasound MRCP CT ERCP PTC,a,b,c,Where is obstructive site ？,MRCP,Where is obstructive site ？,MRCP,Where is obstructive site ？,PTC,b,a,c,Where is obstructive site ？,ERCP,如梗阻性黄疸未发现胆道扩张？ Primary sclerosing cholangitis Intrahepatic cholestasis（ me

14、dical jaundice）,Where is obstructive site ？,Where is obstructive site ？,MRCP,Etiology of surgical jaundice ？,Stone： Tumor： Parasite： Congenital anomaly Inflammation (chronic pancreatitis) Iatrogenic biliary injury Trauma,Etiology of surgical jaundice ？,history： Physical examination： Auxiliary examin

15、ation： laboratory examination Image data,外科黄疸的处理Treatment of surgical jaundice,针对病因治疗 围手术期处理 减黄治疗,针对病因治疗Etiological treatment,tumor：切除 lithiasis：取尽结石，去除病灶，通畅引流,围手术期处理Perioperational management,保肝 纠正凝血功能：vitK1 维持水电酸碱平衡 防治感染 营养支持,减黄治疗biliary drainage,介入：PTGD PTCD 内镜：ERBD ENBD 腹腔镜或开腹：外引流 内引流,Etiologica

16、l treatment or biliary drainage?,biliary drainage:姑息治疗 或 术前准备,介入：PTGD经皮肝穿刺胆囊引流,介入：PTCD经皮肝穿刺胆道外引流（B-US guidance）,介入：PTC +内支架置入（B-US guidance）,endoscope,endoscope ：导管,ERCP,内镜：ERCP 置管,ENBD内镜下鼻胆管引流（重症胆管炎）,ERBD内镜逆行胆管引流（胆管良性狭窄 、肿瘤对症处理或术前准备）,内镜：ERBD内镜逆行胆管引流（塑料：可更换；金属：永久性）,operation：T tube biliary drainage,手术：胆汁内引流(切除后重建 、姑息短路),summary,obstruction,CB 反流入血,liver,Surgical jaundice,summary,Etiology of surgical jaundice,lithiasis tumor foreign matter stricture and atresia biliary injury （iatrogenic/trauma）,summary,Diagnosis