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1、Biliary tract diseasesEssentials of anatomy -1BiliarytractIntra-hepaticbileductExtra-hepaticbileductGallbladderCommonbileductEssentials of anatomy -2Intra-hepaticBileDuctBilecanaliculiSegmentalbileductLobalbileductHepaticpartofleftandrighthepaticductEssentials of anatomy -3Extra-hepaticBileDuctLefta
2、ndrighthepaticductThecommonhepaticduct(CHB)Diameter:0.4-0.6cm2-4cmlengthCommonbileduct(CBD)Diameter:0.6-0.8cmlength:7-9cmGallbladder:thebody,thefundus,TheneckEssentials of anatomy -4Calottriangle:Thetriangleboundedbythecommonhepaticductmedially,thecysticductinferiorlyandtheinferiorsurfaceofthelivers
3、uperiorlyisknownasCalottriangle.Thefactthatcysticartery,righthepaticartery¶-righthepaticductrunwithinthetrianglemakesanimportantareaofdissectionduringcholecystectomy.胆囊胆囊胆囊胆囊三角三角Special Investigation of the biliary Tract -1UltrasoundNon-invasive,painless,easilyperformed,repeatedlyFirstchoiceforb
4、iliarytractdiseasenBileductstones:Stonesingallbladder:HighechowhichcastanacousticshadowandwhichmovewithchangesinposturenJaundicedifferentialdiagnosis:DilatationoftheductsCBD:diameter1.0cmnOtherdisease:cholecystitis,tumorect.nDuringsurgery:todetectbileductstonesSpecial Investigation of the biliary Tr
5、act -2RadiologynPlainabdominalradiograph:Radio-opaquegallstonesAirinthebiliarytreenOralcholecystography:BiliarycontrastmediumAfattymealnCholangiographyPercutaneoustranshepaticcholangiography(PTC)showintraandextrahepaticbiliaryductclearlycomplication:bileleakage,cholangitis,hemorrhageSpecial Investig
6、ation of the biliary Tract -2nEndoscopicretrogradecholangiopancreatography(ERCP)outlinethebiliarytreeandpancreaticductinspecttheampullaofVaterexamofthefluidofduodenum,bile,pancreaticfluid.nEndoscopicsphincterotomy(EST)nEndoscopicnaso-biliarydrainage(ENBD)nComputedtomography(CT)Magneticresonancechola
7、ngio-pancreatography(MRCP)n Choledochoscopy:Operation,PostopertionCholelithiasis-胆石病胆石病nCholelithiasisIncluding:gallstonesbiliaryductstonesClassificationofstones:nCholesterolstones:hard,layedoncross-sectionnPigmentstones:crumblewhensquashednMixedstones:radio-opaqueCholelithiasis Cholelithiasis Chole
8、lithiasis Gallstones -胆囊结石胆囊结石 Riskfactor:nWomenarethreetimesmorelikelythanmentodevelopstonesnObesitynPregnancynDietaryfactors:highenergy,lowinfibrenFastingnBiliaryinfectionnParasiticinfestationClinicalfeatureofgallstonesn20-40%patientwithoutsymptomwhichiscalledasymptomaticgallstonesnChroniccholecys
9、titisnBiliarycolicnAcutecholecystitisGallstones -胆囊结石胆囊结石 SymptomsnGastrointestinaltractsymptoms:upperabdominaldiscomfort,nausea,aftermeals,esp.fattymeals.Biliarycolic:mostcommomsymptomnAlargeorfattymealsandchanginginpositionwhensleepingcanprecipitatethepainGallstones -胆囊结石胆囊结石 SymptomsnDuetoimpacti
10、onofstoneintheneckofthegallbladder:thepressureincrease.nOccursinthemidortheupper-rightportionoftheupperabdomen.nSeverepainstartsabruptly,continuous,withrestlessness,vomitting,sweating.nPainradiatetotherightbackandshoulder.Gallstones -胆囊结石胆囊结石 Mirizzisyndrome:nObstructionofthecommonhepaticductbyaston
11、eimpactedinthecysticductorHartmannspouchnPressonthebileductor(morecommonly)ulcerateintotheductleadstocholecystocholedochalfistulanCholecystitis,cholangitis,andobstructivejaundice.nCholangiography:narrowofthebileductattheportahepatisnAnatomyvariation:cystductrunsparalleltothehepaticductGallstones -胆囊
12、结石胆囊结石 Gallstones -胆囊结石胆囊结石 SignnRightupperareaoftheabdomentenderness,rigidity,reboundtendeness.nGallbladderpalpablenMurphysign:inspiratoryarrestduringsubcostalpalpationnJaundice:commonbileductstonesorMirizzisyndromenFeverandchillwithinfectionGallstones -胆囊结石胆囊结石 ExamnJaundice(choledocholithiasis):b
13、loodtestoftheliverfunction,elevationoftheenzymealkalinephosphateandbilirubinnWBCcountishighnUltrasoud:themaindiagnosisexam.Gallstones -胆囊结石胆囊结石 DiagnosisnHistorynPhysicalexamnUltrasoudexam:highechowithanacousticshadowandmovingwithchangesinpostureGallstones -胆囊结石胆囊结石 UltrasoudGallstones -胆囊结石胆囊结石 CTG
14、allstones -胆囊结石胆囊结石 TreatmentThefirstchoiceisoperation:nsymptomaticgallstonesngallstoneswithcomplicationsGallstones -胆囊结石胆囊结石 CBDexploration(胆道探查胆道探查)PreoperationnCBDstonesnJaundiceandbileductdilatationDuringoperationnCholangiographyindicateCBDstoneandbileductdilatationnPalpablestones,ascarid,tumorn
15、CBDdiameter1.0cmnGallstonemigrateintoCBDnPancreatitisnDrawoutpurulentorhaematoidbileorbilewithsandystonesGallstones -胆囊结石胆囊结石 Laparoscopiccholecystectomy(LC)nfirstperformedin1987nremovalofthegallbladderisguidedbyalaparoscopenashorthospitalstay,aquickrecuperation,andaverysmallincisionGallstones -胆囊结石
16、胆囊结石 LCNon-SurgicalTherapynunwillingtoundergosurgerynwhohaveseriousmedicalproblemsthatincreasetherisksofsurgeryncannotbeusedforpatientswhohaveacutegallbladderinflammationGallstones -胆囊结石胆囊结石 Bile duct stones-胆管结石胆管结石 Including:primarybileductstonessecondarybileductstonesSite:intrahepaticbileductston
17、esextrahepaticbileductstones ExtrahepaticbileductstonesPathology:nBiliarytractobstruction:uncompletely,bileductdilatationnInfection:ductwalledma,congestionpurulentbilebloodsepsisbileductwallulcerfistulabetweenbileductandhepaticartery&portalveinBile duct stones-胆管结石胆管结石 ClinicalmanifestationnMaybesil
18、entnObstructivejaundiceascendingcholangitisacutepancreatitisChacrottriad:epigastricpainjaundicefeverandchillExtrahepaticbileductstonesBile duct stones-胆管结石胆管结石 n Abdominalpain:epigastricorrightupperquadrantoftheabdomenradiatetotherightbackandshoulder,nausea,vomitingnHighfeverandchill:obstructioninfe
19、ctionpressureinductincreasebacteriaflowsintobloodsepsistemperature:39-40n Jaundice:intermittence,fluctuantThesevereofthejaundicedependsonthedurationoftheobstruction.Completeimpactationofastonecausesevereprogressivejaundice.IntolerableitchingExtrahepaticbileductstonesBile duct stones-胆管结石胆管结石 Physica
20、lexamn Tendernessofepigastricandupperareaoftheabdomenn peritonealirritationsignn GallbladdermaybepalpableLabtestn WBCcountishighn elevationoftheenzymealkalinephosphateandbilirubinn bilirubininureaishighn urobillinogeninureaislowurobillinogeninfecesislowExtrahepaticbileductstonesBile duct stones-胆管结石
21、胆管结石 Imagingtechniquen Ultrosound:stonesinbileduct,bileductdilatationn CT/MRIn ERCPDiagnosisn Charcottriadn LabtestandimagingexamDifferentialdiagnosisn Renalcolicn Intestinalcolicn CarcinomaoftheVaterampullanCarcinomaoftheheadofpancreasExtrahepaticbileductstonesBile duct stones-胆管结石胆管结石 MRCP Extrahe
22、paticbileductstonesBile duct stones-胆管结石胆管结石 TreatmentnOperationisthemaintherapynPrinciples:TrytoremovalallstonesReliefbileductstenosisandobstructionTheobstructiveductmustbedrainedadequatelyn Preoperationmanagement:controlinfection:antibioticscorrectelectrolyteandacid-alkalibalancevitaminK,nutrition
23、,etc.ExtrahepaticbileductstonesBile duct stones-胆管结石胆管结石 IntrahepaticbileductstonesPathology:ObstructionhepatocyteinjuryInfectionhepaticabscessCholangitisbilecirrhosisofliverBile duct stones-胆管结石胆管结石 Bile duct stones-胆管结石胆管结石 IntrahepaticbileductstonesnPigmentstonesmainlynLeftmorethanrightnCoexistwi
24、thextrahepaticbileductstonescommonlyEtiologynInfectionnCholestasisnBiliaryAscariasisPathologynStenosis:intrahepaticbileductnCholangitisnBiliarycarcinoma IntrahepaticbileductstonesClinicalmanifestationnFeatureofextrahepaticbileductstones(whencoexist)nAsymptomaticordiscomfortofliverareaandchestbacknOb
25、struction:infection,fever,chill,acuteobstructivesuppurativecholangitis(AOSC)nAbscessnBilelivercirrhosishypertensionofportalveinnCarcinomaofbiliarytract:frequencyattackofcholangitis,progressivejaundice,abdominalpain,feverhardtocontrol,age50becomethin.Bile duct stones-胆管结石胆管结石 Intrahepaticbileductston
26、esPhysicalexamnLiverswellingasymmetricalnTendernessatliverareanPercussiontendernessoverhepaticregionnOthers:infectionandcomplicationDiagnosisnHistorynImagingexam:ultrasoudPTCBile duct stones-胆管结石胆管结石 IntrahepaticbileductstonesTreatmentnOperation:themainmethodnPrinciple:extractallstonesreliefstenosis
27、andobstruction:keypointremovalintrahepaticinfectivefocusrecoverythebiledrainagepreventrecrudescencenhighpositionedCholangiolithotomy:经肝胆管切开取石术经肝胆管切开取石术nInternaldrainage:Roux-enYcholangiojejunostomy：胆肠吻合术胆肠吻合术nRemovalintrahepaticinfectivefocuslocalcirrhosis:leftlaterallobeandrightposteriorlobeBile du
28、ct stones-胆管结石胆管结石 Biliary infection-胆道感染胆道感染nCholecystitisCholangitisnAcuteSubacuteChronicAcute cholecystitis -急性胆囊炎急性胆囊炎nChemicaland(or)bacterialinflammationndividedintotwocategories:acutecalculouscholecystitis(ACC)9095%acuteacalculouscholecystitis(AAC)510%EtiologynObstructionofcystduct:80%byanimp
29、actedgallstoneothers:torsionorstenosisofcystduct,ascaridnBacterialinflammationnTrauma(previoussurgery),chemicalstimulusPathologynAcutesimplecholecystitisnAcutepurulentcholecystitisnAcutegangrenouscholecystitisnPerforationofgallbladder:peritonitisAcute cholecystitis -急性胆囊炎急性胆囊炎Acute cholecystitis -急性
30、胆囊炎急性胆囊炎Acute calculous cholecystitis Nosogenesisn Cystductobstructionbygallstonestheresultischemicalinflammationofthecystwalln SecondarybacterialinfectionretrogressionthroughcystductbybloodorlymphnOthersAcute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecystitis Clinicalmanifestationn female,fatty
31、,forty,3Fn Historyofgallbladderdiseasen Typicalonset:biliarycolicn Patientstendtomovearoundtoseekrelieffromthepainn ItisprolongedandlastshoursordaysNausea,vomiting,andlow-gradefeverAcute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecystitis SignnEpigastricorrightupperquadranttenderness,guardingmayb
32、efoundnMurphysign(aninspiratorypauseonpalpationoftherightupperquadrant)nGallbladdermaybepalpable.nMassintherightupperquadrantnDiffusiveperitonitisnElderlypatients:absenceoftypicalphysicalsignstheincidenceofcomplicationishighernUncommoninchildrenAcute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecys
33、titis LabtestnWBCcountLeukocytosiswithleftshiftNormalWBCCountdoesnotruleoutcholecystitisnLiverFunctionTests(LFTs)SerumBilirubinelevatedSerumAlkalinePhosphataseelevatedSerumAminotransferasesnormalnPancreaticStudiesAmylaseelevatedAcute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecystitis Imagingexam
34、Ultrasound:nEnlargementofthegallbladdernGallbladderwallthickness3mmnSonographicMurphysSignnHalosign(gallbladderwallwithasonolucentdouble-linedhalo)nGallstonesnHepatobiliaryscanAcute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecystitis DiagnosisnTypicalclinicalmanifestationnLabtestnImagingexamnEasy
35、todiagnosisDifferentialdiagnosisnAcutepancreatitisnAcuteappendicitisnPerforationofpepticulcernHepaticabscessnPerforationofcoloncarcinomanHepatitisnPneumoniaandpleurisy(right)Acute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous cholecystitis TreatmentnNonsurgicaltreatment:fastingalowfatdietwhenfoodistolera
36、tedaftertheacuteattack.IntravenousfluidNasogastricsuctionAntibioticspaincontrolnOperation:thefinalmethodnEmergencysurgerynOnsetin48-72hoursnInvalidationofnonsurgicaltreatment(gangrene,perforation,pancreatitis,orinflammationofthecommonbileductoccurs)Acute cholecystitis -急性胆囊炎急性胆囊炎Acute calculous chol
37、ecystitis TreatmentOperationnCholecystectomy:mostcasesnCholecystostomy:highriskcaseslocalsevereedema,conglutinationAcute cholecystitis -急性胆囊炎急性胆囊炎Acute acalculous cholecystitis EtiologynUncertainnAfterseveretrauma,operation,andburnsnSevereillnesscasesnTPNforalongtimenBerelatedtobilestasisPathologynS
38、ametoacutecalculouscholecystitisnHighrateofnecrosisandperforationofgallbladderAcute cholecystitis -急性胆囊炎急性胆囊炎Acute acalculous cholecystitis ClinicalmanifestationnMorecommoninmenthanwomen(27:1)nSametoacutecalculouscholecystitisnEasytomakeanerrordiagnosisnUltrasoundisthemostusefulinvestigationnGallbla
39、dderispalpableTreatmentnOncethediagnosisismade,animmediateoperationisnecessaryMethod:nCholecystectomynCholecystostomyn n胆囊造瘘胆囊造瘘胆囊造瘘胆囊造瘘(Cholecystostomy)(Cholecystostomy)(Cholecystostomy)(Cholecystostomy)n n病情危重病情危重病情危重病情危重n n不能耐受手术不能耐受手术不能耐受手术不能耐受手术n n胆囊炎症严重，解剖不清胆囊炎症严重，解剖不清胆囊炎症严重，解剖不清胆囊炎症严重，解剖不清Acu
40、te cholecystitis -急性胆囊炎急性胆囊炎Acute acalculous cholecystitis n n胆囊造瘘术胆囊造瘘术(Cholecystostomy)Acute cholecystitis -急性胆囊炎急性胆囊炎Acute acalculous cholecystitis Acute obstructive suppurative cholangitis(AOSC) nAcutecholangitisofseveretype(ACST)nEtiology:obstructionofbileductbiliaryinfectionObstructivefactor:n
41、Bileductstones76-88%nBiliaryascariasis22-26%nBiliarytractstenosis8.7-11%nTumorofampullanPrimarysclerosingcholangitisAcute obstructive suppurative cholangitis(AOSC) PathologynCompletebileductobstructionintraorextrahepaticbileductnPurulentinfection:bileductnBacteria:Escherichiacoli,streptococcusfaecal
42、is,Klebsiella,pseudomonasAnaerobicbacteriaAcute obstructive suppurative cholangitis(AOSC) Clinicalmanifestationn nHistoryofbiliarydiseaseandbiliaryoperationn nStartsabruptlyandprogressivelyn nReynoldspentad:abdominalpainjaundicefeverandchillsmentalstatuschangessepticshockAcute obstructive suppurativ
43、e cholangitis(AOSC) SignnTemperature:39C,or120b/mnBloodpressure:lownJaundicenTenderness:EpigastricorrightupperquadranttendernessnMentalstatuschangesnPeritonitisnPercussiontendernessoverhepaticregionnPalpablegallbladdern MildhepatomegalyAcute obstructive suppurative cholangitis(AOSC) LabtestnWBCcount
44、ishigh,20X109/LseverepatientsmaybeleukopenicPLTcountislow,(10-20)X109/LnProthrombintime(PT)islongnLiverfunction:AlkalinephosphataseandBilirubiniselevatednrenalfunctionandelectrolytesnBloodcultures:Between20-30%ofbloodculturesarepositive.ManyexhibitpolymicrobialinfectionsnAmylaseand/orlipase:Involvem
45、entofthelowerCBDmaycauseelevatedamylaseandpancreatitis.nBiliaryculturesAcute obstructive suppurative cholangitis(AOSC) ImagingStudiesUltrasound:nusedmostcommonlytomakethediagnosisofbiliarydilationndifferentiateintrahepaticfromextrahepaticobstructionandimagedilatedductsCTscan:nadjunctiveorreplaceultr
46、asoundndilatedintrahepaticandextrahepaticductsandinflammationofthebiliarytreeareimagedAcute obstructive suppurative cholangitis(AOSC) DiagnosisnReynoldspentadnLabtestnImagingexamnT39,or120R/MnWBC20X109/L,PLTislowAcute obstructive suppurative cholangitis(AOSC) TreatmentPrinciple:nEmergencydecompressi
47、ontorelievebileductobstructionanddrainagenControlinfection:broad-spectrumantibioticsAcute obstructive suppurative cholangitis(AOSC) Nonsurgicalmanagement:ncomplementarytosurgicalorendoscopictreatmentsnbroad-spectrumantibioticsnfluidinfusionnelectrolyteimbalancescorrectednothersAcute obstructive supp
48、urative cholangitis(AOSC) NonoperativedecompressionnEndoscopy:endoscopicsphincterotomy(EST)endoscopicnasobiliarydrainage(ENBD)nPercutaneoustranshepaticcholangiographyanddrainage(PTCD)IffailureoperationAcute obstructive suppurative cholangitis(AOSC) SurgicaldecompressionnTosavelifenSimpleandhelpfulnC
49、holedochotomydecompressionandT-tubedrainagenCholecystostomyTumor of biliary tract nIncludinggallbladdertumorandbileducttumornBenigntumorsisrarelyNearlytwo-thirdsofcarcinomaariseinthegallbladder,whiletheremainder(cholangiocarcinoma)originatefromthebileductsandperiampullaryregion.Tumor of biliary trac
50、t (Gallbladder carcinoma) nThemostcommonbiliarytracttumornWomenaremorecommonlyafflictedthanmennThemedianageatpresentationofgallbladdercanceris59.6yearsEtiologyandriskfactorsnTheriskofdevelopinggallbladdercancerishigherinpatientswithcholelithiasisnChroniccholecystitis:calcifiedgallbladdernGallbladder
51、adenomasTumor of biliary tract (Gallbladder carcinoma) PathologynMostlocatedinbodyandfundusofgallbladdernOver90%ofgallbladderneoplasmsareadenocarcinomasnTheremaining10%aresquamouscellormixedtumorsnSpreadlocallybylymphatic,vascular,orintraneural,invasionTumor of biliary tract (Gallbladder carcinoma)
52、Signsandsymptomsn nEarlydisease,asymptomatic.n nLatediseaserightupperquadrantpain,nausea,vomiting,fattyfoodintolerance,anorexia,jaundice,andweightloss.Physicalfindingsmayincluden ntendernessn nanabdominalmassn nhepatomegalyn njaundicen nfevern nascitesTumor of biliary tract (Gallbladder carcinoma) L
53、abtestandimagingexamn nSerumexam:CA-199,CA-125n nUltrasound:gallbladderwallthickeningacomplexmassfillingthegallbladdern nCTscan:morehelpfulinassessingadenopathyandspreadofdiseaseintotheliver,portahepatis,oradjacentstructuresTumor of biliary tract (Gallbladder carcinoma) TreatmentOperationn nSimplech
54、olecystectomy:NevinIstagen n Radicaloperation:NevinII,III,IVstageresectionshouldincludethegallbladderbed(segmentsIVbandV)andaportahepatislymphadenectomyn nPalliativeoperation:laterstagewithjaundice.Torelievesymptoms.Tumor of biliary tract (Carcinoma of bile duct ) Etiologyandriskfactorsn nUlcerative
55、colitisisaclearriskfactorforbileducttumorsn nPrimarysclerosingcholangitis,congenitalanomaliesofthepancreaticobiliarytreen nParasiticinfectionsn nStonesTumor of biliary tract (Carcinoma of bile duct ) Pathologyn n50to75%ofcancersarelocatedintheupperthirdoftheextrahepaticbiliarytractn npapillarytypes,
56、nodulartypes,sclerosingtypen nmorethan95%ofbileducttumorsareadenocarcinomasn nmostbileducttumorsgrowslowly,spreadingfrequentlybylocalextensionandrarelybythehematogenousrouteTumor of biliary tract (Carcinoma of bile duct ) SignsandsymptomsnJaundiceisthemostfrequentsymptomnonfluctuatingnabdominalpainn
57、weightlossnpruritusnfevernanabdominalmass:gallbladdernnausea,vomitingncholangitisTumor of biliary tract (Carcinoma of bile duct ) Labtestandimagingexamn ntotalbilirubinelevationsimilarly,n nalkalinephosphatasen nultrasoundmayfunctionasagoodscreeningtest,butitrarelysuggestsadiagnosisinthisdisease.n n
58、PTCn nERCP,MRCPTumor of biliary tract (Carcinoma of bile duct ) Figure Computed tomography (CT) image showing cholangiocarcinoma in the hilum of the liver.Tumor of biliary tract (Carcinoma of bile duct ) Treatmentn nOperationisthemaintherapymethodn nProximaltumors:tumorslocalexcision,Cholangiojejuno
59、stomyn nMid-ductal:earlystage,Cholangiojejunostomyn nDistaltumors:pancreaticoduodenectomyn nPalliativeoperation(therapy) 小结小结ConclusionRemarks1、ImagingDiagnosisofBiliaryTractDiseases非侵袭性非侵袭性Non-invasiveUS、CT、MRI、MRCPCholescintiography侵袭性侵袭性InvasivePTC、ERCP、Choledoscopy2、Howtodiagnosisbiliarytractdis
60、easesaccurately？病史采集病史采集historytaking体格检查体格检查physicalexamination影像检查影像检查imagingexamination实验室检查实验室检查laboratoryexamination3、Surgicaltreatmentofbiliarytractdiseases胆囊切除术胆囊切除术openVslaparoscopic胆总管探查术胆总管探查术胆肠内引流术胆肠内引流术肝叶切除术肝叶切除术肝脏移植术肝脏移植术内镜手术内镜手术1.1.胆固醇结石，胆色素结石形成机制胆固醇结石，胆色素结石形成机制? ?2.2.急性胆囊炎的诊断要点？急性胆囊炎的
61、诊断要点？3.3.肝外胆管结石的临床表现和治疗原则？肝外胆管结石的临床表现和治疗原则？4.AOSC4.AOSC的临床表现和外科处理原则？的临床表现和外科处理原则？5.5.名词解释名词解释 Calot triangle Calot triangle； Mirizzi syndromeMirizzi syndrome；AOSCAOSCquestions1 1. .典型的胆结石典型的胆结石B B超图像是：超图像是：( )( )A A低回声光团，无声影低回声光团，无声影 B B不均匀强回声光田，无声影不均匀强回声光田，无声影C C强回声光团，无声影强回声光团，无声影 D D强回声光团，有声影强回声光团
62、，有声影E E低回声光团，有声影低回声光团，有声影2 2. .穿行于穿行于CalotCalot三角内的重要结构为：三角内的重要结构为：()A.A.肝右动脉和门静脉肝右动脉和门静脉 B.B.肝右动脉和胆囊动肝右动脉和胆囊动脉脉C.C.胆囊动脉、肝右动脉和副右肝管胆囊动脉、肝右动脉和副右肝管 D.D.肝右动脉和副右肝肝右动脉和副右肝管管E.E.门静脉和副右肝管门静脉和副右肝管3 3. .胆道病变中胆道病变中B B超显示较差的部位是：超显示较差的部位是：()A A肝内胆管肝内胆管 B B肝总管肝总管C C胆囊胆囊 D D胆总管胆总管上上段段E E胆总管下段胆总管下段女女. .6565岁。因右上腹痛伴
63、发热岁。因右上腹痛伴发热2 2天入院。既往有类似病天入院。既往有类似病史。病人有高血压病、冠心病及心衰病史，史。病人有高血压病、冠心病及心衰病史，3 3个月前曾因个月前曾因心衰住院，现已好转。体格检查：心衰住院，现已好转。体格检查：T T38.38.55，P P102102次次/ /分，分，R R2222次分，次分，B.PB.P16016090mmHg,90mmHg,巩膜巩膜无黄染，右上腹压痛，腹肌紧张，反跳痛无黄染，右上腹压痛，腹肌紧张，反跳痛(+)(+)，可扪及肿，可扪及肿大的胆囊，大的胆囊，MurphyMurphy征征( (+ +) )，胆囊区叩击痛；血，胆囊区叩击痛；血WB.CWB.C
64、1515109109L L，N N0.0.8080。4.4.最可能的诊断是：最可能的诊断是：( )( )A.A.急性胆管炎急性胆管炎B.B.急性胰腺炎急性胰腺炎C.C.急性胆囊炎急性胆囊炎D.D.急性阑尾炎急性阑尾炎E.E.十二指肠球部溃疡穿孔十二指肠球部溃疡穿孔女女. .6565岁。因右上腹痛伴发热岁。因右上腹痛伴发热2 2天入院。既往有类似病天入院。既往有类似病史。病人有高血压病、冠心病及心衰病史，史。病人有高血压病、冠心病及心衰病史，3 3个月前曾因个月前曾因心衰住院，现已好转。体格检查：心衰住院，现已好转。体格检查：T T38.38.55，P P102102次次/ /分，分，R R22
65、22次分，次分，B.PB.P16016090mmHg,90mmHg,巩膜巩膜无黄染，右上腹压痛，腹肌紧张，反跳痛无黄染，右上腹压痛，腹肌紧张，反跳痛(+)(+)，可扪及肿，可扪及肿大的胆囊，大的胆囊，MurphyMurphy征征( (+ +) )，胆囊区叩击痛；血，胆囊区叩击痛；血WB.CWB.C1515109109L L，N N0.0.8080。5.5.为进一步明确诊断应首选：为进一步明确诊断应首选：( )( )A. A. P PTCTCB. CTB. CTC. ERCPC. ERCPD. MRID. MRIE. BE. B超超女女. .6565岁。因右上腹痛伴发热岁。因右上腹痛伴发热2 2
66、天入院。既往有类似病天入院。既往有类似病史。病人有高血压病、冠心病及心衰病史，史。病人有高血压病、冠心病及心衰病史，3 3个月前曾因个月前曾因心衰住院，现已好转。体格检查：心衰住院，现已好转。体格检查：T T38.38.55，P P102102次次/ /分，分，R R2222次分，次分，B.PB.P16016090mmHg,90mmHg,巩膜巩膜无黄染，右上腹压痛，腹肌紧张，反跳痛无黄染，右上腹压痛，腹肌紧张，反跳痛(+)(+)，可扪及肿，可扪及肿大的胆囊，大的胆囊，MurphyMurphy征征( (+ +) )，胆囊区叩击痛；血，胆囊区叩击痛；血WB.CWB.C1515109109L L，N
67、 N0.0.8080。6.6.首选的治疗方法是：首选的治疗方法是：( )( )A. A. 胆囊切除术胆囊切除术B. B. 胆囊造口术胆囊造口术C. C. 非手术治疗非手术治疗D. D. 胆总管探查术胆总管探查术E. E. 经皮经肝胆管穿刺引流术经皮经肝胆管穿刺引流术(PTCD )(PTCD )本次课应用的教材教具参考书本次课应用的教材教具参考书1.Nation-wide textbook of institutes ofhigher medicine education Surgeryforseven-yearmasterofmedicinedegree.2. Sabiston textbook of sugery 17thedition3.SurgerybyHuangJiasi4.InternetTHANKS!
