談?wù)劇澳懡Y(jié)石”

1、談?wù)劇澳懡Y(jié)石”,山東大學(xué)齊魯醫(yī)院（青島）普通外科 姜遠(yuǎn)輝,,1.什么是膽結(jié)石？2.哪些人容易長(zhǎng)膽結(jié)石？（高危因素及如何預(yù)防）3.膽結(jié)石有哪些癥狀？4.膽結(jié)石的危害5.如何治療膽結(jié)石？,什么是膽結(jié)石？,“膽結(jié)石”又稱(chēng)膽系結(jié)石病或膽石癥，是指膽管或膽囊內(nèi)生成的結(jié)石引起劇烈腹痛、黃疸、發(fā)熱等癥狀，是膽道系統(tǒng)的常見(jiàn)病。,分類(lèi),膽囊結(jié)石 肝內(nèi)膽管結(jié)石 膽管結(jié)石

2、 肝外膽管結(jié)石,,,,得了膽結(jié)石會(huì)有什么癥狀？,膽囊結(jié)石：大部分無(wú)癥狀，少數(shù)病人的膽囊結(jié)石的典型癥狀為膽絞痛，表現(xiàn)為急性或慢性膽囊炎。主要臨床表現(xiàn)如下：1.膽絞痛：尤其是飽餐、進(jìn)食油膩后而引起膽絞痛，疼痛位于右上腹或上腹部，呈陣發(fā)性，或者持續(xù)疼痛陣發(fā)性加劇，可向右肩胛部和背部放射，可伴惡心、嘔吐。部分病人因痛劇而不能準(zhǔn)確說(shuō)出疼痛部位。首次膽絞痛出現(xiàn)后，約70%的病人一年內(nèi)會(huì)復(fù)發(fā)。,,2.上腹隱痛

3、多數(shù)病人僅在進(jìn)食過(guò)量、吃高脂食物、工作緊張或休息不好時(shí)感到上腹部或右上腹隱痛，或者有飽脹不適、噯氣、呃逆等，易被誤診為“胃病”。,,,,,,,,,,,,,,,診斷,全面要有重點(diǎn)有判斷有思路（各判斷之間的聯(lián)系） 具體分類(lèi)中所屬位置具體但要求足夠的可信度, 依據(jù)動(dòng)態(tài)History, present, development 對(duì)策Feedback,,全 面 具 體,治療,Diagnostics,

4、Diagnosis,PancreatitisacuteBiliary or gallstone associated Severe, I,II; Fulminant GallstoneIn Gallbladder: pacted？Strangulated? perforated？In CBD: Pacted? changitis？AOSC?Metabolism高滲，酮癥，低血糖；電解質(zhì)；… … General cond

5、ition,,Complete,Treatment,Diagnosis about AGP,concrete,Etiology of AP,,,,,,,,,,,,,,,,,,,,,,,,,,Treatment Strategy for critical Patients, SAP II , AOSC,對(duì)因治療梗阻，感染灶全身狀態(tài)的評(píng)估與維護(hù)氧供，氧輸送；循環(huán)；糖代謝臟器功能：心、肺、肝、腎、腦手術(shù)的時(shí)機(jī)選擇與創(chuàng)造,Eff

6、ective, but higher risks morbidity Mortalityop within 48h 83％ 18％op after 48h 48％ 12％StrategyDiscriminate th

7、ose with obstruction and CholangitisEndoscopy delayed operation,The role of emergency operation,,,,Role of ERCP & EST During Severe Attack,Three trial / randomized and control Neoptolemos

8、 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 symp

9、toms and progression,Operation to prevent the relapse,RecommendationCholecystectomy should be performed to avoid the recurrence of Gallstone associated pancreatitis.EvidenceRecurrence in 29％~63％ cases if,Recommendatio

10、n 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

11、of the inflammatory response and clinical recovery.,EST to Prevent Further Attack,建議:對(duì)全身?xiàng)l件不適宜手術(shù)的病人，為降低膽石性胰腺炎復(fù)發(fā)的危險(xiǎn)，EST是膽囊切除術(shù)的替代措施。然而，理論上有導(dǎo)致無(wú)菌性胰腺壞死感染的危險(xiǎn)（B級(jí)） 依據(jù)：EST in 5 series with a total of 109 cases: median follow-