Cholangitis stricture

Introduction to biliary tract stenosis Acute bile duct inflammation, recurrent episodes, mucosal erosion, ulceration, connective tissue hyperplasia, scar formation and bile duct stricture. Stenosis can occur from the intrahepatic bile duct to the lower end of the common bile duct, but it is common to use the left and right hepatic ducts, the common hepatic duct, and the stenosis at the opening of the bile duct. The narrowness is mostly ring-shaped, long-shaped, and can exist in multiple places at the same time. Intrahepatic bile duct stones often associated with hepatic bile duct stricture. The proximal end of the hepatic bile duct stenosis, bile pigment accumulation, liver parenchyma can occur in different degrees of damage and fibrosis, severe lesions of the liver lobe (segment) have different degrees of atrophy, the remaining liver lobe is compensatory hyperplasia, easy secondary infection Suppurative cholangitis, infection can increase the stenosis and promote the formation of stones, forming a vicious circle. Biliary cirrhosis and portal hypertension can occur in advanced stages. Its clinical manifestations, diagnosis, and treatment of the same bile duct stones. basic knowledge The proportion of illness: 0.0032% Susceptible people: no special people Mode of infection: non-infectious Complications: gallstones

Causes of cholangitis stenosis

Chronic non-specific infection (25%):

This disease is associated with ulcerative colitis. In the case of infectious bowel disease, intestinal bacteria invade the biliary system from the portal vein, forming chronic inflammation, hyperplasia of the bile duct wall fibrous tissue, and narrowing the bile duct wall. It has been reported that in the case of colonic resection due to ulcerative colitis, the portal vein blood is cultured to grow bacteria; bacteria are injected into the portal vein of the animal, and inflammation is found around the bile duct. However, some people believe that this disease is not related to ulcerative colitis, whether it is accompanied by ulcerative colitis, does not change the natural course and outcome of primary sclerosing cholangitis.

Immunity factor (25%):

This disease is often accompanied by ulcerative colitis, and some are associated with diseases such as segmental enteritis, chronic fibrotic thyroiditis (Riedls thyroiditis) and retroperitoneal fibroinflammatory sclerosis. The immune complexes in the patient's serum are often higher than normal, and when these substances precipitate in the tissue, they can cause local inflammation. Badenheimer measured the immune complexes in the patient's serum, whether or not associated with ulcerative colitis, the immune complexes in their serum were significantly higher than the healthy control group. In patients with ulcerative colitis, a certain proportion of anti-nuclear antibodies and anti-smooth muscle antibodies in serum are positive, supporting the views of these patients on the incidence and immune factors. However, the application of hormone or immunosuppressive drugs can improve the symptoms, but it does not improve the pathological changes of the bile ducts, nor can it change the course of the patients. Therefore, whether primary sclerosing cholangitis is related to immune factors remains to be confirmed by further research.

Other factors (20%):

The disease is related to congenital factors, roundworm infection, alcoholism, lithic acid and other factors.

Pathophysiology

The main pathological changes of the disease, infiltration of inflammatory cells around the bile duct wall and bile duct in the intrahepatic portal area, mainly lymphocytes, few polynuclear white blood cells, occasionally visible macrophages and eosinophils, and with the development of lesions Focal small point necrosis and fibrous tissue hyperplasia, bile duct epithelial cells gradually shrink and disappear, and the wall hardening is not smooth and thickened, eventually causing extreme fibrosis of the bile duct wall, resulting in thickening of the wall and abnormal lumen The stenosis is a string of balls, and the smallest of the lumens is only a pencil lead, but the diameter is only 2 mm. The lesion range sometimes only affects a segment of the common bile duct, but most of the common bile duct or even the left and right hepatic ducts are affected at the same time. In most cases, chronic cholecystitis and hepatoduodenal ligaments adhere to a cord-like structure, and almost no bile duct-like structure is seen. At the same time, obstructive jaundice and biliary cirrhosis can occur, and portal hypertension and liver failure can occur in the late stage of the disease.

Cholangitis stenosis prevention

(1) Pay attention to strengthening nutrition, pay attention to high sugar, high protein, high vitamin, low fat, easy to digest diet.

(2) Emergency patients should receive fasting and intravenous infusion, and pay attention to the location and nature of abdominal pain, whether there is chills, high fever, shock, etc. Cooperate with preoperative skin preparation, blood matching, etc.

(3) When itching, pay attention to keep the skin clean, bathe and change clothes, and receive intramuscular vitamin K1.

(4) Actively treat diseases of the biliary system and eat less high-fat and high-cholesterol foods.

Complications of cholangitis stenosis Complications gallstones

Can be complicated by gallstones, obstructive jaundice, primary pancreatitis.

Symptoms of biliary tract stenosis Common symptoms Internal hepatic duct obstruction High fever chills abdominal pain Yellow sputum Hepatomegaly

Symptoms of biliary tract stenosis

Clinical manifestations of extrahepatic bile duct stones

Depends on the presence or absence of infection and obstruction. Usually it is usually asymptomatic. However, when the stone blocks the bile duct and is secondary to infection, its typical clinical manifestation is Charcot triad, ie abdominal pain, chills, fever and jaundice. 1 abdominal pain: occurs under the xiphoid process and the upper right abdomen, mostly colic, a paroxysmal attack, or persistent pain bursts, can be radiated to the right shoulder with nausea and vomiting. 2 chills, high fever: secondary infection of bile duct obstruction, the intra-biliary pressure increased, the infection spreads retrogradely through the bile duct, bacteria and toxins enter the hepatic sinus through the capillary tube, and then enter the systemic circulation to cause systemic infection. About 2/3 of the patients may have chills and high fever during the course of the disease, generally showing relaxation heat, and the body temperature is as high as 39~40 °C. 3 jaundice: jaundice can occur after biliary obstruction, its severity, occurrence and duration depends on the degree of biliary obstruction, whether it is complicated by infection, and whether there are gallbladder and other factors. Astragalus often has dark urine, shallow stools, and some skin itching. The jaundice caused by cholelithiasis is intermittent and fluctuating.

Clinical manifestations of intrahepatic bile duct stones

When combined with extrahepatic bile duct stones, the clinical manifestations are similar to those of extrahepatic bile duct stones. Those who have not combined with extrahepatic bile duct stones can be asymptomatic for many years or only have pain in the liver area and chest and back. In the event of obstruction and secondary infection, there is chills or high fever, and even acute obstructive suppurative cholangitis. Unless the bilateral bile ducts are obstructed or advanced in biliary cirrhosis, intrahepatic bile duct stones generally do not develop significant jaundice. Intrahepatic bile duct stones are easy to cause biliary liver abscess when infected, liver abscess can be worn under the armpit, and can further penetrate the diaphragm and lung to form bile duct bronchospasm, coughing yellow bitter bile-like sputum. Late stage biliary cirrhosis can cause portal hypertension. Longer onset of the disease, frequent episodes of cholangitis in the near future, with progressive jaundice, abdominal pain and fever are difficult to control, and symptoms such as weight loss, especially those over the age of 50, should be suspected of having hepatobiliary cancer. The main manifestation is that the liver is asymmetrical and swollen, and there is tenderness and sputum pain in the liver area. When the infection and complications are combined, the corresponding signs appear.

Examination of biliary tract stenosis

Blood biochemical examination

It can show multiple abnormalities of obstructive jaundice, increased serum total bilirubin (large fluctuations in different periods of the same patient), alkaline phosphatase increased significantly, and it is not easy to fall to normal level after treatment. Severe or moderate increase in serum transaminase. Blood routine examinations, in addition to the obvious increase in white blood cells in the presence of cholangitis, can also be found in lymphocytosis, or occasionally abnormal lymphocytes or eosinophils. Immunological examination of some patients with elevated immunoglobulins, antinuclear antibodies, anti-smooth muscle antibodies. 45% of patients had elevated IgM, and 75% had increased ceruloplasmin and increased urinary copper excretion. However, anti-cell mitochondria are negative. HLA-DRW52a antigen is up to 100% positive. Some cases have some damage to kidney function.

Auxiliary examinations can have a variety of clinical manifestations, depending on the location and extent of the lesion. Thompson is divided into 4 types according to the site: type I: sclerosing cholangitis of the common bile duct; type II: sclerosing cholangitis secondary to acute necrotizing cholangitis; type III: chronic diffuse sclerosing cholangitis; Type IV: Chronic diffuse sclerosing cholangitis with intestinal inflammatory disease. According to the scope of sclerosing cholangitis lesions are divided into: 1 diffuse type, throughout the liver, external bile duct; 2 extrahepatic bile duct segment type; 3 intrahepatic, external bile duct sclerosis with cirrhosis.

Cholangiography

It is the most convincing method for determining the scope of diagnosis and lesions, including ERCP, PTC, intraoperative cholangiography, and T-tube retrograde cholangiography. Among them, ERCP has the most advantages, and it can not only display the changes of intrahepatic and extrahepatic bile duct morphology, but also display pancreatic duct lesions. At the time of the examination, the catheter for ERCP is further inserted into the cystic duct to obtain detailed information of the intrahepatic bile duct. For this reason, balloon blocking technique is often used to assist. PTC has only half the success rate, mostly used for ERCP failure, or has undergone biliary jejunostomy. Intraoperative cholangiography and T-tube retrograde cholangiography are suitable for surgical treatment or postoperative diagnosis. The characteristics of biliary tract development are as follows: (1) the bile duct of the lesion has irregular multiple stenosis, and the surface of the bile duct mucosa is smooth; 2 the stenosis lesion is limited or diffuse, and can also be segmental change; 3 the stenosis of the proximal bile duct is slightly dilated; 4 lesions involving the intrahepatic bile duct, the intrahepatic bile duct branch is reduced, stiff and thin like a dendritic or beaded, hemispherical expansion, inner diameter of 2 ~ 3mm. In about 80% of cases, the intrahepatic and extrahepatic bile ducts were involved at the same time. 20% only involved the extrahepatic bile duct. The inner diameter of the common bile duct (CBD) was less than 4 mm, the wall was significantly thickened, and the biliary system had no stones and tumor signs. When the gallbladder is involved, the gallbladder wall is thick, and the function is reduced or disappeared.

B -mode ultrasound

Because endoscopic retrograde cholangiography and transhepatic cholangiography are invasive procedures, B-mode ultrasound has become a non-invasive alternative to diagnosis. The typical B ultrasound imaging is as follows: 1 The biliary lumen is obviously narrow, mostly uniform, generally 4mm, and the bile duct can be seen in segmental or localized PSC; 2 the bile duct wall is obviously thickened, generally 4~5mm; Intrahepatic bile duct echo enhancement; 4 involvement of the gallbladder visible wall thickening, reduced function; 5 sonogram without stones and tumors.

Magnetic resonance cholangiography (MRC)

Biliary tree imaging technology can help in diagnosis. The mild expansion of peripheral bile ducts that are not connected to the central bile duct in several hepatic lobe is an MRI sign, but its role in revealing bile duct stricture is reduced due to limited spatial resolution of MRC.

99mTc-DISIDA scan

A biliary scintigraphy with 99mTc-labeled diisopropylcarbamoimide acetoacetate is a non-invasive test for suspected patients. After intravenous injection, continuous gamma imaging, because of the delay of liver parenchyma clearance, to determine the obstruction of different branches of the main bile duct, showing the expansion of the bile duct and intrahepatic and extrahepatic bile duct stenosis and extent, low resolution is its shortcoming.

CT

It can show the expansion and deformation of the intrahepatic bile duct of the patient.

Liver histology

Histological abnormalities can be seen in most patients with liver biopsies. Common histological abnormalities include: peripheral biliary fibrosis and inflammation, edema and fibrosis, focal proliferation of bile ducts and ductules, focal bile duct obstruction and loss, copper deposition and cholestasis. Typical manifestations are concentric fibrosis of the peripheral bile duct with or without hepatic bile duct hyperplasia, but these changes are only seen in wedge biopsies, which are rarely seen in fine needle aspiration.

Diagnosis and differentiation of biliary tract stenosis

Diagnose based on

(1) History of no bile duct surgery.

(2) no common bile duct stone disease: history of stenotic cholangitis examination.

(3) thickening and hardening of the bile duct wall, and progressive obstructive jaundice.

(4) Long-term follow-up excludes cholangiocarcinoma.

(5) No congenital bile duct abnormalities.

(6) No primary biliary cirrhosis.

Diagnostic characteristics

(1) Young men.

(2) biliary stricture liver disease.

(3) The onset is slow.

(4) Cholangiography showed multiple stenosis, irregular and "spherical" signs of intrahepatic and extrahepatic bile ducts.

(5) Liver histology revealed fibrosis, inflammation, and visible cholestasis around the bile duct.

(6) It is associated with inflammatory bowel disease, especially ulcerative colitis.

(7) Related to HLA and AI-B8-DR3.

(8) There is a high risk of developing cholangiocarcinoma.

Diagnostic criteria

(1) Characteristic abnormal cholangiography signs (segmental or extensive biliary changes).

(2) Abnormal clinical, biochemical, and liver histological findings (although often non-specific).

(3) Exclude the following conditions: 1 biliary calcification (except in the case of quiescent period). 2 biliary surgery (excluding simple cholecystectomy). 3 congenital biliary abnormalities. 4 acquired biliary tract lesions associated with immunodeficiency syndrome. 5 ischemic stenosis. 6 biliary tumors. 7 Exposure to irritating chemicals (eg formalin). 8 other liver diseases (such as primary biliary cirrhosis or chronic active hepatitis).

Differential diagnosis

Chronic active hepatitis:

Earlier, there were reports of chronic active hepatitis. The main reason is the discovery of debris-like necrosis in the histological examination of these patients, a phenomenon that is now considered a feature. Relying on cholangiography can solve the differential diagnosis between the two,

Difficulties in the identification of stenotic cholangitis. In addition, patients with chronic active hepatitis often have acute hepatitis, often have a history of hepatitis exposure, or blood transfusion, injection pollution, etc., the age of onset is relatively light, usually after 2 to 3 weeks of onset, jaundice gradually subsides, serum ALT is significantly elevated and GGT It can be identified without any increase or slight increase in ALP.

Secondary sclerosing cholangitis:

The disease has a history of recurrent bile duct disease or history of biliary tract surgery. The inflammatory stenosis of the bile duct is mostly ring-shaped, the stenosis is short, and the biliary mucosal epithelial damage is obvious. It may have erosion, ulcer and granuloma formation, often accompanied by stones.

Primary cholangitis:

In a few cases, only the intrahepatic or extrahepatic bile ducts are present before the onset of the disease. When there is only intrahepatic bile duct disease, attention should be paid to the differentiation of primary cholangitis. Primary cholangitis is a disease that occurs mostly in young women. It is histologically characterized as non-suppurative cholangitis. The serum contains high titers of antibodies and does not occur in the extrahepatic bile duct.

Primary cholangiocarcinoma:

The age of onset of the disease is usually between 40 and 50 years old, often with weight loss or weight loss, and surgical exploration and histological examination can confirm the diagnosis. For cases of segmental or diffuse bile duct stricture, it is more difficult to distinguish it from cholangiocarcinoma due to the extensive stenosis of the biliary tract and the extensive fibrosis of the biliary tree, especially when the intrahepatic bile duct is not invaded, the intrahepatic bile duct Extensive expansion is more common in cholangiocarcinoma than common. However, patients with extrahepatic bile duct stricture must consider the possibility of cholangiocarcinoma. If necessary, cytology or biopsy may be used to exclude cholangiocarcinoma. It is worth noting that because of the malignant tendency, the possibility of malignant transformation should be considered at the time of initial diagnosis or follow-up. Astragalus suddenly aggravated, cholangiography showed biliary or biliary tract segmental expansion, polypoid mass, and diameter 1.0cm, progressive stenosis or dilation, etc., should consider the occurrence of cholangiocarcinoma. At this time, the use of serum tumor markers (CEA, C19-9) and biliary cytology, magnetic resonance cholangiography and ECT, etc., can be an exciting result for the diagnosis.

Primary biliary cirrhosis:

The age of onset of the disease is more common in 20 to 40 years old, the course of disease is slow, the jaundice is fluctuating, the liver and spleen are large, the serum anti-mitochondrial antibody is positive, the immunoglobulin is obviously increased, and the diagnosis and differential diagnosis are less difficult.

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