Bile duct obstruction

Introduction Biliary obstruction refers to any part of the bile duct excretion due to bile duct lesions, tube wall disease, infiltration and compression outside the tube wall, causing bile duct mechanical obstruction due to poor bile excretion or even complete blockage. The direct harm is normal secretion. The bile can not be excreted smoothly into the intestines, leading to indigestion, cholestasis, jaundice, abnormal liver function, followed by a series of pathophysiological changes such as various functions of the body, multiple organ failure, and even death. How to deal with this type of disease, we discuss endoscopic treatment and surgical treatment.

Cause

This is a disease with a high mortality rate in surgical acute abdomen, and most of them are secondary to bile duct stones and biliary ascariasis. However, lesions such as bile duct stricture and biliary tumor can sometimes be secondary to this disease. These diseases cause bile duct obstruction, cholestasis, and secondary bacterial infections. The pathogenic bacteria are almost all from the intestine, and are retrogradely into the biliary tract through the channel of the ampulla or the anastomosis of the biliary tract. Bacteria can also enter the biliary tract through blood or lymphatic channels. The pathogens are mainly Escherichia coli, Klebsiella, Streptococcus faecalis and certain anaerobic bacteria.

On the basis of obstructive diseases such as the original stones, bile duct infection, bile duct mucosal hyperemia, aggravation of bile duct obstruction, bile gradually becomes purulent, the pressure in the bile duct is continuously increased, and the bile duct in the proximal side of the obstruction is gradually enlarged. Under the action of bile duct hypertension containing purulent bile, the liver can be swollen, and the intrahepatic bile duct and surrounding liver parenchyma cells can also undergo inflammatory changes.

Hepatocytes produce large pieces of necrosis, which can form multiple small abscesses in the liver. The bile duct can also cause ulceration and biliary bleeding due to infection with suppuration. Due to the high pressure in the bile duct, the intrahepatic capillary bile duct is broken, and the purulent bile or even the bile thrombus enters the blood circulation through the intrahepatic sinus, resulting in bacteremia and sepsis. A small number of pus embolisms can also occur in the lungs. In the later stage, a series of pathophysiological changes such as septic shock, liver and kidney failure or diffuse intravascular coagulation may occur, which is acute obstructive suppurative cholangitis or acute severe cholangitis. Once these pathological changes occur, even if the surgery relieves the bile duct hypertension, it still leaves damage in the liver parenchyma and bile duct, which is also the seriousness of the disease.

an examination

Related inspection

Urinary bile acid T-tube cholangiography intravenous cholangiography oral cholangiography

1. Examination method: All MRCP examinations were performed using a Philips Gyroscan 1.5T superconducting magnetic resonance scanner with a field strength of 1.5 Tesla, a body coil, and breathing under a breath-gated breath, and images were acquired using a heavy T2-weighted TSE pulse sequence. Parameters: repetition time / echo time = 2 000 ~ 8 000 / 140 ~ 330ms, field of view: 320 ~ 350mm, layer thickness: 4mm, layer gap 1mm, layer number 20 ~ 50, echo chain length: 16 ~ 32, average Signal acquisition: 4 to 6 times, right front oblique 20 to 40 degrees non-standard coronal position, total inspection time 4 to 11 minutes, flow compensation, space preset saturation and fat suppression technology to eliminate artifacts, improve image quality. The 3D reconstruction uses the maximum intensity projection (MIP) to reconstruct the horizontal projection images of 12 different angles at a 15 degree interval with the vertical body axis as the central axis. 37 patients underwent B-US examination and 38 underwent non-biliary enhanced CT scan.

2. Image analysis:

(1) The presence of obstruction and judgment of the presence of obstruction and obstruction level in one of the following criteria: 1 in patients with unresectable gallbladder, the maximum internal diameter of the common bile duct (CBD) is greater than 7 mm, and the maximum internal diameter of the CBD is greater than 10 mm in the patient with cholecystectomy; There is a clear stenosis and interruption of the common hepatic duct (CHD) or CBD. Extrahepatic obstruction is divided into the hilar part, the common hepatic duct level and the upper, middle and lower sections of the CBD;

(2) Differential diagnosis of benign and malignant obstruction: sudden truncation, irregular bile duct in the stenosis, proportional expansion of the common bile duct and intrahepatic bile duct, and irregular filling defect in the bile duct cavity as malignant obstruction.

Differential diagnosis

1, Mirizzi syndrome

Mirizzi syndrome refers to the gallbladder neck or gallbladder stones compressing the common bile duct, and the clinical manifestation is obstructive jaundice. According to Cseades classification: type I, simple bile duct compression; type II, gallbladder bile duct formation, but the fistula is less than 1/3 of the common bile duct circumference; type III, the fistula is greater than 2/3 of the common bile duct circumference Type IV, complete obstruction of the common bile duct.

2, gallbladder cancer invades the bile duct

Gallbladder cancer generally has no special symptoms in the early stage, and was found by chance when it was pathologically examined after cholecystectomy. Once gallbladder cancer occurs, it spreads faster and more widely. Cancer cells can directly infiltrate the liver bed into the liver, or transfer to the cystic duct and the common bile duct through the lymphatics. The literature reports that 80% of gallbladder carcinomas with gallstones, some manifested as acute cholecystitis. In recent years, the incidence of gallbladder cancer has been on the rise, and it has become a more common biliary tumor. Foreign scholars have reported that in 17 cases of advanced gallbladder carcinoma undergoing hepatic pancreaticoduodenectomy, 10 patients underwent radical resection, of which the 5-year survival rate was 50%. However, the prognosis of gallbladder cancer has a variety of factors related to the depth of tumor invasion, lymph node metastasis, cancer cell differentiation and residual cancer. Simply expanding the scope of surgery does not necessarily improve the efficacy of the treatment. In view of the high incidence of concurrent syndromes after hepatic pancreaticoduodenectomy, the overall prognosis of gallbladder cancer is poor. At present, the surgical indications for the implementation of hepatic pancreaticoduodenectomy for advanced gallbladder cancer are more consistent:

(1) No distant metastasis and abdominal implant transfer.

(2) There is metastasis of lymph nodes around the head of the pancreas and/or lymph nodes around the common hepatic artery.

(3) Planting directly invades neighboring organs such as liver, bile duct, and duodenum.

3, primary liver cancer invades the biliary tract

The main route of biliary invasion of liver cancer is direct invasion. The rupture of liver cancer into the biliary tract and the obstruction of the bile duct cause obstructive jaundice are relatively rare, accounting for about 1% of liver cancer. Followed by blood and lymphatic metastasis. The main ways of biliary metastasis are:

(1) Liver cancer cells directly invade and form tumor thrombus in them, and the biliary tract tumor thrombus is connected with the primary tumor in a "dumbbell shape" to cause biliary obstruction.

(2) The biliary tract tumor thrombus is detached from the primary cancer, and the biliary obstruction is formed down to the extrahepatic biliary tract.

(3) Liver cancer invades the biliary tract and causes blood clots (cancerous thrombosis) in the cancer cells to block the biliary tract. Intraoperative exploration should be alert to the possibility of this disease if there is a tumor thrombus in the biliary tract and the bile duct mucosa is normal. For patients with local conditions, systemic conditions and liver function, patients should be treated for one-stage resection of tumors and invading bile ducts. For patients with unresectable tumors or inability to tolerate liver resection, choledocholithiasis and biliary stent drainage are used in domestic and foreign literature reports. Surgery, the hepatic artery is placed through the gastroduodenal artery for postoperative chemotherapy. At the same time, it does not affect liver blood supply. It can be considered that this method is superior to simple biliary thrombectomy and biliary drainage for patients who cannot tolerate liver resection.

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