胆道临床诊疗课件.ppt

1、胆道系统的应用解剖和生理胆道系统的应用解剖和生理 胆道系统的应用解剖和生理胆道系统的应用解剖和生理 Anatomy&Physiology 肝内胆管肝内胆管 肝内胆管起肝内胆管起自毛细胆管，自毛细胆管，继而汇集成小继而汇集成小叶间胆管，肝叶间胆管，肝段、肝叶胆管段、肝叶胆管及肝内部分的及肝内部分的左右肝管。左右肝管。左、右肝管出肝后，在肝门部汇合形成肝总管左、右肝管出肝后，在肝门部汇合形成肝总管（common hepatic duct）。肝总管直径为）。肝总管直径为0.140.6cm，长约，长约34cm，其下端与胆囊管汇合形，其下端与胆囊管汇合形成胆总管（成胆总管（common bile duc

2、t）。胆总管长约）。胆总管长约48cm，直径，直径0.60.8cm。肝外胆道肝外胆道 肝外胆道包括肝外胆道包括左、右肝管、肝左、右肝管、肝总管、胆总管、总管、胆总管、胆囊。胆囊。Oddi 括约肌主要包括胆管括约肌、括约肌主要包括胆管括约肌、胰管括约肌和壶腹括约肌胰管括约肌和壶腹括约肌控制和调节胆总管和胰管的排放控制和调节胆总管和胰管的排放防止十二指肠内容物返流防止十二指肠内容物返流胆汁的生成、分泌和代谢胆汁的生成、分泌和代谢 成人每日分泌胆汁约成人每日分泌胆汁约8001200ml，胆汁主，胆汁主要由肝细胞分泌。要由肝细胞分泌。胆汁中胆汁中97%是水，其他成是水，其他成分主要有胆汁酸与胆盐、胆固

3、醇、磷脂和胆红分主要有胆汁酸与胆盐、胆固醇、磷脂和胆红素等。素等。Function of gallbladder Concentration and preservation of the bile.Secretion Contraction and empty胆道疾病的特殊检查方法胆道疾病的特殊检查方法 X-ray Ultrasonography,EUS,IDUS CT MRI,MRCP(Magnetic resonance cholagiopancreatography)PTC,PTBD ERCP Scintigraphy Choledochoscopy Cholangiography 胆

4、道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法胆道疾病的特殊检查方法CT/US引导引导PTCD显示胆管病变部位、范显示胆管病变部位、范围、性质、程度围、性质、程度PTC显示肝总管狭窄显示肝总管狭窄可通过造影管行胆管引流可通过造影管行胆管引流（PTCD）或置放胆管内支架用）或置放胆管内支架用作治疗。作治疗。胆道疾病的特殊检查方法胆道疾病的特殊检查方法内镜下逆行胰

5、胆管造影术内镜下逆行胰胆管造影术Endoscopic retrograde cholangiopancreatography 是电子十二指肠镜直视下通过十二指肠乳突将导管是电子十二指肠镜直视下通过十二指肠乳突将导管插人胆管和（或）胰管内进行造影。可直接观察十二插人胆管和（或）胰管内进行造影。可直接观察十二指肠及乳头部的情况和病变，取材活检；收集十二指指肠及乳头部的情况和病变，取材活检；收集十二指肠液、胆汁、胰液。取石，放置支架或鼻胆（胰）管肠液、胆汁、胰液。取石，放置支架或鼻胆（胰）管引流，引流，EST，IDUS，子母镜（，子母镜（Spy Glass）等）等核素扫描核素扫描 胆道梗阻时显像时间

6、的延迟，有助于黄疽胆道梗阻时显像时间的延迟，有助于黄疽的鉴别诊断。本法为无创检查，辐射物剂量的鉴别诊断。本法为无创检查，辐射物剂量小，对病人无损害。突出优点是在肝功能损小，对病人无损害。突出优点是在肝功能损伤，血清胆红素中度升高时亦可应用。伤，血清胆红素中度升高时亦可应用。常见胆道疾病常见胆道疾病Common Biliary Disease常见胆道疾病常见胆道疾病1，先天性疾病（胆道闭锁，胆总管囊肿，先天性疾病（胆道闭锁，胆总管囊肿,胆胰管汇合异常）胆胰管汇合异常）2，结石（肝内外胆管结石，胆囊结石，结石（肝内外胆管结石，胆囊结石,Mirizzi综合征）综合征）3，肿瘤（胆囊癌，胆管癌），肿瘤

7、（胆囊癌，胆管癌）4，寄生虫（蛔虫），寄生虫（蛔虫）5，医源性胆管损伤（，医源性胆管损伤（LC时损伤胆管）时损伤胆管）6,急、慢性胆囊炎和急性胆管炎急、慢性胆囊炎和急性胆管炎（急性梗阻性化脓性胆（急性梗阻性化脓性胆 管炎管炎AOSC）7，原发性硬化性胆管炎原发性硬化性胆管炎 胆道闭锁是新生儿持续性黄疸的最常见病因。胆道闭锁是新生儿持续性黄疸的最常见病因。病变可累及整个胆道，亦可仅累及肝内或肝外病变可累及整个胆道，亦可仅累及肝内或肝外的部分胆管，其中以肝外胆道闭锁常见，占的部分胆管，其中以肝外胆道闭锁常见，占85%90%。发病率女性高于男性。发病率女性高于男性。胆道闭锁胆道闭锁病病 因因 胆管闭

8、锁是一种进展性的胆管闭锁和硬化性病胆管闭锁是一种进展性的胆管闭锁和硬化性病变。很多患儿出生时能排泄胆汁，以后进展成为变。很多患儿出生时能排泄胆汁，以后进展成为完全性胆管闭锁。其病因主要有两种学说：完全性胆管闭锁。其病因主要有两种学说：先天性发育畸形学说先天性发育畸形学说 病毒感染学说病毒感染学说胆道闭锁胆道闭锁胆道闭锁胆道闭锁病病 理理 胆管闭锁所致梗阻性黄疽，可致肝细胞损胆管闭锁所致梗阻性黄疽，可致肝细胞损害，肝脏因淤胆而显著肿大、变硬，呈暗绿害，肝脏因淤胆而显著肿大、变硬，呈暗绿或褐绿色，肝功能异常。若胆道梗阻不能及或褐绿色，肝功能异常。若胆道梗阻不能及时解除，则可发展为胆汁性肝硬化，晚期

9、为时解除，则可发展为胆汁性肝硬化，晚期为不可逆性改变。不可逆性改变。胆道闭锁胆道闭锁大体类型主要分为三型：大体类型主要分为三型：型型 完全性胆管闭锁完全性胆管闭锁型型 近端胆管闭锁，远端胆管通畅近端胆管闭锁，远端胆管通畅型型 近端胆管通畅，远端胆管纤维化近端胆管通畅，远端胆管纤维化以以、型常见。型常见。胆道闭锁胆道闭锁胆道闭锁胆道闭锁临床表现临床表现 黄疸：梗阻性黄疽是本病突出表现。黄疸：梗阻性黄疽是本病突出表现。营养及发育不良营养及发育不良肝脾肿大：是本病特点。肝脾肿大：是本病特点。胆道闭锁胆道闭锁诊诊 断断 凡出生后凡出生后12个月出现持续性黄疽，陶土色大便，个月出现持续性黄疽，陶土色大便

10、，伴肝肿大者均应怀疑本病。下列各点有助于确诊：伴肝肿大者均应怀疑本病。下列各点有助于确诊：黄疽超过黄疽超过34周仍呈进行性加重，对利胆药物治周仍呈进行性加重，对利胆药物治疗无效；对苯巴比妥和激素治疗试验无反应；血清疗无效；对苯巴比妥和激素治疗试验无反应；血清胆红素动态观测呈持续上升，且以直接胆红素升高胆红素动态观测呈持续上升，且以直接胆红素升高为主；为主；胆道闭锁胆道闭锁十二指肠引流液内无胆汁；十二指肠引流液内无胆汁；B超检查显示肝外胆管和胆囊发育不良或缺如；超检查显示肝外胆管和胆囊发育不良或缺如；99mTc-EHIDA扫描肠内无核素显示；扫描肠内无核素显示；ERCP和和MRCP能显示胆管闭锁

11、的长度。能显示胆管闭锁的长度。胆道闭锁胆道闭锁 手术治疗是唯一有效方法。手术宜在出生后手术治疗是唯一有效方法。手术宜在出生后2个个月进行，此时尚未发生不可逆性肝损伤。若手术过月进行，此时尚未发生不可逆性肝损伤。若手术过晚，病儿已发生胆汁性肝硬化，则愈后极差。晚，病儿已发生胆汁性肝硬化，则愈后极差。治治 疗疗 胆道闭锁胆道闭锁手术方式：手术方式：尚有部分肝外胆管通畅，胆囊尚有部分肝外胆管通畅，胆囊大小正常者，可用胆囊或肝外胆大小正常者，可用胆囊或肝外胆管与空肠行管与空肠行Roux-en-Y型吻合。型吻合。肝外胆管完全闭锁，肝内仍有肝外胆管完全闭锁，肝内仍有胆管腔者可采用胆管腔者可采用Kasai肝

12、门空肠肝门空肠吻合术。吻合术。肝移植肝移植先天性胆总管囊肿先天性胆总管囊肿 先天性胆道扩张症可发生于肝内、肝外胆先天性胆道扩张症可发生于肝内、肝外胆管的任何部分，好发于胆总管。本病好发于管的任何部分，好发于胆总管。本病好发于东方国家，尤以日本常见。女性多见，男女东方国家，尤以日本常见。女性多见，男女之比约为之比约为 1:34。幼儿期即可出现症状，约。幼儿期即可出现症状，约80%病例在儿童期发病。病例在儿童期发病。先天性胆总管囊肿先天性胆总管囊肿病病 理理 根据胆管扩张的部位、范围和形态，分为五种类型：根据胆管扩张的部位、范围和形态，分为五种类型：型：囊性扩张。临床上最常见。型：囊性扩张。临床上

13、最常见。型：憩室样扩张。型：憩室样扩张。型：胆总管开口部囊性脱垂。型：胆总管开口部囊性脱垂。型：肝内外胆管扩张。型：肝内外胆管扩张。型：肝内胆管扩张（型：肝内胆管扩张（Caroli病）。病）。先天性胆总管囊肿先天性胆总管囊肿临床表现临床表现 典型临床表现为腹痛、腹部包块和黄疽三联典型临床表现为腹痛、腹部包块和黄疽三联症。腹痛位于右上腹部症。腹痛位于右上腹部，可为持续性钝痛；黄，可为持续性钝痛；黄疽呈间歇性疽呈间歇性；80%以上病人右上腹部可扣及表以上病人右上腹部可扣及表面光滑的囊性肿块。晚期可出现胆汁性肝硬化面光滑的囊性肿块。晚期可出现胆汁性肝硬化和门静脉高压症的临床表现。囊肿破裂可导致和门静

14、脉高压症的临床表现。囊肿破裂可导致胆汁性腹膜炎。胆汁性腹膜炎。先天性胆总管囊肿先天性胆总管囊肿诊诊 断断 对于有典型对于有典型“三联症三联症”及反复发作胆管炎者及反复发作胆管炎者诊断不难。但诊断不难。但“三联症三联症”俱全者仅占俱全者仅占20%30%，多数病人仅有其中，多数病人仅有其中12个症状，故个症状，故对怀疑本病者需借助其他检查方法确诊。对怀疑本病者需借助其他检查方法确诊。先天性胆总管囊肿先天性胆总管囊肿治治 疗疗 本病一经确诊应尽早手术，否则可因反复本病一经确诊应尽早手术，否则可因反复发作胆管炎导致肝硬化、癌变或囊肿破裂等发作胆管炎导致肝硬化、癌变或囊肿破裂等严重并发症。完全切除囊肿和

15、胆肠严重并发症。完全切除囊肿和胆肠Roux-en-Y吻合是本病的主要治疗手段，疗效好。吻合是本病的主要治疗手段，疗效好。(Intrahepatic Duct Stone)Pathogenesis of Gallstones 主要为胆固醇性结石或以胆固醇为主的混合主要为胆固醇性结石或以胆固醇为主的混合型结石。女性常见，男女比例型结石。女性常见，男女比例1：3。形成的原因：胆汁的成分和理化性质发生变形成的原因：胆汁的成分和理化性质发生变化，胆汁中的胆固醇呈过饱和状态，易于沉淀析化，胆汁中的胆固醇呈过饱和状态，易于沉淀析出、结晶形成结石；胆汁中存在促成核因子，可出、结晶形成结石；胆汁中存在促成核因子

16、，可分泌大量的糖蛋白促使成核和结石形成；胆囊收分泌大量的糖蛋白促使成核和结石形成；胆囊收缩能力降低，胆囊内胆汁淤积也有利于结石形成。缩能力降低，胆囊内胆汁淤积也有利于结石形成。Cholesterol saturation of bile,stasis of bile within the gallbladder,and nucleating factors appear to be important.Diagnosis-Gallstone Recurrent attacks of right upper quadrant or epigastric pain or discomfort,na

17、usea and vomiting Gallbladder colic,results from the temporary obstruction of the gallbladder outlet by a stone in the cystic duct or the infundibulum Physical findings:right upper quadrant or epigastric tenderness to palpation and voluntary muscle guarding.Jaundice is not a feature of cholelithiasi

18、s unless common duct obstruction.Diagnosis Imaging studies:Ultrasonography demonstration that the stones move to the dependent portion of the gallbladder when the position of the patient is changed and the stone produces acoustic shadowing.Blood RTTreatment The definitive treatment of symptomatic ga

19、llstones is laparoscopic cholecystectomy.The major advantages of the laparoscopic procedure are that patients have less pain and a shorter hospitalisation and are able to return to their activities sooner.Open cholecystectomy is indicated only in patients in whom the laparoscopic is impossible or un

20、safe.Impossible to establish safe access to the peritoneal cavity Adhesions Anatomic abnormalitiesTreatment Other treatments Oral dissolution therapy:(UDCA)Contact dissolution therapy:Methyl tert-butyl Extracorporeal shock wave lithotripsyMirizzi综合征综合征及其分型及其分型是一种少见的胆囊结石并发症是一种少见的胆囊结石并发症容易漏诊和误诊容易漏诊和误诊

21、可引起肝总管狭窄和梗阻可引起肝总管狭窄和梗阻并发阻塞性黄疸和肝功能损害并发阻塞性黄疸和肝功能损害国内报道其占同期胆囊切除术的国内报道其占同期胆囊切除术的l3国外发病率为国外发病率为0.71.4Mirizzi综合征综合征(Mirizzi syndrome，MS)MS是指胆囊结石长期嵌顿于胆囊壶腹部或颈部，从外部压迫肝总管、胆总管，导致后者狭窄、梗阻，并发胆囊炎、胆管炎、梗阻性黄疸、肝功能损伤及各种胆内瘘的综合征 1905年，Kehr首先描述了胆囊结石引起的胆道部分梗阻及相关炎症过程Mirizzi教授1940年将该类疾病以综合征的形式进行了系统介绍，成为MS相关最早的报道Puestow，首先报道了

22、胆囊结石相关自发性胆内瘘，指出内瘘可发生于胆囊和胸、腹腔脏器，如胃、十二指肠、结肠以及支气管间，补充了MS复杂的解剖特点 胆囊结石嵌顿于胆囊颈部或壶腹部，胆囊萎缩，囊壁异常增厚或变薄胆囊管多发生闭塞胆囊结石外部压迫胆管或侵透胆管壁胆囊管过长或过短，或平行于胆总管低位汇入病变近侧胆道炎症明显，胆管壁增厚，而远侧胆管结构正常可形成胆内瘘，涉及胆管、胃、十二指肠、结肠、甚至气管，瘘管欠规则发生于任何年龄，患者多分布于50-70岁，男女比例相当结石长期存在引起MS的中位时间约29.6年可呈急性发作，如急性胆囊炎、胆管炎或急性胰腺炎，也可呈现慢性过程一半以上的患者主诉右上腹疼痛，60%以上的患者出现梗阻

23、性黄疸，胆石性肠梗阻时有发生部分患者CA-199异常升高，导致MS与以梗阻性黄疸为主要表现的胆胰恶性肿瘤鉴别困难1982年，Mcsherry等根据ERCP所见，提出了一种分类法：I型为胆囊管或胆囊颈巨大结石嵌顿压迫肝总管：型为结石部分或完全突破进入肝总管，形成胆囊胆管瘘1989年，Csendes等通过对219例MS的研究，认为所谓MS和胆囊胆管瘘是同一病理过程的不同发展阶段，并进行了分型：I型为胆囊颈或胆囊管结石嵌顿压迫肝总管(即经典MS)；型为胆囊胆管瘘形成，瘘管口径小于胆管周径的13；型为瘘管口径累及胆管周径23：IV型为胆管壁因结石压迫而完全受损B超是筛查MS的首要诊断工具对肝胆系统结石

24、、胆囊炎症及胆囊囊肿大的诊断有很高的敏感性对MS诊断的敏感性只有27胆囊增大，肝总管扩张而胆总管正常MS?PTC和ERCP是诊断MS的重要手段直接显示：结石压迫导致的胆管偏位、偏侧性(外压性)充盈缺损，边缘光整MRCP非介入性胰胆管成像技术，无需造影剂、无损伤、无痛苦、无并发症很好地显示胆道系统的正常及异常解剖，直接提示肝管受压于胆囊管结石，肝总管以上区域扩张MRCP为诊断MS的最佳检查方法反复右上腹部疼痛多年，发作时伴黄染实验室与体检：急性发作时有直接胆红素升高、肝功能损害B超提示：胆囊结石、胆囊肿大或萎缩及胆囊管结石伴嵌顿CT提示：肝内胆管扩张，胆囊管扩张，胆总管直径正常MRCPERCP术

25、前明确诊断对术中处理有一定的帮助，能有针对性地处理好嵌顿的胆囊管结石，避免损伤胆管根据MS不同类型采用不同的治疗方法以达最佳治疗胆囊切开取石造瘘术 适用于各型急性胆管炎急诊手术时术中炎症重，解剖不清，不勉强行胆囊切除手术，否则易损伤胆管而造成严重后果 3个月后再行二期手术急诊ERCP+ENBD/ERBD+二期手术急诊处理急诊处理胆囊或胆囊大部分切除术-I型MS胆囊大部切除加胆管修补及T管引流术-II型应用最广将胆囊大部或部分切除后，保留胆囊颈部避免损伤胆管用胆囊颈部残端修补缺损的胆管在胆管修补的下方放置T管作支架需注意保留足够多的胆囊壁、无张力修补，选择合适的T管，T臂跨过缺损处，T管引流时间

26、为3个月，以防修补处胆管狭窄切除胆囊，行胆管空肠RouxY吻合术，适用于胆管缺损比较大的III、IV型患者，以避免胆管狭窄，引起反复发作性的胆管炎 Va型病例，可行胆囊切除或部分切除，对十二指肠、胃、结肠或小肠内瘘可越过受累组织，行单纯缝合Mirizzi Vb型存在肠梗阻症状，须予以先行解决，经3个月以上恢复期后再行二期手术 Choledocholithiasis Clinical Manifestations and Diagnosis Common duct calculi may be asymptomatic or cause biliary colic,bile duct obstr

27、uction,cholangitis or pancreatitis.Jandice will be intermittent if the obstruction is partial and intermittent,or it maybe progressive if a stone becomes impacted in the distal duct.Chills and fever are usually associated with slight abdominal discomfort and a mild elevation of serum bilirubin,but a

28、ny of these signs of cholangitis may be absent.Clinical Manifestations and Diagnosis Physical examination may be normal.Jaundice and mild tenderness in the epigastrium and right upper quadrant may be present.Ultrasonography is not reliable in the detection of common duct stones.Endoscopic retrograde

29、 cholangiopancreatography(ERCP)is indicated for most patient who have bile duct obstruction.Percutaneous transhepatic cholangiography(PTC)is an alternative,but ERCP permits visualization of other portions of the gastrointestinal tract and allows for the performance of pancreatography and endoscopic

30、sphincterotomy with stone extraction,when indicated.Treatment Should be treated with antibiotic.AOSC(Acute Obstructive Suppurative Cholangitis)may be present,and decompression of the duct system must be carried out immediately.This can be done by establishing percutaneous transhepatic biliary draina

31、ge or by endoscopic sphincterotomy,but immediate laparotomy and insertion of a T-tube should be done if these simpler procedures fail or are nor available.Treatment Patients thought to have choledocholithiasis preoperatively undergo ERCP.when stones are identified,endoscopic sphincterotomy and stone

32、 extraction is performed Open choledocholithotomy and cholecystectomy are performed if the duct system cannot be cleared of stones.Open Choledocholithotomy Patients who are not candidates for laparoscopic procedures and those in whom endoscopic cholangiography and stone extraction are not possible m

33、ay require open choledocholithotomy After the stones have been removed,the duct should be closed with a T-tube,which has a large side arm,allowing percutaneous stones removal later,if necessary.Acute Calculous Cholecystitis Acute cholecystitis is a chemical or bacterial inflammation of the gallbladd

34、er that may cause severe peritonitis and death unless proper treatment is instituted.In about 95%of cases,gallstones are present in the gallbladder,and in about 5%they are not.The incidence of Acute calculous cholecystitis is higher in females,with a female-to-male ratio of 3:1 Pathogenesis Obstruct

35、ion:Obstruction of the cystic duct or the junction of the gallbladder and the cystic duct by a stone or by edema formed as the result of local mucosal erosion and inflammation caused by a stone Bacteria:Positive cultures of bile or gallbladder wall are found in 50%to 75%of cases.Deaths and complicat

36、ions from untreated cholecystitis are almost always related to septic complications of the disease.Other factors:In animal experiments,the presence of pancreatic juice,gastric juice,or concentrated bile in the lumen of the obstructed gallbladder causes acute cholecustitis.Pathology The inflamed gall

37、bladder is enlarged The serosal surface is congested May have areas of gangrene or necrosis The wall is edematous and thickened.Manifestations Most patients have symptoms referable to the gallbladder prior to the development of acute cholecystitis but 20%to 40%are asymptomatic.The development of acu

38、te cholecystitis progresses through the sequence of distention,and later by inflammation of the gallbladder and adjacent peritoneal surfaces.Radiation of the pain around the right side toward the tip of the scapula.Nausea and vomiting occur in 60%to 70%of patients,are the only other significant symp

39、toms.Physical Findings Tenderness in the right upper quadrant,the epigastrium,or both.Most common and reliable About half of all patients have muscle rigidity in the right upper quadrant,and about one fourth have rebound tenderness.Murphys sign.consisting of inspiratory arrest during deep palpation

40、of the right upper quadrant,is not a consistent finding but is almost pathognomonic when present.Jaundice occurs in approximately 10%of patients.Bowel sounds are absent in only about 10%of patients Fever maybe absentLaboratory Finding White blood cell count is elevated in 85%of cases One half have e

41、levation of the serum bilirubin Serum amylase is increased in one thirdImaging Studies Ultrasonography:Not specific,a thickened gallbladder wall and pericholecystic fluid are sometimes present.Complications Perforation:One third of these complications.Occurs when a gangrenous area becomes necrotic a

42、nd bile leaks into the peritoneal cavity Pericholecystic abscess:Result from a perforation of the gallbladder that is walled off by omentum or adjacent organs such as the colon,stomach,or duodenum.Fistula:15%.occurs when the gallbladder becomes attached to a portion of the gastrointestinal tract and

43、 perforates into it.Treatment Preoperative management should include administration of an antibiotic that is effective against the enteric organisms found in the bile of approximately 80%of patients with gallstones and acute cholecystitis.These organisms include both gram-positive and negative aerob

44、es and anaerobes.The definitive treatment of acute cholecystitis is cholecystectomy.The timing of operation was debated.Treatment Conversion to open cholecystectomy is indicated when the laparoscopic procedure cannot be completed safely or when bleeding or a bile leak cannot be stopped without riski

45、ng injury to important structures.Cholecystectomy for acute cholecystitis is performed with a mortality rate of less than 0.2%and a major morbidity rate of less than 5%.The incidence of bile duct injury is approximately 0.4%.Chronic Cholecystitis The term chronic cholecystitis with cholelithiasis is

46、 often used to connote symptomatic gallbladder disease.Chronic inflammatory changes are found in the gallbladders.Approximately 98%of patients with symptomatic gallbladder disease have gallstones.Pathology The pathologic findings in chronic cholecystitis are best interpreted in light of the clinical

47、 manifestations of the disease.two types of chronic cholecystitis exist:Secondary chronic cholecystitis:Follows an episode of acute cholecystitis.Acute cholecystitis is caused by gallbladder outlet obstruction,always by a stone.In cases that do not progress to perforation,these abnormalities gradual

48、ly resolve over 3 to 4 weeks.Simultaneously,granuloma formation begins.The mucosa itself becomes thin and loses its villous appearance.Pathology Primary chronic cholecystitis:Occurs primarily without antecedent acute cholecystitis Is characterized by a thin-walled gallbladder,with an intact mucosa t

49、hat retains its villous configurationStones are almost present in both forms of chronic cholecystitis.Diagnosis Recurrent attacks of right upper quadrant or epigastric pain or discomfort,usually following meals.Nausea and vomiting may occur during the attack.Intervals between attacks are variable,ma

50、ybe continuous or separated by several years.No fever or other signs of inflammation are present.Treatment The definitive treatment for symptomatic gallstones is laparoscopic cholecystectomy.Chronic Acalculous Cholecystitis Acute inflammation of the gallbladder without stones is a recognized entity