Inflammatory stricture of the bile duct

　　1. Etiology of the disease

　　1. Chronic non-specific infection

　　This disease is related to ulcerative colitis. During infectious enteritis, intestinal bacteria invade the biliary tract system via the portal vein, causing chronic inflammation, fibrosis of the bile duct wall, and narrowing of the bile duct. Some reports indicate that during colon resection due to ulcerative colitis, bacteria were cultured from the portal vein blood; when bacteria were injected into the portal vein of animals, inflammation was found around the bile duct. However, some people believe that there is no fundamental connection between this disease and ulcerative colitis. Whether accompanied by ulcerative colitis or not, it does not change the natural course and outcome of primary biliary cirrhosis.

　　II. Autoimmune diseases

　　This disease is often accompanied by ulcerative colitis, and some are also accompanied by segmental enteritis, chronic fibrous thyroiditis (Riedl's thyroiditis), and retroperitoneal fibrosing inflammatory sclerosis, and other diseases. The immune complexes in the patient's serum are often higher than those in normal people. When these substances precipitate in the tissue, they can cause local inflammation. Badenheimer

　　The immune complexes in the patient's serum are significantly higher than those in the healthy control group, regardless of whether they have ulcerative colitis. Patients with ulcerative colitis have a certain proportion of positive antinuclear antibodies and anti-smooth muscle antibodies, which supports the view that the onset of these patients is related to immune factors. However, the use of corticosteroids or immunosuppressive drugs can improve symptoms, but does not improve the pathological changes of the bile ducts and cannot change the course of the disease of the patients. Therefore, whether primary biliary cholangitis is related to immune factors still needs further research to be confirmed.

　　II. Other factors

　　The disease is related to congenital factors, Strongyloides infection, alcoholism, lithocholic acid, and other factors.

　　Bile duct inflammatory stricture can be accompanied by late-stage cirrhosis.

　　Cirrhosis (hepatic cirrhosis) is a common clinical chronic progressive liver disease, which is a diffuse liver injury formed by long-term or repeated action of one or more etiologies. In China, most cases are post-hepatitis cirrhosis, a small part is alcoholic cirrhosis and schistosomiasis cirrhosis. Pathologically, there is extensive necrosis of liver cells, nodular regeneration of residual liver cells, proliferation of connective tissue and formation of fibrous septa, leading to destruction of the liver lobule structure and formation of pseudo-lobules, resulting in gradual deformation and hardening of the liver, and the development of cirrhosis. In the early stage, due to the strong compensatory function of the liver, there may be no obvious symptoms, while in the later stage, the main manifestations are liver function damage and portal hypertension, with involvement of multiple systems, and complications such as upper gastrointestinal bleeding, hepatic encephalopathy, secondary infection, splenic dysfunction, ascites, and neoplasia may occur in the late stage.

　　1. Clinical manifestations of extrahepatic bile duct stones

　　It depends on whether there is infection and obstruction. Generally, there may be no symptoms in daily life. However, when gallstones block the bile duct and secondary infection occurs, the typical clinical manifestation is Charcot's triad, that is, abdominal pain, chills and high fever, and jaundice. ① Abdominal pain: It occurs under the xiphoid process and in the upper right abdomen, mostly in cramping pain, presenting as paroxysmal attacks, or persistent pain with paroxysmal exacerbation, which can radiate to the right shoulder accompanied by nausea and vomiting; ② Chills and high fever: After bile duct obstruction and secondary infection, the pressure in the bile duct increases, the infection spreads retrogradely along the bile duct, bacteria and toxins enter the liver sinus via the capillary bile ducts and reach the hepatic veins, and then enter the systemic circulation, causing systemic infection. About 2/3 of the patients may have chills and high fever during the course of the disease, generally presenting as remittent fever, with high body temperature reaching 39~40℃; ③ Jaundice: Jaundice may appear after bile duct obstruction, and its severity, onset, and duration depend on the degree of bile duct obstruction, whether complications such as infection occur, and factors such as the presence of gallbladder. Jaundice is often accompanied by dark urine, light feces, and some may experience pruritus. The jaundice caused by gallstone obstruction is usually intermittent and fluctuating.

　　2. Clinical manifestations of intrahepatic bile duct stones

　　The clinical manifestations of extrahepatic bile duct stones are similar when combined with extrahepatic bile duct stones. Those without extrahepatic bile duct stones may have no symptoms for many years or only have discomfort such as distension and pain in the liver and chest back areas. If obstruction and secondary infection occur, chills or fever may appear, or even acute obstructive suppurative cholangitis. In general, there will be no obvious jaundice unless both bile ducts are obstructed or advanced biliary cirrhosis. When intrahepatic bile duct stones are complicated with infection, they are prone to cause biliary liver abscess, and the abscess can break through the diaphragm and further break through the diaphragm and lung to form a bile duct bronchial fistula, coughing up yellowish, bitter sputum-like sputum. In the late stage, the development of biliary cirrhosis can cause portal hypertension. For patients with a long history, frequent attacks of cholangitis in recent years, progressive jaundice, difficultly controlled abdominal pain and fever, and symptoms such as weight loss, especially those over 50 years old, it should be suspected of the possibility of combined cholangiocarcinoma. The main manifestations are uneven enlargement of the liver, tenderness and percussion pain in the liver area. When complications such as infection occur, the corresponding signs and symptoms appear.

　　1. Pay attention to strengthen nutrition, and pay attention to high sugar, high protein, high vitamin, low-fat, and easy-to-digest diet when eating.

　　2. When non-surgical treatment is adopted, attention should be paid to changes in the condition. If the body temperature exceeds 39 degrees, inform the medical staff to deal with the upper abdominal colic pain, and pay attention to whether there are stones excreted in the feces when taking traditional Chinese medicine.

　　3. Acute patients should receive fasting and intravenous fluid infusion, and pay attention to the location, nature, and presence of chills, fever, shock, and other symptoms of abdominal pain at any time. Coordinate with preoperative skin preparation, blood matching, and other aspects.

　　4. When itchy, pay attention to keep the skin clean and hygienic, take a bath and change clothes, and receive intramuscular vitamin K1.

　　5. Actively treat bile duct system diseases and eat less high-fat and high-cholesterol foods.

　　1. Examination for extrahepatic bile duct stones

　　Ultrasound examination can detect gallbladder duct stones and images of bile duct dilation. PTC and ERCP can provide the location, quantity, size of the stones, as well as the location and degree of bile duct obstruction. Ultrasound examination is generally the first choice, and ERCP or PTC can be added if necessary. CT is generally only considered when there are doubts or failure in the above examinations.

　　2. Examination of intrahepatic bile duct stones

　　For patients with simple bile duct stones without infection or other complications, especially those who are easily misdiagnosed as hepatitis or gastrointestinal diseases during the 'stationary period', attention should be paid to differentiation. Imaging examinations are helpful for diagnosis and differential diagnosis. B-ultrasound and PTC examination can show the distribution of intrahepatic bile duct stones and the stenosis and dilation of the hepatic bile ducts, which is of great significance for determining the diagnosis and guiding treatment. The X-ray characteristics of PTC include: ① The common bile duct or left and right hepatic ducts have annular stenosis, with dilation of the bile ducts near the stenosis, in which stone shadows can be seen; ② The left and right hepatic ducts or some parts of the intrahepatic bile ducts do not show shadows; ③ The intrahepatic bile ducts of the left and right lobes show asymmetrical, localized, spindle-shaped, or pear-shaped dilation. CT also has important diagnostic value, especially for those with concurrent biliary cirrhosis and carcinoma.

　　1. Minimize the intake of fat, especially animal fat, do not eat fatty meat and fried foods, and as much as possible replace animal oil with vegetable oil.

　　2. A considerable number of gallbladder inflammation and cholelithiasis are indeed related to high cholesterol levels and metabolic disorders in the body, so it is necessary to limit foods with high cholesterol content such as fish roe, yolks of various eggs, and the livers, kidneys, hearts, and brains of various carnivorous animals.

　　3. The best way to cook food is steaming, boiling, stewing, and braising, and it is forbidden to consume large amounts of fried, baked, grilled, smoked, or preserved food.

　　4. Increase the intake of foods rich in high-quality protein and carbohydrates such as fish, lean meat, dairy products, fresh vegetables, and fruits to ensure calorie supply, thereby promoting the formation of glycogen in the liver and protecting the liver.

　　5. Eat more tomatoes, corn, carrots, and other foods rich in vitamin A to maintain the integrity of gallbladder epithelial cells and prevent the shedding of epithelial cells to form the core of stones, thereby causing stones or increasing the size and number of stones.

　　6. If conditions permit, drink more fresh vegetable or melon juice, such as watermelon juice, orange juice, carrot juice, etc., and increase the frequency and quantity of drinking water and eating, to increase the secretion and excretion of bile, and reduce inflammation and bile stasis.

　　7. Eat less vegetables such as turnips and celery that are rich in fiber, as this may increase gastrointestinal motility due to difficulty in digestion, thereby triggering biliary colic.

　　8. Quit smoking and drinking and reduce the intake of spicy and irritating foods, such as wasabi oil, to avoid stimulating the gastrointestinal tract and exacerbating the condition.

　　9. It is advisable to consume light, easy to digest, low fiber, temperature-appropriate, non-irritating, low-fat liquid or semi-liquid diet, and never indulge in eating and drinking for a moment of pleasure, as this may cause unnecessary trouble, even induce bile duct bleeding and endanger life.

　　First, extracorporeal bile duct stones are still mainly treated surgically

　　1. Cholecystotomy and stone extraction with T-tube drainage:Applicable to simple bile duct stones, with unobstructed superior and inferior ends of the bile duct, without stenosis or other lesions. If accompanied by gallbladder stones and cholecystitis, cholecystectomy can be performed simultaneously. Those with conditions can adopt intraoperative bile duct造影, B-ultrasound examination, or fiberoptic bile ductoscopy, which can help reduce the residual rate of bile stones. If non-surgical treatment is unsuccessful, symptoms recur or worsen, surgical treatment is required.

　　2. Biliary-enteric anastomosis:Also known as biliary-enteric internal drainage surgery. Suitable for: ① Bile duct dilatation ≥2.5cm, lower end with inflammatory stricture and other obstructive lesions, and difficult to be relieved by surgical methods, but the upper bile duct must be unobstructed; ② Stones that are sandy in appearance and difficult to remove completely, with stone residue or recurrence, commonly used is biliary jejunum Roux-en-Y anastomosis.

　　3. Oddi's sphincteroplasty:Indications are the same as biliary-enteric anastomosis, especially for those with mild bile duct dilatation who are not suitable for biliary-enteric anastomosis. 4. Endoscopic sphincterotomy for stone removal: Suitable for gallstones impacted in the ampulla and lower end of the common bile duct, especially for patients who have undergone cholecystectomy. The success rate can reach 90%, and the mortality rate is only 1.0% to 1.5%. However, if the number of stones in the bile duct exceeds 5, the stones are larger than 1cm, or the stricture segment is too long, the effect of this operation is poor, and laparotomy should be performed. The contraindications are: ① Those who have undergone Billroth II gastric jejunostomy; ② Those with bleeding tendency and coagulation dysfunction; ③ Those who have had a recent attack of pancreatitis; ④ Those with duodenal diverticula in the papilla area and nearby.

　　Two, the treatment of intrahepatic bile duct stones should adopt a comprehensive treatment mainly based on surgical methods

　　1. Surgical treatment:The principle is to remove stones as cleanly as possible, relieve bile duct stricture and obstruction, remove intrahepatic infectious foci, establish and restore unobstructed bile duct drainage, and prevent recurrence. Among them, relieving stricture is the key to surgical treatment. Therefore, it is necessary to abandon the wrong practice of attempting to relieve the bile duct bile drainage within the liver by performing extrahepatic biliary-enteric anastomosis. Surgical methods include: ① High bile duct incision and stone removal; ② Biliary-enteric internal drainage; ③ Removal of intrahepatic infectious foci.

　　2. Integrated treatment of Chinese and Western medicine:In conjunction with surgery and other comprehensive treatments, acupuncture and the use of anti-inflammatory and bile-promoting traditional Chinese medicine can be used to control inflammation and expel stones.

　　3. Treatment of residual stones:When residual gallstones are found in the bile duct after T-tube cholangiography, the T-tube can be removed after the sinus tract forms and a fiberoptic cholangioscope can be inserted through the sinus tract. Stones can be removed under direct vision using stone forceps, net baskets, etc. If the stones are too large, laser lithotripsy, micro-explosion crushing, or other methods can be used to break the residual stones into small pieces and then remove them separately. Stones can also be dissolved through the T-tube by injecting contact dissolution drugs. The long-term efficacy of dissolution therapy is not certain, and there are certain adverse reactions.