Bile duct obstruction

　　胆管梗阻这是外科急腹症中死亡率较高的一种疾病，多数继发于胆管结石和胆道蛔虫症。但胆管狭窄和胆管肿瘤等病变有时亦可继发此症。上述疾病造成胆管阻塞，胆汁郁积，以及继发细菌感染。致病菌几乎都来自肠道，经乏特壶腹或经胆肠吻合口的通道逆行进入胆道。细菌亦可通过血行或淋巴通道进入胆道。致病菌主要为大肠杆菌，克雷白菌，粪链球菌和某些厌氧菌。

　　在原有结石等阻塞性疾病的基础上发生胆管感染，胆管粘膜充血水种，加重胆管的梗阻，胆汁逐渐变成脓性，胆管内的压力不断增高，梗阻近侧的胆管逐渐扩大。在含有脓性胆汁的胆管高压的作用下，肝脏可肿大，肝内小胆管及周围的肝实质细胞亦可发生炎性改变。

　　肝细胞产生大片坏死，可形成肝内多发性小脓肿。胆管也可因感染化脓造成溃疡和胆道出血。由于胆管内高压造成肝内毛细胆管破溃，脓性胆汁甚至胆栓即由此经肝内血窦进入血循环，造成菌血症和败血症。少数还可发生肺部脓性栓塞。在后期，可发生感染性休克、肝肾功能衰竭或弥漫性血管内凝血等一系列病理生理性变化，此即为急性梗阻性化脓性胆管炎或称急性重症胆管炎。这些病理改变一旦发生，即使手术解除了胆管高压，但在肝实质和胆管仍会留下损害，这也是本症的严重性的存在。

　　胆管梗阻除了其临床表现外，还可引起其他疾病。本病易引起胆汁反流，恶心，呕吐，右上腹持续性疼痛。如果梗阻时间过长，可能会引起胆囊缺血坏死。

　　先天性胆管梗阻有哪些症状？

　　①黄疸：梗阻性黄疸是先天性胆道闭锁突出表现。一般出生时并无黄疸，1~2周后出现，呈进行性加深。巩膜和皮肤由金黄变为绿褐或暗绿色，大便渐为陶土色，尿色随黄疸加深而呈浓茶样，尿布样、黄皮肤、有瘙痒抓痕。2~3个月后可发生出血倾向及凝血机制障碍。

　　②营养及发育不良：初期患儿情况良好，营养发育正常，表现与黄疸深度不相符。随后情况所有逐渐恶化，至3~4个月时出现营养不良、贫血、发育迟缓、反应迟钝等

　　③肝脾肿大：是先天性胆道闭锁的特点。出生时肝脏正常，随病情发展而呈进行性肿大，3个月左右即可发展为胆汗性肝硬化及门静脉高压症，最终常因感染、出血、肝衰竭、肝昏迷，于出生1年内死亡。

　　Bile duct obstruction is mostly secondary to bile duct stones and biliary ascariasis, and some patients are secondary to bile duct tumors. These diseases cause bile duct obstruction, bile stasis, and secondary bacterial infection.

　　To prevent bile duct obstruction, it is necessary to actively treat bile duct diseases, and preventive measures include:

　　Regular diet

　　When fasting, bile becomes concentrated and sticky, forming mud-like after increasing its viscosity. If regular meals are taken, it can effectively prevent the precipitation and separation of solid substances in bile due to bile stasis.

　　Rational diet搭配

　　In daily life, attention should be paid to the structure of diet, maintain moderate nutrition, and try to be comprehensive, high in protein, low in fat, and low in cholesterol.

　　Prevention of parasitic infection

　　Intestinal parasites are the primary disease of biliary tract infection, closely related to pigment gallstones. It is necessary to develop good hygiene habits in daily life, wash hands before and after meals, wash fruits and vegetables before eating, and maintain a good living environment, which can effectively prevent intestinal parasitic infections.

　　For bile duct tumors, comprehensive examinations should be conducted, diagnosis should be made as early as possible, and active treatment should be carried out.

　　1. Image analysis: (1) The presence of obstruction and the judgment of obstruction level based on the following criteria: ① For patients without cholecystectomy, the maximum internal diameter of the common bile duct (CBD) is greater than 7 mm; for patients with cholecystectomy, the maximum internal diameter of the CBD is greater than 10 mm; ② There is clear stenosis and interruption in the common hepatic duct (CHD) or CBD. Extrahepatic obstruction is divided into portal, common hepatic duct level, and upper, middle, and lower three segments of the CBD; (2) Differential diagnosis of benign and malignant obstructions: sudden cutoff, irregular narrowing of the bile duct, proportional expansion of the common bile duct and intrahepatic bile duct, and irregular filling defects in the bile duct lumen are indicative of malignant obstruction.

　　2. Examination methods: All MRCP examinations use Philips Gyroscan 1.5T superconducting magnetic resonance scanner, field strength of 1.5 Tesla, body coil, data acquisition under平静breathing with respiratory gating, and using the heavy T2-weighted TSE pulse sequence to obtain images. Parameters: repetition time/echo time = 2,000～8,000/140～330 ms, field of view: 320～350 mm, slice thickness: 4 mm, slice gap: 1 mm, number of slices: 20～50, echo train length: 16～32, average signal acquisition: 4～6 times, right anterior oblique 20～40 degrees non-standard coronal position, total examination time 4～11 minutes, flow compensation, using spatial preset saturation and fat suppression techniques to eliminate artifacts and improve image quality. 3D reconstruction uses maximum intensity projection (MIP) with the vertical body axis as the axis, and reconstructs 12 images of different angles at 15-degree intervals. B-US examination was performed in 37 cases, and non-choledochal enhanced CT scanning was performed in 38 cases.

　　Diet should be scientifically arranged, and it should be achieved by 'Seven Shoulds' and 'Five Taboos'.

　　Seventh, to:First, eat more foods rich in vitamin A, such as green vegetables, carrots, tomatoes, cabbage, etc., and eat more bananas, apples, and other fruits in daily life. Second, use vegetable oil to fry, and the dishes eaten should be mainly stewed, braised, and steamed. Third, eat more lean meat, chicken, fish, walnuts, black fungus, kelp, and seaweed, etc. Fourth, eat more foods that can promote bile secretion and relax the posterosphincteric muscles of the bile duct, and have a choleretic effect, such as hawthorn, Chinese hawthorn, corn silk (drink tea slowly). Fifth, eat breakfast, and do not go for too long without eating. Sixth, exercise regularly to prevent constipation. Seventh, lose weight.

　　Fifth, avoid:First, avoid foods with high cholesterol, such as animal hearts, livers, brains, intestines, as well as yolks, salted eggs, fish roe, and chocolate, etc. Second, avoid high-fat foods such as lard, fried foods, and pastries with too much oil, as excessive fat can cause gallbladder contraction and lead to pain. Third, avoid overeating during holidays or family and friends gatherings. Because overeating can promote the secretion of bile in large quantities, and the strong contraction of the gallbladder can cause inflammation of the gallbladder and local colic pain, etc. Fourth, avoid spicy and stimulating seasonings such as chili and pepper. Fifth, avoid smoking, drinking, coffee, etc., as these刺激性 foods can cause excessive stomach acid, causing the gallbladder to contract strongly and leading to biliary spasm and difficulty in bile excretion, which is prone to causing biliary colic.

　　Traditional Chinese medicine believes that acute obstructive suppurative cholangitis belongs to the category of jaundice, and the cause is damp-heat. According to its clinical symptoms, it can be summarized as the four major symptoms of 'Pain, Heat, Jaundice, and Syncope'. Its pathogenesis is the accumulation of damp-heat, which generates heat over time, turns into pus over time, and has a strong heat-toxin, which is prone to transforming into heat-syncope. Because the gallbladder is one of the six bowels, it should be drained and not stored, it likes to be relaxed, and its function is to be unobstructed. Therefore, the principle of treatment should be both symptomatic and root treatment, using unobstructed as the guiding principle. The treatment methods can be summarized into three aspects:

　　①Strengthening the Body and Nourishing Yin, Saving Yang and Reversing the Inversion: Suitable for shock phase. Often combined with various anti-shock measures of Western medicine, such as Shengmai Powder, Compound Danshen Injection, and Shenfu Decoction.

　　②Clearing Heat and Detoxifying, Cooling Blood and Dispersing Blood: This is aimed at combating infection and alleviating various toxic blood symptoms and bleeding tendencies, often combined with Western medicine's antibacterial drugs and hormones, etc.

　　③Expelling Damp-Heat and Dissolving Gallstones: Mainly using purgative and bile-promoting traditional Chinese medicine, such as Qingdan Decoction and Daidao Pailishuang.