急性重症胆管炎不同梗阻部位的临床特征和治疗方案

Clinical manifestation and management of acute cholangitis severe type with different types of obstruction

目的通过分析不同梗阻部位的急性重症胆管炎（ACST）的临床特征，探讨合理的治疗方案。方法回顾性分析1997年1月至2006年12月成都市第一人民医院收治的164例不同梗阻部位的ACST患者的临床资料。按梗阻部位不同将患者分为肝外型（122例）、肝内型（18例）和混合型（24例）。采用χ2检验、连续校正χ2检验和Fisher确切概率法对数据进行分析。结果肝外型与混合型患者临床表现及特征比较差异无统计学意义（P〉0．05）。肝内型患者腹痛、黄疸的发生率明显低于肝外型患者（P〈0．05），而神志改变以及对术前体液复苏治疗效果均优于肝外型患者（P〈0．05）。全组病死率为9．8％（16／164）。行手术治疗者123例。肝内型和混合型患者在术后并发症发生率和病死率与肝外型比较差异无统计学意义（χ2=0．172，0．789；1．769，1．948，P〉0．05）。肝外型患者急诊手术时胆道高压发生率、胆道减压后生命体征明显好转率高于混合型和肝内型患者（P〈0．05）。非急诊手术病死率、并发症发生率明显低于急诊手术（P〈0．05）。结论肝内型ACST患者的临床表现及特征不同于肝外型和混合型患者。不同梗阻部位患者手术并发症发生率、病死率无明显差异。急诊手术并发症发生率、病死率高。合理选择手术时机可降低ACST患者并发症发生率和病死率。

Objective To investigate the clinical manifestation and management of acute cholangitis severe type （ACST） with different types of obstruction. Methods From January 1997 to December 2006, 164 consecutive patients with ACST had been admitted to Chengdu First People＇s Hospital. All patients were divided into extrahepatic type group （n = 122）, intrahepatie type group （n = 18） and mixed type group （n =24） according to the types of obstruction. Clinical manifestation and therapeutic outcome of the 3 groups were analyzed using chi-square test, continuity correction test or Fisher exact test. Results There was no significant difference in clinical manifestation between patients with extrahepatic type and those with mixed type （ P 〉 0. 05 ）. The incidence of jaundice and abdominal pain in patients with intrahepatic type is significantly lower than those with extrahepatic type （ P 〈 0.05 ）. The incidences of distention in consciousness and response to initial medical treatment were higher than those with extrahepatic type （P 〈 0.05 ）. The total mortality rate was 9.8% （16/164）. Of all patients, 123 received open surgery. There was no significant difference in morbidity and mortality in patients with intrahepatic type and mixed type （χ2 = 0. 172,0. 789 ; 1. 769, 1. 948, P 〉 0.05）. In emergency operation, the incidence of biliary high pressure and postoperative vital sign improvement rates were significant higher in patients with extrahepatic type than the other 2 types （ P 〈 0. 05 ）. The morbidity and mortality of patients who received emergency operation were higher than non-emergency operation （P 〈 0.05 ）. Conclusions The clinical manifestation of ACST is different between intrahepatic obstructive type and the other 2 types. There is no significant difference in morbidity and mortality among the 3 types of obstruction. The morbidity and mortality are high in patients who received emergency operation. Proper management of surgical tinting is helpful in decreasing the morbidity and motality of ACST.