Bornman Philippus C, van Beljon Johan I, Krige Jake E J
Department of Surgery, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.
J Hepatobiliary Pancreat Surg. 2003;10(6):406-14. doi: 10.1007/s00534-002-0710-1.
Acute cholangitis remains a life-threatening complication of biliary obstruction, particularly in the elderly with comorbid disease or when there is a delay in diagnosis and treatment. The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broad-spectrum antibiotics. The choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available. The timing and choice of biliary decompression varies depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause. Biliary sepsis resolves in most patients with conservative treatment, thus allowing time to perform more detailed non-interventional imaging (e.g., spiral computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP]) to determine the underlying cause and level of biliary obstruction. Those with cholangitis who do not respond to conservative therapy will require urgent biliary decompression. In patients with choledocholithiasis, endoscopic drainage is now the treatment of choice or, if this fails, transhepatic biliary decompression is a useful alternative. Various endoscopic options are available for managing choledocholithiasis, ranging from endoscopic papillotomy (EP) and extraction of stones, to the placement of a biliary drainage system. In patients who respond to antibiotic therapy, EP with stone extraction is preferred, while in those with ongoing sepsis and multiple large stones, the placement of a stent with or without an EP is the safest option. Transhepatic biliary drainage is now reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones. Surgical biliary decompression is seldom required in the emergency setting, but still plays an important role in the definitive treatment of the underlying cause.
急性胆管炎仍然是胆管梗阻的一种危及生命的并发症，尤其是在患有合并症的老年人中，或者在诊断和治疗延迟时。初始治疗包括液体复苏、纠正凝血功能障碍以及给予广谱抗生素。在获得血培养结果之前，抗生素的选择应覆盖与胆管炎相关的革兰氏阴性菌和革兰氏阳性菌。胆管减压的时机和选择因对抗生素治疗的反应、合并症的存在以及潜在病因而异。大多数患者通过保守治疗可使胆源性败血症得到缓解，从而有时间进行更详细的非介入性成像检查（如螺旋计算机断层扫描[CT]、磁共振胆胰管造影[MRCP]），以确定潜在病因和胆管梗阻的部位。对保守治疗无反应的胆管炎患者需要紧急胆管减压。对于胆总管结石患者，内镜引流目前是首选治疗方法，若失败，经肝胆管减压是一种有效的替代方法。有多种内镜治疗方法可用于处理胆总管结石，从内镜乳头切开术（EP）和结石取出术到放置胆管引流系统。对抗生素治疗有反应的患者，首选EP并取出结石；而对于持续败血症且有多个大结石的患者，放置支架（无论是否进行EP）是最安全的选择。经肝胆管引流目前仅用于内镜引流失败以及怀疑肝门部胆管癌或肝内结石的患者。在急诊情况下很少需要手术胆管减压，但它在潜在病因的确定性治疗中仍起着重要作用。
