Nordin Nazrul, Alex George, Clarnette Tom, Stephens Nicola, Oliver Mark
Departments of Gastroenterology and Clinical Nutrition General Surgery Medical Imaging, Royal Children's Hospital, Flemington Road, Melbourne, VIC 3052, Australia.
J Paediatr Child Health. 2012 Aug;48(8):705-9. doi: 10.1111/j.1440-1754.2012.02452.x. Epub 2012 Apr 12.
Symptomatic choledocholithiasis in infancy is not common. It usually presents with jaundice and acholic stools and is diagnosed on abdominal ultrasonography. Favourable outcome of conservative management has been reported, but specific management guidelines are not well defined in the literature. We describe three cases using a combination of ursodeoxycholic acid and antibiotics as a treatment paradigm, which could potentially negate more invasive treatment. All three patients had ultrasonography proven choledocholithiasis with concomitant obstructive liver function test. They were treated with a combination of ursodeoxycolic acid and antibiotics. Patient 1 had an Escherichia coli urinary tract infection and was treated with oral bactrim. Intravenous amoxicillin, gentamicin and metronidazole were used for the other two patients. All three patients responded with a return to normal-coloured stools within 48 h of combination treatment. Repeat ultrasonography done within 11 days after the first study for all three patients confirmed complete resolution of choledocholithiasis. It is postulated that this improvement is as a result of a reduction in inflammation and oedema, associated with a low-grade cholangitis, following antibiotic treatment. This is coupled with improved bile flow with ursodeoxycholic acid therapy. The findings suggest the potential application of this safe, non-invasive therapeutic strategy as initial management in infants with this condition. A follow-up prospective randomised controlled trial may be an answer to prove the validity of this observation but due to the rarity of this problem, it would be a challenge to recruit sufficient number of patients.
婴儿期有症状的胆总管结石并不常见。它通常表现为黄疸和陶土样大便，通过腹部超声检查确诊。已有保守治疗取得良好效果的报道，但文献中尚未明确具体的治疗指南。我们描述了三例采用熊去氧胆酸和抗生素联合治疗的病例，这种治疗模式可能避免更具侵入性的治疗。所有三例患者经超声检查证实患有胆总管结石，并伴有肝功能检查异常。他们接受了熊去氧胆酸和抗生素联合治疗。患者1患有大肠杆菌尿路感染，接受口服复方新诺明治疗。另外两名患者使用了静脉注射阿莫西林、庆大霉素和甲硝唑。所有三名患者在联合治疗后48小时内大便颜色恢复正常。所有三名患者在首次检查后11天内进行的重复超声检查证实胆总管结石已完全消失。据推测，这种改善是由于抗生素治疗后与轻度胆管炎相关的炎症和水肿减轻，以及熊去氧胆酸治疗使胆汁流动改善。这些发现表明，这种安全、非侵入性的治疗策略有可能作为这种疾病婴儿的初始治疗方法。后续的前瞻性随机对照试验可能是证明这一观察结果有效性的答案，但由于这个问题罕见，招募足够数量的患者将是一个挑战。
