Tabata M, Nakayama F
Prog Clin Biol Res. 1984;152:163-74.
Hepatolithiasis is associated with bile stasis and bacterial infection. Gallstones found in the intrahepatic bile duct are mostly calcium bilirubinate stones, the presence of which is closely related to the presence of bacteria. In the present study, a high incidence of bile infection was found in hepatolithiasis: 52 of 54 cases (96.3%). This is in concordance with the other reports from Japan as well as from East Asia. E coli was the most frequent isolate followed by Klebsiella, Streptococcus (D), and Pseudomonas. Because of the frequent isolation of E coli in calcium bilirubinate stone cases, beta-glucuronidase from E coli has been thought to be responsible for the formation of calcium bilirubinate stones by effecting hydrolysis of bilirubin glucuronide to free bilirubin, which is insoluble in water. The recent introduction of improved anaerobic culture techniques has led to an increasing number of reports on the presence of anaerobes in the biliary tract. Anaerobes were isolated in 6 of 29 cases of hepatolithiasis (20.7%) in our series but more frequently in Kaohsiung, Taiwan (25 of 57 cases, or 44.4%). Bacteroides and Clostridium were the most frequent isolates from the biliary tract and were shown to have beta-glucuronidase activity. Anaerobes were often found together with aerobes, suggesting the possibility of a synergistic effect that may influence the occurrence and development of cholangitis, which is often associated with hepatolithiasis. Though the biliary tract and liver are usually sterile, when an infection of the biliary tract occurs the route by which bacteria reach the region is thought to be hematogenous, lymphatic, or direct intraluminal ascending infection, the last being the most likely. Treatment of cholangitis associated with hepatolithiasis should be directed toward the removal of stones and termination of bile stasis. When cholangitis ensues, control of bacterial infection by antibiotics should be started without delay. The choice of antibiotics in controlling cholangitis is presented.
肝内胆管结石与胆汁淤积及细菌感染有关。肝内胆管结石大多为胆红素钙结石，其存在与细菌的存在密切相关。在本研究中，肝内胆管结石患者胆汁感染的发生率很高：54例中有52例（96.3%）。这与日本以及东亚的其他报告一致。大肠埃希菌是最常分离出的菌株，其次是克雷伯菌、D群链球菌和铜绿假单胞菌。由于在胆红素钙结石病例中经常分离出大肠埃希菌，人们认为大肠埃希菌产生的β-葡萄糖醛酸酶通过将胆红素葡萄糖醛酸酯水解为不溶于水的游离胆红素，从而导致胆红素钙结石的形成。最近改进的厌氧培养技术的应用使得关于胆道中厌氧菌存在的报告越来越多。在我们的系列研究中，29例肝内胆管结石患者中有6例（20.7%）分离出厌氧菌，但在台湾高雄更为常见（57例中有25例，即44.4%）。拟杆菌属和梭菌属是从胆道中最常分离出的菌株，并且显示具有β-葡萄糖醛酸酶活性。厌氧菌常与需氧菌一起被发现，这表明可能存在协同作用，可能影响通常与肝内胆管结石相关的胆管炎的发生和发展。尽管胆道和肝脏通常是无菌的，但当发生胆道感染时，细菌到达该区域的途径被认为是血行性、淋巴性或直接管腔内上行感染，最后一种可能性最大。与肝内胆管结石相关的胆管炎的治疗应旨在去除结石并消除胆汁淤积。当胆管炎发生时，应立即开始用抗生素控制细菌感染。文中介绍了控制胆管炎时抗生素的选择。
