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目的 通过对37例良性阻塞性黄疸病人围减黄手术期血清总胆红素（TBil)和直接胆红素（DBil)的测定，了解其变化规律，确定其临床意义。方法 分别于手术前1天。手术后1、3、7、10、14、18、21天采集血标本，使用生化分析仪测定其中TBil,DBil的含量。结果 减黄效果良好组TBil和DBil在减黄术后前几天迅速下降，之后平稳消退，减黄效果不良组中不少病例TBil和DBil在术后不但不消退，反而有一定的升高，原因不明，之后缓慢减低。在减黄过程中无明显消退阶段。结论 以10天时TBil,DBil的结果预后较为合适，且DBil的预后效果稍好于TBil。     

肝动脉栓塞化疗并发梗阻性黄疸的诊断与治疗

肝海绵状血管瘤是肝脏最常见的良性肿瘤,近年来接受肝动脉栓塞化疗的患者越来越多,相关的并发症、后遗症也随之增多,其中胆管损伤所致的梗阻性黄疸是严重的并发症之一.对于这类症状不典型的梗阻性黄疸有可能误诊为胆道恶性肿瘤,从而对后续处理带来难以预料的影响.同济大学附属同济医院收治2例肝动脉栓塞化疗治疗肝血管瘤后发生梗阻性黄疸患者,总结其诊断与治疗经验.     

a-硫辛酸对阻塞性黄疸大鼠肝细胞线粒体内能量代谢保护作用及机制

目的 探讨α-硫辛酸对阻塞性黄疸大鼠肝细胞线粒体内能量代谢的保护作用及其机制. 方法 将72只SD雄性大鼠随机分为对照组（SO组）,胆总管结扎＋0.9%氯化钠溶液组（BDL＋NS组）,胆总管结扎α-硫辛酸组（BDL＋LA组）.分别于术后7 d、14 d和2l d检测肝细胞线粒体内MDA、SOD、ATP、ADP和AMP含量并计算总腺苷酸（TAN）和能荷（EC）. 结果 BDL＋NS组各时间点肝细胞线粒体内MDA、ADP、AMP含量明显升高,而SOD、ATP、EC含量却明显降低.胆总管结扎7 d、14 d时,肝细胞线粒体内MDA含量BDL＋LA组比BDL＋NS组低,差异有统计学意义（P＜0.01）;2l d时,AMP、MDA含量BDL＋NS组和BDL＋LA中都更进一步升高,但两组比较差异无统计学意义（P＞0.05）.胆总管结扎7 d、14 d时,肝细胞线粒体内SOD含量、ATP含量BDL＋LA组比BDL＋NS组下降程度有显著性差异（7 d,P＜0.01;14 d,P＜0.05）;21 d时,两组肝细胞线粒体内SOD含量都进一步下降,但差异无统计学意义（p＞0.05）. 结论 α-硫辛酸在阻塞性黄疸早、中期有保护线粒体能量代谢作用,减轻了阻塞性黄疸时肝的损伤.     

Phenylalanine breath test as a method to evaluate hepatic dysfunction in obstructive jaundice

BACKGROUND: The purpose of this study was to investigate whether the hepatic dysfunction associated with obstructive jaundice can be measured from changes in expiratory 13CO2 levels after intravenous administration of l-[1-(13)C]phenylalanine, using a rat model of obstructive jaundice. MATERIALS AND METHODS: Under pentobarbital anesthesia, bile duct ligation (BDL) was performed (n=12). In the control group, simple laparotomy was performed (n=12). On postoperative day 7, 20 mg/kg l-[1-(13)C]phenylalanine was administered via the femoral vein. Phenylalanine breath test (PBT) was performed for 30 min. We compared single point of 13CO2 level (SPT: T: min) and sum of 13CO2 output (ST) values between BDL and control rats. We examined the correlation of SPT or ST with phenylalanine hydroxylase activity (PHA) and blood chemical parameters. RESULTS: Both SPT and ST values decreased in BDL compared to control 3 min after the start of PBT (SP10; 103+/-12 (per thousand) versus 84+/-16 (per thousand) P=0.025). PHA/g liver in BDL was significantly decreased compared to control (40.81+/-4.80 (U) versus 28.93+/-9.60 (U) P=0.008). PHA/g liver was correlated with SPT with correlation coefficient of more than 0.715, 10 min after the start of PBT, and the maximum correlation was at SP20 (r=0.801). Blood chemical parameters were correlated with S15 (total bilirubin, r=-0.717; alkaline phosphatase, r=-0.841; gamma-glutamyl transpeptidase, r=-0.759; alanine aminotransferase, r=-0.776; albumin, r=0.819). CONCLUSIONS: In the breath test with intravenously l-[1-(13)C]phenylalanine, hepatic dysfunction associated with obstructive jaundice could be measured in a short period.     

The effects of thromboxane A2 synthetase inhibitor (OKY-046) on complete hepatic ischemia in rats with obstructive jaundice

The effects of OKY-046, a thromboxane A₂ synthetase inhibitor, on hepatic dysfunction produced by liver cell ischemia were studied in an experimental model of rats with obstructive jaundice. The experiments were performed 7 days after the rats underwent bile duct ligation. Warm total ischemia of the liver was induced by Pringle's method over a 20-min period and the animals were divided into two groups according to whether or not OKY-046 was administered. The reperfusion time was 30 min in each group. OKY-046 was administered via the femoral vein at a rate of 100 g/kg per min from 15 min before the blockade to the end of the experiment. The level of ATP in the liver tissue of the OKY-046 group was elevated slightly, but not significantly, compared to that of the control group. The ratio TXB₂/6-keto PGF₁ in the liver tissue was lower in the OKY-046 group than in the control group, and significant differences were found between the two groups in the water content of the liver and the mitochondrial score as examined by transmission electron microscopy. Thus, it was observed that an improvement in the balance of TXA₂ and PGI₂ associated with OKY-046 administration protected the cellular structure of the mitochondria in the rat liver.     

The fundamental factor determining the clinical prognosis of prolonged jaundice—Relation to the arterial ketone body ratio

Factors related to the prognosis of patients with hyperbilirubinemia were investigated in 16 highly jaundiced patients. Patients who died within 3 weeks showed a deterioration of the hepatic energy status, measured by the arterial ketone body ratio, but patients who did not die within 3 weeks after the measurement of the ketone body ratio had a ratio within the normal range, despite high total bilirubin levels (18 mg/0.1 L). C3, C4 and CH50 in the former were also significantly lower than those in the latter. However, endotoxin and high fever occurred to the same extent, in the both groups. Thus, hepatic energy balance is the most pertinent factor related to prognosis, and is concerned with both the hepatocyte and reticuloendothelial systems. On the other hand, infection or endotoxin, when the energy balance is disturbed, becomes an aggravating but not a fundamental factor.     

中长链脂肪乳对阻塞性黄疸病人围手术期肝功能和免疫功能的影响

２１例阻塞性黄疸病人被分为长链脂肪乳（ＬＣＴ）输注组和中长链脂肪乳（ＭＣＴ／ＬＣＴ）输注组。术前１天，术后１、３天和７天抽血检测天冬氨酸转氨酶（ＧＰＴ），总补体、补体Ｃ３、Ｃ４和ＳＩＬ－２Ｒ。结果显示：ＭＣＴ／ＬＣＴ组ＧＰＴ术后呈下降趋势，而ＬＣＴ组变化不显著；ＭＣＴ／ＬＣＴ组补体较ＬＣＴ组增加明显；两组病人术后ＳＩＬ－２Ｒ均升高，ＬＣＴ组升高更明显。表明中长链脂肪乳有保护和改善肝功能、免疫功能的作用     

Secondary gallbladder hydatidosis and nonfragmanted germinative membrane sourced obstructive jaundice caused by intrabiliary ruptured hepatic hydatid cyst (a case report): two rare complication of the intrabiliary ruptured hepatic hydatid cyst

Intrabiliary rupture is the most frequently seen complication of the hepatic hydatid cysts. Obstructive jaundice can be seen as a complication of the intrabiliary ruptured hepatic hydatid cysts due to the migrated cystic content into bile ducts. In this study, we present two rare complications seen in a patient who has intrabiliary ruptured hepatic hydatid cyst. Obstructive jaundice and secondary gallbladder hydatidosis depending on to the intrabiliary ruptured hepatic hydatid cyst in a 58-year-old man patient were diagnosed and treated. A large choledochal nonfragmanted germinative membran was found in the choledochus as the reason of biliary obstruction. Hepatic hydatid cyst is a world-wide disease. Intrabiliary rupture must be kept in mind in the patients who has hepatic hydatid cyst and biliary tract problems.     

加味大柴胡汤对阻塞性黄疸大鼠TLR4表达的影响

目的 探讨加味大柴胡汤在临床上辅助治疗阻塞性黄疸的理论机制.方法 制作阻塞性黄疸大鼠模型,分为7、14、21 d共3个时段,每个时段分3组,即:(1)假手术+生理盐水组(SO+NS组);(2)胆总管结扎+生理盐水组(BDL+NS组);(3)胆总管结扎+加味大柴胡汤组(BDL+MMDB组).每组6只SPF级SD大鼠,在各时段取大鼠肝组织及下腔静脉血,检测AST、ALB及TB;用RT-PCR检测,TLR4 mRNA的表达.结果 胆总管结扎7 d时,BDL+MMDB组与BDL+Ns组外周血TB、AST比SO组均上升,且后者明显.BDL+MMDB组与SO组及BDL+NS组相比,差异均有统计学意义(P<0.01).胆总管结扎14、21 d时,BDL+MMDB组与BDL+Ns组外周血TB、AST持续升高,且后者增高更明显.BDL+MMDB组与SO组及BDL+Ns组相比,差异均有统计学意义(P<0.01).正常肝组织中TLR4mRNA的表达不明显.胆总管结扎7、14、21 d时,BDL+MMDB组与BDL+Ns组TLR4 mRNA表达持续显著增加,且后者增加更明显.同时段中BDL+MMDB组与S0组相比、BDL+MMDB组与BDL+NS组相比,差异均有统计学意义(P<0.01).结论 加味大柴胡汤可以通过降低肝组织中TLR4,从而减轻内毒素所致肝脏的损伤.     

Functional assessment of liver for extended hepatic resection in patients with obstructive jaundice

We studied whether the maximal excretion rate of indocyanine green (ICG Bmax) and the 2-h ICG excretion rate in the bile could be used to estimate the separate functions of the left and right liver in 20 patients with biliary obstruction at the hepatic hilus. ICG Bmax was measured after biliary decompression. An operative procedure that preserved the side of the liver with a positive ICG Bmax value was selected. Eighteen patients tolerated extensive hepatic resection, such as right trisegmentectomy, extended right lobectomy, extended left lobectomy, or left lobectomy. However, prolonged jaundice was observed postoperatively in five of the six patients with 2-h excretion rates of less than 25% and who had undergone extended right lobectomy. One patient on whom extended right lobectomy had been performed died because of postoperative hepatic failure. His ICG Bmax value was +0.6 and his 2-h excretion rate was very low (3%). ICG Bmax and the 2-h excretion rate in the bile reflected well the degree of separate hepatic dysfunction in patients with biliary obstruction at the hepatic confluence. If ICG Bmax value is more than +1.0, resection of more than two segments, such as trisegmentectomy or extended hepatic lobectomy, may be tolerated, and if the ICG Bmax value is positive, hepatic lobectomy may be tolerated. ICG Bmax and 2-h excretion rate in bile are useful indicators of hepatic functional reserve of the separate lobes of the liver in patients with biliary obstruction at the hepatic hilus.     

Significance of altered bilirubin subfractions in bile following hepatectomy

BACKGROUND: Hyperbilirubinemia occurs as a sign of hepatic failure after hepatectomy. The pathogenesis of this event has not been elucidated. In cases complicated with postoperative infection, hyperbilirubinemia is prolonged and the composition of bilirubin subfractions in bile changes markedly. A reduction in the proportion of bilirubin diglucuronide (BDG) is especially notable. This study was aimed at clarifying the relationship between infection and biliary bilirubin subfractions, with a view to shedding light on the mechanisms of change. MATERIALS AND METHODS: Rats underwent either laparotomy or partial hepatectomy (Hx). Daily intraperitoneal injections of lipopolysaccharide (LPS) or natural saline were administered for 3 days following surgery. Total serum bilirubin levels and proportions of BDG and bilirubin in bile were measured until Day 5 after the operation. Hepatic levels of UDP-glucuronic acid (UDP-GA), UDP-glucose, NAD(+), and total adenine nucleotides (TAN) and activities of UDP-glucuronyltransferase (UDP-GT) and UDP-glucose dehydrogenase were measured on Day 4. RESULTS: In hepatectomized rats treated with LPS (Hx-LPS), total serum bilirubin levels were elevated, biliary bilirubin levels were decreased, and the proportion of biliary BDG was decreased on Day 4. Hepatic levels of UDP-GA, NAD(+), and TAN and activities of UDP-GT in Hx-LPS were reduced. In all groups tested, a significant linear correlation between BDG and UDP-GA and between UDP-GA and NAD(+) was found. CONCLUSIONS: The reduction of UDP-GA might be effected by reduced hepatic levels of NAD(+) in endotoxemia following hepatectomy. It is therefore suggested that alterations in biliary bilirubin subfractions might accurately reflect the energy state of the remnant liver following hepatectomy.     

Cardiac and hepatic metabolism in spontaneously hypertensive rats following acute blood loss

Seven spontaneously hypertensive rats (SHRs) and eight Wistar-St rats were used to assess the influence of hemorrhage on myocardial and hepatic energy metabolism. They received 2% halothane and pancuronium, 0.3mg·kg^–1, during preparation. After discontinuation of halothane, blood (2ml·100g body weight^–1) was gradually withdrawn over a 5min period from a femoral artery. Thirty min after induction of hemorrhage, the heart and liver were removed and myocardial and hepatic metabolites (ATP, lactate, pyruvate and glycogen) were measured by the enzymatic methods. Acidosis and decreased hematocrit were noted in the both groups after hemorrhage. Mean arterial pressure (MAP) in SHR was significantly higher than that in Wistar rat before hemorrhage. However, there were no significant differences in MAP and heart rate between the two groups after hemorrhage. Although there were no significant differences in cardiac metabolites, a significant decrease of hepatic ATP and an increase of hepatic lactate/pyruvate ratio were found in SHR when compared with Wistar rat. These results suggest that human hypertensive disease may run a high risk in connection with acute hemorrhage.(Kashimoto S, Nonaka A, Nakamura T, et al: Cardiac and hepatic metabolism in spontaneously hypertensive rats following acute blood loss. J Anesth 6: 284–288, 1992)     

Influence of hepatic dysfunction on cyclosporine metabolism in the pig

Cyclosporine (CyA) is eliminated from the body via biliary excretion at a rate directly proportional to bile production and the functional status of the liver. Previous reports demonstrated that disturbances in the hepatic excretory function with a rise in the plasma bilirubin level are positively correlated with high blood concentrations of CyA and CyA plus metabolites (CyA + M). Less information is available about the blood concentrations of the CyA parental substance or CyA metabolites in the case of liver dysfunction when there was no elevation of serum bilirubin content. To answer this question, we compared the pharmacokinetic profile of CyA in a cholestatic and in a ischemic model in pigs. Our results show that in pigs receiving a single dose of CyA after liver ischemia, the blood concentrations of CyA and CyA + M are significantly increased independently of the serum bilirubin concentration, probably through a slow down of CyA metabolism by impairment of cytochrome P450 III A.     

Percutaneous aspiration and sclerotherapy of a giant simple hepatic cyst causing obstructive jaundice: A case report and review of literature

BACKGROUNDGiant simple hepatic cysts causing intrahepatic duct dilatation and obstructive jaundice are uncommon. A variety of measures with different clinical efficacies and invasiveness have been developed. Nonsurgical management, such as percutaneous aspiration and sclerotherapy, is often applied. CASE SUMMARYThe case is a 39-year-old female with a 5-mo history of cutaneous and scleral icterus, loss of appetite, and dark urine. Lab tests showed jaundice and liver function abnormalities. Imaging revealed a giant simple hepatic cyst obstructing the intrahepatic bile ducts. A combination of percutaneous catheter aspiration and lauromacrogol sclerotherapy was successfully performed and the effects were satisfactory with the size of cyst decreasing from 13.7 cm × 13.1 cm to 3.0 cm × 3.0 cm. Further literature review presented the challenges of managing giant simple hepatic cysts that cause obstructive jaundice and compared the safety and efficacy of a combination of percutaneous aspiration and lauromacrogol sclerotherapy with other management strategies.CONCLUSIONGiant simple hepatic cysts can cause obstructive jaundice, and a combination of percutaneous catheter aspiration and sclerotherapy with lauromacrogol are suggested to treat such cases.     

Decrease in hepatic mitochondrial redox state by massive infusion of citrate-phosphate-dextrose solution in jaundiced rabbits

To clarify the mechanism of metabolic derangement by massive blood transfusion to the damaged liver, the changes in the hepatic mitochondrial redox state, as reflected in arterial ketone body ratio (acetoacetate/3-hydroxybutyrate), were studied in jaundiced rabbits by infusion of massive citrate-phosphate-dextrose (CPD) solution. The jaundiced rabbits received common bile duct ligation (BDL group), and the sham group had a simple exploration of the bile duct. CPD solution was infused for 3 h at a rate of 9 ml/kg/h in each group. As metabolic parameters, blood gas, pyruvate, lactate, citrate and ketone body ratio were analyzed in the arterial blood. During the course, arterial ketone body ratio decreased significantly (p less than 0.01) in the BDL group with severe metabolic acidosis, while it was maintained at high value in the sham group with metabolic alkalosis. Organic acids were more highly accumulated in the BDL group than in the sham group. These results suggested a hepatodepressant effect of massive blood transfusion, especially in the damaged liver.     

法舒地尔对阻塞性黄疸大鼠肝缺血再灌注损伤的影响

目的 探讨法舒地尔对阻塞性黄疸大鼠肝缺血再灌注损伤的影响.方法 成熟SD大鼠160只随机分成实验组(A组)及对照组(B组)两大组,两组再分别分为4个亚组,分别为假手术组(A1、B1组)、阻塞性黄疸组(A2、B2组)、肝缺血再灌注组(A3、B3组)及阻塞性黄疸+肝缺血再灌注组(A4、B4组).A2、B2组采用双重结扎切断胆总管的方法建立模型,A3、B3组采用阻断肝门部血管30 min后再灌注的方法建立模型.A4、B4组于建立阻塞性黄疸模型1周后再次建立缺血再灌注模型.A组于缺血前30 min腹腔内注射法舒地尔10 mg/kg,B组对应注射等量生理盐水.两组分别于再灌注0h、1h、2h、6h取材,检测血清肝功能改变及血清内皮素1水平.采用SPSS软件对重复测量结果进行统计分析,光镜下观察肝脏病理学改变.结果 实验组各时点血清转氨酶水平、血清内皮素1水平均显著低于对照组(P＜0.05),实验组各时点光镜下肝脏病理组织学损伤也较对照组明显减轻.结论 法舒地尔对阻塞性黄疸大鼠的肝缺血再灌注损伤具有保护作用.     

精氨酸对梗阻性黄疸大鼠肝损伤的保护作用及其对肝细胞凋亡的影响

目的 探讨梗阻性黄疸时精氨酸是否对肝脏具有保护作用及其对肝细胞凋亡的影响.方法 Wistar大鼠42只随机分为3组:A组为假手术组、B组为梗阻性黄疸组、C组为精氨酸治疗组;B组和C组采取双重结扎大鼠胆总管制作梗阻性黄疸模型,C组术后第1天开始每天腹腔注射精氨酸500 mg/(kg·d),分别于术后第7天和第14天取材,采集鼠血清检测TBIL、DBIL、ALT、AST;大鼠肝脏组织进行HE染色切片观察组织形态,电镜观察胞内形态并对组织切片应用Bax、Bcl-2试剂盒行免疫组化染色.结果 与A组大鼠相比,B组大鼠血清胆红素和转氨酶明显增高.肝细胞损伤不断加重并出现显著凋亡改变,随着胆总管结扎时间的延长而更加明显.应用精氨酸治疗的C组大鼠,其肝功能和肝脏组织病理学改变较B组轻.B组和C组大鼠肝组织中Bax、Bcl-2蛋白表达均随时间而增多,但B组Bax表达增多较明显,而C组Bcl-2蛋白表达增多较明显.结论 精氨酸对梗阻性黄疸大鼠肝脏有保护作用,可能是通过上调肝脏组织Bcl-2蛋白表达,下调肝脏组织Bax蛋白的表达减少细胞凋亡来实现的.     

Prognosis of the posttraumatic vegetative state

Summary Of 1373 patients who, following severe brain injury had been comatose for over 6 hours, 140 (10%) were in a vegetative state one month later. Fifty-nine regained consciousness but none of those aged over 40 became independent during the first year. Of those still in a vegetative state after 3 months, none became independent irrespective of age. Of all patients comatose for over 6 hours after severe brain injury, only 1% was in a vegetative state after one year.Certain scores for features such as age, pupillary reactions, eyeopening and eye movements indicate either a favourable prognosis, a fatal outcome or irreversible coma. It is only in some 10% of all patients in coma or in a vegetative state during the first two weeks after the accident that it is possible to predict with a high degree of probability (p > 0.95), an unfavourable outcome (death or irreversible coma) within one year. At no time after the onset of coma is it possible to predict or distinguish, with a fair degree of probability (e.g. p > 0.80), those patients who will remain in a vegetative state from those who will die.     

胆汁经口回输在恶性梗阻性黄疸患者围手术期的应用

目的 探讨胆汁经口回输在中、重度低位恶性梗阻性黄疸患者围手术期的临床应用效果。方法回顾性分析2014年1月至2021年12月哈尔滨医科大学附属第一医院普外科行胰十二指肠切除术治疗的224例中、重度低位恶性梗阻性黄疸患者的临床资料。其中150例胰十二指肠切除术前行PTCD减黄：70例行胆汁回输（PTCD+胆汁回输组）,80例胆汁不回输（PTCD组）;其余74例术前未行PTCD减黄（直接手术组）。结果 PTCD+胆汁回输组较PTCD组和直接手术组术后住院时间[（17.2±5.7）d vs (21.5±8.3)d vs (22.8±9.8)d]、排气时间[（47.5±11.6）h vs (54.9±17.0)h vs (56.5±15.9)h]及中心静脉拔管时间[（9.9±2.8）d vs (12.0±3.6)d vs (14.3±6.4)d]短（P<0.05）,且术后胃排空延迟的发生率也显著低于PTCD组和直接手术组[4.28%(3/70) vs 12.50%(10/80) vs 12.16%(9/74),P<0.05]。胰十二指肠切除术后第10天,PTCD+胆汁回输组C反应蛋...