- 胆结石专业英语
- 发布于 2011-08-29 22:41 来源：田明国医生
Learning objectives学习目的:掌握以下内容：
1 classifications of gallstones 胆石分类
2 what is asymptomatic gallstones and its management?无症状胆石的概念及其处理宁夏回族自治区人民医院肝胆外科田明国
3 Complications of gallstones 胆囊结石并发症有哪些？
4 features of symptomatic gallstones（biliary colic）症状性胆囊结石的特征（胆绞痛）
5 diagnosis of gallstones 胆囊结石诊断
6 surgical treatment of symptomatic gallstones 症状性胆囊结石的外科治疗
7 indications for CBD exploration during cholecystectomy(胆囊切除时胆总管探查指征)
8 clinical manifestations of acute cholecystitis(AC)急性胆囊炎临床表现
9 diagnosis of AC 急性胆囊炎诊断
10 Treatment of AC 急性胆囊炎的治疗
Gallstone（胆石、胆囊结石） disease has plagued mankind for over 2000 years. The first recognized case of cholelithiasis was reported 1500 years ago. The incidence of biliary stone disease varies widely throughout the world. Approximately 10% of the population in the US and 7%-10% of the population in China has cholelithiasis. The incidence of gallstones in Africa is quite low, on the contrary, it is the highest in some primitive Indians in the US.
一、Classification of gallstones
The scheme for classifying gallstone disease is based on stone location and composition. The stones may be found either in the gallbladder, extrahepatic biliary tract（肝外胆管）, or within the intrahepatic ductal system（肝内胆管系统）. In western countries, most stones are exclusively in the gallbladder, and up to 15% of patients will have common bile duct stones most of which are actually gallbladder stones that pass into the CBD（胆总管）, either through the cystic duct or, occasionally, through a biliary fistula（胆瘘）. Intrahepatic stones are often primary and occur predominantly in parts of Aisa. In China, the primary common bile duct or intrahepatic duct stones were very common in the past especially in rural areas. It has been reduced greatly in the past 30 years because of improvement of sanitation(卫生) and nutrition（营养）.According to stone composition,gallstones are grouped into cholesterol（胆固醇） and pigment 色素(bilirubin胆红素) types, although stones are rarely composed of just one of these elements(pure), and mixed type.
1．Cholesterol Gallstones Cholesterol gallstones are 70% cholesterol or more. The two types of cholesterol stones are the pure cholesterol stone and the mixed cholesterol stone.The pure stone is almost 100% cholesterol. It is characteristically single, ovoid or spherical in shape（卵形或球形）, and 0.5 to 4 cm in diameter. On cut section, it has a white to slightly yellow color, with a more pigmented center, and a radiating crystalline（放射状晶体） pattern. The mixed cholesterol stone, usually 0.1 to 2 cm in diameter, contains variable amounts of pigment but is always more than 70% cholesterol by weight. These stones are usually multiple and may have a mulberry桑椹状 (bumpy spheroid) or faceted shape（多面体状）. Dark brown pigment is often found in the center of such stones and in ringlike zones（环状）.
2．Pigment Stones Pigment stones may be black or brown. Except that both types of stones are dark, because of the presence of calcium bilirubinate（胆红素钙）, they have little in common and should be considered as two separate diseases. Both types of pigment stones contain less than 20% cholesterol. Stones containing between 20% to 70% cholesterol are rare (i.e., stones are either cholesterol or pigment types on this basis).
Black Stones. These are usually less than 1 cm in diameter, jet black, brittle. They are formed by the supersaturation（过饱和） of calcium salts of bilirubin（胆红素钙盐）, carbonate（碳酸盐）, and phosphate（磷酸盐）, most often secondary to hemolysis（溶血）. They almost always form in the gallbladder.
Brown Stones. These are usually small stones, less than 1 cm in diameter. They are brown or brownish yellow and are soft and often deformable or mushy（不成形，泥状）. They develop secondary to bacterial contamination of the biliary tract, caused by bile stasis（胆汁淤积）, and as such may form either in the bile ducts or gallbladder. They are largely composed of bacterial cell bodies and precipitated calcium bilirubinate. Brown stones contain calcium palmitate（棕榈酸钙） derived from the bacterial cell wall.
3．Mixed stones. These are usually of various shapes and colours with different composition including cholesterol, pigment, calcium salts and other materials. Most can be shown under X-ray because of containing calcium salts. On cut section, it is usually laminated 薄层状or radiating deep inside and laminated on the outer parts.
二、Pathogenesis(发生机理)
The Three Stages of Cholesterol Gallstone Formation: Supersaturation（过饱和）, Accelerated Crystallization（加速结晶）, and Stone Formation from Crystals（晶体形成结石） Supersaturation is almost always caused by cholesterol hypersecretion rather than by a reduced secretion of phospholipid磷脂 or bile salts胆盐. Multiple mechanisms produce cholesterol hypersecretion, and many of these are related to known risk factors for cholesterol stone formation including age, obesity肥胖, female gender女性, high calorie diet and genetics.
三、NATURAL HISTORY OF GALLSTONES胆石自然病程
Understanding the natural history of cholelithiasis is central to the rational management(合理治疗) of patients with gallstones. Gallstone disease may be divided into three clinical stages: asymptomatic gallstones, symptomatic gallstones, and complicated gallstone disease. When stones first form, they are asymptomatic, and most patients remain in this clinical stage throughout life. The stones do not obstruct the opening into the cystic duct, and the gallbladder is able to fill and empty; if the gallbladder does become obstructed, this may not cause pain. For unknown reasons, some cases of asymptomatic disease progress to the symptomatic stage, in which pain, biliary colic(胆绞痛), develops. Pain is caused when the gallbladder contracts against an obstructing gallstone lodged at its outlet, at or in the cystic duct. Disease in the symptomatic stage may then progress to the complicated stage of cholelithiasis, in which complications develop in the gallbladder or bile ducts. The main complication in the gallbladder is acute cholecystitis(急性胆囊炎), an inflammation of the gallbladder wall. Acute cholecystitis if untreated may resolve or result in gallbladder perforation(穿孔), with resultant abscess(脓肿), fistula(瘘管), or generalized peritonitis(弥漫性腹膜炎) . If a fistula forms, stones may enter the gastrointestinal tract. When the stones are large and enter the small intestine via a cholecystoduodenal(胆囊十二指肠的) fistula, they may lodge in the ileum (回肠)and produce small-bowel obstruction, a condition called gallstone ileus(胆石性肠梗阻). The presence of gallstones in the bile ducts is termed choledocholithiasis(胆总管结石). The stones usually originate in the gallbladder. They may pass asymptomatically from the bile duct into the duodenum, especially if they are less than 3 mm in diameter. They may obstruct the biliary tree and cause biliary colic or jaundice, usually intermittent or incomplete jaundice. Choledocholithiasis may also lead to acute cholangitis(急性胆管炎), also called acute suppurative cholangitis(急性化脓性胆管炎), a severe and life-threatening bacterial inflammation that affects the whole biliary system. Repeated bouts of cholangitis may lead to bile duct strictures(狭窄), abscesses, and eventually destruction of the liver, a condition called secondary biliary cirrhosis(继发性胆汁性肝硬化). Acute gallstone pancreatitis(胰腺炎) is another severe complication of choledocholithiasis. It develops when stones obstruct the free flow of pancreatic juice; usually, they obstruct the common channel(共同通路) formed by the union of the bile and pancreatic ducts close to their entry into the duodenum.
四、ASYMPTOMATIC GALLSTONES无症状性胆囊结石
The diagnosis of asymptomatic stones is incidental. Fifteen percent of stones are radioopaque(放射不透光) and may be seen on abdominal radiographs or even chest radiographs obtained to evaluate nonbiliary symptoms. Stones may also be detected by computed tomography (CT), although this is not a sensitive technique, or when ultrasonography of the upper abdomen is performed for nonbiliary symptoms非胆道症状. Asymptomatic gallstones are found occasionally during “pelvic”盆腔 ultrasonography in women. Gallstones may also be discovered in asymptomatic patients during abdominal surgery for unrelated conditions. Patients with abdominal symptoms may still have asymptomatic gallstones. Classic studies have demonstrated that dyspeptic(消化不良的) symptoms, such as nausea(恶心), bloating(饱胀) , eructation(打嗝), and flatulence(胀气), are equally common in all persons of the same age, whether or not gallstones are present. Nor can symptoms in the lower bowel in the absence of pain be attributed to gallstones.
Several studies have followed asymptomatic patients for many years . Between 20% and 30% of patients become symptomatic within 20 years. In very few patients do complications develop before a period without symptoms, so prophylactic预防性cholecystectomy is not indicated to prevent sudden, unexpected complications in persons with asymptomatic stones. Death resulting from a complication arising in a previously asymptomatic patient is extremely rare.
Cholecystectomy during the asymptomatic stage is indicated in a few uncommon situations. Porcelain gallbladder, a rare, premalignant condition in which the wall of the gallbladder becomes calcified, is an absolute indication for cholecystectomy. Malignant transformation occurs in about 25% of untreated patients . Patients with gallstones larger than 3 cm may also be at increased risk for cancer. Patients who have a family history of gallbladder cancer sometimes request ultrasonographic examinations, and when stones are found, cholecystectomy is a reasonable choice, often partly for psychological reasons. To date, no screening program is available for those who may be at higher risk for genetic reasons. Gallstone disease in children is a relative indication for cholecystectomy. The management of gallstones discovered at laparotomy is controversial.
五、SYMPTOMATIC GALLSTONES症状性胆囊结石
The diagnosis of symptomatic gallstones depends on the presence of characteristic symptoms and the demonstration of stones on diagnostic imaging. The chief symptom is biliary colic胆绞痛, which develops when pressure in the gallbladder is increased by contraction of the gallbladder against an obstructing stone. The pain, which is transmitted传导 along visceral nerves内脏神经 and is not associated with peritoneal signs腹膜刺激征, has typical features, but in many patients, biliary colic has atypical features . Four traits are characteristic of typical biliary colic. It is episodic(间歇性); patients suffer discrete attacks of pain, between which they feel well. It is severe(严重性), bringing the patients to care quickly; the pain is often so severe that patients cry or compare the pain to labor. It is located in the epigastrium or right upper quadrant上腹或右上腹, and it comes on in the middle of the night or after a meal, often a fatty or heavy meal.. Other common features of the pain are that it is steady, increases in severity during 30 minutes and lasts 2 to 4 hours, often radiates to the back, is associated with nausea and vomiting, and may be followed by an episode of diarrhea. Patients usually walk or roll around in an attempt to relieve the pain.
Atypical pain is common. Sometimes the pain is continuous rather than episodic, lasting days or more. This may happen when a stone is impacted嵌顿 in the cystic duct. The pain may be located predominantly in the back or the left upper or right lower quadrant. Not all attacks are necessarily severe, and some patients do not relate their pain to meals or time of day. There is no formula固定形式 to determine when pain is arising from stones. The less typical the pain, the more carefully the clinician should search for another cause, even in the presence of stones―causes such as renal colic(肾绞痛), peptic ulcer(消化性溃疡) disease, hiatal hernia(裂孔疝), esophageal spasm(食道痉挛), abdominal tumor, abdominal wall hernia, liver disease, and disease of the small and large intestine, including irritable bowel(肠激惹) disease. Diaphragmatic(膈肌的) problems and extraabdominal diagnoses, such as pleuritic(胸膜) and myocardial(心肌) pain, must also be considered. Treatment of atypical biliary colic is appropriate when other causes of pain have been eliminated.
Because biliary colic is a mechanically induced pain transmitted along visceral nerves内脏神经, an attack produces few abdominal findings. Mild right upper quadrant tenderness(压痛) may be present.
六、Diagnosis of gallstones
1．Abdominal radiography腹部放射学检查. Supine仰卧 and upright abdominal radiographs 腹部放射片are of limited value in identifying鉴别 gallstones. Visualization显示 of gallstones on plain abdominal radiographs腹部平片 is possible only in 15% of patients whose stones are grossly calcified明显钙化. Nonetheless, gallstones are so common that they are the most frequent cause of discrete right upper quadrant calcifications. Gallstones in this area may be confused with renal calculi肾结石, contrast material显影剂 or calculi in diverticuli 息室内钙化of the hepatic flexure of the colon结肠肝区, vascular calcifications血管钙化, or other problems such as granulomas肉芽肿 or hepatic cysts肝囊肿. This examination may be very helpful in eliminating other causes of acute abdominal pain.
2．Oral cholecystography口服胆囊造影 is an older test. A radioopaque dye放射显影剂, administered orally口服, is absorbed by the intestine肠道吸收, secreted by the liver肝脏分泌, and concentrated by the gallbladder胆囊浓缩. When the gallbladder is imaged 显像12 hours later, the stones appear as filling defects 充盈缺损. Another sign indicative of stones is nonvisualization不显示 of the gallbladder, provided the pills were taken and intestinal and hepatic function is normal. This indicates that the cystic duct is obstructed or that gallbladder wall inflammation has progressed to a point at which the gallbladder cannot concentrate the dye. Cholecystography is slightly less sensitive than ultrasonography (95% vs. 98%). Other disadvantages are that it entails radiation exposure蒙受放射 and requires patient compliance配合. Also, digestive, hepatic, and gallbladder function must be intact正常。Diagnostic imaging is used to confirm the presence of gallstones.
3． Abdominal ultrasonography is the standard diagnostic test. Stones are acoustically dense and return strong echoes（回声） to an ultrasonic transducer超声探头. They also prevent the passage of sound into the region of view behind the stone, thereby producing an acoustic shadow（声影） Echoes without shadows may be caused by gallbladder polyps（息肉）. A definitive sonographic diagnosis requires both echogenic structures and posterior acoustic shadows . The patient should be fasting for several hours so that gallbladder filling is maximal; a full gallbladder greatly facilitates the demonstration of these features. Sometimes, the stones are so dense that all sound is reflected from the tops of the stones, and they appear as inverted Us 反向U字rather than round objects. Usually, little or no associated gallbladder wall thickening is seen. The biliary ducts are assessed for evidence of dilatation（扩张） or choledocholithiasis（胆总管结石）.
4．Computed tomography CT scans are not a first-line test for the diagnosis of cholelithiasis. Obvious gallstones frequently are missed by routine CT, although they may be seen as incidental findings, if they are densely calcified（钙化）. In addition to failing to demonstrate calculi that might be seen more easily by ultrasonography or oral cholecystography, CT has the additional disadvantage, compared to cholecystosonography, of relying on ionizing radiation（离子放射） for images. Utilizing X-rays striking a series of sensitive detectors, images are created by computers, based on different sections and individual levels, and the entire body can be visualized. Although this test is not particularly sensitive for identifying gallstones, it does provide important information regarding the nature, extent, and location of biliary dilatation and masses in and around the biliary tract and pancreas. In general, this test provides more useful information than US when the concern is extrahepatic obstruction owing to causes other than choledocholithiasis. Limiting factors for CT scanning include patient exposure to ionizing radiation and cost.
七、Treatment of gallstones 胆囊结石治疗
Development of gallstone treatment: Over the centuries, the clinical management of gallstone disease has been influenced by our evolving understanding of the pathogenesis of gallstones. In the Middle Ages , it was not uncommon for the affluent aristocracy （贵族）suffering from biliary colic to be referred by the local alchemists to spas whose waters were rich in magnesium sulfate（硫酸镁）. Although perhaps not appreciated at the time, magnesium sulfate is a potent stimulant（有力的刺激物） of gallbladder contraction and emptying and help evacuate the gallbladder of small stones.. The treatment for symptomatic gallstone disease remained relatively primitive and ineffective until the late 1800s. As surgical techniques began to evolve, John Bobbs, an Indiana surgeon, and others attempted to perform cholecystolithotomy（胆囊造瘘取石术）, removing the stone from the gallbladder and leaving the organ in situ（器官原位保留）. While this proved to be effective in ameliorating (改善)acute symptoms, physicians were disappointed by the recurrence of symptoms in many of these patients. In 1882, Karl Langenbuch, a noted German surgeon, performed the first successful cholecystectomy（胆囊切除）. During the last 100 years, open cholecystectomy has remained the gold standard for the definitive management of patients with symptomatic cholelithiasis.
Dispite the efficacy and safety of cholecystectomy, physicians have long pursued and investigated other less invasive options, such as oral or contact dissolution（溶解） and ESWL（体外振波碎石）. However these methods are quite limited. The introduction and development of laparoscopic techniques（腹腔镜技术） have revolutionized the operative treatment of gallstone diseases. In many parts of the world, LC has become the preferred treatment for patients with symptomatic gallstone disease. The main advantage of this procedure has been its avoidance of a large incision through the skin and muscles of the right upper quadrant, leading to decreased hospital stay, convalescence（康复）, and postoperative pain. OC and LC alleviate缓解 the majority of symptoms in patients with biliary colic in 90 to 95 percent of cases.
Indications for common bile duct exploration during cholecystectomy are胆总管探查指征：1 preoperative jaundice or pancreatitis术前有黄疸和胰腺炎; 2 dilated bile duct and stones in it detected by ultrasound or CT超声或CT发现胆管扩张内有结石; 3 stones or ascrid or mass found by palpatation术中触诊发现胆管内结石、蛔虫或肿块; 4 pus, blood or muddy bile aspirated by puncture of CBD胆总管穿刺吸出脓液、血液或胆泥; 5 stone or obstruction shown by intraoperative cholangiography术中胆道造影发现结石或梗阻。
八、COMPLICATED GALLSTONE DISEASE 胆囊结石并发症
(一)、Acute Calculous Cholecystitis急性结石性胆囊炎
1 Etiology and pathology病因病理
Acute calculous cholecystitis（结石性胆囊炎） is an inflammatory complication of cholelithiasis. It is usually a sterile chemical inflammation（无菌化学性炎症）, but secondary bacterial inflammation may occur. The two conditions that seem to be necessary for inflammation to develop are an obstructed cystic duct（胆囊管梗阻） and altered bile chemistry. . With obstruction, the gallbladder becomes a secretory rather than an absorptive organ, and it becomes full and tense. Hyperemia（充血） and edema（水肿） of the gallbladder wall cause it to thicken and take on a reddish external aspect; pericholecystic fluid（胆囊旁积液） is often present. Gangrene（坏疽） may supervene（接着发生） when secondary contamination（感染） with putrefactive organisms（腐败菌） occurs. Perforation（穿孔） is more common under these circumstances. Emphysematous cholecystitis（气肿性胆囊炎） is another severe variant in which gas produced by gas-forming organisms accumulates （积聚）in the wall and lumen（腔） of the gallbladder. The gas is detected on images and at surgery.
2、Diagnosis
1）. Clinical manefastations:
An attack of acute cholecystitis begins as an attack of biliary colic―a mechanical problem that evolves into an inflammatory problem. As in biliary colic, the initial event in acute cholecystitis is obstruction of the cystic duct by an impacted（嵌顿的） gallstone. Although the resulting pain is similar in onset and character to the pain associated with biliary colic, it is unremitting（不间断的） and may persist for several days. In a limited number of cases, the cystic duct remains obstructed, and one of the complications of acute cholecystitis may develop. These include empyema（积脓）, gangrene（坏疽）, and contained or free perforation of the gallbladder with abscess formation.
The diagnosis of cholecystitis depends on the constellation（一群） of symptoms, signs, and characteristic findings on diagnostic imaging modalities. The pain of acute cholecystitis is similar to, but more severe than, the pain of biliary colic. The pain is typically in the right upper quadrant （右上腹）or epigastrium（上腹） and is unremitting持续的 in comparison with the time-limited pain of biliary colic. The inflammatory process炎症过程 progresses to affect the parietal peritoneum（壁层腹膜）, and patients become reluctant to move. In most patients, systemic complaints（主诉）, such as anorexia（厌食）, nausea（恶心）, vomiting（呕吐）, and chills, are also present. The signs of acute cholecystitis include the systemic manifestations of inflammation（全身炎症反应）, such as fever and tachycardia（心动过速）; rigors（寒战） are uncommon. Local inflammatory signs, including tenderness and guarding（压痛、肌卫）, and peritoneal signs（腹膜刺激征） are usually present in the right upper quadrant or more diffusely（广泛）. A mass, the inflamed gallbladder, is occasionally palpable（可触到的）, but guarding often prevents the appreciation of mass formation. Murphy's sign―inspiratory arrest（吸气暂停） during deep palpation of the right upper quadrant―is characteristic of acute cholecystitis. This is most informative when the acute inflammation has subsided（减退） and direct tenderness is absent. Severe jaundice（黄疸） is rare, but mild jaundice may be present―up to 6 mg/dL. Severe jaundice suggests the presence of common bile duct stones, cholangitis, or obstruction of the common hepatic duct by severe pericholecystic inflammation（胆囊旁炎症） resulting from impaction of a large stone in Hartmann's pouch（袋）, which mechanically obstructs the bile duct (Mirizzi's syndrome). Some patients, especially the elderly, may have acute cholecystitis with minimal signs and symptoms, such as anorexia without spoken complaints of pain. Many patients do not have fever. It is not uncommon for acute cholecystitis to coexist with choledocholithiasis or it’s complications (acute cholangitis and acute pancreatitis). The coexistence of two of these conditions often explains an unusual or atypical clinical presentation.
2）. Laboratory tests实验室检查
Laboratory abnormalities（异常） may include leukocytosis白细胞增多 (typically a white blood cell count of 12,000 to 15,000/mm3). However, many patients have a normal white blood cell count. A white cell count above 20,000 should suggest further complication of cholecystitis, such as gangrene, perforation, or cholangitis. Serum chemistries血清化学检查, including bilirubin胆红素 (usually < 3 mg/dL), alkaline phosphatase碱性磷酸酶, and amylase淀粉酶, also may be abnormal.
3）. Ultrasound超声
Diagnostic imaging 诊断性成像confirms the clinical impression of acute calculous cholecystitis. Ultrasonography（超声） is the most sensitive and specific test for diagnosing acute cholecystitis. Ultrasonographic findings include stones, thickening 增厚of the gallbladder wall ( 4 mm), and pericholecystic fluid胆囊周围积液. A sonographic Murphy's sign超声莫非征 has also been described (which in this case means direct tenderness over the gallbladder when it is compressed by the ultrasonic probe超声探头).
4）. Radionuclide cholescintigraphy（胆囊核素闪烁扫描）
Radionuclide cholescintigraphy occasionally is needed to provide additional information in cases that are not well defined by ultrasonography.. Concentration of the radionuclide（核素） in the bile by the liver allows the demonstration of bile flow from the liver into the common hepatic duct, filling（充盈） or nonfilling of the gallbladder, and emptying of the gallbladder and biliary tree into the duodenum. Because they depend on hepatic excretion of bile, these tests are not useful when the serum bilirubin exceeds 3 mg/dL. Nonfilling of the gallbladder after 4 hours of observation in the appropriate clinical setting is good evidence of acute cholecystitis. A completely normal test result is filling within 30 minutes.
5）. CT
Computed tomography occasionally is performed in evaluating the patient with abdominal pain and acute illness. CT may demonstrate evidence of acute cholecystitis, including gallbladder wall thickening, pericholecystic fluid and edema, gallstones, and air in the gallbladder or gallbladder wall (emphysematous cholecystitis), although it is less sensitive for these conditions than ultrasonography.
3 Treatment
1）.Conservative treatment
The initial management for patients with acute cholecystitis includes hospitalization（住院）, intravenous fluid resuscitation(静脉补液), and systemic antibiotics. The antibiotic regimen should be appropriate for typical bowel flora (gram-negative rods and anaerobes 革兰阴性杆菌和厌氧菌). Typical regimens are (a) a third-generation cephalosporin头孢菌素 with good anaerobic coverage, (b) a second-generation cephalosporin combined with metronidazole甲硝唑, and (c) an aminoglycoside氨基糖甙类 with metronidazole. Although enterococci 肠球菌are frequently cultured from the gallbladder in acute cholecystitis, it is not necessary to cover these organisms separately because they are rarely a solitary pathogen单独的病原体. In many cases, the inflammation is sterile无菌的; however, antibiotics have become standard because it is difficult to determine who has become secondarily infected.
2）. Definitive treatment彻底性治疗
Early and delayed cholecystectomy早期和延迟胆囊切除术
The definitive treatment of acute cholecystitis is cholecystectomy, but the timing of the procedure手术时机 is controversial争议. Early cholecystectomy is performed soon after the patient is admitted with the diagnosis of acute cholecystitis, usually the same day or the next day. Interval or delayed cholecystectomy is performed 2 to 3 months after nonoperative treatment of the acute attack. The interval is intended to allow the acute inflammation to settle. Early cholecystectomy has the advantage of resolving the illness in a shorter time frame. However, the laparoscopic approach must be used early in the course of the disease, while inflammation around the gallbladder is still minimal. This operation is best performed within 48 hours after the onset of symptoms and in the same fashion as for symptomatic gallstones. Open cholecystectomy is also an option in acute cholecystitis and can probably be performed safely somewhat later (up to 72 hours) after the onset of the illness. Perioperative antibiotics围手术期抗生素 are universally recommended.
Delayed cholecystectomy
When delayed cholecystectomy is selected, the acute attack is managed with intravenous fluids and antibiotics. The response to treatment must be assessed frequently, and assessment should include physical examination and monitoring of the patient's fever curve 体温曲线and laboratory values. If the patient's condition does not improve, then the treatment must be altered―to a different antibiotic regimen更换不同的抗生素, percutaneous cholecystostomy（经皮胆囊造瘘）, or operative cholecystectomy, or cholecystostomy, usually percutaneous cholecystostomy . In most patients, acute cholecystitis resolves with nonoperative treatment, and delayed cholecystectomy can be performed after 2 to 3 months, usually laparoscopically. This regimen is occasionally the only option for patients who present after 3 to 4 days of continuous symptoms of acute cholecystitis.
Cholecystostomy胆囊造瘘术
Cholecystostomy can be performed in patients with acute cholecystitis who are failing systemic therapy but are not candidates for cholecystectomy because of locally severe illness or concomitant medical problems. Cholecystostomy can be performed either operatively or percutaneously. The latter is less invasive and allows the gallbladder to be drained, which almost uniformly resolves the episode发作 of acute cholecystitis. However, the patient must be observed closely, and if improvement does not occur within 24 hours, laparotomy开腹手术 is indicated. Failure to improve after percutaneous cholecystostomy is usually caused by gangrene of the gallbladder or perforation. After the acute episode resolves, the patient can undergo either cholecystectomy or percutaneous stone extraction and removal of the cholecystostomy tube. The latter is an option in elderly or debilitated衰弱的 patients for whom a general anesthetic全麻 is contraindicated禁忌.
