膽石症的臨床治療

Management of Biliary Calculus Diseases

膽石症雖然是一個古老疾病，但仍然是膽道疾病中最常見。近幾十年來，對膽石症形成機轉的了解雖有長足的進步，但對確實的過程仍不清楚。膽石症依其成份可分為膽固醇結石，棕色素結石和黑色素結石；其形成機轉各有不同。膽石依其存在位置可分為膽囊結石，總膽管結石和肝內結石；3種結石疾病可獨立存在或合併存在。膽囊結石症的發生率並不低，但大多無症狀。對無症狀膽囊結石之處置，密切觀察是一合理的治療；反之，對有症狀或複雜性結石，則必需給予切除。腹腔鏡膽囊切除術是目前的首要選擇，而膽道傷害是其主要合併症。總膽管結石可造成急性膽囊炎，急性膽石性胰臟炎，兩者皆必需迅速治療。膽道引流和膽石清除是治療急性膽道炎的重要步驟。膽道引流可經內視鏡膽道支架引流和經皮穿肝膽道引流。內視鏡膽道乳頭切開術合併取石網截石術，是截取總膽管結石的首要選擇。經皮穿肝膽道鏡截石術和外科總膽管切開截石術，是另外的選擇。對於急性嚴重性膽石性胰臟炎，早期施予內視鏡膽道乳頭切開術以取出阻塞結石，可降低胰臟炎的合併症，則是公認有效的方法。肝內結石症在東方國家比較盛行，可造成反復性的膽道炎，肝膿瘍和肝硬化。膽道狹窄和膽道感染是肝內結石形成的重要因子。外科手術切除加上手術後膽道鏡截石術，是治療的首要方法。但對於不適合或不願意手術的病患，經皮穿肝膽道鏡截石術是另一選擇。總之，膽石症的臨床表徵是極多樣化的，唯有在肝膽外科醫師，放射科醫師和內視鏡醫師充分的合作下，以多方面的考量治療，才能很成功完美的治療膽石症。

Gallstone diseases are old disease entities, it yet remains the most prevalent disease affecting the biliary system. Although there have been some major advances in the understanding of the pathogenesis of gallstone formation, the detailed mechanism is still unclear. Three types of gallstones are defined, including cholesterol, brown pigment and black pigment stones. They also differ from each other concerning their lithogenic mechanism. According to the location of gallstones, biliary calculus diseases can be classified as cholelithiasis, choledocholithiasis and hepatolithiasis. They can exist alone or in combination. Cholelithiasis is a high prevalence disease. But most of the patients are asymptomatic and watchful observation for these patients is a reasonable strategy. Otherwise, symptomatic and complicated cholelithiasis needs management. Laparoscopic cholecystectomy is the gold standard of treatment and biliary injury is the major morbidity. Choledocholithiasis can cause complications of acute cholangitis, acute biliary pancreatitis and should be treated as soon as possible. Biliary decompression and stone removal are the major steps in treating acute cholangitis. Biliary decompression can be achieved by endoscopic biliary stenting or percutaneous biliary drainage. Endoscopic sphincterotomy is the procedure of choice for stone removal. Percutaneous stone extraction or surgical choledocholithotomy are the other alternatives. Early endoseopic sphincterotomy to remove the impacted stone is a well accepted management for severe acute biliary pancreatitis. This management can reduce biliary morbidity, like biliary sepsis. Hepatolithiasis is a high prevalence disease in Asian countries and can cause cholangitis, liver abscess and secondary biliary cirrhosis. Biliary stricture and biliary infection are the major contributory factors for hepatolithiasis formation. Surgical resection with postoperative cholangioscopy stone removal via the T tube fistula is the major treatment. Percutaneous transhepatic cholangioscopic stone removal is an alternative for patients who are unsuitable for or unwilling for surgical procedures. Gallstone diseases have multiple clinical pictures. The successful management requires a multidisciplinary approach under the close cooperation of surgeons, radiologists and endoscopists.