肝癌 Open Access
Copyright ©The Author(s) 2003. Published by Baishideng Publishing Group Inc. All rights reserved.
世界华人消化杂志. 2003-11-15; 11(11): 1686-1689
在线出版日期: 2003-11-15. doi: 10.11569/wcjd.v11.i11.1686
HCC合并阻塞性黄疸ERCP164例
龚彪, 潘亚敏, 沈丽, 胡冰, 吴萍, 王书智, 周岱云
龚彪, 潘亚敏, 沈丽, 胡冰, 吴萍, 王书智, 周岱云, 中国人民解放军第二军医大学东方肝胆外科医院内镜科 上海市 200433
龚彪, 男, 1965-06-16生, 上海市人, 汉族. 1987年第二军大学医疗系毕业. 科主任, 副教授. 主要从事消化及内镜专业.
通讯作者: 龚彪, 200433, 上海市, 中国人民解放军第二军医大学东方肝胆外科医院内镜科.
电话: 021-25070839 传真: 021-25070839
收稿日期: 2002-12-05
修回日期: 2002-12-20
接受日期: 2002-12-26
在线出版日期: 2003-11-15

目的

通过总结164例肝癌合并梗阻性黄疸患者的ERCP表现, 以探讨此种患者黄疸的病因和ERCP表现特征.

方法

常规ERCP检查, 术中视病情尽可能充分显影肝内胆管系统并常规行胆管引流, 术后大剂量抗生素预防性治疗. 胆道癌栓按Ueda分型, 肝门部及肝门周围恶性胆管狭窄参照Bismuth肝门部胆管癌分型的标准进行分型.

结果

本组患者中97.5%为胆道恶性梗阻, 其中67.7%为肝门及其周围胆管恶性狭窄、20.1%为胆管癌栓, 7.3%为胆管癌栓并肝门周围胆管恶性狭窄, 1.8%为肝门部淋巴结转移, 1.2%为腹膜后淋巴结转移. 2.4%为良性胆管病变, 其中胆总管结石和胆总管下端炎性狭窄各占1.2%. 110例表现为肝门周围胆管恶性狭窄者, III型和IV型占95.4%; 33例表现为胆管癌栓者, III型和IV型占90.9%. 6例胆管癌栓行乳头切开取出部份癌栓, 病理组织学检查为血栓性坏死组织、肿瘤可能1例, 纤维炎性坏死组织1例, 坏死组织及破碎结石1例, 坏死肿瘤组织2例, HCC-透明细胞型1例. 2例细胞刷细胞学检查均为胆管脱落上皮细胞.

结论

肝癌出现梗阻性黄疸绝大多为恶性梗阻, 并以肝门及肝门周围恶性胆管狭窄最多见, 其次为胆管癌栓, 部份患者可同时表现为恶性胆管狭窄和胆管癌栓, 肝门及腹膜后淋巴结转移引起黄疸少见. 其他少见原因为胆总管结石和胆总管下端炎性狭窄.

关键词: N/A
引文著录: 龚彪, 潘亚敏, 沈丽, 胡冰, 吴萍, 王书智, 周岱云. HCC合并阻塞性黄疸ERCP164例. 世界华人消化杂志 2003; 11(11): 1686-1689
ERCP characteristics of 164 patients of hepatocellular carcinoma with obstructive jaundice
Biao Gong, Ya-Min Pan, Li Shen, Bing Hu, Ping Wu, Shu-Zhi Wang, Dai-Yun Zhou
Biao Gong, Ya-Min Pan, Li Shen, Bing Hu, Ping Wu, Shu-Zhi Wang, Dai-Yun Zhou, Endoscopy Center, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai 200438, China
Corresponding author: Biao Gong, Endoscopy Center, Eastern Hepatobiliary Hospital, 225 Changhai Road, Shanghai 200438, China.
Received: December 5, 2002
Revised: December 20, 2002
Accepted: December 26, 2002
Published online: November 15, 2003

AIM

To study the etiology and the manifestation of ERCP in patients of obstructive jaundice with HCC.

METHODS

Routine ERCP examinations were performed in 164 cases of hepatocellular carcinoma complicated with obstructive jaundice. Intrahepatic bile duct system was filled as much as possible. Biliary drainage and antibiotics were given routinely after the procedures.

RESULTS

Overall, 97.5% presented as malignant bile duct obstruction and 2.4% was benign biliary tract lesion. Among malignant obstruction, malignant hepatic hilar and perihilar bile duct stricture were found in 67.7%, intraductal tumor thrombus in 20.1%, intraductal thrombus with malignant perihilar stricture in 7.3%, metastasis of hilar lymph nodes in 1.8%, retroperitoneal lymph node metastasis in 1.2%. While in benign lesions, choledolithiasis and distal common bile duct stenosis were found in 1.2%, respectively. In 110 cases presented as malignant perihilar stricture, 95.4% were diagnosed as type III and IV. In 33 cases of ductal thrombi, 90.9% were classified as type III and IV. In 6 cases who were performed papillatomy to remove tumour thrombi, histopathologically, one was diagnosed possibly tumour, one of debris stone and necrotic tissues respectively, two of necrotic tumor tissues and 1 of HCC respectively. Two cases of bile duct cytology were shown exfoliated epithelial cells.

CONCLUSION

HCCs with obstructive jaundice are mostly caused by malignant stricture, particularly perihilar and hilar strictures. Next are tumour thrombi in biliary tract. Malignant perihilar stricture and tumour thrombi could be both existed in some patients. Jaundice caused by hilar and retroperitoneal lymph node metastasis is rare. Not all obstructive jaundice in HCC patients is malignant, a very small part could be caused by common bile duct stone and distal duct stenosis.

Key Words: N/A
0 引言

肝细胞癌(HCC)是我国常见的恶性肿瘤之一[1]. HCC在确诊时大约19-44%已有黄疸[2,3], 最常见原因为合并有肝硬化或肝癌侵犯肝实质所致的肝细胞性黄疸. 但当肿瘤侵犯肝内外胆管或肝门部淋巴结肿大压迫胆管时即可出现梗阻性黄疸, 有时肿瘤坏死组织和血块脱落入胆道引起胆道阻塞也可出现梗阻性黄疸[1-4]. 一般认为并发黄疸的HCC患者预后极差, 患者常在短期内死亡. 目前国内外有关肝细胞肝癌合并阻塞性黄疸的报道多为零星手术或尸检报道[2-5], 未见大宗病例报道, 更未见大宗内镜逆行胰胆管造影检查的系列报道. 我们回顾性地总结了1998-01/2000-12期间, 164例肝癌合并梗阻性黄疸患者的ERCP表现.

1 材料和方法
1.1 材料

1998-01/2000-12因HCC并发梗阻性黄疸成功地进行了ERCP检查164例, 男134例, 女30例, 年龄31-76岁. 所有患者均有明确皮肤巩膜黄染、血清ALP和GGT明显增高、血胆红素水平明显增高并以直接胆红素增高为主、B超和/或CT或MRI和MRCP检查提示HCC并胆管扩张. HCC的诊断基于患者的临床表现、血AFP增高、B超或CT. 其中26例为手术病理证实为HCC, 64例曾行过肝动脉造影及栓塞治疗(TAE), TAE术次为1-8次, 平均TAE术次数3.8次; 15例曾行经皮经肝穿刺酒精注射治疗. 患者出现临床症状至ERCP检查的时间为15 d-49 mo, 其中有9例患者以梗阻性黄疸为首发症状. ERCP检查之前血清总胆红素水平为197 umol/L (51-660 umol/L), 血清直接胆红素水平143 umol/L (34-434 umol/L), ALP156-1523U/L, GGT371-2358 U/L; CT和B超提示57例合并有门静脉癌栓, 16例合并有肝静脉癌栓.

1.2 方法

用Olympus JF240、TJF200和TJF240型十二指肠镜进行常规ERCP检查. 术中根据B超和/或CT或MRCP检查的胆系病变情况, 充分显影肝外胆管, 视病情尽可能充分显影肝内胆管系统, 肝内胆管显影后根据病变情况、有无手术治疗的适应证等, 常规行鼻胆管或内置管或金属内支架引流术[6], 以达预防术后胆管炎、手术前减黄或姑息性减黄治疗目的, 术后常规大剂量抗生素预防性抗感染治疗. 胆管癌栓: 胆管显影见有膨胀性胆管内充盈缺损, 缺损较光滑, 近端胆管扩张呈软藤征; 按Ueda et al [7]胆道癌栓分型, I型-胆管癌栓位于胆管II级分支; II型-癌栓延伸至胆道I级分支; III型-癌栓延伸到肝总管(IIIa)或肿瘤脱落到肝总管腔内生长(IIIb); IV型-肿瘤碎片脱落在胆总管腔内造成堵塞. 肝门部及肝门周围恶性胆管狭窄: 表现为肝总管和/或左右肝管及其分支不规则狭窄, 狭窄近端胆管扩张, 多呈软藤征, 并参照Bismuth et al [8]肝门部胆管癌分型的标准进行分型, I型-肝总管狭窄但左右肝管汇合部未受累; II型-肝总管狭窄并左右肝管汇合部已受累; IIIa型-右肝管及总肝管狭窄, 左肝管未受累; IIIb型-肝总管及左肝管狭窄, 右肝管未受累; IV型-肝总管及左右肝管均狭窄. 肝门部及肝外胆管淋巴结转移压迫: 为肝门部或肝外胆管局限性外压性狭窄并近端胆管软藤样扩张. 胆总管结石为胆总管内游离性充盈缺损并近端胆管枯树枝征, 并取出结石证实. 胆总管下端炎性狭窄均为ERCP造影示胆总管下端规则性狭窄, 狭窄以上肝内外胆管扩张, 行十二指肠乳头切开术或胆管引流术后黄疸消退.

2 结果
2.1 HCC并梗阻性黄疸的原因

本组患者中97.6%为胆道恶性梗阻引起的阻塞性黄疸, 其中67.7%为肝门及其周围胆管恶性狭窄引起、20.1%为胆管癌栓、7.3%为胆管癌栓并肝门周围胆管恶性狭窄所致、1.8%为肝门部淋巴结转移所致、1.2%为腹膜后淋巴结转移所致. 本组中有2.4%为良性胆管病变引起的梗阻性黄疸, 其中2例为胆总管结石所致, 均经乳头切开取石证实为结石, 其中1例患者为HCC手术后9 mo出现黄疸; 另2例则为胆总管下端炎性狭窄, 乳头切开、胆管引流后黄疸消退.

2.2 HCC并恶性梗阻性黄疸的ERCP表现

164例临床诊断为HCC并阻塞性黄疸患者中有110例表现为肝门周围胆管恶性狭窄, 参照Bismuth肝门部胆管癌的分型标准, I型0例, II型5例, III型26例(IIIa15例, IIIb11例), IV型79例; 严重肝门部恶性狭窄(III型+IV型)105例, 占狭窄病例的95.5%, 这说明HCC侵犯肝门部胆管后引起的恶性胆管狭窄基本上均为重度广泛狭窄. 33例胆管癌栓, 按Ueda胆管癌栓的分型, I型0例, II型3例, III型21例(IIIa11例, IIIb10例), IV型9例. 12例表现有胆管癌栓并有肝门部或肝门周围胆管恶性狭窄. 5例为淋巴结转移所致梗阻性黄疸, 其中3例为肝门部淋巴结转移, 2例为腹膜后淋巴结转移.

2.3 胆道病理学检查

本组中有6例胆管癌栓行乳头切开取出部份癌栓, 癌栓多为肉色或灰白色, 易碎, 病理组织学检查为血栓性坏死组织、肿瘤可能1例, 纤维炎性坏死组织1例, 坏死组织及破碎结石1例, 坏死肿瘤组织2例, HCC-透明细胞型1例. 2例细胞刷细胞学检查均为胆管脱落上皮细胞.

3 讨论

HCC较常浸润血管, 特别是门静脉, 引起肝癌肝内转移和门静脉癌栓形成. 一般认为肝癌胆管浸润和胆管内肿瘤生长较少见, 此种患者常表现为进行性梗阻性黄疸, 临床上有人称之为"黄疸型肝肿瘤"(icteric hepatoma), 目前只有较少例数的手术或尸检报道, 而且多为胆管癌栓的零星报道[2-5,9-18], 最大宗病例报道也只有27例, 未见大宗ERCP造影表现的报道. 此种患者在黄疸的鉴别诊断上有时会非常困难, 常常会误诊为胆管癌或胆管结石, 特别是血AFP阴性的病例.

HCC最常见为肿瘤外压或浸润一侧肝内胆管系统, 但这种方式常不会出现梗阻性黄疸, 因为即使一叶肝内胆管完全梗阻, 只要无明显的肝硬化, 另一叶可代偿而不出现黄疸; 只有当双侧肝内胆管系统或肝外大的胆管被肿瘤压迫或浸润后, 才会出现梗阻性黄疸. 其次为HCC侵犯胆管后胆管内生长形成胆管癌栓[19-22], 引起机械性梗阻: (1)肿瘤延着胆管生长, 并向远端延伸, 形成肿块阻塞肝外胆管[23-25]; (2)部份肿瘤组织自近端胆管腔内生长处脱落, 进入远端胆管引起梗阻[26]; (3)肿瘤出血, 部份或完全阻塞胆管树引起梗阻; 最终梗阻的部位可能临近肿瘤侵犯处或相距很远, 其取决于胆管和碎片的大小[27,28].

我们总结了164例临床诊断为HCC并梗阻性黄疸患者的ERCP造影表现, 为文献中最大宗报道. 我们发现HCC患者的梗阻性黄疸97.6%为胆道恶性梗阻引起的阻塞性黄疸, 最常见者为肝癌浸润肝门及其周围胆管致狭窄引起的, 其次为肿瘤胆管腔内生长即胆管癌栓引起的、少部份患者同时有肝癌浸润肝门及肝门周围胆管所致狭窄和肿瘤胆管内生长引起的胆管癌栓、也有肝门部或腹膜后淋巴结转移所致. 本组中27例经病理证实为HCC并梗阻性黄疸者中, ERCP造影表现为肝门及肝门周围胆管恶性狭窄16例, 胆管癌栓6例; 胆管癌栓并肝门部胆管狭窄2例、肝门部淋巴结转移2例、胆总管结石1例. 也再次提示HCC浸润肝门部胆管引起胆管恶性狭窄为HCC并梗阻性黄疸的最常见的原因. 值得注意的是, 本组中2例为胆总管结石所致, 另2例则为胆总管下端炎性狭窄致梗阻性黄疸, 上述患者均经乳头切开取石或引流后黄疸消退证实, 这说明并非所有原发性肝癌患者的梗阻性黄疸均为恶性梗阻所致, 因此在HCC合并梗阻性黄疸的鉴别诊断时要首先排除良性梗阻的可能.

本组中33例胆管癌栓, 按Ueda胆管癌栓的分型, I型0例、II型3例、III型21例、IV型9例. 胆管癌栓相对于胆管恶性狭窄患者在治疗上的方法为多, 特别是以黄疸为首发症状者, 部份患者可手术切除原发癌灶或手术取出癌栓[7,13], 不能手术治疗患者可以行乳头切开并取出游离癌栓进行胆管引流, 为其他治疗方法创造条件[29]. 本组中有12例表现有胆管癌栓和肝门部或肝门周围胆管恶性狭窄, 此种患者常常已失去了手术的机会, 但由于胆管癌栓内镜治疗中易出血, 严重肝门部梗阻易出现术后感染. 因此对于此组患者治疗上难度可能相对更大. 另有5例为淋巴结转移所致梗阻性黄疸, 其中3例为肝门部淋巴结转移所致, 2例为腹膜后淋巴结转移所致, 对于此种患者内镜下胆管引流常常可达到充分引流, 因此内镜引流的效果也相对较好. 有6例胆管癌栓行乳头切开部分游离癌栓取出术, 病理组织学检查为坏死肿瘤组织2例, 血栓性坏死组织、肿瘤可能1例, 纤维炎性坏死组织1例, 坏死组织及破碎结石1例, HCC-透明细胞型1例. 2例细胞刷细胞学检查均为胆管脱落上皮细胞. 这说明取出癌栓的病理确诊率也不高, 可能为肿瘤出血或坏死脱落后组织变性所致[30]. 胆道细胞刷细胞学检查2例均为脱落胆管上皮细胞, 提示细胞刷活检的阳性率更低. 因取癌栓和细胞学检查, 有增加胆道出血和感染的机会的可能, 风险相对较大, 故一般临床诊断明确者我们不常规行此2种检查. 因本组取癌栓活检和胆道细胞刷细胞学检查的例数很少, 是否将其列入常规检查有待进一步临床研究.

本组中除9例患者以梗阻性黄疸为首发症状就诊外, 绝大部份患者因诊断为HCC行手术或介入治疗后较长时间后才出现梗阻性黄疸, 其中26为HCC手术治疗后, 64例为肝动脉造影及栓塞治疗术后, 15例为经皮经肝穿刺酒精注射治疗术后. 因此我们提出HCC患者经手术、介入性治疗后, 生存期得到明显延长后, 或者反复肝动脉栓塞治疗或酒精注射治疗后肝组织坏死, 是否使过去较少见的HCC合并梗阻性黄疸的发生率增加这样一个值得临床医生进一步研究的课题.

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