胰液反流对急性肝损伤影响的实验研究
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摘要
目的:胰腺和胆道的某些疾病常同时或先后发生于同一个体,这种“胰胆同病”现象越来越受到广泛的重视。目前许多动物实验和临床资料证实胰腺与胆系疾病之间存在着内在联系,这与胰管、胆管联合部形成共同通道开口于十二指肠壶腹部有关,当共同通道过长形成胰胆合流异常(pancreaticobiliary maljunction PBM)或其开口处因结石、肿物、瘢痕或壶腹括约肌痉挛而阻塞时,胰液、胆汁之间则会发生相互混流和反流。近年来对由于存在胰胆合流异常胰液反流所致的胆系慢性病变及胆道梗阻后致胰液、胆汁排泄不畅所引起的胆源性胰腺炎作了系统研究与报道。且有大量动物实验及临床研究对胆道梗阻时肝脏损伤的机制、病理生理改变作了比较系统详尽的论述,同时也证实了胆道梗阻时反映肝功能的多项血清学指标及肝脏病理形态有不同程度的变化。而对于因胰胆共同通道阻塞后胰液反流入胆道引起急性胆囊炎同时发生的急性肝损伤少见详尽报道。
本实验采用向家兔胆管内注入胰酶的方式模拟制备胰胆共同通道阻塞致胰液反流时发生急性胆囊炎和肝损伤的动物模型,观察胰液反流入胆道引发急性胆囊炎同时血清丙氨酸转氨酶(ALT)、门冬氨酸转氨酶(AST)、碱性磷酸酶(ALP)、r-谷氨酰转肽酶(GGT)、总胆红素(TBIL)等反映肝功能的各项指标,胆囊胆汁淀粉酶(AMY),血清、肝组织一氧化氮(NO)、一氧化氮合酶(NOS)及肝脏病理形态的变化,进一步研究胰液反流对急性肝损伤的影响以及NO在急性肝损伤中的作用,为研究发生胆道梗阻胰液反流时引起的急性肝损伤机制提供理论依据。
方法:选择健康家兔,雌雄不限共45只,体重2.0-2.5kg/只(购自河北医科大学实验动物中心),随机分为3组,假手术组(SO),单纯胆道梗阻组(BDL),胆道梗阻并注入胰酶组(M),所有家兔手术前禁食过夜,自由饮水。3%戊巴比妥钠按35mg/kg耳缘静脉麻醉,无菌条件下取腹部正中切口(3cm)开腹,观察肝脏及胆囊大体形态,寻找胆总管。胆道梗阻并注入胰酶组仔细钝性剥离胆总管,结扎近肠端,以儿科静脉留置针穿刺成功后,见黄绿色胆汁流出,以1ml注射器抽出0.2ml胆汁,用微量枪抽取50U/ml的胰液0.2ml注入1ml的注射器中,以每分钟0.1ml的速度注入胆总管,观察无胆汁流出后,穿刺点近肝端结扎胆总管;单纯胆道梗阻组仔细钝性剥离胆总管并予以结扎;假手术组只仔细剥离胆总管。所有实验动物术后3天处死,观察肝脏、胆囊大体形态,留取胆囊胆汁2ml进行淀粉酶检测,并取血标本检测ALT、AST、ALP、GGT、TBIL、NO、NOS等指标,各组均取适量肝脏、胆囊组织,秤取肝脏组织100mg研磨成匀浆,取上清液于-20℃保存用于测NO、NOS,其余肝脏组织以及胆囊组织置于10%中性甲醛中以备制石蜡切片,行HE染色,光镜下(放大400倍)观察。所有数据均采用SPSS FOR WINDOWS 13.0软件包进行统计学处理,所得结果,计量资料均采用均数±标准差(X|-±S)表示,各组间均数比较采用单因素方差分析,P<0.05认为有统计学意义。
结果:
1肝脏、胆囊组织病理学变化
1.1假手术组肉眼观肝脏红润无肿胀,被膜光滑;胆囊色泽稍暗,粘膜完整,与周围组织无粘连。光镜下观察肝脏形态结构正常,无炎细胞浸润,细胞无肿胀、变性和坏死;胆囊粘膜上皮完好,各层无充血、水肿及炎细胞浸润。
1.2单纯胆道梗阻组肉眼观肝脏呈暗红色,明显肿胀,被膜光滑;胆囊色泽暗,体积增大,表面无溃疡、脓苔。光镜下观察肝脏组织变化表现为肝细胞浊肿、空泡变性、散在小灶性或片状坏死、炎细胞浸润;胆囊粘膜上皮轻度脱落,固有膜、肌层、浆膜充血、水肿,并有少量炎细胞浸润。
1.3胆道梗阻并注入胰酶组肉眼观肝脏呈暗红色,明显肿胀,少数动物被膜可见散在的脓白苔;胆囊色泽晦暗,较梗阻组增大,胆囊底部有大小不一脓苔。光镜下观察肝脏组织表现为肝细胞浊肿、空泡变性、灶性或片状坏死、炎细胞浸润,少数动物肝脏组织空泡变性、坏死面积较大;胆囊粘膜上皮重度脱落,甚至消失,粘膜、固有膜、肌层、浆膜均可见高度水肿、充血,可见大量炎细胞浸润。
2血清ALT、AST、ALP、TBIL、GGT的变化
2.1 ALT胆道梗阻并注入胰酶组、单纯胆道梗阻组较假手术组血清ALT明显升高,各组间比较P<0.05,有统计学意义。
2.2 AST胆道梗阻并注入胰酶组、单纯胆道梗阻组较假手术组血清AST明显升高,各组间比较P<0.05,有统计学意义。
2.3 ALP、TBIL、GGT胆道梗阻并注入胰酶组与单纯胆道梗阻组血清ALP、TBIL、GGT均明显升高,以胆道梗阻并注入胰酶组升高较为明显,但两组间比较P值均大于0.05,差异无统计学意义;与假手术组比较有显著差异(p<0.05)。
3血清、肝组织NO、NOS的变化
胆道梗阻并注入胰酶组及单纯胆道梗阻组血清及肝组织NO、NOS均明显升高,两组间比较无统计学意义(p>0.05);与假手术组比较有显著性差异(p<0.05)。
4胆囊胆汁淀粉酶的变化
胆道梗阻并注入胰酶组及单纯胆道梗阻组与假手术组比较胆囊胆汁淀粉酶明显升高,有显著差异(p<0.05);单纯胆道梗阻组及假手术组之间比较,无统计学意义(p>0.05)。
结论:
1胆道梗阻并注入胰酶组血清ALT、AST较单纯胆道梗阻组升高,表明胰液反流可加重肝损伤。
2胆道梗阻后引起急性胆囊炎的同时发生肝损伤。但胆道梗阻并注入胰酶组与单纯胆道梗阻组比较血清ALP、GGT、TBIL各指标变化无显著差异,说明在发病早期胆道梗阻、胆汁淤积可能是引起肝损伤的主要原因,尽早解除胆道梗阻是防治肝损伤的主要治疗手段。随着胰液反流时间的增加是否会使肝损伤明显加重尚待进一步研究。
3胆道梗阻并注入胰酶组及单纯胆道梗阻组肝组织、血清中NO、NOS与假手术组比较明显升高,说明NO、NOS参与肝损伤过程,并起到重要作用。
Objective: Some diseases about the pancreas and gallbladder often occur at the same person, The phenomenon of“the pancreas and gallbladder disease come on at the same time”has been taken more and more attention. Many experiments and clinical datum have approved that the pancreas and gallbladder diseases have some internal relationship. All of this attributed to pancreatcobiliary, when it was obstructed with small stone、foreign matter and the dysfunction of Oddi spincter that the pancreatic juice and bile could mutual reflux ,and the abnormal flux of pancreatic juice and bile could cause the injury of gallbladder and pancreas. Recently, many animal experiments and clinical researches have detailedly discussed the injury of hepatic when the bile duct obstructed, and it approved that the obstruction of bile duct causes the changes of hepatic function index and the changes of the liver tissue. However ,it is rarely reported on the hepatic injury caused by the pancreatic juice reflux to the bile duct after pancreatcobiliary duct has been obstructed .In our experiment, we methoded of injecting pancreatic juice to rabbit bile duct as model to simulate the pancreatic juice regurgitation , and studyed the changed of ALT、AST、ALP、GGT、TBIL in the serum ,and the NO、NOS in serum and the liver tissue , observed the change of the liver tissue pathologic structure , further to study the effect of pancreatic juice regurgitation on acute liver injury ,and the effect of NO in the process of hepatic injury. And provide the theoretical base for the liver injury when bile duct has been obstructed.
Methods: 45 healthy rabbits weighing 2.0-2.5Kg were randomly divided into 3 groups:the sham operation group(SO group)、the simple bile duct ligated group(BDL group),and the group which the bile duct injected with pancreatic enzyme before it ligated (M group),in which male and female were equally and each group including 15 rabbits . All the rabbits were prohibited to eat but not drink before operation. After animal model successfully settled, all the animals were killed after three days, and determined the serum ALT、AST、ALP、GGT、TBIL , the bile AMY,NO、NOS of serum and the liver tissue ,got the liver tissue ,and observed the pathologic changes with light microscope after HE staining. The experimental data expressed as mean standard deviation. The statistic significance is analyzed by SPSS 13.0, a statistic software.
Result:
1 The change of the liver appearance: The liver of BDL group and the M group become swelling; The change of the liver of part of animals in M group are serious, and sparse pus on the surface could be seen. In the light microscope ,the liver tissue both of the BDL group and M group have the changes as dropsy、vacuole denaturalization and putrescence in small section, the white blood cell invaded. And a few animals in M group are severer than BDL group.
2 The serum hepatic function index: the ALT、AST become higher in the M group and BDL group ,when compared with the SO group, have significant difference (p<0.05); Compared the M group with BDL group, have difference (p<0.05); While TBIL、GGT、ALP became higher in the M group and BDL group, when compared with the SO group, have difference (p<0.05) , compared the M group with BDL group, it have no obvious difference(p<0.05).
3 The bile amylase: In the M group are obviously higher than the SO group and BDL group , have significant difference(p<0.05).Compared BDL group with SO group, have no difference (p>0.05).
4 Compare the NO、NOS of the liver and the serum between the SO group and M group or the BDL group , have difference ( p<0.05); But compare the M group with BDL group, it have no obvious difference (p>0.05).
Conclusions:
1 After pancreaticobiliary duct has been obstructed, the pancreatic juice and bile could mutual reflux, the levels of ALT and AST in M group increased obviously ,Compared with BDL group have difference. Which approved that when pancreaticobiliary duct has been obstructed, pancreatic juice reflux to bile duct attribute a certain effect on the process of the liver injury.
2 After pancreaticobiliary duct has been obstructed and pancreatic juice injected to bile duct caused acute or chronic cholecystitis, and lead to the liver injury. While compared with BDL group, the levels of ALP、GGT and TBIL in M group have no obvious difference . Approved the bile duct obstructed and cholestasis are the important reason of the hepatic injury. It’s the effectively method to resume the function of liver that releasing the obstructing of bile duct as early as possible.
3 Compared with the sham operation group the level of NO and NOS in serum and liver tissue increased obviously both in M and BDL group . Which approve NO and NOS play an important role in the course of the liver injury.
本实验采用向家兔胆管内注入胰酶的方式模拟制备胰胆共同通道阻塞致胰液反流时发生急性胆囊炎和肝损伤的动物模型,观察胰液反流入胆道引发急性胆囊炎同时血清丙氨酸转氨酶(ALT)、门冬氨酸转氨酶(AST)、碱性磷酸酶(ALP)、r-谷氨酰转肽酶(GGT)、总胆红素(TBIL)等反映肝功能的各项指标,胆囊胆汁淀粉酶(AMY),血清、肝组织一氧化氮(NO)、一氧化氮合酶(NOS)及肝脏病理形态的变化,进一步研究胰液反流对急性肝损伤的影响以及NO在急性肝损伤中的作用,为研究发生胆道梗阻胰液反流时引起的急性肝损伤机制提供理论依据。
方法:选择健康家兔,雌雄不限共45只,体重2.0-2.5kg/只(购自河北医科大学实验动物中心),随机分为3组,假手术组(SO),单纯胆道梗阻组(BDL),胆道梗阻并注入胰酶组(M),所有家兔手术前禁食过夜,自由饮水。3%戊巴比妥钠按35mg/kg耳缘静脉麻醉,无菌条件下取腹部正中切口(3cm)开腹,观察肝脏及胆囊大体形态,寻找胆总管。胆道梗阻并注入胰酶组仔细钝性剥离胆总管,结扎近肠端,以儿科静脉留置针穿刺成功后,见黄绿色胆汁流出,以1ml注射器抽出0.2ml胆汁,用微量枪抽取50U/ml的胰液0.2ml注入1ml的注射器中,以每分钟0.1ml的速度注入胆总管,观察无胆汁流出后,穿刺点近肝端结扎胆总管;单纯胆道梗阻组仔细钝性剥离胆总管并予以结扎;假手术组只仔细剥离胆总管。所有实验动物术后3天处死,观察肝脏、胆囊大体形态,留取胆囊胆汁2ml进行淀粉酶检测,并取血标本检测ALT、AST、ALP、GGT、TBIL、NO、NOS等指标,各组均取适量肝脏、胆囊组织,秤取肝脏组织100mg研磨成匀浆,取上清液于-20℃保存用于测NO、NOS,其余肝脏组织以及胆囊组织置于10%中性甲醛中以备制石蜡切片,行HE染色,光镜下(放大400倍)观察。所有数据均采用SPSS FOR WINDOWS 13.0软件包进行统计学处理,所得结果,计量资料均采用均数±标准差(X|-±S)表示,各组间均数比较采用单因素方差分析,P<0.05认为有统计学意义。
结果:
1肝脏、胆囊组织病理学变化
1.1假手术组肉眼观肝脏红润无肿胀,被膜光滑;胆囊色泽稍暗,粘膜完整,与周围组织无粘连。光镜下观察肝脏形态结构正常,无炎细胞浸润,细胞无肿胀、变性和坏死;胆囊粘膜上皮完好,各层无充血、水肿及炎细胞浸润。
1.2单纯胆道梗阻组肉眼观肝脏呈暗红色,明显肿胀,被膜光滑;胆囊色泽暗,体积增大,表面无溃疡、脓苔。光镜下观察肝脏组织变化表现为肝细胞浊肿、空泡变性、散在小灶性或片状坏死、炎细胞浸润;胆囊粘膜上皮轻度脱落,固有膜、肌层、浆膜充血、水肿,并有少量炎细胞浸润。
1.3胆道梗阻并注入胰酶组肉眼观肝脏呈暗红色,明显肿胀,少数动物被膜可见散在的脓白苔;胆囊色泽晦暗,较梗阻组增大,胆囊底部有大小不一脓苔。光镜下观察肝脏组织表现为肝细胞浊肿、空泡变性、灶性或片状坏死、炎细胞浸润,少数动物肝脏组织空泡变性、坏死面积较大;胆囊粘膜上皮重度脱落,甚至消失,粘膜、固有膜、肌层、浆膜均可见高度水肿、充血,可见大量炎细胞浸润。
2血清ALT、AST、ALP、TBIL、GGT的变化
2.1 ALT胆道梗阻并注入胰酶组、单纯胆道梗阻组较假手术组血清ALT明显升高,各组间比较P<0.05,有统计学意义。
2.2 AST胆道梗阻并注入胰酶组、单纯胆道梗阻组较假手术组血清AST明显升高,各组间比较P<0.05,有统计学意义。
2.3 ALP、TBIL、GGT胆道梗阻并注入胰酶组与单纯胆道梗阻组血清ALP、TBIL、GGT均明显升高,以胆道梗阻并注入胰酶组升高较为明显,但两组间比较P值均大于0.05,差异无统计学意义;与假手术组比较有显著差异(p<0.05)。
3血清、肝组织NO、NOS的变化
胆道梗阻并注入胰酶组及单纯胆道梗阻组血清及肝组织NO、NOS均明显升高,两组间比较无统计学意义(p>0.05);与假手术组比较有显著性差异(p<0.05)。
4胆囊胆汁淀粉酶的变化
胆道梗阻并注入胰酶组及单纯胆道梗阻组与假手术组比较胆囊胆汁淀粉酶明显升高,有显著差异(p<0.05);单纯胆道梗阻组及假手术组之间比较,无统计学意义(p>0.05)。
结论:
1胆道梗阻并注入胰酶组血清ALT、AST较单纯胆道梗阻组升高,表明胰液反流可加重肝损伤。
2胆道梗阻后引起急性胆囊炎的同时发生肝损伤。但胆道梗阻并注入胰酶组与单纯胆道梗阻组比较血清ALP、GGT、TBIL各指标变化无显著差异,说明在发病早期胆道梗阻、胆汁淤积可能是引起肝损伤的主要原因,尽早解除胆道梗阻是防治肝损伤的主要治疗手段。随着胰液反流时间的增加是否会使肝损伤明显加重尚待进一步研究。
3胆道梗阻并注入胰酶组及单纯胆道梗阻组肝组织、血清中NO、NOS与假手术组比较明显升高,说明NO、NOS参与肝损伤过程,并起到重要作用。
Objective: Some diseases about the pancreas and gallbladder often occur at the same person, The phenomenon of“the pancreas and gallbladder disease come on at the same time”has been taken more and more attention. Many experiments and clinical datum have approved that the pancreas and gallbladder diseases have some internal relationship. All of this attributed to pancreatcobiliary, when it was obstructed with small stone、foreign matter and the dysfunction of Oddi spincter that the pancreatic juice and bile could mutual reflux ,and the abnormal flux of pancreatic juice and bile could cause the injury of gallbladder and pancreas. Recently, many animal experiments and clinical researches have detailedly discussed the injury of hepatic when the bile duct obstructed, and it approved that the obstruction of bile duct causes the changes of hepatic function index and the changes of the liver tissue. However ,it is rarely reported on the hepatic injury caused by the pancreatic juice reflux to the bile duct after pancreatcobiliary duct has been obstructed .In our experiment, we methoded of injecting pancreatic juice to rabbit bile duct as model to simulate the pancreatic juice regurgitation , and studyed the changed of ALT、AST、ALP、GGT、TBIL in the serum ,and the NO、NOS in serum and the liver tissue , observed the change of the liver tissue pathologic structure , further to study the effect of pancreatic juice regurgitation on acute liver injury ,and the effect of NO in the process of hepatic injury. And provide the theoretical base for the liver injury when bile duct has been obstructed.
Methods: 45 healthy rabbits weighing 2.0-2.5Kg were randomly divided into 3 groups:the sham operation group(SO group)、the simple bile duct ligated group(BDL group),and the group which the bile duct injected with pancreatic enzyme before it ligated (M group),in which male and female were equally and each group including 15 rabbits . All the rabbits were prohibited to eat but not drink before operation. After animal model successfully settled, all the animals were killed after three days, and determined the serum ALT、AST、ALP、GGT、TBIL , the bile AMY,NO、NOS of serum and the liver tissue ,got the liver tissue ,and observed the pathologic changes with light microscope after HE staining. The experimental data expressed as mean standard deviation. The statistic significance is analyzed by SPSS 13.0, a statistic software.
Result:
1 The change of the liver appearance: The liver of BDL group and the M group become swelling; The change of the liver of part of animals in M group are serious, and sparse pus on the surface could be seen. In the light microscope ,the liver tissue both of the BDL group and M group have the changes as dropsy、vacuole denaturalization and putrescence in small section, the white blood cell invaded. And a few animals in M group are severer than BDL group.
2 The serum hepatic function index: the ALT、AST become higher in the M group and BDL group ,when compared with the SO group, have significant difference (p<0.05); Compared the M group with BDL group, have difference (p<0.05); While TBIL、GGT、ALP became higher in the M group and BDL group, when compared with the SO group, have difference (p<0.05) , compared the M group with BDL group, it have no obvious difference(p<0.05).
3 The bile amylase: In the M group are obviously higher than the SO group and BDL group , have significant difference(p<0.05).Compared BDL group with SO group, have no difference (p>0.05).
4 Compare the NO、NOS of the liver and the serum between the SO group and M group or the BDL group , have difference ( p<0.05); But compare the M group with BDL group, it have no obvious difference (p>0.05).
Conclusions:
1 After pancreaticobiliary duct has been obstructed, the pancreatic juice and bile could mutual reflux, the levels of ALT and AST in M group increased obviously ,Compared with BDL group have difference. Which approved that when pancreaticobiliary duct has been obstructed, pancreatic juice reflux to bile duct attribute a certain effect on the process of the liver injury.
2 After pancreaticobiliary duct has been obstructed and pancreatic juice injected to bile duct caused acute or chronic cholecystitis, and lead to the liver injury. While compared with BDL group, the levels of ALP、GGT and TBIL in M group have no obvious difference . Approved the bile duct obstructed and cholestasis are the important reason of the hepatic injury. It’s the effectively method to resume the function of liver that releasing the obstructing of bile duct as early as possible.
3 Compared with the sham operation group the level of NO and NOS in serum and liver tissue increased obviously both in M and BDL group . Which approve NO and NOS play an important role in the course of the liver injury.
引文
1 陈斌.胰液返流对肝脏病理学改变的实验研究.陕西医学杂志.2000.9(9):572-574
2 沈世鹏,萧蓉葆,等.胆石病.北京:人民卫生出版社.2年 1 月第 1 版:15
3 石景森,王作仁,等.胰胆管合流异常与胆胰疾病的关系(附 28 例分析).中国实用外科杂志.1995,15(10):600-602
4 王跃,石民生,杨翔,等.实验性胆道梗阻对多脏器损害的病理形态学研究.临床与实验病理学杂志.1996,12(3):270-272
5 孟莹.一氧化氮和内毒素在梗阻性黄疸致病机制方面的作用.胃肠病学和肝病学杂志.2006,12(6):634-636
6 刘鹏,李开宗,付由池,等.一氧化氮在大鼠梗阻性黄疸肝损伤中的作用.第四军医大学学报.1996,17(5):356-359
7 余宙耀,刘树人,等.一氧化氮在急性肝衰竭中的作用.中国医师杂志.1999,8(8):17-19
8 邢古生,耿进朝,等. 胰胆管合流异常的病理、临床及影像学诊断.中华放射学杂志.2006,2(2):216-218
9 公伟,李占元,等.胰胆合流异常和胆胰疾病.普通外科进展.2005,6(3):138-140
10 钟明安,肖现民,等.胰胆合流异常的病理特征与诊治进展.肝胆外科杂志.2000,8(5):399-401
11 陈风,汪健.胰胆管合流异常及其相关疾病.医学综述.2006,2(3):179-180
12 董倩,单若冰,等.胰胆合流异常病理、诊断及治疗原则.中国实用儿科杂志.1999,9(9):521-522
13 李永国,等.胰胆疾病发病学上的相互关系.中华实验外科杂志.1987,4(1):44-46.
14 李永国,黄仲初,等.胆石症病因学的探讨-胰胆返流与胆石形成的关系.湖南医学院学报.1985,3(1):67-72
15 俸家富,涂植光,等.肝功能相关的血清酶学研究进展.医学综述,2007,2(3):225-228
16 Giannini EG, testa R, Savarino V. Liver enzyme alteration :a guide for clinicians , 2005,172(3):367-369
17 Knight JA, Liver function tests: their rote in the diagnosis of hepatobiliary diease . J Inrus Nurs, 2005,28(2):108-117
18 Limdi JK, Hyde GM. Evaluation of abnormal liver function tests . Postgrad Med J, 2003,79(932):307-312
19 Bhudhisawasdi V, Muisuk K; Areejitranusoun P, et al. Cilinical vatue of biliary alkaline phosphatase in non-jaundiced chotangiocarcinoma. J cancer Res Clin Oncol,2004,130(2):87-92
20 易露茜,苏先狮.乙型肝炎 A/G、ALP/ALT 比值的临床意义.湖南医学,2003,17(6):457-459
21 宋国培.肝功能血清酶学检测的临床意义.临床肝胆病杂志.2003,19(4):195-197
22 夏振龙.重症急性胆管炎与高胆红素血症.中国实用外科杂志.1986,1(1):37
23 冯白明.肝炎后高胆红素血症诊治分析.医药论坛杂志.2007,1(1):53-55
24 孙瑞,孙备.重症急性胰腺炎并发肝损伤的研究进展.国际外科学杂志.2006,33(6):401-403
25 Laoada k ,Lioh M, Fuju K, et al. pathology and cellular kinetios of gallbladder with an anomalous junction of the pancreaticobillary duct. Am castroemtserot,1996,91:1007
26 Guecrud M, morera l, Rodrignez M. et al. Normal and anormalous pancreaticobillary union in children and adolescents.Gastrointat Endosco,1999,50:189
27 陈刚,邹声泉.诱生型一氧化氮合酶在胆道感染大鼠肝细胞中的表达.中华肝胆外科杂志.2000,4(2):114-116
28 Nathan CF, Xie QW.Nitric oxide synthases,roles,tolls,and controls.Cell.1994,79-95
29 陈江,等.一氧化氮与肠屏障功能.肠外与肠内营养.2006,1(1):51-54
30 zhou JF, Cai D, zhu YG, et al. A study on relationship of nitrie oxide, oxidation, peroxidation with chonic cholecystitis. World J Gastroentero, 2000, 6: 501-507
31 zhou JF, zhu YG, Yang JL ,et al. A study on relationship of chronic cholecystitis with stone and nitric oxidation peroxidation lipoperoxidation. Am J comprehen Med, 2000, 2: 260-264
32 Liaudet L, Soriano FG, Szaboc. Biology of nitric oxide sigmaling, Crit Care Med, 2000,28: N37-52
33 Harbrecht BC, Billiard TR, Stadler J , et al. Nitric oxide synthesis serves to reduce hepatic damage during acute murine endotoxe mia. Crit Care Med,1992,20:1568-1575
34 张剑,李茂德,何生.一氧化氮在阻塞性黄疸病人肝脏损害中的作用.中华肝胆外科杂志.2003,7(7):416-418
35 乔文礼,张玲霞,等.一氧化氮与内皮素-1 在梗阻性黄疸兔肝细胞损伤中作用的实验研究.内蒙古医学杂志.2002,34(6):471-473
36 朱锡光,薛本立.一氧化氮在大鼠急性胆道感染后肝损伤 中 的 作 用 及 其 机 理 研 究 .ACTA ACADEMIAE MEDICINAE MILITARIS TERTIAE .1997,8:1372
1 邢古生,耿进朝,等.胰胆合流异常的病理、临床及影像学诊断.中华放射学杂志.2006,2(2):216-218
2 沈世鹏,萧蓉葆,主编.胆石病.北京:人民卫生出版社.2000年 1 月第 1 版:15
3 石景森,王作仁,等.胰胆管合流异常与胆道疾病的关系(附 28 例分析).中国实用外科杂志.1995,15(10):600-601
4 黄志强,石景森,王炳黄,主编.外科黄疸疾病诊断治疗学.北京:人民军医出版社.2003,459-495
5 陈宝莹,魏经同,王耀程,等.Oddi 括约肌解剖生理及其运动功能.世界华人消化杂志.2003,9:442-44
6 公伟,李占元,等.胰胆合流异常和胆胰疾病.普通外科进展.2005,6(3):138-140
7 ItokawaF, Itoi T, Nakaiaum,etal.Assessment of occult Pancreaticobiliary reflux in patients with Pncreaticobiliary diease by ERCP. Gastracration, 2004, 39:988-994
8 Xiao Y, Liu, lu Z, et al. Patential diagnostic value of pancreatic isoanylaz for pancreaticobiliary maljunction with mild biliary dicatation in pataints and a porcine model .pediatr sury ,2004,39:1490-1494
9 Sai JK. Snyama M, Kurakara Y, et al. occut pancreaticobiliary reflux and gallbladder carcinoma . Nippons hokakibyo Gakkai zasshi (Japanese). 2003,100:981-956
10 肖现民,等.不断加深对胰胆管合流异常的认识.肝胆外科杂志.2003,11:161-162
11 Dietch EA, sitling K, Lim Bery R, et al. Obstructive jaundice Promotes bacterial truns location from gut .AM J sury ,1990,159(1):79-84
12 李永国,黄仲初,等.胆石症病因学的探讨-胰胆返流与胆石形成的关系.湖南医学院学报.1985,3(1):67-72
13 陈为民,洪燕玲,韦立新.梗阻性黄疸治疗前后内毒素 IL-6和 IL-8 水平的比较.中国基层医药,2006,13(3):384-394
14 钱建钟,潘奎,等.肿瘤坏死因子在梗阻性黄疸肝损伤中的实验研究〔J〕.肝胆外科杂志.1999,7(5):393-394
15 贾士勇,黄志强,等.肿瘤坏死因子在梗阻性黄疸鼠肝中的免疫学分析〔J〕中华实验外科学杂志,1995,1294):197-498
16 刘利新,韩德五.肠源性内毒素血症与肝微循环障碍.中国微循环杂志.2000,4(4):251-252
17 姜双,王志新,等.梗阻性黄疸肝细胞损伤机制研究现状.2002,8(6):343-344
18 zhang J X, Pegot W, Chemens MG, et al, Endothelin-1 induce direct constriction of heratic sinudoids. Au J Physiol,1994,26:624-625
19 乔文礼,张玲霞,等.一氧化氮与内皮素-1 在梗阻性黄疸兔肝细胞损伤中作用的实验研究.内蒙古医学杂志.2002,34(6):471-473
20 Hibbs JB, Taintor R, Vavin Z, et al, Nitric oxide:a cytotoxic activcated macrophage effector molecule. Bioche BiophysRes Commun,1995,157:87-94
21 Harbrecht BG, Billiar TR. Stadler J.et al. inhibition of nitric oxide synthesis diromg endotoxemia promotes intrahepatic thrombosis and oxygen radical mediated hepatic injury. J Leukod Biol,1992,52:390-394
22 Harbrecht BG, Billiar TR, Stadier J, et al. Nitric oxide synthesis xerces to reduce hepatic damage during acute munne endotoxe mia. Crit Care Med,1992,20:1568-1575
23 Kurose I, Miura S, Higuchi H, et al. Increased nitric oxide synthase activity as a cause of mitochondriat dystunction in rat hepatocytes roles for tumor necrosis gactor alpha. Hepatology, 1996, 24:1185-1192
24 Wang JF, Spolarics Z, Greenberg SS, et al. Lipopolysac charideclpss in vivi strmalates nitric oxide production by the perfused rat liver. Faszb, 1993, TCA 2430:1405
25 郭宇廷,余秀专,周怀文,等.一氧化氮在梗阻性黄疸患者肝损伤中的作用及意义.肝胆外科杂志.2004,12(6):458-460
26 张蒙,苏映军,陈壁,等.内毒素及肿瘤坏死因子对肝细胞超微结构的影响.第四军医大学学报,1999,20(5):389-391
27 黄小强,杨可桢,黄志强,等.阻断胆管后肝微循环改变的实验研究.中华实验外科杂志,1967,4(4):151-153
28 王晶明,贾力群,等.肝外梗阻性黄疸的血流动力学研究.中国医学影像学杂志,2001,9(6):412-413
29 王长友,等.梗阻性黄疸肝细胞损伤机制.中国综合临床,Res Commun,1995,157:87-94
21 Harbrecht BG, Billiar TR. Stadler J.et al. inhibition of nitric oxide synthesis diromg endotoxemia promotes intrahepatic thrombosis and oxygen radical mediated hepatic injury. J Leukod Biol,1992,52:390-394
22 Harbrecht BG, Billiar TR, Stadier J, et al. Nitric oxide synthesis xerces to reduce hepatic damage during acute munne endotoxe mia. Crit Care Med,1992,20:1568-1575
23 Kurose I, Miura S, Higuchi H, et al. Increased nitric oxide synthase activity as a cause of mitochondriat dystunction in rat hepatocytes roles for tumor necrosis gactor alpha. Hepatology, 1996, 24:1185-1192
24 Wang JF, Spolarics Z, Greenberg SS, et al. Lipopolysac charideclpss in vivi strmalates nitric oxide production by the perfused rat liver. Faszb, 1993, TCA 2430:1405
25 郭宇廷,余秀专,周怀文,等.一氧化氮在梗阻性黄疸患者肝损伤中的作用及意义.肝胆外科杂志.2004,12(6):458-460
26 张蒙,苏映军,陈壁,等.内毒素及肿瘤坏死因子对肝细胞超微结构的影响.第四军医大学学报,1999,20(5):389-391
27 黄小强,杨可桢,黄志强,等.阻断胆管后肝微循环改变的实验研究.中华实验外科杂志,1967,4(4):151-153
28 王晶明,贾力群,等.肝外梗阻性黄疸的血流动力学研究.中国医学影像学杂志,2001,9(6):412-413
29 王长友,等.梗阻性黄疸肝细胞损伤机制.中国综合临床,
2 沈世鹏,萧蓉葆,等.胆石病.北京:人民卫生出版社.2年 1 月第 1 版:15
3 石景森,王作仁,等.胰胆管合流异常与胆胰疾病的关系(附 28 例分析).中国实用外科杂志.1995,15(10):600-602
4 王跃,石民生,杨翔,等.实验性胆道梗阻对多脏器损害的病理形态学研究.临床与实验病理学杂志.1996,12(3):270-272
5 孟莹.一氧化氮和内毒素在梗阻性黄疸致病机制方面的作用.胃肠病学和肝病学杂志.2006,12(6):634-636
6 刘鹏,李开宗,付由池,等.一氧化氮在大鼠梗阻性黄疸肝损伤中的作用.第四军医大学学报.1996,17(5):356-359
7 余宙耀,刘树人,等.一氧化氮在急性肝衰竭中的作用.中国医师杂志.1999,8(8):17-19
8 邢古生,耿进朝,等. 胰胆管合流异常的病理、临床及影像学诊断.中华放射学杂志.2006,2(2):216-218
9 公伟,李占元,等.胰胆合流异常和胆胰疾病.普通外科进展.2005,6(3):138-140
10 钟明安,肖现民,等.胰胆合流异常的病理特征与诊治进展.肝胆外科杂志.2000,8(5):399-401
11 陈风,汪健.胰胆管合流异常及其相关疾病.医学综述.2006,2(3):179-180
12 董倩,单若冰,等.胰胆合流异常病理、诊断及治疗原则.中国实用儿科杂志.1999,9(9):521-522
13 李永国,等.胰胆疾病发病学上的相互关系.中华实验外科杂志.1987,4(1):44-46.
14 李永国,黄仲初,等.胆石症病因学的探讨-胰胆返流与胆石形成的关系.湖南医学院学报.1985,3(1):67-72
15 俸家富,涂植光,等.肝功能相关的血清酶学研究进展.医学综述,2007,2(3):225-228
16 Giannini EG, testa R, Savarino V. Liver enzyme alteration :a guide for clinicians , 2005,172(3):367-369
17 Knight JA, Liver function tests: their rote in the diagnosis of hepatobiliary diease . J Inrus Nurs, 2005,28(2):108-117
18 Limdi JK, Hyde GM. Evaluation of abnormal liver function tests . Postgrad Med J, 2003,79(932):307-312
19 Bhudhisawasdi V, Muisuk K; Areejitranusoun P, et al. Cilinical vatue of biliary alkaline phosphatase in non-jaundiced chotangiocarcinoma. J cancer Res Clin Oncol,2004,130(2):87-92
20 易露茜,苏先狮.乙型肝炎 A/G、ALP/ALT 比值的临床意义.湖南医学,2003,17(6):457-459
21 宋国培.肝功能血清酶学检测的临床意义.临床肝胆病杂志.2003,19(4):195-197
22 夏振龙.重症急性胆管炎与高胆红素血症.中国实用外科杂志.1986,1(1):37
23 冯白明.肝炎后高胆红素血症诊治分析.医药论坛杂志.2007,1(1):53-55
24 孙瑞,孙备.重症急性胰腺炎并发肝损伤的研究进展.国际外科学杂志.2006,33(6):401-403
25 Laoada k ,Lioh M, Fuju K, et al. pathology and cellular kinetios of gallbladder with an anomalous junction of the pancreaticobillary duct. Am castroemtserot,1996,91:1007
26 Guecrud M, morera l, Rodrignez M. et al. Normal and anormalous pancreaticobillary union in children and adolescents.Gastrointat Endosco,1999,50:189
27 陈刚,邹声泉.诱生型一氧化氮合酶在胆道感染大鼠肝细胞中的表达.中华肝胆外科杂志.2000,4(2):114-116
28 Nathan CF, Xie QW.Nitric oxide synthases,roles,tolls,and controls.Cell.1994,79-95
29 陈江,等.一氧化氮与肠屏障功能.肠外与肠内营养.2006,1(1):51-54
30 zhou JF, Cai D, zhu YG, et al. A study on relationship of nitrie oxide, oxidation, peroxidation with chonic cholecystitis. World J Gastroentero, 2000, 6: 501-507
31 zhou JF, zhu YG, Yang JL ,et al. A study on relationship of chronic cholecystitis with stone and nitric oxidation peroxidation lipoperoxidation. Am J comprehen Med, 2000, 2: 260-264
32 Liaudet L, Soriano FG, Szaboc. Biology of nitric oxide sigmaling, Crit Care Med, 2000,28: N37-52
33 Harbrecht BC, Billiard TR, Stadler J , et al. Nitric oxide synthesis serves to reduce hepatic damage during acute murine endotoxe mia. Crit Care Med,1992,20:1568-1575
34 张剑,李茂德,何生.一氧化氮在阻塞性黄疸病人肝脏损害中的作用.中华肝胆外科杂志.2003,7(7):416-418
35 乔文礼,张玲霞,等.一氧化氮与内皮素-1 在梗阻性黄疸兔肝细胞损伤中作用的实验研究.内蒙古医学杂志.2002,34(6):471-473
36 朱锡光,薛本立.一氧化氮在大鼠急性胆道感染后肝损伤 中 的 作 用 及 其 机 理 研 究 .ACTA ACADEMIAE MEDICINAE MILITARIS TERTIAE .1997,8:1372
1 邢古生,耿进朝,等.胰胆合流异常的病理、临床及影像学诊断.中华放射学杂志.2006,2(2):216-218
2 沈世鹏,萧蓉葆,主编.胆石病.北京:人民卫生出版社.2000年 1 月第 1 版:15
3 石景森,王作仁,等.胰胆管合流异常与胆道疾病的关系(附 28 例分析).中国实用外科杂志.1995,15(10):600-601
4 黄志强,石景森,王炳黄,主编.外科黄疸疾病诊断治疗学.北京:人民军医出版社.2003,459-495
5 陈宝莹,魏经同,王耀程,等.Oddi 括约肌解剖生理及其运动功能.世界华人消化杂志.2003,9:442-44
6 公伟,李占元,等.胰胆合流异常和胆胰疾病.普通外科进展.2005,6(3):138-140
7 ItokawaF, Itoi T, Nakaiaum,etal.Assessment of occult Pancreaticobiliary reflux in patients with Pncreaticobiliary diease by ERCP. Gastracration, 2004, 39:988-994
8 Xiao Y, Liu, lu Z, et al. Patential diagnostic value of pancreatic isoanylaz for pancreaticobiliary maljunction with mild biliary dicatation in pataints and a porcine model .pediatr sury ,2004,39:1490-1494
9 Sai JK. Snyama M, Kurakara Y, et al. occut pancreaticobiliary reflux and gallbladder carcinoma . Nippons hokakibyo Gakkai zasshi (Japanese). 2003,100:981-956
10 肖现民,等.不断加深对胰胆管合流异常的认识.肝胆外科杂志.2003,11:161-162
11 Dietch EA, sitling K, Lim Bery R, et al. Obstructive jaundice Promotes bacterial truns location from gut .AM J sury ,1990,159(1):79-84
12 李永国,黄仲初,等.胆石症病因学的探讨-胰胆返流与胆石形成的关系.湖南医学院学报.1985,3(1):67-72
13 陈为民,洪燕玲,韦立新.梗阻性黄疸治疗前后内毒素 IL-6和 IL-8 水平的比较.中国基层医药,2006,13(3):384-394
14 钱建钟,潘奎,等.肿瘤坏死因子在梗阻性黄疸肝损伤中的实验研究〔J〕.肝胆外科杂志.1999,7(5):393-394
15 贾士勇,黄志强,等.肿瘤坏死因子在梗阻性黄疸鼠肝中的免疫学分析〔J〕中华实验外科学杂志,1995,1294):197-498
16 刘利新,韩德五.肠源性内毒素血症与肝微循环障碍.中国微循环杂志.2000,4(4):251-252
17 姜双,王志新,等.梗阻性黄疸肝细胞损伤机制研究现状.2002,8(6):343-344
18 zhang J X, Pegot W, Chemens MG, et al, Endothelin-1 induce direct constriction of heratic sinudoids. Au J Physiol,1994,26:624-625
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24 Wang JF, Spolarics Z, Greenberg SS, et al. Lipopolysac charideclpss in vivi strmalates nitric oxide production by the perfused rat liver. Faszb, 1993, TCA 2430:1405
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28 王晶明,贾力群,等.肝外梗阻性黄疸的血流动力学研究.中国医学影像学杂志,2001,9(6):412-413
29 王长友,等.梗阻性黄疸肝细胞损伤机制.中国综合临床,Res Commun,1995,157:87-94
21 Harbrecht BG, Billiar TR. Stadler J.et al. inhibition of nitric oxide synthesis diromg endotoxemia promotes intrahepatic thrombosis and oxygen radical mediated hepatic injury. J Leukod Biol,1992,52:390-394
22 Harbrecht BG, Billiar TR, Stadier J, et al. Nitric oxide synthesis xerces to reduce hepatic damage during acute munne endotoxe mia. Crit Care Med,1992,20:1568-1575
23 Kurose I, Miura S, Higuchi H, et al. Increased nitric oxide synthase activity as a cause of mitochondriat dystunction in rat hepatocytes roles for tumor necrosis gactor alpha. Hepatology, 1996, 24:1185-1192
24 Wang JF, Spolarics Z, Greenberg SS, et al. Lipopolysac charideclpss in vivi strmalates nitric oxide production by the perfused rat liver. Faszb, 1993, TCA 2430:1405
25 郭宇廷,余秀专,周怀文,等.一氧化氮在梗阻性黄疸患者肝损伤中的作用及意义.肝胆外科杂志.2004,12(6):458-460
26 张蒙,苏映军,陈壁,等.内毒素及肿瘤坏死因子对肝细胞超微结构的影响.第四军医大学学报,1999,20(5):389-391
27 黄小强,杨可桢,黄志强,等.阻断胆管后肝微循环改变的实验研究.中华实验外科杂志,1967,4(4):151-153
28 王晶明,贾力群,等.肝外梗阻性黄疸的血流动力学研究.中国医学影像学杂志,2001,9(6):412-413
29 王长友,等.梗阻性黄疸肝细胞损伤机制.中国综合临床,