肝癌热消融术后胆道出血6例诊治分析
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摘要
目的探讨肝癌热消融术后胆道出血的原因、诊断及处理方法。方法回顾性分析我院2013年5月至2018年5月肝癌热消融术后发生胆道出血的6例患者的病例资料。通过内镜或数字减影血管造影(DSA)检查出血点,明确胆道出血诊断后行选择性肝动脉栓塞治疗,术后检测血红蛋白、肝功能等指标判定治疗效果。结果术前影像学诊断3例患者有肝内胆管轻度扩张。内镜检查示6例患者均见十二指肠乳头部有持续出血伴有血凝块形成。DSA检查示4例患者有明确出血点,2例未发现明确出血点。给予选择性肝动脉栓塞治疗,术后患者即自诉胆绞痛消失,术后24 h内仍有血便但血红蛋白稳定,24 h之后血便逐渐消失。经选择性肝动脉栓塞治疗后,6例患者止血效果良好,有效率为100%,均顺利出院。出院后随访半年均未再次发生胆道出血。结论肝内胆管局部扩张是肝癌消融术后胆道出血的主要危险因素之一。胆道出血三联征是典型症状,内镜检出率高,DSA检查明确诊断尚需结合临床症状。选择性肝动脉栓塞是有效的治疗方法,对DSA检查未见出血点的患者行选择性肝动脉栓塞术诊断性治疗也可取得满意疗效。
Objective To explore the causes, diagnosis and treatment of biliary tract hemorrhage after hepatic cancer thermal ablation. Methods The clinical data of 6 patients with biliary tract hemorrhage developed after hepatic cancer thermal ablation in our hospital from May 2013 to May 2018 were retrospectively analyzed. Endoscopic or digital subtraction angiography(DSA) was used to determine the bleeding points. After a definite diagnosis of biliary tract hemorrhage, selective hepatic artery embolization was performed. Hemoglobin, hepatic function and other indicators were detected after surgery to evaluate the treatment effect. Results Preoperative imaging diagnosis showed that 3 patients had mild dilatation of the intrahepatic bile duct. Endoscopy examination showed that there was persistent bleeding in the duodenal papilla with blood clot formation in all 6 patients. DSA examination showed that there were clear bleeding points in 4 patients, and no bleeding points in 2 patients. After embolization, the patients complained of biliary colic disappearance. Within 24 h after embolization,the patients still had hematochezia but the hemoglobin levels were stable. After 24 h operation, the hematochezia gradually disappeared. After selective hepatic artery embolization treatment, 6 patients obtained good hemostatic effects with the effective rate being 100%. All patients were discharged. No biliary bleeding reoccured in the 6-month follow-up.Conclusion Local expansion of intrahepatic bile duct is one of the main risk factors of biliary tract hemorrhage after hepatic cancer ablation. Triad of biliary bleeding is a typical symptom. Endoscopic detection rate is high. DSA examination diagnosis still need to be supported by clinical symptoms. Selective hepatic artery embolization is an effective treatment method. Selective hepatic artery embolization is also satisfactory in diagnostic treatment of patients without bleeding points on DSA examination.
Objective To explore the causes, diagnosis and treatment of biliary tract hemorrhage after hepatic cancer thermal ablation. Methods The clinical data of 6 patients with biliary tract hemorrhage developed after hepatic cancer thermal ablation in our hospital from May 2013 to May 2018 were retrospectively analyzed. Endoscopic or digital subtraction angiography(DSA) was used to determine the bleeding points. After a definite diagnosis of biliary tract hemorrhage, selective hepatic artery embolization was performed. Hemoglobin, hepatic function and other indicators were detected after surgery to evaluate the treatment effect. Results Preoperative imaging diagnosis showed that 3 patients had mild dilatation of the intrahepatic bile duct. Endoscopy examination showed that there was persistent bleeding in the duodenal papilla with blood clot formation in all 6 patients. DSA examination showed that there were clear bleeding points in 4 patients, and no bleeding points in 2 patients. After embolization, the patients complained of biliary colic disappearance. Within 24 h after embolization,the patients still had hematochezia but the hemoglobin levels were stable. After 24 h operation, the hematochezia gradually disappeared. After selective hepatic artery embolization treatment, 6 patients obtained good hemostatic effects with the effective rate being 100%. All patients were discharged. No biliary bleeding reoccured in the 6-month follow-up.Conclusion Local expansion of intrahepatic bile duct is one of the main risk factors of biliary tract hemorrhage after hepatic cancer ablation. Triad of biliary bleeding is a typical symptom. Endoscopic detection rate is high. DSA examination diagnosis still need to be supported by clinical symptoms. Selective hepatic artery embolization is an effective treatment method. Selective hepatic artery embolization is also satisfactory in diagnostic treatment of patients without bleeding points on DSA examination.
引文
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[8]生守鹏,郑加生,崔石昌,钱智玲,崔雄伟,李建军.肝肿瘤消融相关胆道出血的临床表现及治疗[J].中国介入影像与治疗学,2016,13:3-6.
[9]聂常富,朱明辉.原发性肝癌合并胆道出血的诊疗进展[J].中华肝脏外科手术学电子杂志,2017,6:444-446.
[10]杨健,杨敏玲.医源性胆道出血的DSA诊断及介入治疗[J].当代医学,2014,20:66-67.
[2]王能,钱国军,沈强,盛月红,张磊.经皮肝穿刺射频治疗肝恶性肿瘤的严重并发症分析[J].中华肝胆外科杂志,2011,17:186-188.
[3]范志勇,孙中杰,胡海田,杜立学,刘青光.PTBD术后胆道出血的临床特征及诊治分析[J].海南医学,2016,27:3910-3912.
[4]张宗明.胆道出血的诊治现状[J].外科,2017,6:1-7.
[5]孔晔宏,张少君,乔秋阁.肝肿瘤热消融术后出血性并发症的风险因素分析及预见性处理[J].河北医药,2014,36:1547-1549.
[6]吕鲁闽,刘崇远.10例胆道出血的诊断及治疗临床分析[J].福建医药杂志,2012,34:38-40.
[7]MARYNISSEN T,MALEUX G,HEYE S,VANINBROUKX J,LALEMAN W,CASSIMAN D,et al.Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure:case series and review of the literature[J].Eur J Gastroenterol Hepatol,2012,2:905-909.
[8]生守鹏,郑加生,崔石昌,钱智玲,崔雄伟,李建军.肝肿瘤消融相关胆道出血的临床表现及治疗[J].中国介入影像与治疗学,2016,13:3-6.
[9]聂常富,朱明辉.原发性肝癌合并胆道出血的诊疗进展[J].中华肝脏外科手术学电子杂志,2017,6:444-446.
[10]杨健,杨敏玲.医源性胆道出血的DSA诊断及介入治疗[J].当代医学,2014,20:66-67.