[https://www.medsci.cn](https://www.medsci.cn) 1 1 ## 消化 # 指南共识|《中国慢性胆囊炎、胆囊结石内科诊疗共识意见》 **2022-03-25 **small year **梅斯医学整理 [胆囊结石](https://www.medsci.cn/search?q=胆囊结石)[慢性胆囊炎](https://www.medsci.cn/search?q=慢性胆囊炎) [https://www.medsci.cn/user/feeds?uid=75546529310](https://www.medsci.cn/user/feeds?uid=75546529310) [消化新前沿   企业/](https://www.medsci.cn/user/feeds?uid=75546529310) [关注](javascript:void(0);)[javascript:void(0);](javascript:void(0);)[互相关注](javascript:void(0);) > 一睹为快～ 慢性胆囊炎一般是由长期存在的胆囊结石所致 的胆囊慢性炎症，或急性胆囊炎反复发作迁延而来， 其临床表现差异较大，可表现为无症状、反复右上腹 不适或腹痛，也可出现急性发作。其典型腹部超声 检查表现为胆囊壁增厚 ( 壁厚 ≥3 mm) 、毛糙，合并胆囊结石可表现为胆囊内强回声及后方声影。根据 胆囊内是否存在结石，分成结石性胆囊炎与非结石 性胆囊炎。胆囊结石分成[胆固醇](https://www.medsci.cn/search?q=%E8%83%86%E5%9B%BA%E9%86%87)结石或以胆固醇为 主的混合性结石和胆色素结石，中国人群中胆固醇 结石占 70 ％以上。 对于慢性胆囊炎、胆囊结石患者，应按是否有症 状、是否有并发症分别进行个体化治疗。治疗目标 为祛除病因、缓解症状、[预防](https://www.medsci.cn/guideline/list.do?q=%E9%A2%84%E9%98%B2)复发、防治并发症。 ** ( 一 ) 饮食调整 ** 胆囊结石及慢性结石性胆囊炎的发病与饮食及 肥胖有关。建议规律、低脂、低热量膳食，并提倡定 量、定时的规律饮食方式。 ** ( 二 ) 口服药物溶石治疗 ** 无症状的胆囊结石患者可不实施治疗，而有症 状的患者如不宜手术，且经腹部超声检查评估为胆 囊功能正常、 X 线检查阴性的胆固醇结石，可考虑口服溶石治疗。常用的药物有熊去氧胆酸 (UDCA) 。 UDCA 是一种亲水 的二羟胆汁酸，能抑制肝脏胆固醇的合成，显著降低 胆汁中胆固醇及胆固醇酯水平和胆固醇的饱和指 数，有利于结石中胆固醇逐渐溶解。推荐 UDCA 剂 量 ≥10 mg·kg-1·d-1 ，应连续服用 6 个月以上。 若服用 12 个月后腹部超声检查或胆囊造影无改善者即应停药。 UDCA 是目前唯一被美国 [FDA](https://www.medsci.cn/search?q=FDA) 批准 用于非手术治疗胆结石的胆汁酸药物。 【陈述】口服 UDCA 对胆囊功能正常的 x 线 检查阴性的胆同醇结石患者有较好的溶石作用。推 荐 UDCA 剂量 ≥10 mg·kg-1·d-1 ，应连续服用 6 个月以上。 推荐强度：条件推荐。证据级别：中等质量。 ** ( 三 ) 缓解胆源性[消化](https://ipsen2017.medsci.cn/ipsen/sporty/show-details/3074/2)不良症状 ** 慢性胆囊炎、胆囊结石患者嗳气、腹胀、脂肪餐 不耐受等[消化](https://ipsen2017.medsci.cn/ipsen/sporty/show-details/3074/2)功能紊乱症状常见。对有胆源性消化 不良症状患者宜补充促进胆汁合成和分泌的消化酶 类药物，如复方阿嗪米特肠溶片。因其含有利胆成 分的阿嗪米特，可高效地促进胆汁合成和分泌，同时 增强胰酶的活性，促进吸收碳水化合物、脂肪和蛋白 质；还含有 3 种胰酶及二甲硅油，能有效促进消化， 快速消除腹胀。国内研究显示，慢性胆囊炎、胆囊结 石患者口服复方阿嗪米特肠溶片对腹胀的总有效率为 80 ％。亦可应用米曲菌胰酶片等其他消化酶 类药物治疗，同时可结合茴三硫等利胆药物促进胆 汁分泌。 对于合并有不同程度上腹部疼痛患者，可加用 钙离子通道拮抗剂缓解症状。匹维溴铵为临床常用 的消化道钙离子通道拮抗剂，可用于治疗胆道功能 紊乱有关的疼痛，其直接作用于 Oddi 括约肌表面的钙离子通道，从而缓解 Oddi 括约肌痉挛，改善胆道系统的压力梯度。 【陈述】胆源性消化不良症状可通过补充促进 胆汁合成和分泌的消化酶类药物对症治疗。 推荐强度：条件推荐。证据级别：低质量。 ** ( 四 ) 缓解胆绞痛症状 ** 胆绞痛急性发作期间应予禁食及有效的止痛治 疗。来自国外的循证医学证据推荐治疗药物首选 NSAID( 如双氯芬酸和吲哚美辛 ) 或镇痛剂 ( 如哌替啶 ) 。一项 Cochrane 系统评价纳入 12 项随机对照研究共 828 例胆绞痛患者，发现 NSAID 较解痉 药有更高的疼痛完全缓解率，与阿片类药物相似。多项研究还表明， NSAID 可降低胆绞痛患者发生急性胆囊炎的风险。但国内尚缺乏相关临床研究，临床上仍以解痉药更常用，包括阿托品、 山莨菪碱 (654-II) 和间苯三酚等。需要注意的是，这些药物并不能改变疾病转归，且可能掩盖病情，因此需密切观察病情变化，一旦无效或疼痛复发，应及时停药。因吗啡可能促使 Oddi 括约肌痉挛进而增加胆管内压力，故一般禁用。 【陈述】对于胆绞痛急性发作患者，国内临床 上常用解痉药缓解胆绞痛症状，国外推荐选择 NSAID 、镇痛剂缓解症状，但目前国内尚缺乏相关 临床研究。 推荐强度：条件推荐。证据级别：中等质量。 ** ( 五 ) 抗[感染](https://www.medsci.cn/guideline/list.do?q=%E6%84%9F%E6%9F%93)治疗 ** 慢性胆囊炎患者通常不需要使用[抗生素](https://www.medsci.cn/guideline/list.do?q=%E6%8A%97%E7%94%9F%E7%B4%A0)。 如出现急性发作，建议首先采用经验性抗菌药物治 疗，在明确致病菌后应根据药物敏感试验结果选择 合适的抗菌药物进行目标治疗，如病因为寄生虫或病毒感染，需进行驱虫或抗病毒治疗。 【陈述】慢性胆囊炎通常不需要使用抗生素。如急性发作可经验性使用抗菌药物治疗。 推荐强度：条件推荐。证据级别：低质量。 ** ( 六 ) 外科治疗 ** 1 ．手术适应证：目前尚缺乏对无症状胆囊结石 患者行预防性胆囊切除的随机对照研究，鉴于无症状胆囊结石患者未来较低的症状和并发症发生率，建议在充分评估胆囊壁的前提下对无症状患者随访观察，不推荐行预防性胆囊切除术。 慢性胆囊炎、胆囊结石患者在内科治疗的基础上，如出现以下表现，则需考虑外科治疗：疼痛无缓解或反复发作，影响生活和工作者；胆囊壁逐渐增厚达 4 mm 及以上或胆囊壁局部增厚或不规则疑似胆囊癌者；胆囊壁呈陶瓷样改变；胆囊结石逐年增多和增大或胆囊颈部结石嵌顿者，合并胆囊功能减 退或障碍。 【陈述】对无症状的胆囊结石患者。建议随访观察。不推荐预防性胆囊切除。 推荐强度：条件推荐。证据级别：低质量。 2 ．合并胆囊息肉的手术适应证：胆囊息肉患病 率为 1 ％～ 7 ％，最常见的良性息肉是腺瘤。研究表明，胆囊息肉越大，胆囊癌的发生率越高，直径 ≥ 1 cm 的胆囊息肉癌变率高达 50 ％。故直径 ≥ 1 cm 的胆囊息肉伴或不伴胆囊结石的患者，不论有无症状，均建议行胆囊切除术。 【陈述】无论症状如何，胆囊息肉直径 ≥1 cm 伴或不伴胆囊结石的患者均建议行胆囊切除术。 推荐强度：强烈推荐。证据级别：中等质量。 3 ．常见并发症的处理 ①慢性胆囊炎急性发作：慢性胆囊炎急性发作 时，会导致胆囊内胆汁淤积合并感染，如果感染未能及时控制，胆囊壁会出现坏疽，最终可导致胆囊穿 孔，临床上可出现感染性休克症状，危及生命，此时应以外科治疗为主。 ②急性胆源性胰腺炎：对于急性胆源性胰腺炎 伴胆总管梗阻、胆管炎的患者，宜行经内镜逆行性胰 胆管造影术 (ERCP) 、经皮穿刺肝胆管引流术或手术治疗。对于急性胆源性胰腺炎伴胆囊结石、胆囊炎的患者，宜尽早行胆囊切除，防止急性胰腺炎复发。 ③ Mirizzi 综合征： Mirizzi 综合征的解剖成因是胆囊管与肝总管伴行过长或者胆囊管与肝总管汇合位置过低，邻近胆囊壶腹 (Hartmann 袋 ) 的结石压迫肝总管或胆总管，炎症反应反复发作可导致胆囊肝总管瘘管，胆囊管消失，结石部分或全部堵塞肝总管。 Mirizzi 综合征患者的治疗以外科手术为主。 ④结石性肠梗阻：结石性肠梗阻约占所有肠梗阻的 1 ％，是在胆囊与肠道间形成瘘管 ( 以胆囊十二指肠瘘最为常见，占 68 ％ ) ，因结石通过瘘管进 入肠道所致，多于回盲部发生肠梗阻。结石性肠梗 阻的治疗以外科干预解除梗阻为主。 ⑤胆囊癌：胆囊癌是慢性胆囊炎、胆囊结石最为严重的并发症。除了临床表现 ( 如右季肋区疼痛、包块、黄疸等 ) 和实验室检查以外，胆囊癌[诊断](https://www.medsci.cn/guideline/list.do?q=%E8%AF%8A%E6%96%AD)主要依赖影像学检查，包括腹部超声、 CT 、 MRI 和内镜超声等。由于胆囊癌预后较差，高度怀疑胆囊癌 的患者无论是否存在症状均应预防性切除胆囊。 【陈述】如慢性胆囊炎急性发作。或并发急性 胆源性胰腺炎、 Mirizzi 综合征、结石性肠梗阻。甚至 出现胆囊癌时。应根据患者情况遵循外科治疗原则。 推荐强度：条件推荐。证据级别：低质量。 ** ( 七 ) 中药、[针灸](https://www.medsci.cn/search?q=%E9%92%88%E7%81%B8)治疗 ** 传统中药在慢性胆囊炎治疗方面有悠久历史， 可根据患者不同的 I 临床表现辨证施治。同时可配合 中医其他疗法，如针灸、耳穴疗法、药物贴敷等。 【陈述】可根据患者不同临床表现辨证施治， 同时可配合中医其他治疗，如针灸、耳穴疗法、药物贴 敷等。 推荐强度：条件推荐。证据级别：低质量。 ** 六、预后及随访 ** 慢性胆囊炎、胆囊结石患者一般预后良好。无症状患者推荐每年进行 1 次随访，随访内容包括体格检查、肝功能实验室检查和腹部超声检查。 【陈述】慢性胆囊炎、胆囊结石一般预后良好，推荐每年进行 1 次随访。 推荐强度：强烈推荐。证据级别：低质量。 原文出处： 中华消化杂志编辑委员会 , 中华医学会消化病学分会肝胆疾病协作组 , 袁耀宗 , 等 . 中国慢性胆囊炎 , 胆囊结石内科[诊疗](https://www.medsci.cn/guideline/search?keyword=%E8%AF%8A%E7%96%97)[共识](https://www.medsci.cn/guideline/list.do?q=%E5%85%B1%E8%AF%86)意见 (2018 年 )[J]. 临床肝胆病杂志 , 2019, 35(6):6. 小提示：本篇资讯需要登录阅读，点击跳转登录 微信扫一扫  分享 版权声明： 本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料，版权均属于梅斯医学所有。非经授权，任何媒体、网站或个人不得转载，授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章，或“梅斯号”自媒体发布的文章，仅系出于传递更多信息之目的，本站仅负责审核内容合规，其内容不代表本站立场，本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系，我们将立即进行删除处理。 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createdTime=Sat Mar 26 03:32:27 CST 2022, time=2022-03-26, status=1, ipAttribution=)] [https://www.medsci.cn/user/feeds?uid=c26333174215](https://www.medsci.cn/user/feeds?uid=c26333174215) 2022-06-27 **[雕雕](https://www.medsci.cn/user/feeds?uid=c26333174215) ** [#慢性胆囊炎#](https://www.medsci.cn/topic/show?id=ba9e53662d0) [216](https://www.medsci.cn/comment/like?id=a46c1e221337c) ** 0 ** 举报 2. 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createdTime=Sat Mar 26 03:32:27 CST 2022, time=2022-03-26, status=1, ipAttribution=)] [https://www.medsci.cn/user/feeds?uid=27f02081545](https://www.medsci.cn/user/feeds?uid=27f02081545) 2022-05-07 **[1581f247aam](https://www.medsci.cn/user/feeds?uid=27f02081545) ** 由于胆囊癌预后较差，高度怀疑胆囊癌 的患者无论是否存在症状均应预防性切除胆囊。？？？如何高度怀疑 [179](https://www.medsci.cn/comment/like?id=984a121e61090) ** 0 ** 举报 3. 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createdTime=Sat Mar 26 03:32:27 CST 2022, time=2022-03-26, status=1, ipAttribution=)] [https://www.medsci.cn/user/feeds?uid=27f02081545](https://www.medsci.cn/user/feeds?uid=27f02081545) 2022-05-07 **[1581f247aam](https://www.medsci.cn/user/feeds?uid=27f02081545) ** 胆囊癌：胆囊癌是慢性胆囊炎、胆囊结石最为严重的并发症？？？ [160](https://www.medsci.cn/comment/like?id=750a121e6095d) ** 0 ** 举报 4. 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