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欢迎回到Ninja Nerd播客。
Welcome back to the Ninja Nerd podcast.
别老盯着我看。
Stop looking at me.
他老是盯着我。
He keeps looking at me.
我能感觉到，真的能感觉到。
I can feel I can feel
他一直盯着我。
him staring at me.
能感觉到那些目光直往我身上扎。
Can feel the stares coming.
咱们留着这一段吗？
Are we gonna keep that one
放里面？
in there?
是的
Yeah.
咱们就留着这个吧，各位。
Let's keep that one in there, guys.
这真是个不错的开场方式。
Well, this is a great way to start the podcast.
今天我们要聊的是胰腺和肝胆系统癌症。
Today, we're talking about pancreatic and hepatobiliary cancer.
和之前一样，我们继续按顺序讲肿瘤学系列内容。
Like we've been doing, we're moving through our oncology playlist.
一个一个来。
We're going one by one.
这次我们准备了四个病例。
So we have four cases for this one.
对吧，扎克？
Right, Zach?
是的。
Yeah.
内容真多。
It's a lot.
好。
Alright.
那咱们别浪费时间了。
Well, then let's not waste any time.
对。
Yeah.
你打算怎么开始？
What are you doing?
赶紧开始吧。
Get started.
走起。
Let's go.
你正在做什么？
What are doing?
好的。
Alright.
第一个病例。
Case one.
一位63岁的男性吸烟者。
We have a 63 year old man who is a smoker.
六周来一直瘙痒，尿液发黑，大便发白。
Six week history of pruritus, dark urine, pale stools.
没腹痛也没发烧，但体重莫名掉了七磅。
No abdominal pain or fever, but we do note a seven pound unintentional weight loss.
在做任何检查之前，你们有什么初步判断吗？
Any differentials before going with any testing with with anything at all?
我先说个直觉吧，瘙痒、深色尿、浅色大便，这明显是高胆红素血症。
I mean, just off the top of the dome here, at pruritus, dark urine, pale stool sounds like hyperbilirubinemia.
我的想法就这么简单。
I mean, that's just me thinking about it.
对吧？
Right?
所以，明显是在说胰腺和肝胆系统的癌症。
So, obviously, talking about pancreatic and hepatobiliary cancer.
对吧？
Right?
我知道，理论上瘙痒是因为胆汁酸升高。
So I know that there's theoretically, pruritus is due to elevated bile acids.
尿液发黑、大便发白，通常是因为胆红素堆积，尤其是尿里。
The dark urine, the pale stools, that's usually associated probably more with the bilirubin that's probably built up, especially in the urine.
大便里没胆红素，就少了那种深色，就是粪胆素没了。
And if you don't have the bilirubin in the stools, it loses that kind of darkish color to it, that stercobilin.
胆红素。
Billon.
这大概就是我的想法。
So that's my thought.
不过我也预期会看到一些黄疸。
I would expect to see some jaundice though as well.
做体格检查时，我肯定会问：你眼睛有没有发黄？也就是黄疸？
I don't you know, that's something I would also be looking for doing a physical exam saying, hey, do you have any kind of, like, yellowish discoloration of the eyes, icterus?
手心、脚底有没有发黄？
Is there any kind of yellowish discoloration of the hands, the palms, soles of the feet?
诸如此类的症状。
Things like that.
不过，这基本上就是我接下来会考虑的方向。
But that's kinda what I would think about from there.
如果真是这样，那很可能就是黄疸，而且根据这个情况，大概率是梗阻性黄疸。
If that is the case, I'm thinking that there's something causing jaundice, and it's probably, given the scenario, obstructive jaundice.
所以胰腺癌是我最担心的，尤其是对吸烟、体重下降、还有大便异常的患者——比如脂肪泻，大便发白、油腻，这些都可能是胰腺功能不全的表现。
So pancreatic cancer, which is definitely one of the things I get concerned about, especially in a patient who is a smoker, they have weight loss, and they have some features here of excrement, like, pancreatic insufficiency, maybe via the steatorrhea if they're, like, pale and let's let's say that they're greasy.
这听起来有点怪。
That sounds weird.
大便油乎乎的。
Greasy stools.
但这确实挺让人担心是胰腺癌。
But that's definitely kinda concerning for pancreatic cancer.
原因就是，如果肿瘤长在头部，就会压到总胆管。
And the reason why is if it's at the head, it mashes on the common bile duct.
总胆管一被压住，胆汁就流不到小肠里了。
And if you mash in the common bile duct, that bile can't get passed into the small intestines.
所以大便才会发白。
That's why they get the pale stools.
胆红素就堵在那儿了。
Bilirubin backs up.
胆盐也回流了。
Bile salts back up.
它们会进入血液循环。
They get into the circulation.
然后开始渗到组织里去。
They start spilling out into tissues.
就会引起瘙痒。
You get pruritus.
一部分还会排到尿里，导致尿胆红素升高，所以尿色变深，很可能还伴有黄疸。
They kind of spill over into the urine, you get hyperbilirubineuria, that's where get the dark urine, and then you probably have some jaundice.
所以这才是我最担心的，体重下降也明显提示可能是恶性肿瘤。
So that's what I'd be concerned about, and the weight loss is definitely concerning for malignancy.
太不妙了。
Ominous.
对吧？
Right?
吸烟是胰腺导管腺癌一个非常非常大的风险因素。
And smoking is a huge, huge risk factor for pancreatic adenocarcinoma.
我知道我们在谈胰腺肝胆癌，但你怎么能确定这跟肝脏没关系呢？
I know we're obviously talking about pancreatic hepatobiliary cancer, but how can you rule out that it's not liver related?
是的。
Yeah.
没法确定。
You can't.
对吧？
Right?
也有可能是别的原因。
I I could always be something else.
可能是肝炎。
It could be hepatitis.
也可能是胆结石。
It could be cholelithiasis.
其实那儿可能有好多不同的情况。
Like, they could have a lot of different things there.
他们可能只是得了胰腺癌，或者胆总管里有结石。
They could just have pancreatic cancer or maybe they could have a stone in the common bile duct.
也可能是胆管癌。
They could have a cholangiocarcinoma.
也就是说，胆管里长了肿瘤。
So they could have a tumor in the bile duct.
也可能是肝炎。
They could have hepatitis.
也可能是药物引起的。
It could be due to medication related.
也可能是病毒性肝炎。
It could be due to viral hepatitis.
还可能是布加综合征。
There could be Budd Chiari syndrome.
可能性太多了，说不完。
There could be so many different things.
那你是先从
So do you just start off with a
一堆化验开始，慢慢 narrowing down 吗？
whole bunch of labs and see what you kinda boil down to?
我第一件事就是确认胆红素和碱性磷酸酶是不是真的很高。
I would just make sure that the bilirubin in alk phos is really elevated first.
因为这能告诉我是不是有胆汁淤积。
That's probably the first thing because that's gonna tell me if they have cholestasis.
如果我做肝功能检查，我预期碱性磷酸酶会偏高。
And so if I did a LFT workup, I would expect expect the alkaline phosphatate level to be high.
如果它高了，那更可能是胆管系统或者胰腺头部那边有梗阻。
And if that's high, it's more likely an obstructive pathology, somewhere within the duct system or near the pancreas, like, head.
所以这大概是我最先要查的。
So that's probably what I'd start out with first.
如果结果出来是碱性磷酸酶、胆红素、还有AST、ALT这些肝酶都高，那我就觉得问题出在肝脏附近。
If it came back where it had an elevated alk phos, bilirubin, and elevated LFTs, like AST, ALT, then I'm thinking something around the liver.
但如果发现不是真正的肝细胞损伤，而是明显指向胆道梗阻或者胆管相关的问题，这时候我就会重点查碱性磷酸酶和胆红素指标。
But if I had something that came up where it's not truly hepatic hepatocellular injury, it really seems like it's more specifically obstructive or choledoco related or something within the biliary system, that's when I would be checking the alk phos and the biliary.
我会先确认是不是这两项升得最明显。
I've been seeing if those are the primary elevated ones.
如果这两项真的偏高，那肯定哪里出了问题，可能是总胆管、胆管系统附近，或者胰管和胆胰管汇合的壶腹区域。
If that came back elevated, something is going on, something in the common bile duct, near the ductal systems, or near the pancreatic duct and where they join the ampulla.
这时候我就会安排做个右上腹超声。
So that's when I would probably go to a right upper quadrant ultrasound.
只要碱性磷酸酶和胆红素升高，哪怕肝功能指标AST、ALT突然也升了，我都会立刻安排右上腹超声。
Anytime you have elevated Alk Phos, elevated bilirubin, and even if you have an acute elevation in the LFTs, like AST and ALT, I get a right upper quadrant ultrasound.
第一步先排除梗阻，这是最要紧的。
Right away, it's gonna rule out obstruction first thing.
明白了。
Cool.
就算他没任何疼痛，也不打紧。
And even though he has no pain, it doesn't matter.
你的化验结果已经指向这个方向了。
Your your labs have steered you in that direction.
说来有趣，很多时候他们得的是无痛性梗阻性黄疸。
Oftentimes, funny enough, they have what we would call painless obstructive jaundice.
这让我更倾向于怀疑是胰腺导管腺癌。
And that makes me think more likely than anything for it to be, like, pancreatic adenocarcinoma.
因为情况有点特别，胰腺头部靠近胆总管，压住它，导致胆汁反流，一路回流到胆囊管和胆囊，胆囊就肿起来了。
Because what happens is, it's kinda weird, pancreatic head goes near the kambal duct, smashes on it, backs up, and it backs up into the cystic duct into the gallbladder, and the gallbladder enlarges.
所以你摸右上腹的时候，能摸到一个包块，那就是肿大的胆囊。
And so you can actually go and you can palpate near the right upper quadrant, and you'll feel a mass, and it's their gallbladder.
如果你按下去，一般人会以为是胆囊发炎，肯定疼。
And if you press down, you would think, oh, that would elicit pain if it was, like, inflammation of the gallbladder.
但这种情况下，它就是不疼。
But in this case, it doesn't.
这叫卡瓦西耶征。
It's called Carvossier's sign.
Carvossier征对由胰腺导管腺癌引起的无痛性梗阻性黄疸和胆囊无痛性肿大，几乎可以说是特异性的表现。
And Carvossier's sign is kind of like I'd say it's somewhat pathognomonic for pancreatic adenocarcinoma that's causing obstructive jaundice and a painless enlargement of the gallbladder.
遇到这种情况，我们通常就会往这个方向考虑。
That's usually the kind of thing to think about.
就这一点来说，真的让我挺震惊的。
And and that right there, because that's just that's shocking for me to hear that.
但正因为它是无痛的，这就把鉴别诊断引向了完全不同的方向，跟有痛的情况完全不一样。
But right there, that could be a huge differential to many different things saying that if it is painless, it it does lead you in a different direction than Yeah.
而不是因为疼。
Than it being painful.
对。
Yeah.
如果病人是疼的，尤其是右上腹痛，我第一反应就是胆总管结石。
Because if I had a patient who was, like, it was painful, then I'm definitely thinking about, like, especially if it's right upper quadrant pain, choledocholithiasis is a big one.
还有急性胆管炎，也得重点考虑。
Ascending cholangitis is a big one.
胆管癌，也可能是这个原因。
Cholangiocarcinoma, it could be.
确实有可能是。
It definitely could be.
肝炎，任何类型的肝炎损伤，通常都会伴有右上腹疼痛。
Hepatitis, any kind of hepatitis related injury, probably gonna have some degree of, like, right upper quadrant pain.
所以，既然这通常是无痛的，那在这种情况下来讲，更让人怀疑是胰腺导管腺癌。
So the fact that this is usually painless is is definitely gonna be more suspicious, I think, in this case for pancreatic adenocarcinoma.
我们做了右上腹超声，结果出来：胆总管12毫米，肝内胆管扩张，没有胆结石，胰腺头部有个边界不清的3厘米肿块。
Well, we do the right upper quadrant ultrasound, and we get the result back where we have a CBD 12 millimeter intrahepatic ducts dilated, no gallstones, indistinct three centimeter mass at the pancreatic head.
对。
Yeah.
胆总管肿得厉害。
So the compound duct is gargantuous.
这尺寸可真不小。
That's pretty big.
肝内胆管也扩张了。
And intrahepatic ducts are dilated.
这说明胆汁淤积得很厉害，胆汁都倒流了。
That means that a lot of the there's lots and lots of obstructive cholestasis, so backflow of bile.
没发现胆结石，那就排除了胆总管结石。
No gallstones mean there's no choledocholithiasis.
胆总管和壶腹区域都没看到任何结石。
There's no stones that are kind of, like, in the common bile duct, none in the kind of the ampullary area.
胆管里也没看到什么肿块，比如胆管癌或者胆道肿瘤之类的。
And then there's nothing kind of in the ducts that we see that's kind of a mass, like a cholangiocarcinoma or biliary duct mass.
这点挺有帮助的。
So that's kind of helpful.
胆囊也没问题，不是胆囊炎。
And then the gallbladder is fine, so there's no cholecystitis.
除了胰头那个三厘米的肿块，其他实在没什么特别明显的异常。
There's no kind of things that really scream at me except for that three centimeter mass at the pancreatic head.
然后，很明显，总胆管正在出现那种
And then, obviously, the common bile duct is having that
梗阻的表现。
obstructive presentation.
没错。
It's Yeah.
它很大。
It's big.
它在反流，你知道的，胆汁回流了。
It's being it's, you know, it's it's backflowing.
对。
Yep.
这通常让我觉得，很可能是胰腺导管腺癌，伴有梗阻性胆汁淤积的典型表现。
And that usually kinda screams to me like this is probably pancreatic adenocarcinoma with a obstructive cholestasis kind of picture.
那接下来你的诊断步骤是什么？
Then what's your next diagnostic step?
那我可能会建议，咱们得把胰腺的影像看得更清楚一点。
I'd probably then say, let's get a better image of the pancreas.
首先呢，有个专门针对胰腺的扫描方案。
And so the first thing is there's a pancreas pancreatic protocol.
所以我一般会做腹部CT。
So I get an abdominal CT.
会用造影剂，重点盯着胰腺，拍非常非常薄的断层图像。
I would do with contrast, and it's really gonna focus in and take very, very, very thin sectioned looks at the pancreas.
这样就能看得特别清楚了。
I'll get it I'll be able to get a really, really good idea.
肿瘤是在胰腺头部吗？
Is this in the pancreatic head?
它长什么样？
What does it look like?
有没有侵犯附近的血管？
Is it invading some nearby vasculature?
它大吗？
Is it large?
范围广吗？
Is it extensive?
有没有侵入胰体？
Is it into the body?
有没有跑到胰尾去了？
Has it gone to the tail?
有没有开始影响周围器官？
Has it starting to involve nearby organ systems?
所以接下来我一般会先做个更清楚的检查，看看具体情况。
And so that'd probably be my first way to go from here, get a better look at it.
如果你心里有点怀疑，但又不太确定，其实还可以做内镜超声。
And then you also really could if let's say that you had any degree of suspicion, I'm like, I'm not sure if this is, you can always do an endoscopic ultrasound.
直接取组织活检，因为我们靠影像看到的胰腺肿块只是影像诊断，最终还得靠组织病理来确认。
Go down and grab tissue because we can see a pancreatic mass, right, on imaging, and that's imaging related diagnosis, but we may need a tissue diagnosis.
所以我觉得如果CT结果高度提示是胰腺癌，那就可以安排做EUS也就是超声内镜，取一点样本。要是需要抽吸组织的话，直接扎进去抽一点组织出来，确认是不是胰腺腺癌，
And so I would say if I get the CT really screams pancreatic cancer, you could go forward with an EUS, endoscopic ultrasound, take a small little kind of FNA, if if I need a little aspiration, pop it right into there, pull back some tissue, see if I can confirm that that's like a pancreatic adenocarcinoma.
这大概就是我处理这个病例会采取的流程了。
That's probably the way that I would go forward with this one.
好的。
Okay.
CT显示胰头有一个3厘米的肿块。
CT shows a three centimeter mass in the pancreatic head.
我们确实查到有肿块。
We have that mass.
这个肿块的位置刚好挨着肠系膜上静脉，是这样的。
It it's kind of a it abuts the superior mesenteric vein Okay.
但没有包裹住血管。
But there's no vessel encasement.
好的。
Alright.
肝脏没有病灶。
No liver lesions.
通过内镜超声引导下的细针穿刺，我们确诊了导管腺癌，CA19-9指标是620，正常值应该低于37。
And then on that endoscopic ultrasound with the fine needle aspiration, we do show ductal adenocarcinoma, and we have a CA nineteen nine level of six twenty with the norm being less than 37.
是的。
Yeah.
这很有帮助。
That's helpful.
我刚才忘了提CA19-9这个指标。
I forgot to mention a CA nineteen nine.
它本身不能确诊，但很有参考价值。
It's not like diagnostic, so it's helpful.
能帮我们做鉴别诊断。
It helps in the differential.
比如，当我看到胰腺有肿块时，CA19-9更多是预后指标。
Like, if I have a pancreatic mass, c a nineteen nine is more a prognostic level.
比如，如果病人是结直肠癌，我们就会查CA指标。
So it's, for example, if a patient has colorectal cancer, we check c a levels.
如果是卵巢癌，那就查CA125。
If they have ovarian cancer, we check c a one twenty five levels.
这个是酶吗？还是说到底是个啥？
Is that, like, an enzyme or what what is
这是肿瘤标志物。
It's got, a tumor marker.
哦，肿瘤标志物啊。
Oh, tumor marker.
对。
Yeah.
就跟我们之前聊睾丸癌时说的AFP一样，都是类似的。
So it's like is so similar to, like, when we talked about testicular cancers, like AFP Yeah.
还有LDH和β-hCG。
LDH and beta h c g.
差不多是同一个道理。
It's kind of a similar thing.
其实就是个标志物。
It's kind of like a marker.
它本身不一定能直接确诊，尤其是这种情况，但确实会发出强烈信号，提示可能性更大。
It's not necessarily per se diagnostic, especially in this case, but it does scream somewhat it's more likely.
但它最主要的作用是帮我们建立一个基线值。
But its primary indication and utilization is saying, here's what their baseline is.
所以我们之前测这个值特别好，这样一旦开始治疗——比如做胰十二指肠切除术，或者别的手术——我们就能看看术后CA19-9的数值变成什么样了。
So it's good that we got that because then what we can do is once we start treating them, maybe we do a Whipple, maybe we do some other kind of procedure, we say, what does the c a ninety nine looks like now after we've done the procedure?
飙升了。
Through the roof.
对。
Yeah.
所以这明显强烈指向胰腺癌。
So it definitely screams a lot of this is it's definitely pancreatic cancer.
没侵犯其他血管，这点挺有利的。
The fact the fact that it hasn't invaded any other vessels is helpful.
明白了。
Okay.
现在还看不出来有没有转移。
You can't really tell if there's metastasis just yet.
胰腺癌一般不会特别远地扩散到其他地方。
Pancreatic cancer doesn't oftentimes, like, super crazy distantly metastasize.
它更多是侵入血管，把血管包得死死的，但通常不会跑到肺部那种地方。
It goes into the vessels and can encase those pretty bad, but it doesn't usually, like, go, like, to the lungs or something.
可能会转移到肝脏。
They may go to the liver.
肝脏算是它最常去的地方了，不过大多数时候还是局限在原位附近。
It's kind of the closest thing that it may go to, but it's usually it's gonna stay kind of right
就停在那儿，慢慢侵袭周围的血管。
there and it just starts to invade nearby vasculature.
幸运的是，我们这位病人肝脏上没有任何病灶。
And and, fortunately, for our patient, there was no liver lesions.
是的。
Yeah.
对。
Yeah.
所以我觉得，这位病人的情况确实属于可切除的胰腺癌，预后还算不错。
So that's So I think that this is definitely a patient who has a I'd say a a decent I'd say a resectable pancreatic cancer.
那他的预后能算比较乐观吗？
So his prognosis is can be fairly okay?
我觉得是有这个可能的。
It's I think it's a a possibility.
现在关键是要跟外科团队好好沟通一下。
I think that it's just the tough thing now is that we have to talk to surgery.
外科。
Surgery.
所以跟外科沟通的时候，我们得说：嘿。
And so when we talk to surgery, we have to say, hey.
我这儿有个病人，确诊是胰腺导管腺癌。
I I I got a patient who's got a pancreatic ductal carcinoma.
他出现了梗阻性黄疸。
They got obstructive cholestasis.
他的CA19-9指标高得有点吓人。
They got a c a nineteen nine level that's pretty high.
目前来看，没有血管侵犯，也没有远处转移的迹象。
They have no vascular invasion, no distant metastasis that is visible at this point in time.
你觉得该做哪种手术比较合适？
What's your recommendation for surgical procedure?
我觉得唯一可行的方案，可能就是做惠普尔手术，也就是胰十二指肠切除术。
And I think the only thing you can really do is maybe like a Whipple, which is like a pancreaticoduodenectomy.
不过这手术可真够复杂的。
But that's a pretty complicated procedure.
这事儿牵扯的东西可太多了。
There's a lot of things that go into it.
所以从外科整体评估来看，我觉得这才是该做的决定。
So that's what I would say would be the decision based upon the surgical kind of, like, overall evaluation.
他们觉得这方案对这病人来说是最合适的吗？
Do they think that this is the best way to go with that one?
因此我觉得，这里还是选惠普尔手术比较靠谱。
So that's why I'd say Whipple would probably be the way to go here.
术后辅助化疗也得跟上，这很关键。
And then adjuvant chemotherapy would probably be the good way.
化疗药种类可多了。
There's all kinds of agents.
吉西他滨用得最多，但最重要的是得先做惠普尔手术，还得跟外科团队好好沟通，看看他们觉得行不行。
I think gemcitabine is the commonly utilized one, but I think the big thing is your whipple and talking with surgery to see if that's a good go for them.
肿瘤切掉之后，理论上说，那个梗阻性胆汁淤积应该就会好转了。
For the the the tumor, once you remove it, theoretically, the obstructive cholecystitis should improve.
对。
Yep.
很明显，如果他们的胆红素水平特别高，情况可能不太乐观，症状也会更严重。
Obviously, the time frame, if they're having, like, a really, really high bilirubin level, it can, you know, portend a relatively poor kind of, like, symptom mythology.
所以，梗阻性黄疸、瘙痒这些症状都是常见的。
So, obviously, obstructive jaundice, pruritus, etcetera.
理论上可以先放个支架临时缓解，但我们的目标还是尽可能做胰十二指肠切除术。
You could theoretically put a stent in there temporarily, but the goal here is gonna be doing the whipple if you can.
如果肿瘤位置更靠尾部，就得做远端胰腺切除，有时候还得切脾脏，因为癌细胞确实可能累及脾脏。
If it was, like, more distal, like, near the tail, you'd have to do a distal pancreatectomy, and sometimes they remove the spleen too because it can actually go to the spleen.
这也是我们得考虑的一个问题。
So that's another thing that we have to worry about.
所以要是肿瘤在更靠尾部的位置，就可能影响到脾脏。
So if it was more distal, it would go to the spleen.
那我们就得把那部分胰腺切掉，脾脏也可能得一并切除。
So I'd have to cut that portion out and then potentially remove the spleen as well.
所以通常的方案就是手术切除。
So that's the options that you usually have is surgically removing it.
化疗才是该坚持的方案。
Chemotherapy would be the way to go adumantly.
有时候只能在没法切除的情况下才用。
Sometimes we only can if it's, like, not resectable.
如果切不了，那就只能靠化疗和一些缓解性操作，比如放个支架。
You may be stuck with just, like, chemotherapy and, like, palliative procedures, like putting in a stent because you can't cut it out.
这大概就是我对这个病人的建议了。
So that's kinda what I would say for this patient here.
好的。
Alright.
第二个病例。
Case two.
好的。
Alright.
这位58岁的男性，有长期代偿性的乙肝肝硬化病史。
We have a 58 year old man with a long standing compensated history of hepatitis b cirrhosis.
明白了。
Okay.
每半年做一次超声，发现右叶新长了一个2.5厘米的病灶。
Semiannual ultrasound shows a new two and a half centimeter right lobe lesion.
他的甲胎蛋白值从12升到了180。
His AFP level rose from 12 to a 180.
你第一反应会想到什么？
Where does your mind go?
首先，我马上想到肝细胞癌。
So first thing is hepatocellular carcinoma.
当然，也可能有别的可能性，这个我们都知道。
I mean, there's a lot of other things that, you know, you could think about here.
但一听说超声发现肝叶占位、甲胎蛋白飙升，再加上肝硬化病史，还是乙肝引起的——这简直警报大作，基本不可能是别的病，十有八九就是肝癌。
But right off the get go, when I hear ultrasound shows a lobe lesion, AFP's elevated, and they have a history of cirrhosis, and on top of that, it's hepatitis b related, those are, like it's like alarm bells are screaming that this could be nothing else but hepatocellular carcinoma.
也可能是结节或者胆管癌之类的，但可能性极低。
There could be things like nodules and cholangiocarcinomas and things like that.
几乎不可能。
Very, very unlikely.
肝硬化患者患肝细胞癌的风险非常高。
When a patient has cirrhosis, they're super high risk for hepatocellular carcinoma.
即使没有肝硬化，只要感染了乙肝，患肝细胞癌的风险也很高。
If you have hepatitis b without cirrhosis, you're super high risk of hepatocellular carcinoma.
而他这两项都占了。
So they have both of those.
是的。
Yeah.
这情况不妙。
That's that's not good.
对。
Yeah.
而且这位患者查出了病灶，甲胎蛋白指数也有异常。
And they have a lesion and they have an AFP level.
还记得之前提过CA199吗？这个指标多少和胰腺腺癌有点关联对吧。
So remember how we said c a 99 is kinda somewhat associated with, know, your pancreatic adenocarcinomas.
在现在这种情况下，要是甲胎蛋白指数高得离谱，基本就高度提示是肝细胞癌了。
AFP levels that are really, really high in this kind of scenario do somewhat scream hepatocellular carcinoma.
好的。
Okay.
那我觉得目前的情况是，超声已经查出有病灶，而且甲胎蛋白也升高了
So what I would say is now that we have an ultrasound that shows that they have a lesion, they got an AFP that bumped.
我会直接安排做三期CT
I'm gonna go straight to a triphasic CT.
就是腹部三期CT，我们会观察造影剂流过肝脏的情况，看看这个肿块会不会有强化，也就是亮度会不会突然变高
So it's a triphasic abdominal CT, and it looks at the the contrast as it moves through the liver to look to see if the mass kind of, like, hyper attenuates and it really, really gets bright.
之后我们还要看门静脉期的造影剂洗脱情况，确认会不会快速出现门静脉期洗脱
And then we look at the portal venous wash out to look to see if they have a quick portal venous wash out.
这样通常是最清楚看到肿块动脉期强化、以及门静脉期快速洗脱的方法，这基本就能提示是肝细胞癌了。
And that usually is gonna be the best way of being able to kinda take a look at the mass and look for a arterial hyperenhancement and then a quick portal venous wash out would be pretty suggestive of hepatocellular carcinoma.
明白了。
Alright.
三相CT结果出来了，病灶确实有动脉期强化和门静脉期洗脱。
The triphasic CT comes back with a lesion showing arterial hyperenhancement with portal washout.
有包膜表现，没侵犯门静脉，也没有肝外转移。
Capsular appearance, no portal vein invasion, no extra hepatic disease.
好的。
Alright.
这不错。
Well, that's good.
没累及门静脉其实挺好的，说明情况没那么糟。
So the fact that it didn't get to the portal vein is actually not that's that's a decent thing.
嗯。
Okay.
一旦癌细胞侵入门静脉，情况就复杂多了。
Because once you get portal vein invasion, it makes things a lot more challenging.
要是出现门静脉侵犯，很多本来想给病人做的治疗就都没法进行了。
A lot of the things that you wanna try to do for the patient, you can't really do for them when you get portal vein invasion.
特别是有些手术操作，根本做不了。
Especially, like, there's procedures.
这个我们待会儿细说。
We'll talk about them.
比如经动脉化疗栓塞，就是把化疗药和微小的栓塞颗粒混合后打进去，堵住肿瘤的供血血管。
There are things like do have these transarterial chemoembolization where you shoot chemo and you shoot at these, like, little, like, emulsified, like, little embolic materials and you block off the blood flow to the actual tumor.
因为这类肿瘤通常血供特别丰富。
Because usually these tumors are super vascular.
只要把血流一堵，肿瘤就可能被饿死。
If you block off the blood flow, you could potentially starve the tumor.
理论上，肿瘤可能缩小，甚至被清除，至少也能杀死一大片癌组织。
And, theoretically, you could reduce its size, maybe even remove it, or at least kind of, like, kill a good chunk of that cancerous tissue.
但如果你的门静脉完全被堵死了，那就没法做这个了，因为根本没别的血供了。
But if you have a if you have a paddock a portal vein that's completely, like, cut off, you can't do that because now you have no other kind of, like, blood supply.
这时候问题就彻底来了。
The the the complete problematic issue would arise.
所以我觉得还不错的是，他们没出现门静脉侵犯，但这儿确实有个挺严重的病灶。
So that's one thing I think is decent is that they don't have any portal vein invasion, but they got they got a pretty, like, nasty kind of, like, lesion here.
我得弄清楚的是，他们有没有门静脉高压？
I think the thing I have to know is is do they have portal hypertension?
而且他们也没表现出任何门静脉高压的症状。
And they don't have any kind of, like, portal hypertension symptoms.
门静脉高压的症状，比如腹水之类的。
So portal hypertension symptoms would be things like ascites.
我翻了病历，没看到任何腹水的记录，而且从我看到的情况来看，他们代偿得还挺好的。
I don't see any mention of ascites in the patient's history, and they're pretty compensated from what I read, actually.
另外，如果有门静脉高压，通常还会出现食管静脉曲张、脐周静脉曲张这些表现。
The other thing is they would have things like esophageal varices that would be present, capit medusae.
他们的肝功能指标也可能稍微偏高。
They could have a potentially a an elevated LFTs as well somewhat.
这些都算是信号，黄疸也是肝功能失代偿的另一个表现。
And so these are all kind and then jaundice would also be another way of kind of them presenting with a decompensated state.
所以我看不出他们有门静脉高压，或者严重的并发症和失代偿迹象。
So I don't see any concerns of portal hypertension or kind of like a a decompensated or high degree of comorbidity of their disease.
这意味着，我有可能切掉一部分肝脏。
So what that tells me is that there's a chance that I could remove a piece of that actual liver.
你想想这种情况。
So think about this.
如果一个乙肝肝硬化患者得了肝癌，还伴有门静脉高压，肝脏病变范围很大，你切掉一大块后，剩下的肝组织功能已经很差了。
If I had a patient who had hepatitis b cirrhosis, they now have cancer, and they have portal hypertension, they have a lot of disease in their liver, and you cut out a good chunk of and the remaining tissue that's left is, like, not very functional Yeah.
那患者的生存期就会变得非常糟糕。
You're gonna leave them with a very, very bad overall kind of, like, lifespan now.
对。
Yeah.
因为他们现在剩下的功能性肝组织已经很少了。
Because now they have very little functional tissue.
大部分都已经被破坏了。
Most of it's destroyed.
他们很可能出现失代偿，发展成肝功能衰竭。
They're gonna potentially decompensate, go into, like, decompensated liver failure.
所以除非剩下的肝组织功能还很好，否则我们绝不会贸然切除大块肝组织。
So that's why we would never wanna do, like, real significant chew like, huge chunks or removal of tissue unless they had good functional liver tissue remaining.
但对这个病人，我觉得他们的肝功能其实还行。
So for this one, I feel like they actually do.
他们的肿瘤并不大。
Their tumor is not huge.
通常小于等于三厘米算是比较合适的大小，而且他们也没有门静脉高压。
Usually, less than or equal to three centimeters is a decent size, and they also have no portal hypertension.
我觉得这个情况适合两种治疗方式，射频消融，效果其实差不多。
I think that this would be good with either two options, radiofrequency ablation, which only really works and has equal equivalent results.
所以，如果你做肝切除的话，复发率其实差不多。
So, like, the recurrence rate is about the same if you were to do a hepatectomy.
你切掉一块组织，比如我通常做个小楔形切除，或者用射频消融。
So you remove a chunk, like, I do, like, a little wedge removal and radiofrequency ablation.
这两种方法都可以考虑。
So those would be the two options.
我可能会跟外科医生聊聊。
I'd probably talk to surgery.
看看他们是怎么想的。
I'd probably see what they think about it.
对这位病人来说，射频消融或者做个小小的楔形肝切除，大概是最合适的方案。
But an RFA or, like, a little, like, wedge hepatectomy would probably be the way to go here for this patient.
这位病人以后有没有可能适合做肝移植？
Would this patient ever get to a point where he would be it'd be
适用肝移植吗？
applicable for a transplant?
我觉得如果他们有门静脉高压的话。
I'd say if they had portal hypertension.
明白了。
Okay.
要是真有门静脉高压，那我基本就得给他们换肝了。
If they have portal hypertension, then I gotta I gotta give them a new liver, probably.
意思是，如果你切掉一部分组织，
Meaning that if you remove tissue,
那我等于把他们撂那儿了。
you're I'm gonna leave them out.
等于让他们以后 Decompensate 的风险大大增加。
I'm gonna put them in a high chance of them decompensating in the future.
那这么干就完全没意义了。
So it wouldn't be any there'd be no reason to do that.
那就只能考虑肝移植了。
You would have to get a transplant.
我觉得要是肿瘤特别大，那肯定得考虑移植。
I'd say if it's a really big tumor Yeah.
如果得切掉一大块肝组织，留下的健康组织太少，或者肿瘤虽然还不到三厘米，但肝脏整体损伤很严重，比如Child-Pugh评分很高，那也得小心。
Where I have to cut out a lot of tissue, and so I'm very I'm leaving very little tissue left, or if it's a tumor size that, let's say, it's still, like, less than three centimeters, but they have significant disease, significant disease on their liver, like, child pugh score is really high.
再加上门静脉高压的话，
And then they have portal hypertension.
我基本就不会考虑射频消融这类治疗了。
I'm probably not gonna do any kind of, like, RFA.
更不会冒险做楔形切除。
I'm not gonna take any chance with a wedge.
直接转诊给肝移植外科医生，跟他们说：
I'll probably just go straight to referring them to a transplant surgeon saying, hey.
咱们看看能不能给这个病人安排个肝移植吧。
Let's see if we can get a transplant for that patient.
明白了。
Gotcha.
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好的。
Alright.
第三个病例。
Case three.
好的。
Alright.
我们现在有一位48岁的女性，有原发性硬化性胆管炎病史。
We now have a 48 year old woman with a history of primary sclerosing cholangitis.
她过去四周出现进行性瘙痒、黄疸，还有陶土色大便。
She had four weeks of progressive pruritus, jaundice, and alcohol and acolic stools.
我差点说成酒精性了。
I almost said alcoholic.
她来就诊时，
And she she presents with She
喝了点啤酒。
had the beer shats.
看到了吧？
See?
我可没说这话。
I I I didn't say it.
是你自己说的。
You said it.
对。
Yeah.
是我讲的。
I said it.
别杀我啊，求你了。
Don't don't kill me, please.
对不起。
I'm sorry.
病人没有发烧。
The patient has no fever.
ALP是720。
ALP is seven twenty.
总胆红素是10。
Total billy is 10.
哇哦。
Wow.
这数值挺高的。
That's high.
确实高。
That's high.
这有点高啊。
That's pretty high.
是啊。
Yeah.
行吧。
Alright.
那PSC跟你说了什么？
So what is the the PSC telling you?
就像个billy那样。
Like a billy.
我平时看到的billy，一般也就四、五、六的样子。
Like, I usually, like, the billies I've seen are, like, four, five, six.
我从来没见超过十的，那也太离谱了。
I've never seen one ten, but that'd be that'd be crazy.
十可不妙。
10 is not good.
对啊。
No.
没错。
No.
她眼睛黄得像……
Her her eyes are are yellow as
太阳。
the sun.
很有可能。
Likely.
没错。
Right.
真的非常有可能，老兄。
Very, very likely, man.
认真的。
Seriously.
但我最想知道的是，这个PSC到底在告诉你什么？
But my my my main question is, like, the PSC, what is that telling you?
PSC不是和溃疡性结肠炎有关吗？
Isn't PSC isn't there connection with ulcerative colitis?
天哪。
Oh, my boy.
说实话，这太棒了。
Honestly, that's awesome.
对。
Yeah.
嘿。
Hey.
我有在留意。
I I pay attention.
有时候确实会。
Sometimes it does.
我会尽量的。
I try to.
偶尔吧。
Sometimes.
我也没提前看。
I didn't read ahead either.
我没作弊。
I didn't I didn't cheat.
这观察得很准，溃疡性结肠炎里这情况其实挺常见的。
That's very, very, like, astute is that it's it's very common in ulcerative colitis.
一般来说，溃疡性结肠炎和原发性硬化性胆管炎经常是一起出现的。
So usually ulcerative colitis and primary scleros and cholangitis are kind of going hand in hand with each other for the most part.
所以只要患者有原发性硬化性胆管炎，那就是个重大风险因素，因为这会引发炎症。
And so whenever a patient has PSC, it's probably one of the biggest risk factors because you're causing, unfortunately, inflammation.
这背后很可能有自身免疫系统对胆管的攻击，这种免疫攻击和炎症会增加突变和异型增生的风险。
So there's probably a degree of, like, autoimmune attack on the biliary tree, and that autoimmune attack and inflammation creates opportunities for display like, mutations, dysplasia.
异型增生会发展成癌症。
Dysplasia turns into carcinoma.
所以他们患胆管癌的风险非常高。
And so it puts them at super high risk of cholangi cholangiocarcinomas.
最让人担心的就是，只要患者有原发性硬化性胆管炎，你就得特别当心，因为他们得胆管癌的风险极高——这种癌长在胆管里。
That's one of the concerning things is anytime a patient has PSC, you definitely have to be really careful because they have a very high risk of cholangiocarcinoma, which is a tumor that occurs in the biliary ducts.
说到PSC通常发生的位置，
Now location wise of where PSC is usually occurring.
PSC更多影响的是肝外胆管系统，肝内胆管受累没那么明显。
So PSC affects more often the extrahepatic duct system, not as much the intrahepatic duct system.
而我们说原发性胆汁性肝硬化时，那主要是肝内胆管发炎很严重。
Usually, that where we talk about primary biliary cirrhosis, that one definitely has a lot of intrahepatic duct inflammation.
但PSC呢，虽然也可能波及两者，但主要还是攻击肝外胆管。
But this one, it can kind of involve both, but it's primarily gonna be hitting those extrahepatic ducts.
所以当我看到原发性硬化性胆管炎的时候，我第一反应就是胆汁淤积性梗阻的症状，
But, yeah, that's what I'm definitely thinking is when I see a primary sclerosing cholangitis, they have symptoms where it's obstructive cholestasis.
胆汁淤积性梗阻意味着患者会有瘙痒——因为胆盐升高，还有黄疸——因为胆红素升高，以及灰白色大便，说明粪便里基本没有胆盐或胆红素，所以颜色才这么淡。
Obstructive cholestasis meaning they have pruritus probably because of the elevated bile salts, jaundice because of elevated bilirubin and a colic stools, which just means that they don't have, probably, any kind of bile salts or bilirubin in their actual stool to give it that color.
明白了。
Okay.
所以我会特别留意碱性磷酸酶和总胆红素，这两项指标肯定高得离谱。
And so that's what I'm definitely thinking the alk phos and total bilirubin level that's through the roof.
这是梗阻性胆汁淤积。
It's obstructive cholestasis.
从这点来看，我完全可以考虑。
So from there, I think I could definitely consider.
我可能会直接建议做个MRCP，但其实更稳妥的做法是先做个右上腹超声，看看情况。
I would probably feel good enough just saying we can do an MRCP, but I think it's always astute to, like, do a right upper quadrant ultrasound first and say, hey.
有没有胆道肿块？
Is there a biliary mass present?
哦，明白了。
Oh, okay.
确实有个胆道肿块，像是胆管树上的肿块。
There is a biliary mass, like a biliary tree mass.
好的。
Alright.
那我们就做MRCP吧。
Then let's do an MRCP.
我觉得，如果直接上最确定的检查，那肯定是MRCP。
I think from here, I feel pretty confident that if I wanted to go straight to the most definitive test, I'd see it being MRCP.
如果我有点怀疑这是胰腺癌，或者别的什么东西堵住了胆管，我先做个右上腹超声看看。
If I had any degree of where I'm, like, thinking, could this possibly possibly be be pancreatic adenocarcinoma or any kind of thing else, anything else obstructing that biliary tree, I do a right upper collagen ultrasound first and see that.
不过咱们还是先做MRCP吧。
But I'd let's let's start with MRCP.
我今天有点放飞自我了。
I'm gonna be a little spicy.
行。
Alright.
我喜欢这种风格。
I like the spicy.
MRCP显示肝总管汇合处有个两厘米的明显狭窄。
MRCP shows a dominant two centimeter stricture at the hepatic duct confluence.
明白了。
Okay.
肝内胆管明显扩张。
Significant intrahepatic duct dilation.
是的。
Yeah.
所以，当我想到——
So when I okay.
这又是另一回事。
So that's another thing.
他们之前说那叫什么来着？
They called what was that?
叫肝门部的克拉金肿瘤。
A perihilar Klatskin tumor.
对，没错。
So yeah.
其实就是胆管细胞癌。
It's it's so it's basically cholangiocarcinoma.
这种肿瘤可能发生在不同部位。
There's different areas that it can occur.
最常见的地方是右肝管和左肝管汇合的地方，虽然我不记得具体比例了，但发生率还挺高的，那里会形成一个汇合区。
The most common area, and I don't remember the percentage, but it's a pretty decent size, that when you have the right hepatic duct and the left hepatic duct come together, they make a confluence.
然后，它们最终会合并成肝总管。
And then, eventually, they become the common hepatic duct.
肝总管再和胆囊管连接，胆囊管就变成了总胆管。
And then the common hepatic duct combines with the cystic duct, and then the cystic duct becomes the common bile duct.
所以，通常就在右肝管和左肝管汇合的这个地方——也就是汇合区——克雷茨金肿瘤或者胆管癌最常发生。
So, usually, right at that point where, like, the right and left hepatic duct kinda come together, that confluence, they call that the perihilar region, and that's where the Klatskin tumors or the cholangiocarcinoma is usually most commonly form.
所以我觉得，问题就出在肝管汇合处。
So that's where I'm thinking that that's happening is the hepatic duct confluence.
正因为肿瘤长在这儿，所以它上面的所有胆管都开始鼓起来，对。
And because of that, it's occurring right there, all the ducts proximal to it are getting all bulgy Yep.
变得扩张、增粗。
And dilated and enlarged.
所以这很可能就是原因了，大概率是胆管癌。
So that's that's the likely cause there is a probably cholangiocarcinoma.
要真正确认的话，你可能得往上走一趟。
The only way that you can truly kinda confirm this is you probably have to go up.
你得做个ERCP检查。
You probably have to do an ERCP.
我觉得咱们这儿该做的就是做逆行胰胆管造影。
So that's that's probably what I would say here is to go down, do a retrograde cholangiopancreatography.
从食道下去，穿过胃和小肠，直接从壶腹穿过去，再往上沿着总胆管走。
So you go down the esophagus, you go down the stomach, small intestine, pop right through the ampulla, and then move upwards through the common bile duct.
一边往上走，一边打点造影剂，就能看得更清楚了。
As you move upwards, you can kind of shoot some contrast and get a better look.
我真没开玩笑。
I'm not even kidding.
他们往上走的时候，会带个小工具，能刮一刮。
As they go up, they have this little device that it can scrape.
你就想象一下，有个小刷子，他们能用它轻轻刷一刷那里的细胞。
Like, imagine you got, like, a little, like, a little brush and they can brush the cells there.
然后就可以做一种叫刷检或者刷取活检的操作。
And then you can do what's called, like, a brush a brushing or a brush biopsy.
把那些细胞取下来，收集起来送病理科，看看是不是胆管癌。
And it can take some of those cells and then you can collect it and send it to the pathologist to see if it looks like cholangiocarcinoma.
天哪。
Wow.
所以依我看，从这儿的影像来说，我大概会直接做ERCP，顺便做个刷检或者活检，看看有没有胆管癌的迹象。
So that's probably what I would say is I'd probably from this look out here, I'd I'd probably do an ERCP, get a brush cytology or a biopsy while you're there, and see if it shows any potential for, like, cholangiocarcinoma.
这事儿咱们之前聊过。
We talked about this before.
我觉得是第一个病例的时候吧。
I think it was in the first case.
那CA19-9的值呢？
What about that CA 99 level?
可能会升高。
Can be elevated.
再查一次这个指标吗？
Go for that again?
对。
Yeah.
可以的。
You can.
这个病里确实可能升高。
It can definitely be elevated in this one.
很多胰腺和胆道系统的疾病都会导致这个指标上升。
I would say it's possible a lot of the pancreatic and the biliary tree diseases can have those.
你最好记成是胰腺相关的，不过其实也不一定。
I would try to keep it more easily remembered in your mind as pancreatic, but it can't.
好的。
Okay.
肯定会上升的。
For sure, it'll be elevated.
那这个我先放一放。
Well, I'll I'll leave that one go for now.
好。
Okay.
我们做一下刷检。
We do the brushings.
结果是腺癌阳性。
It's positive for adenocarcinoma.
胸腹CT我们也得做一遍，确保万无一失。
CT of the chest and abdomen, we do that just to make sure we're thorough.
没有远处转移。
There are no distant mets.
你下一步打算怎么处理？
What's your next step?
所以现在，我遇到的这位病人没有远处转移。
So at this point, I I I see a patient who doesn't have any distant mets.
希望也没有其他类型的血管侵犯。
They got, hopefully, no other kind of, like, vascular invasion too.
如果血管侵犯不严重，肝脏周围也没有太多扩散，转移灶也不多，那就可以做——这听起来有点奇怪。
If there's not a lot of vascular invasion and there's not a lot of spread into the liver, like, around the surrounding liver parenchyma and there's not a lot of met metastasis, you can do a it's, like, weird.
做肝段胆管楔形切除，简直疯狂。
You do an in block bile duct liver wedge resection, and it's pretty crazy.
你得把总胆管切掉，再切掉肿瘤上方那块区域。
You, like, you cut the common bile duct and then you cut where, like, the like, right above where the tumor is.
把整个病变部分切除，然后重新连接到肠道里。
You remove that whole disease section and then you reroute that into the intestines.
你得把空肠拉上来。
So you actually take you bring the jejunum up.
天啊。
Wow.
所以你会把空肠拉上来，在肝总管汇合处之前，让那些肝管直接接入空肠。
So you bring the jejunum up and then you have the right before the confluence, you have those, like, hepatic ducts empty directly right into the jejunum.
这样胆汁酸和胆红素就能进入肠腔，继续帮助消化脂肪、促进排便这些功能。
And so that you can still get your bile acids and your bilirubin into the intestinal lumen so that you can still involve it in front of stools and helping with the emulsification of fats and stuff like that too.
我觉得既然已经开腹了，趁这个机会，因为肿瘤容易在肝内扩散，不如顺便切掉一小块肝组织。
And then since I I think it's always wise while you're there because it does get intrahepatically, it's probably also good to take a little resection of liver.
以防万一还有残留的微小转移灶，这么做会更有保障。
Just in case there is any residual micrometastasis, it might be helpful.
所以我一般会切掉一小块肝楔形组织，就在汇合处下方切断，把胆管重新接进空肠，再顺手切掉一点肝组织。
So I'll probably remove, like, a little liver wedge, cut where that confluence is, cut below, reroute those into the jejunum, and then, again, remove a little piece of the liver.
这大概是最稳妥的做法。
That's probably the way to go.
术后还得配合化疗，把可能残留的微小转移灶彻底清除掉。
And then you probably have to follow-up with some chemotherapy after that just to get any any residual micrometastasis out.
这操作真是够特别的。
That's bizarre.
我懂。
I know.
外科医生就是这样，这是我从肿瘤学里学到的一点。
Surgeons are that's one thing I've learned about oncology.
做这种手术，真的说不上来，太……
Surgery for these things are so, like, I don't know.
我不想说难听的，但真的挺优雅的。
I don't wanna, like, be mean, but it's, like, elegant.
你明白吧？
You know?
他们想出来的那些招儿，简直疯狂。
It's like crazy the things that they think about with
确实如此。
this It is.
就是就是。
It's it's
这简直是一门艺术。
an it's an art.
有些东西我以前连听都没听过。
It's things I've never even heard of before.
是啊。
Yeah.
太惊人了。
Amazing.
对啊。
Yeah.
所以，正常情况下你大概就会这么处理。
And so that's kind of the way you probably would go.
要是有血管侵犯、肝脏多处转移或者扩散了，那这些病人基本就只能化疗了。
If it wasn't like, if they had vascular invasion, lot of hepatic invasion, metastasis, it's probably just gonna be chemo for these patients.
你懂的。
You know?
如果肿瘤没法手术切除，那大概也就只能给他们用化疗了。
That that's probably the probably the only thing that you'd really offer them if it was, like, not resectable.
所以血管侵犯范围挺大的，好多大血管都受牵连了。
So it's pretty large vascular invasion, so you got a lot of vast vessels involved with it.
对。
Yep.
已经有转移了。
There's metastasis.
那就不值得再动手术了。
It's it's not worth going after then.
我估计直接建议化疗就行。
I'd probably just say chemo.
行。
Alright.
这个病例，我觉得咱们还能做。
For this one, I think we can do it.
最后一个病例了。
One last case left.
病例四。
Case four.
好的。
Alright.
这位72岁的女性，早就确诊有瓷化胆囊。
We have a 72 year old woman with a known porcelain gallbladder.
听着真不靠谱。
Doesn't seem real.
对吧？
Right?
咱们先停这儿吧。
Gonna go
别往下说了。
ahead and stop right there.
我得问一下。
I gotta ask.
对。
Yeah.
什么叫瓷化胆囊？
What's a porcelain gallbladder?
对。
Yeah.
没错。
Yeah.
这在慢性胆囊炎里还挺常见的。
So this is pretty common with chronic, like, cholecystitis.
比如慢性胆囊炎，你可能也会遇到急性胆囊炎，就是胆囊发炎、感染。
So if vision is chronic cholecystitis, so they have you can have acute cholecystitis, which is like inflammation, infection of the gallbladder.
如果反复发作——这种情况确实会发生——长期发炎会导致钙化。
If you get repeated attacks, which can happen, this can cause a lot of inflammation that causes calcifications.
就跟胰腺炎一个道理。
It's just like pancreatitis.
要是急性胰腺炎反复发作，就可能变成慢性胰腺炎。
If you get acute pancreatitis and you keep getting bouts of acute pancreatitis, you can develop chronic pancreatitis.
对。
Mhmm.
这种情况挺常见的。
And that usually occurs.
里面会有很多钙化和纤维组织长出来。
It gets lots of calcifications and fibrous tissue that develops there.
慢性胆囊炎也是类似，整个胆囊都会严重钙化。
It's kind of the same thing where it's chronic cholecystitis that the entire, like, gallbladder gets super calcified.
我记不清具体比例了。
I I don't remember the percentage.
我印象中，要是胆囊出现瓷化，大概有三到四成的概率会发展成胆囊癌。
I wanna say it's, like, thirty or forty percent probability that if you have a porcelain gallbladder, you'll develop gallbladder cancer.
天哪。
Wow.
所以这个概率还挺高的，得记住，一听就让人惊讶。
So it's it's around it's a pretty high statistics, a decently high number enough to remember it and be like, oh, wow.
这确实挺让人担心的。
That's that's concerning.
所以只要病人有瓷化胆囊，就必须赶紧把胆囊切掉，因为它很容易癌变。
So anytime a patient has a porcelain gallbladder, the fur you've got to get that gallbladder out because there's a very high chance that it can become just plastic enough that it can turn into cancerous tissue.
所以其实就是钙化了。
So really it's just it's calcified.
而且还有纤维化。
It's fibrotic.
对。
Yeah.
这可不是什么好事。
It's it's not good.
不。
No.
不行。
No.
癌变的风险很高。
There's a high risk of Of converting into Cancer.
胆囊癌。
Gallbladder cancer.
是的。
Yeah.
明白了。
Okay.
患者还伴有间歇性右上腹钝痛，以及六磅的非自愿体重下降。
The patient also has intermittent dull right upper quadrant pain and a six pound unintentional weight loss.
没有发烧。
No fevers present.
是的。
Yeah.
所以这看起来像是胆囊的问题。
So this seems like gallbladder.
我的意思是，也可能是慢性胆囊炎急性发作。
I mean, it could be a flare up of their chronic cholecystitis.
确实有可能。
It definitely could be.
对。
Mhmm.
但一听到体重下降，我就又担心了。
But when I hear weight loss, again, that's concerning.
再加上知道他们胆囊有问题，这更让人不安了。
And then when I know that they have a gallbladder, that's also concerning.
所以我真的很担心是胆囊癌。
So I'm I'm definitely concerned about gallbladder cancer.
这点毫无疑问。
That's definitely for sure.
通常来说，胆囊癌患者，尤其是那些有慢性胆囊炎的——这最常见的原因——会表现出类似胆绞痛的症状，比如右上腹疼痛，疼得厉害。
And, usually, in patients who have gallbladder cancer, especially if they have chronic cholecystitis, which is the most common cause, they can present with, like, features of what seems like a biliary colic, which is, like, the right upper quadrant pain, and it hurts.
然后疼一阵子又缓解了，过会儿又复发。
And then it kinda goes away, and then it comes back.
这种反复发作的情况，让我更倾向于怀疑是胆囊癌。
So those kind of, like, flare ups like that, that makes me think about more of a gallbladder cancer picture.
所以我肯定会马上安排一个右上腹的超声检查。
So I'd I'd probably start right away, get a right upper quadrant ultrasound.
但右上腹超声有个问题，有时候查不出息肉样的病变。
The the problem with a right upper quadrant ultrasound is that sometimes it doesn't pick up a polypoidant.
比如，要是我做胆囊超声，看到一个东西，心想：哎，找到了。
Like, if I saw the if I if I had a gallbladder ultrasound and I see it and I say, oh, there there it is.
那儿有个肿块。
There's there's there's a mass.
没问题。
We're good.
有时候表现没那么典型。
Sometimes it doesn't present like that.
有时候看起来更扁平一些。
Sometimes it's a little more flat.
有时候胆囊壁增厚，但光看这个很难判断。
Sometimes the gallbladder looks thickened, and that's it's hard to tell.
明白了。
Okay.
胆囊壁增厚了。
It's a thickened gallbladder.
这就能说明是胆囊炎吗？
Does that just mean that they have cholecystitis?
不太好确定。
It's hard to tell.
不过我还是会先从这儿开始，免得漏掉什么明显的异常。
I'd start there first, though, just to make sure I'm not missing some kind of just frank abnormality there.
看看胆囊有没有结石、壁是不是增厚了，顺便碰碰运气，看能不能发现什么肿块。
Get a look at the gallbladder, see if there's any stones, see if there's any thickening, and see if by some chance I find a mass.
我得问个关键问题。
Here's my question that I have to know.
这位病人有瓷化胆囊，这是已知的。
This patient has a known porcelain gallbladder.
那为啥还不把它切了？
Why is this thing not removed?
我知道。
I know.
我明白。
I know.
所以有时候是
So sometimes Is
这常见吗？
that common?
不该这样啊。
It shouldn't be.
通常这种东西都得摘掉。
Usually You get that thing out.
不。
No.
这就像你……
This is like your
你根本不该发展到胆囊钙化这一步。
You should never get to a point of of porcelain.
根本不该到这一步。
You should never get to that point.
我知道。
I know.
我不是
I don't
真没想取笑你。
mean to make fun here.
我就是想不通，这事儿咋会发展到这一步呢。
I'm I'm really, like, I'm wondering why it would ever get to that point.
有时候，有些人可能长期有胆囊炎，自己都不知道，已经发展成这样了。
Sometimes people, unfortunately, maybe have chronic cholecystitis and they don't know that they have developed Okay.
胆囊钙化。
Porcelain gallbladder.
很遗憾，有时候就是发现的时候，人家已经胆囊钙化了。
And, unfortunately, it's something that you can find as, oh, they got a porcelain gallbladder.
是啊。
Yeah.
行吧。
Alright.
是的
Yeah.
通常到这一步，你就该建议他们做手术了。
Usually, at that point, you should be referring them for surgery.
当然，如果有什么禁忌症，比如他们有其他问题，或者干脆就失联了，不再复诊，那另当别论。
Now if there's some contraindication, something that's, like, blocking them or they just, I don't know, they fall off the map with follow-up too Sure.
能出的问题其实挺多的。
There's a lot things I think can happen.
但对这位病人来说，百分之百得做。
But for this patient, one hundred percent.
你要是发现胆囊钙化了，真得跟病人说：
You got a porcelain gallbladder, you really should be suggesting, hey.
赶紧把这东西摘了。
Let's get that thing out.
百分之百。
One hundred percent.
尤其是这个比例还这么高。
Especially with that high percentage.
我的意思是，这比例不算特别高，但……
I mean, it it's not a high percentage, but
已经高到值得警惕了。
It's high enough to be concerned.
是的。
Yeah.
这已经足够让人担心了。
Like, that's still very concerning.
对。
Yeah.
所以我只是在想……
So I just I was wondering.
明白了。
Okay.
是的。
Yeah.
比如说，有人跟你说，嘿，扎克。
Like, if someone said, hey, Zach.
你有40%的几率能成为百万富翁。
There's a 40% chance you're gonna become a millionaire.
我肯定会说，哇。
I'm like, oh.
是的。
Yeah.
这对我来说已经够好了。
Good enough for me.
对。
Yeah.
我
I
我以为我想要
thought I wanted
还有希望。
there's hope.
好。
Alright.
我们先做右上腹的超声检查。
So we're starting with the right upper quadrant ultrasound.
是的。
Yeah.
好。
Alright.
胆囊壁钙化，里面有个2.2厘米的息肉样肿块。
So we have a calcified gallbladder wall containing a 2.2 centimeter polypoid mass.
肝脏正常。
The liver's normal.
好的。
Alright.
这说明了什么？
What is that telling you?
我真的很担心是癌症。
I they got they got definitely, I'm concerned for cancer.
当然，也可能是息肉。
I mean, it could be a polyp.
我不确定。
I don't know.
但可能性不大。
But it's it's unlikely.
我觉得这明显是癌症。
I think this is definitely a cancer.
所以我觉得最好再仔细查一下。
So I I think the best thing to do is to get a better look.
我可能会先做几层超薄切片看看。
I'd probably get some very thin sectioned looks.
我估计还得做个CT扫描。
I'd probably get, like, a CT scan.
好的。
Okay.
再仔细瞧瞧这个肿块到底是什么情况。
Get a better look, see if I can have a better look at the mass.
而且还能更清楚地看到肝脏的情况，报告上说肝脏是正常的。
And, also, it'll give me a better tissue picture to see, hey, it says that the liver's normal.
癌细胞有没有扩散到肝脏里？
Has it extended into the liver a little bit?
有没有影响到附近的血管？
Has it involved any of the nearby vast vessels?
所以我得确认清楚，有没有血管侵犯，或者肝脏转移之类的。
So I just would wanna make sure that there's no, like, know, vascular invasion, liver invasion, whatsoever.
得再仔细看看，毕竟这病人得做手术，这样能帮我们更好地规划手术方案。
Just get a better look because now this patient has to get surgery, and so it helped me with the surgical planning.
对。
Right.
我们会给腹部做增强CT。
We get a contrast CT of the abdomen.
结果显示，胆囊黏膜上有个局限性的肿块。
It shows a focal mass confined to the gallbladder mucosa.
还没侵犯到肝脏。
It has not invaded the liver.
好的。
Alright.
最稳妥的做法就是直接切胆囊。
Best thing to do is just get a cholecystectomy.
把这玩意儿干脆摘了。
Cut that son of a gun out.
这确实是最好的处理方式。
That's really the best way to go.
如果他们有肝脏侵犯，我会把肝脏那一块也一起切掉。
If you if you if they had liver invasion, I would extend it into the liver.
换句话说，我会做胆囊切除，再稍微切掉一点肝组织。
So in other words, I do a cholecystectomy and probably do a little bit of, like, liver resection.
但这次我觉得，直接把这玩意儿摘了就差不多了。
But in this case, I think it's we're we're probably good to just cut that puppy out.
术后可以考虑化疗，稍微用点辅助化疗，清除可能残留的微小转移灶。
You can always consider chemotherapy afterwards, like a little bit of adjuvant chemotherapy just to remove any kind of, like, micro metastatic, like, or micro residual disease.
不过，把这玩意儿摘了，大概还是最稳妥的方案。
But, yeah, cutting that puppy out would probably be the best way to go.
我就做胆囊切除。
I'll do a cholecystectomy.
我这边的病例就这些了。
That's all I had for our cases.
病例一到四，
Cases one through four,
搞定。
done.
太棒了。
Very awesome.
咱们现在来快速回顾一下刚才讨论的内容，怎么样？
How about now what like we've been doing, just a rapid review of what we've talked about?
我觉得最重要的是要想到临床表现。
I'd say the biggest thing is thinking about clinical presentations.
对吧？
Right?
一想到胰腺癌患者，大家常提到的关键词或者典型表现就是无痛性梗阻性黄疸。
So when you think about a patient with pancreatic cancer, oftentimes, the buzz term or the classic clinical finding is painless obstructive jaundice.
也就是说，如果你按压那个胆囊区域，患者有库瓦西耶征，皮肤一看就是黄的。
So in other words, if you press on that gallbladder, that area, they got the Kevorser sign, they got they look yellow.
这确实让人担心，尤其是胰腺导管腺癌。
That's definitely concerning, especially for pancreatic adenocarcinoma.
但你也不能排除其他引起胆汁淤积的原因。
But you definitely can't rule out other causes of obstructive cholestasis.
赶紧做个右上腹超声，仔细看看。
So get your right upper quadrant ultrasound, take a good look.
看到胆管扩张了吗？
Do you see any kind of ductal dilation?
看到胰腺有肿块了吗？
Do you see a pancreatic mass?
要是看到了，那就顺着这条线深挖，比如：
If you do, go down that that that rabbit hole saying, okay.
再做个CT，看得更清楚点。
Let's get a CT scan to get a better look.
明白。
Okay.
我们已经做了。
We've done that.
确实有个胰腺肿块。
We definitely have a pancreatic mass.
咱们做个内镜超声，顺便做个细针穿刺，拿个组织确诊一下。
Let's get an endoscopic ultrasound, maybe do an FNA to see if we got a tissue diagnosis.
然后你就能据此做出判断了。
And then from there, you can make your assumption.
先查个CA19-9做基线，方便以后评估治疗效果。
Get a baseline CA nineteen nine just to help you after you do your therapeutics.
要是病人有肝硬化加乙肝，那你就得时刻提防他发展成肝细胞癌。
If I have a patient who has cirrhosis, hepatitis b, if they have those two things, you definitely always wanna be concerned about them developing hepatocellular carcinoma.
我们平时筛查就是靠超声和甲胎蛋白这两项。
The ways that we try to make sure that we're kind of screening for those is getting ultrasounds and AFP levels considering those.
做不做呢，看情况吧。
You can always may or may not do them.
我觉得每六个月都做这两项检查总是好的。
I think it's always good to do both every six months.
如果发现新病灶、体积很大，尤其是比较明显的大小，或者AFP值突然飙升，我就担心了。
If it comes back with lesion is new or it's large, especially pretty decent size, or the AFP shoots up, I'm concerned.
肝细胞癌。
Hepatocellular carcinoma.
做个三期CT，往深了查一查。
Get a triphasic CT, go down that rabbit hole.
动脉期有没有明显强化？门静脉期有没有洗脱？
Do I have the hyperenhancement on the arterial phase and then portal venous washout?
这情况挺让人担心的。
It's pretty concerning.
我觉得我们可能遇到肝细胞癌了。
I think we may have this problem of a hepatocellular carcinoma.
这些我们一般不活检。
We don't biopsy those.
这么做会增加肿瘤扩散、出血，还有其他一堆风险。
You risk seeding, risk bleeding, you risk a lot of problems.
所以我们还是得做活检。
So we biopsy those.
如果病人有原发性硬化性胆管炎或者溃疡，根本不用特意提，大家都知道。
If I have a patient who has primary sclerosing cholangitis or ulcer they don't even have to mention that.
比如说，他们只是得了溃疡性结肠炎。
Let's say that they just had ulcerative colitis.
是的。
Yeah.
他们自己都不知道还合并了原发性硬化性胆管炎，这两者本来就是关联的。
And they don't even know that they have primary sclerosing cholangitis because they're associated.
然后突然间，他们就因为皮肤瘙痒来看病了。
And then all of a sudden, they come in with presentations of pruritus.
可能还伴有黄疸的样子。
Maybe they have some jaundice like appearance.
得警惕一下，会不会是胆管癌？
Be concerned, could it be cholangiocarcinoma?
通常先做个右上腹超声检查。
Oftentimes, get the right upper quadrant ultrasound.
可能会发现胆管有扩张。
It may show some ductal dilation.
胰头部没异常，但更好的检查还是MRCP。
No pancreatic head involvement, but the better test is gonna be the MRCP.
MRCP能清楚看出狭窄部位。
That's gonna show you the stricture.
也能看到胆管扩张的情况。
That's gonna show you the ductal dilation.
还能确认胰腺没有肿块。
That's gonna show you the absence of the pancreatic mass.
要是看到这些迹象，就赶紧做ERCP，刷取细胞，查查是不是胆管癌。
If you see that, pop up ERCP, brush it, get some cells, and look to see if you got a cholangiocarcinoma.
最后一点，如果遇到慢性胆囊炎患者，或者听到‘瓷化胆囊’这个词，你一定要高度警惕胆囊癌的可能性。
Last one, if you have a patient with chronic cholecystitis, or you hear the term porcelain gallbladder, you should have a very high concern for gallbladder cancer.
风险真的非常高。
The risk is super high.
赶紧把这胆囊切了。
Cut that puppy out.
通常上腹部超声就能看得挺清楚，能帮你初步了解情况。
Usually, upper quadrant ultrasounds will give you a good look, little sprinkle of interest into what's going on.
CT扫描效果更好，特别是当你需要切除的范围不止胆囊的时候，对术前规划特别有帮助。
CT scan will give you a really good look, especially for surgical planning if you just are gonna be removing more than the gallbladder.
瓷化胆囊一旦发现，及时切除能显著降低癌变风险。
Oftentimes, porcelain gallbladder, removing it reduces that risk.
如果不幸已经确诊胆囊癌，那还是得切，但有时候可能得连带部分肝脏一起切，术后还得配合化疗。
If, unfortunately, if you had diagnosed a gallbladder cancer, you still gotta remove it, but sometimes you may have to extend outwards into the liver, and you have to follow-up with some chemotherapy.
以上就是我对这些情况的建议，希望对大家有帮助，是的。
So that's what I would say for these, and I I hope that helps them a Yeah.
我的意思是，这说得通。
I mean, that made a lot of sense.
有个最靠谱的检查方法，真挺棒的。
I think it's really cool to have that single best test.
你看，这病人情况这么复杂，
Like, hey, I have I have a lot going on with this patient.
我该从哪儿下手呢？
Where do I start?
对。
Yeah.
我觉得这真的很有帮助。
And I think that's really helpful.
是的。
Yeah.
我懂了。
I gotcha.
太棒了。
Cool.
嘿，我真的希望你们今天听关于胰腺和肝胆癌的讲解觉得很有收获。
Well, hey, I I really hope that you guys liked talking about pancreatic and hepatobiliary cancer today.
希望你们今天过得愉快。
I hope that you're having a good day.
不管是在临床轮转还是考试中遇到这些内容，都希望你们能轻松拿下。
I hope that you whenever you get your exam, whenever you get tested on this, whether it be in the wards or on the boards, you're able to crush it.
希望你们对自己有信心。
I hope you feel confident.
希望你们觉得，就像工程师给你装好了所有零件，你已经准备好了，能稳稳发挥。
I hope you feel like an engineer done got you the way you need to be to be able to do well.
我真的超爱你们所有人。
But, man, I love you guys.
特别感谢你们这么棒，这么给力。
I thank you guys so much for just being so awesome.
祝你今天过得愉快。
Have a great day.
一如既往，咱们下次见。
And as always, till next time.
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