临床带教与英文查房 | 胆石症（三）
摘要： 胆石症（Gallstone Disease）是指胆囊或胆管内形成结石所引起的一系列临床综合征，常见症状包括右上腹痛、恶心、呕吐，严重时可导致黄疸、胆管炎或胰腺炎。临床带教与英文查房通过模拟真实诊疗场景，有助于医学生和住院医师掌握胆石症的鉴别诊断与处理流程。
- 胆石症的典型表现源于结石阻塞胆囊管或胆总管，可引发急性胆囊炎、胆管炎或胰腺炎。
- 床边教学结合英文查房能有效提升医学生对胆石症临床决策和专业英语表达的理解。
- 初步评估应包括腹部超声、实验室检查（如血淀粉酶）、必要时行鼻胃管置入及抗生素治疗。
- 影像学检查首选腹部超声，X线用于排除肠穿孔或梗阻，CT在早期诊断中并非首选因其耗时且特异性低。
- 多学科协作与快速反应对防止病情恶化至关重要，尤其在疑似胆总管结石或并发症时。
小白老师说：Bedside teaching is seen as one of the most important modalities in teaching a variety of skills for the medical profession, which greatly improves certain clinical diagnostic skills in medical students and residents.
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Gallstone Disease 胆石症（三）
IV. In the Doctor’s Office
在医生办公室
Chief Physician: Well, just as the picture shows, the gallbladder lies on the undersurface of the liver, and is connected through the cystic duct to the common bile duct that drain the fluid. Its normal function is to store bile and deliver it to the intestine when it is needed for digestion.
主任医师：如图所示，胆囊位于肝脏的底面，通过胆囊管与排泄胆汁的胆总管相连。它的基本功能是储存胆汁，并将胆汁输送到肠道以消化食物。
Intern: Professor, how come the pain and nausea?
实习医师：教授，病人为什么会有腹痛和恶心呢?
Chief Physician: There are several possibilities, almost all of which are related to the fact that a gallstone has moved the gallbladder, either into the cystic duct, common bile duct, or through the lower end of the bile duct into the intestine. Dr. Black, please show us the possibilities.
主任医师：这有很多可能，最可能的是胆结石从胆囊移位掉入胆囊管、胆总管或通过胆管的下端进入肠道。Black 医生，请给我们解释一下这些可能性。
Resident: OK. If the stone gets stuck in the common bile duct, the patient will become jaundiced and have a fever.
住院医师：好的。如果结石卡在胆囊管，就会导致急性胆囊炎。如果结石卡在胆总管，病人会有黄疸和发热。
Chief Physician: OK, guys. We have a real problem here, and we have to get smart fast in order to keep the patient become sicker. What do you think we ought to do firstly, Dr. Grey?
主任医师：好吧，同志们。我们现在有个问题，我们必须尽快行动以避免病人的病情加重。你认为我们首先应该做什么，Grey医生?
Intern: I’ll start with some labs from the fluid for confirmation. And we should put a catheter in her bladder to monitor her fluids and put down a nasogastric (NG) tube, since her abdomen was pretty quiet when I listened to it.
实习医师：我认为应该先做一些有关体液的实验室检查以确诊。我认为还应该插导尿管记尿量，插鼻胃管，因为我几乎没有听到她的腹部肠鸣音。
Chief Physician: Why the NG tube?
主任医师：为什么要插鼻胃管?
Intern: The NG tube will keep air and gastrointestinal secretions from accumulating in her intestines, and keep her from vomiting.
实习医师：鼻胃管可以防止空气和胃肠分泌物在肠道累积，防止呕吐。
Chief Physician: What about antibiotics?
主任医师：抗生素要用吗?
Resident: Surely, especially since she may have a stone in her common bile duct or acute pancreatitis.
住院医师：当然要用，特别是她可能有结石在胆总管里或有急性胰腺炎。
Chief Physician: Dr. Black, how should we get started on making a definitive diagnosis?
主任医师：Black 医生，我们应该如何确诊？
Resident: I’ll get an upright abdominal X-ray to be sure we haven’t got fooled by our first impression. After all, she might have a hole in her gut, or intestinal obstruction, and those studies will help rule out these possibilities. She also needs an ultrasound of the upper abdomen.
住院医师：应该做一个直立位腹部X线片检查来确保我们没有凭第一印象犯错误。毕竟，她也可能是肠穿孔或肠梗阻。这些检查可以帮助我们排除这些可能性。另外还需要行上腹部超声检查。
Intern: Is it possible for necrotic pancreatitis? Should we get a CT scan?
实习医师：坏死性胰腺炎有可能吗?我们需要做 CT 扫描检查吗?
Chief Physician: Let’s hold off on CT since it’s too time-consuming and not specific. The other studies, together with blood amylase and an endoscope if necessary, can tell us what we need. Let’s get all of them started right now. See you later.
主任医师：CT检查既费时又缺乏特异性，目前并不着急于做。其他检查，再结合血淀粉酶应该可以告诉我们答案，必要时还可以做内镜检查。现在就马上开始吧。待会再接着讨论。
常见问题
胆石症为什么会引起腹痛和恶心？
胆石移动并阻塞胆囊管或胆总管，导致胆汁淤积、胆囊压力升高或继发感染，从而引发右上腹痛、恶心和呕吐。
为什么胆石症患者需要插鼻胃管？
鼻胃管可防止胃肠道分泌物和气体积聚，减轻腹胀，并预防呕吐，尤其适用于肠鸣音减弱或疑似肠梗阻的患者。
胆石症的初步影像学检查有哪些？
首选上腹部超声检查；直立位腹部X线可用于排除肠穿孔或肠梗阻，但对胆结石本身敏感性较低。
何时考虑使用抗生素治疗胆石症？
当怀疑合并胆管炎、胆囊炎或急性胰腺炎等感染性并发症时，应尽早使用抗生素。