隐匿性胆总管结石的诊断评估与风险分层管理进展

Progress in Diagnostic Evaluation and Risk-Stratified Management of Occult Common Bile Duct Stones

摘要: 隐匿性胆总管结石多见于胆囊结石术前评估、胆总管轻度扩张、影像学偶然发现及胆囊切除术中胆道影像检查等场景，常因症状缺如或不典型而被低估。其处理难点在于：未及时处理可能导致急性胆管炎、梗阻性黄疸、胆源性胰腺炎或术后残留结石；过度干预又可能使低负荷、小结石或已自发排石患者承担不必要ERCP及术后胰腺炎风险。本文结合近年研究及国内外指南，从概念界定、自然史、诊断评估、围手术期识别、治疗选择、特殊人群及我国不同级别医疗机构实施策略等方面进行综述，强调以症状、胆管扩张、结石负荷、感染程度、胰腺炎状态、手术时机、ERCP风险和医疗资源可及性为基础进行风险分层。对合并胆管炎、持续梗阻或明确高危结石者应积极引流和取石；对小结石、单发、胆管不扩张且无症状者，应重视ERCP前复核和动态观察；对胆囊切除围手术期发现者，则应结合术中条件、术者经验和患者风险选择术中处理、同期或延期ERCP及随访。

Abstract: Occult common bile duct stones are frequently encountered in clinical scenarios such as preoperative assessment for cholecystolithiasis, mild dilatation of the common bile duct, incidental findings on imaging, and intraoperative biliary imaging during cholecystectomy. Because symptoms are often absent or atypical, these stones are easily underestimated. The major challenge in management lies in balancing the risks of undertreatment and overtreatment: failure to recognize and manage them promptly may result in acute cholangitis, obstructive jaundice, biliary pancreatitis, or retained postoperative stones, whereas unnecessary intervention may expose patients with low stone burden, small stones, or spontaneous stone passage to avoidable ERCP-related complications, particularly post-ERCP pancreatitis. Based on recent studies and current domestic and international guidelines, this review summarizes the definition, natural history, diagnostic evaluation, perioperative identification, treatment options, special populations, and implementation strategies across different levels of medical institutions in China. It emphasizes a risk-stratified approach based on symptoms, bile duct dilatation, stone burden, severity of infection, pancreatitis status, timing of surgery, ERCP-related risk, and healthcare resource availability. Active biliary drainage and stone extraction are recommended for patients with cholangitis, persistent obstruction, or clearly high-risk stones. In contrast, for asymptomatic patients with small, solitary stones, no bile duct dilatation, and low stone burden, confirmation before ERCP and dynamic observation should be emphasized. For stones detected during the perioperative period of cholecystectomy, management should be individualized according to intraoperative conditions, surgeon expertise, patient risk, and the feasibility of intraoperative treatment, simultaneous or delayed ERCP, and follow-up.