唐世芳　綜述　趙禮金　審校

（遵義醫(yī)學(xué)院 1.臨床學(xué)院　2.附屬醫(yī)院　肝膽外科，貴州 遵義 563000）

肝膽管結(jié)石病具有高發(fā)病率的特征，而目前尚無(wú)特效藥。因此，導(dǎo)致較多肝膽管結(jié)石患者由于缺乏有效治療導(dǎo)致膽汁淤積，發(fā)展成肝硬化。并且研究[1]發(fā)現(xiàn)，肝膽管結(jié)石病與肝內(nèi)膽管癌的發(fā)生發(fā)展密切相關(guān)，是肝膽管良性疾病中引起患者死亡的最主要因素之一[2]。膽道感染是該病重要的發(fā)病機(jī)制之一，而近年有研究發(fā)現(xiàn)膽道感染能激活炎癥信號(hào)通路，產(chǎn)生炎癥瀑布效應(yīng)從而引起慢性持續(xù)性炎癥[3]。

近年來(lái)，越來(lái)越多的研究[4-6]明確了Toll樣受體在免疫，特別是在感染免疫中發(fā)揮了重要的作用。Toll樣受體家族（Toll-like receptors，TLRs）是最早發(fā)現(xiàn)的天然免疫模式識(shí)別受體（pattern recognition receptors，PRRs）[7]，通過(guò)識(shí)別外源配體的病原體相關(guān)分子模式（pathogen-associated molecular patterns，PAMPs）、內(nèi)源性配體的損傷相關(guān)分子模式（damage-associated molecular patterns，DAMPs）以及異源物相關(guān)分子模式（xenobiotic-associated molecular patterns，XAMPs）來(lái)刺激先天免疫應(yīng)答，同時(shí)還能通過(guò)獲得性免疫來(lái)對(duì)機(jī)體進(jìn)行保護(hù)[4,8-12]，但是這些應(yīng)答所致的持續(xù)性炎癥反應(yīng)會(huì)對(duì)機(jī)體產(chǎn)生損傷，被認(rèn)為是多種慢性疾病的觸發(fā)因素[4]。越來(lái)越多的研究[4-6]明確了Toll樣受體在免疫，特別是在感染免疫中發(fā)揮了重要的作用。Toll樣受體4（TLR4）是人類發(fā)現(xiàn)的第一個(gè)Toll樣受體相關(guān)蛋白，也是目前研究最廣泛的Toll樣受體相關(guān)蛋白之一，幾乎分布于所有的細(xì)胞系。有研究[13-20]發(fā)現(xiàn)哺乳動(dòng)物膽管上皮細(xì)胞、肝細(xì)胞、腎小管上皮細(xì)胞、腸上皮細(xì)胞等等均有表達(dá)TLR4。內(nèi)毒素/脂多糖（lipopolysaccharide，LPS）是革蘭氏陰性菌細(xì)胞壁的主要成分，是TLR4的天然配體。血液中的LPS主要通過(guò)兩種方式激活TLR4信號(hào)通路：一是LPS被其結(jié)合蛋白LBP運(yùn)送到細(xì)胞膜表面與該處TLR4的結(jié)構(gòu)輔助蛋白CD14形成一個(gè)復(fù)合體，再同TLR4/MD-2相互作用，激活TLR4的下游信號(hào)通路；二是LPS直接與TLR4的附屬蛋白MD-2結(jié)合并相互作用，進(jìn)而激活TLR4下游信號(hào)通路[21]。TLR4信號(hào)轉(zhuǎn)導(dǎo)通路由細(xì)胞內(nèi)的TIR結(jié)構(gòu)域啟動(dòng)[22]，目前研究發(fā)現(xiàn)的能夠與TIR結(jié)構(gòu)域結(jié)合的胞內(nèi)銜接蛋白有髓樣分化因子88（myeloid differentiation factor 88，MyD88）、TIR結(jié)構(gòu)域接合子蛋白/MyD88接合子樣蛋白（Toll-interleukin 1 receptor domain- containing adapter protein/MyD88 adaptor-like protein，TIRAP/Mal）、β干擾素TIR結(jié)構(gòu)域銜接蛋白（TIR-domain-containing adaptor inducing interferon-β，TRIF）和TRIF相關(guān)接頭分子（TRIF-related adaptor molecule，TRAM）[23]，TLR4信號(hào)傳導(dǎo)主要通過(guò)Myd88依賴性通路和Myd88非依賴性通路即TRIF依賴性通路兩種途徑進(jìn)行[24]。Myd88依賴性通路中Myd88激活信號(hào)轉(zhuǎn)導(dǎo)因子包括白介素1受體聯(lián)合激酶4（IL-1R-associated kinase 4，IRAK4）、腫瘤壞死因子受體相關(guān)因子6（TNF receptor-associated factor 6，TRAF6）和激活胞膜激酶（TGF-activated kinase 1，TAK1），激活下游的抑制IκB激酶（inhibitory κB kinase，IKK）和促分裂原活化蛋白激酶（mitogen-activated protein kinases，MAPK）通路，最后導(dǎo)致核轉(zhuǎn)錄因子NF-κB活化和相關(guān)促炎因子的產(chǎn)生。此外，干擾素調(diào)節(jié)因子5（interferon regulatory factor 5，IRF5）也被發(fā)現(xiàn)與Myd88通路有關(guān)[25]。TRIF依賴的Myd88非依賴性通路，能夠激活干擾素調(diào)節(jié)因子3（interferon regulatory factor 3，IRF3）和TANK聯(lián)合激酶1（TANK binding kinase1，TBK1）等信號(hào)轉(zhuǎn)導(dǎo)分子，最終誘導(dǎo)干擾素β（interferon-β，IFN-β）的表達(dá)，引起相關(guān)的炎癥反應(yīng)[23]，研究[26]表明TRIF依賴通路也可以激活NF-κB和MAPK。

近年來(lái)研究[1]發(fā)現(xiàn)LPS/TLR4信號(hào)通路激活后引起持續(xù)炎性損傷可導(dǎo)致膽管上皮細(xì)胞（bile duct epithelia cells，BDECs）增殖，同時(shí)上皮細(xì)胞獲得間質(zhì)細(xì)胞的表型和功能，發(fā)生上皮-間質(zhì)轉(zhuǎn)化（epithelial-to-mesenchymal transition，EMT），參與肝膽管纖維化的進(jìn)程。從而改變膽管樹(shù)內(nèi)膽汁流,導(dǎo)致形成結(jié)石膽汁的產(chǎn)生和分泌[27]。

1　肝膽管結(jié)石病發(fā)病機(jī)制概述

肝膽管結(jié)石也稱作原發(fā)性肝內(nèi)膽管結(jié)石，是指左右肝管匯合處以上的所有膽管內(nèi)的膽結(jié)石。肝膽管結(jié)石的發(fā)病率有較大的地區(qū)差異，亞洲國(guó)家發(fā)病率遠(yuǎn)高于西方國(guó)家，尤其在東亞地區(qū)發(fā)病率非常高，在日本、韓國(guó)、中國(guó)發(fā)病率占肝膽系統(tǒng)疾病的1/4[1,28]。臨床研究[27]表明，結(jié)石形成的最主要的病因是膽道感染，膽汁淤積是結(jié)石形成的必要條件。

2　LPS/TLR4和膽道感染

膽道感染是肝膽管結(jié)石病關(guān)鍵的發(fā)病機(jī)制，可導(dǎo)致病原相關(guān)分子或病原體產(chǎn)生LPS引發(fā)菌血癥[29]，但引起膽道感染的相關(guān)機(jī)制尚未明確，相關(guān)研究表明，發(fā)現(xiàn)LPS/TLR4信號(hào)通路被激活后介導(dǎo)下游的信號(hào)傳導(dǎo)，是膽道感染的相關(guān)機(jī)制之一。

2.1　LPS/TLR4與腸源性內(nèi)毒素

腸道膽鹽缺乏、小腸黏膜屏障損傷后，細(xì)菌會(huì)通過(guò)腸壁吸收進(jìn)入門(mén)靜脈移位于膽管，在膽汁中生長(zhǎng)繁殖造成膽源性感染[30-32]，肝膽管結(jié)石患者幾乎都存在膽道感染。臨床研究[33]發(fā)現(xiàn)，肝膽管結(jié)石患者膽汁中檢測(cè)出大量革蘭陰性菌，其代謝產(chǎn)生的LPS的含量高低與膽管結(jié)石患者感染的程度正相關(guān)。目前對(duì)LPS-TLR4-NF-κB經(jīng)典炎癥通路的研究集中在人體其他正常組織和腫瘤組織的體外培養(yǎng)[34-36]。腸源性內(nèi)毒素的大量產(chǎn)生會(huì)刺激膽道感染的反復(fù)發(fā)生，導(dǎo)致肝內(nèi)膽管多發(fā)結(jié)石可引起肝損傷。大量產(chǎn)生的LPS可激活枯否細(xì)胞（kupffer cells，KCs）NF-κB并促使KCs釋放高水平的TNFα、IL-6及IL-1等炎癥因子，TNFα和IL-6過(guò)量表達(dá)，導(dǎo)致肝細(xì)胞凋亡和壞死，IL-1的升高又進(jìn)一步抑制肝細(xì)胞再生[37]。因此，適當(dāng)調(diào)控KCs NF-κB的活性有促進(jìn)肝細(xì)胞再生的可能。

2.2　LPS/TLR4與KCs

KCs是位于肝竇隙內(nèi)的巨噬細(xì)胞，是肝內(nèi)固定的單核-巨噬細(xì)胞群，同時(shí)也是清除來(lái)自膽腸道內(nèi)的細(xì)菌以及其產(chǎn)生的LPS的主要場(chǎng)所[38]。膽道感染時(shí)，LPS激活KCs合成并產(chǎn)生多種促炎因子[39]。CD14是存在于單核-巨噬細(xì)胞膜表面的LPS受體，可啟動(dòng)LPS介導(dǎo)的信號(hào)通路傳導(dǎo)，研究[21]發(fā)現(xiàn)在生理狀態(tài)下，少量LPS不會(huì)引起KCs細(xì)胞膜表面的CD14的表達(dá)或只有少量表達(dá)，但是異常的高濃度LPS能導(dǎo)致CD14的高表達(dá)，從而誘導(dǎo)炎癥反應(yīng)。CD14在LPS介導(dǎo)KCs分泌各種細(xì)胞因子的過(guò)程中扮演著十分重要的角色[40]。由于CD14是TLR4激活所必需的因子，膽道感染時(shí)，LPS與KCs細(xì)胞膜表面CD14的結(jié)合可能會(huì)通過(guò)激活LPS/TLR4信號(hào)通路從而介導(dǎo)了KCs合成和分泌。

2.3　LPS/TLR4與氧化應(yīng)激

氧化應(yīng)激是指機(jī)體內(nèi)自由基產(chǎn)生過(guò)多，使機(jī)體的清除能力負(fù)荷超出正常水平，打破氧化/抗氧化平衡。研究表明氧化應(yīng)激可導(dǎo)致臟器組織氧化損傷[41-42]。LPS通過(guò)與多種炎癥細(xì)胞或效應(yīng)細(xì)胞膜上的TLR4蛋白結(jié)合誘導(dǎo)產(chǎn)生某些炎癥介質(zhì)和細(xì)胞因子，激活細(xì)胞內(nèi)MAPKs-NF-κB信號(hào)通路，致使產(chǎn)生炎性介質(zhì)大爆發(fā)的瀑布效應(yīng)，最終導(dǎo)致自由基產(chǎn)生[43-45]，引起氧化應(yīng)激反應(yīng)，加重肝膽管組織炎性損傷[46]。膽道感染時(shí)血液中氧、羥自由基增加會(huì)加速膽道內(nèi)膽紅素鈣結(jié)石生成，沉淀顆粒增大，進(jìn)而形成肝膽結(jié)石，再次加重膽道感染，形成惡性循環(huán)[27]。另一方面，膽道梗阻或者門(mén)靜脈內(nèi)毒素血癥發(fā)生時(shí)肝臟內(nèi)氧自由基增加，進(jìn)一步損害KCs的清除能力[47]，從而加重膽道感染促進(jìn)結(jié)石的形成。因此，在梗阻性黃疸的動(dòng)物模型的膽道中應(yīng)用內(nèi)支架引流減壓，可促使KCs清除能力的恢復(fù)[48]。

2.4　LPS/TLR4與葡萄糖醛酸酶mRNA的表達(dá)

LPS進(jìn)入肝膽系統(tǒng)后可以刺激肝臟細(xì)胞、膽管上皮細(xì)胞及膽汁中白細(xì)胞分泌內(nèi)源性β-葡萄糖醛酸酶（β-glucuronidas，β-GD）[49]。β-GD可以分解膽紅素雙葡糖醛酸酯，使結(jié)合膽紅素分解成游離膽紅素，游離膽紅素又與鈣結(jié)合生成膽紅素鈣結(jié)石[49]，參與肝膽結(jié)石的形成。LPS通過(guò)與肝臟細(xì)胞、膽管上皮細(xì)胞膜上的CD14結(jié)合后啟動(dòng)信號(hào)傳導(dǎo)功能，通過(guò)LPS-TLR4-NF-κB信號(hào)通路啟動(dòng)細(xì)胞內(nèi)控制β-GD的基因，由此轉(zhuǎn)錄更多的mRNA，增加β-GD蛋白質(zhì)的合成。實(shí)驗(yàn)研究證明LPS可以使組織源性β-GD的合成和釋放增加，可能有助于解釋不伴有細(xì)菌感染的膽色素結(jié)石的發(fā)病原因[50]。

3　LPS/TLR4與膽汁淤積

TNF-α是由巨噬細(xì)胞、內(nèi)皮細(xì)胞和庫(kù)普弗細(xì)胞釋放的細(xì)胞因子，是LPS/TLR4信號(hào)通路中引起全身效應(yīng)的主要調(diào)節(jié)因子[51]。研究[52]發(fā)現(xiàn)，小鼠注射LPS后，離體灌注的肝臟膽汁流量發(fā)生下降，用抗TNF-α的抗體阻斷后膽汁流量與膽鹽分泌減少，提示TNF-α與LPS/TLR4信號(hào)通路誘導(dǎo)的膽汁淤積有關(guān)。LPS/TLR4信號(hào)通路參與膽囊炎癥的發(fā)生和發(fā)展，導(dǎo)致膽囊功能受到影響，引起肝內(nèi)膽管膽汁淤積，從而形成肝膽管膽石[53]。已有證據(jù)[27]證實(shí)，膽汁淤積是造成肝膽管結(jié)石的必要條件，因此推測(cè)，LPS/TLR4信號(hào)通路通過(guò)對(duì)膽管樹(shù)的調(diào)節(jié)從而參與了肝膽管結(jié)石形成的發(fā)生。

4　LPS/TLR4與EMT

EMT是指具有極性、黏附性的上皮細(xì)胞表型轉(zhuǎn)化成具有非極性、可自由移動(dòng)且缺乏細(xì)胞間連接的間質(zhì)細(xì)胞表型[54]。EMT參與胚胎形成、組織細(xì)胞修復(fù)和再生等生理過(guò)程，創(chuàng)傷后正常的纖維瘢痕修復(fù)過(guò)程持續(xù)存在時(shí)，就會(huì)發(fā)生非正常的病理過(guò)程導(dǎo)致多種組織的纖維化、硬化[55]。有學(xué)者[56-57]研究發(fā)現(xiàn)持續(xù)的炎性損傷可使膽管上皮細(xì)胞（bile duct epithelia cells，BDECs）增殖，上皮細(xì)胞獲得間質(zhì)細(xì)胞表型及功能，發(fā)生EMT，并參與肝膽管纖維化進(jìn)程。同時(shí)，也有體外實(shí)驗(yàn)證實(shí)LPS能刺激BDECs發(fā)生EMT[58]。肝膽管結(jié)石病患者肝組織中的小膽管的BDECs發(fā)生增殖，通過(guò)EMT樣現(xiàn)象或與肌纖維母細(xì)胞相互作用，促進(jìn)疾病的發(fā)生發(fā)展[59]。TLR4參與活化并激活由LPS介導(dǎo)的肝內(nèi)膽管上皮細(xì)胞發(fā)生上皮-間質(zhì)轉(zhuǎn)化[60]。體外研究[61]結(jié)果證明，對(duì)人肝內(nèi)膽管上皮細(xì)胞（human intrahepatic biliary epithelial cells，HIBEpiC）進(jìn)行沉默TLR4基因表達(dá)的轉(zhuǎn)染實(shí)驗(yàn)，有效的抑制LPS誘導(dǎo)的肝內(nèi)膽管上皮細(xì)胞發(fā)生上皮-間質(zhì)轉(zhuǎn)化，并且沉默TLR4表達(dá)后的HIBEpiC中檢測(cè)發(fā)現(xiàn)上皮標(biāo)志物表達(dá)明顯升高，說(shuō)明有效抑制了HIBEpiC發(fā)生EMT。TLR4可作為早期調(diào)控肝內(nèi)膽管上皮細(xì)胞上皮-間質(zhì)轉(zhuǎn)化、抑制膽道纖維化進(jìn)程的藥物治療靶點(diǎn)。因此，探索肝膽管結(jié)石病是否通過(guò)EMT導(dǎo)致肝膽管纖維化以及其全面的調(diào)節(jié)機(jī)制迫在眉睫。

5　結(jié)論與展望

LPS/TLR4信號(hào)通路在肝膽管結(jié)石的發(fā)病機(jī)制中具有非常重要的作用，激活該通路可直接參與肝膽管結(jié)石病的發(fā)生，但具體機(jī)制尚不明確。因此，進(jìn)一步探索LPS/TLR4信號(hào)通路在肝膽管結(jié)石病發(fā)病機(jī)制中的激活過(guò)程與作用至關(guān)重要。這將對(duì)肝膽管結(jié)石發(fā)病機(jī)制提供新的見(jiàn)解，同時(shí)為研究治療及干預(yù)肝膽管結(jié)石病的措施指明新方向。

[1]Kim HJ,Kim JS,Joo MK,et al.Hepatolithiasis and intrahepatic cholangiocarcinoma: a review[J].World J Gastroenterol,2015,21(48):13418–13431.doi: 10.3748/wjg.v21.i48.13418.

[2]程南生.肝膽管結(jié)石并發(fā)癥的防治[J].中國(guó)普外基礎(chǔ)與臨床雜志,2006,13(4):380–381.doi:10.3969/j.issn.1007–9424.2006.04.005.Cheng NS.Prevention and Management of Complications of Hepatolithiasis[J].Chinese Journal of Bases and Clinics in General Surgery,2006,13(4):380–381.doi:10.3969/j.issn.1007–9424.2006.04.005.

[3]Fickert P,Pollheimer MJ,Beuers U,et al.Characterization of animal models for primary sclerosing cholangitis (PSC)[J].J Hepatol,2014,60(6):1290–1303.doi: 10.1016/j.jhep.2014.02.006.

[4]Akira S,Uematsu S,Takeuchi O.Pathogen recognition and innate immunity[J].Cell,2006,124(4):783–801.

[5]Kawai T,Akira S.The roles of TLRs,RLRs and NLRs in pathogen recognition[J].Int Immunol,2009,21(4):317–337.doi: 10.1093/intimm/dxp017.

[6]Kawai T,Akira S.Toll-like receptors and their crosstalk with other innate receptors in infection and immunity[J].Immunity,2011,34(5):637–650.doi: 10.1016/j.immuni.2011.05.006.

[7]Medvedev AE.Toll-like receptor polymorphisms,inflammatory and infectious diseases,allergies,and cancer[J].J Interferon Cytokine Res,2013,33(9):467–484.doi: 10.1089/jir.2012.0140.

[8]Kang JY,Lee JO.Structural biology of the Toll-like receptor family[J].Annu Rev Biochem,2011,80:917–941.doi: 10.1146/annurev–biochem–052909–141507.

[9]Peri F,Calabrese V.Toll-like receptor 4 (TLR4) modulation by synthetic and natural compounds: an update[J].J Med Chem,2014,57(9):3612–3622.doi: 10.1021/jm401006s.

[10]鐘靜靜,萬(wàn)巖巖,刁昱文,等.Toll樣受體靶向藥物的研究進(jìn)展[J].生命科學(xué),2015,27(4):439–444.doi: 10.13376/j.cbls/2015057.Zhong JJ,Wan YY,Diao YW,et al.The research development of Toll-like receptors targeted drugs[J].Chinese Bulletin of Life Sciences,2015,27(4):439–444.doi: 10.13376/j.cbls/2015057.

[11]Bachtell R,Hutchinson MR,Wang X,et al.Targeting the Toll of Drug Abuse: The Translational Potential of Toll-Like Receptor 4[J].CNS Neurol Disord Drug Targets,2015,14(6):692–699.

[12]Takeuchi O,Akira S.Pattern Recognition Receptors and Inflammation[J].Cell,2010,140(6):805–820.doi: 10.1016/j.cell.2010.01.022.

[13]Zhao L,Yang R,Cheng L,et al.LPS-induced epithelialmesenchymal transition of intrahepatic biliary epithelial cells[J].J Surg Res,2011,171(2):819–825.doi: 10.1016/j.jss.2010.04.059.

[14]Ding Y,Liao W,He X,et al.CSTMP Exerts Anti-Inflammatory Effects on LPS-Induced Human Renal Proximal Tubular Epithelial Cells by Inhibiting TLR4-Mediated NF-kappaB Pathways[J].Inflammation,2016,39(2):849–859.doi: 10.1007/s10753–016–0315–5.

[15]Walters KA,Olsufka R,Kuestner RE,et al.Prior infection with Type A Francisella tularensis antagonizes the pulmonary transcriptional response to an aerosolized Toll-like receptor 4 agonist[J].BMC Genomics,2015,16: 874.doi: 10.1186/s12864–015–2022–2.

[16]Bein A,Zilbershtein A,Golosovsky M,et al.LPS induces hyperpermeability of intestinal epithelial cells[J].J Cell Physiol,2016,232(2):381–390.doi: 10.1002/jcp.25435.

[17]He Y,Ou Z,Chen X,et al.LPS/TLR4 Signaling Enhances TGF-beta Response Through Downregulating BAMBI During Prostatic Hyperplasia[J].Sci Rep,2016,6:27051.doi: 10.1038/srep27051.

[18]Gargus M,Niu C,Vallone J G,et al.Human esophageal myofibroblasts secrete proinflammatory cytokines in response to acid and Toll-like receptor 4 ligands[J].Am J Physiol Gastrointest Liver Physiol,2015,308(11):G904–923.

[19]楊雪華,王銳,陳立杰.Toll樣受體4信號(hào)通路對(duì)腦缺血損傷影響的研究進(jìn)展[J].中國(guó)臨床神經(jīng)科學(xué),2016,24(4):470–474.Yang XH,Wang R,Chen LJ.The Progress of Toll-like Receptor 4 Signaling in Cerebral Ischemia[J].Chinese Journal of Clinical Neurosciences,2016,24(4):470–474.

[20]Song B,Zhang Y,Chen L,et al.The role of Toll-like receptors in periodontitis[J].Oral Dis,2017,23(2):168–180.doi: 10.1111/odi.12468.

[21]Kang S,Lee SP,Kim KE,et al.Toll-like receptor 4 in lymphatic endothelial cells contributes to LPS-induced lymphangiogenesis by chemotactic recruitment of macrophages[J].Blood,2009,113(11):2605–2613.doi: 10.1182/blood–2008–07–166934.

[22]Poltorak A,He X,Smirnova I,et al.Defective LPS signaling in C3H/HeJ and C57BL/10ScCr mice: mutations in Tlr4 gene[J].Science,1998,282(5396):2085–2088.

[23]蔡炳岡,朱進(jìn),汪茂榮.Toll樣受體4信號(hào)通路研究進(jìn)展[J].醫(yī)學(xué)研究生學(xué)報(bào),2015,28(11):1228–1232.doi:10.16571/j.cnki.1008–8199.2015.11.026.Cai BG,Zhu J,Wang MR.Progress of toll-like receptor 4 signaling pathway[J].Journal of Medical Postgraduates,2015,28(11):1228–1232.doi:10.16571/j.cnki.1008–8199.2015.11.026.

[24]Thada S,Valluri VL,Gaddam SL.Influence of Toll-like receptor gene polymorphisms to tuberculosis susceptibility in humans[J].Scand J Immunol,2013,78(3):221–229.doi: 10.1111/sji.12066.

[25]Balkhi MY,Fitzgerald KA,Pitha PM.IKKalpha negatively regulates IRF-5 function in a MyD88-TRAF6 pathway[J].Cell Signal,2010,22(1):117–127.doi: 10.1016/j.cellsig.2009.09.021.

[26]Wang Z,Dong B,Feng Z,et al.A study on immunomodulatory mechanism of Polysaccharopeptide mediated by TLR4 signaling pathway[J].BMC Immunol,2015,16:34.doi: 10.1186/s12865–015–0100–5.

[27]呂立升,魏妙艷,湯朝暉.肝膽管結(jié)石成因及分型[J].中國(guó)實(shí)用外科雜志,2016,36(3):348–350.Lu LS,Wei MY,Tang ZH.Causes and cliassification of hepatolithiasis[J].Chinese Journal of Practical Surgery,2016,36(3):348–350.

[28]Li FY,Cheng NS,Mao H,et al.Significance of controlling chronic proliferative cholangitis in the treatment of hepatolithiasis[J].World J Surg,2009,33(10):2155–2160.doi: 10.1007/s00268–009–0154–8.

[29]Sato M,Matsuyama R,Kadokura T,et al.Severity and prognostic assessment of the endotoxin activity assay in biliary tract infection[J].J Hepatobiliary Pancreat Sci,2014,21(2):120–127.doi: 10.1002/jhbp.10.

[30]Choda Y,Morimoto Y,Miyaso H,et al.Failure of the gut barrier system enhances liver injury in rats: protection of hepatocytes by gut-derived hepatocyte growth factor[J].Eur J Gastroenterol Hepatol,2004,16(10):1017–1025.

[31]Yasuda T,Takeyama Y,Ueda T,et al.Breakdown of Intestinal Mucosa Via Accelerated Apoptosis Increases Intestinal Permeability in Experimental Severe Acute Pancreatitis[J].J Surg Res,2006,135(135):18–26.

[32]丁凱,李維勤.重癥急性胰腺炎患者的腸黏膜屏障功能障礙[J].腸外與腸內(nèi)營(yíng)養(yǎng),2008,15(6):373–376.doi:10.3969/j.issn.1007–810X.2008.06.017.Ding K,Li WQ.Gut barrier dysfunction in severe acute pancreatitis[J].Parenteral & Enteral Nutrition,2008,15(6):373–376.doi:10.3969/j.issn.1007–810X.2008.06.017.

[33]李波,夏先明,劉長(zhǎng)安,等.感染性膽汁中內(nèi)毒素的變化及意義[J].中華肝膽外科雜志,2006,12(1):8–10.doi:10.3760/cma.j.issn.1007–8118.2006.01.003.Li B,Xia XM,Liu CA,e al.Changes and significance of bile endotoxin in patients with bile bacterial infection[J].Chinese Journal of Hepatobiliary Surgery,2006,12(1):8–10.doi:10.3760/cma.j.issn.1007–8118.2006.01.003.

[34]Chen S,Xiong J,Zhan Y,et al.Wogonin inhibits LPS-induced inflammatory responses in rat dorsal root ganglion neurons via inhibiting TLR4-MyD88-TAK1-mediated NF-kappaB and MAPK signaling pathway[J].Cell Mol Neurobiol,2015,35(4):523–531.doi: 10.1007/s10571–014–0148–4.

[35]Park MY,Mun ST.Carnosic acid inhibits TLR4-MyD88 signaling pathway in LPS-stimulated 3T3-L1 adipocytes[J].Nutr Res Pract,2014,8(5):516–520.doi: 10.4162/nrp.2014.8.5.516.

[36]Zhang S,Yang N,Ni S,et al.Pretreatment of lipopolysaccharide(LPS) ameliorates D-GalN/LPS induced acute liver failure through TLR4 signaling pathway[J].Int J Clin Exp Pathol,2014,7(10):6626–6634.

[37]徐明清,龔建平,韓本立,等.枯否細(xì)胞NF-κB 激活對(duì)膽源性內(nèi)毒素血癥大鼠肝部分切除后肝細(xì)胞再生的影響[J].中華實(shí)驗(yàn)外科雜志,2002,19(2):147–149.doi:10.3760/j.issn:1001–9030.2002.02.019.Xu MQ,Gong JP,Han BL,et al.Effect of NF-κB activation of Kupffer cells on liver regeneration after partial hepatectomy in rats with biliary endotoxemia[J].Chinese Journal of Experimental Surgery,2002,19(2):147–149.doi:10.3760/j.issn:1001–9030.2002.02.019.

[38]Dixon LJ,Barnes M,Tang H,et al.Kupffer Cells in the Liver[J].Compr Physiol,2013,3(2):785–797.doi: 10.1002/cphy.c120026.

[39]Chen CJ,Kono H,Golenbock D,et al.Identification of a key pathway required for the sterile inflammatory response triggered by dying cells[J].Nat Med,2007,13(7):851–856.

[40]龔建平,徐明清,李昆,等.內(nèi)毒素介導(dǎo)Kupffer細(xì)胞脂多糖受體CD14的表達(dá)[J].第三軍醫(yī)大學(xué)學(xué)報(bào),2001,23(4):425–428.doi:10.3321/j.issn:1000–5404.2001.04.018.Gong JP,Xu MQ,Li K,et al.Expression of CD14 in Kupffer's cells induced by Lipopolysaccharide[J].Acta Academiae Medicinae Militaris Tertiae,2001,23(4):425–428.doi:10.3321/j.issn:1000–5404.2001.04.018.

[41]Huang X,Moir RD,Tanzi RE,et al.Redox-Active Metals,Oxidative Stress,and Alzheimer's Disease Pathology[J].Ann N Y Acad Sci,2004,1012:153–163.

[42]Ansari N,Khodagholi F,Amini M,et al.Attenuation of LPS-induced apoptosis in NGF-differentiated PC12 cells via NF-kappaB pathway and regulation of cellular redox status by an oxazine derivative[J].Biochimie,2011,93(5):899–908.doi: 10.1016/j.biochi.2011.01.012.

[43]Meng Z,Yan C,Deng Q,et al.Curcumin inhibits LPS-induced inflammation in rat vascular smooth muscle cells in vitro via ROS-relative TLR4-MAPK/NF-|[kappa]|B pathways[J].Acta Pharmacol Sin,2013,34(7):901–911.doi: 10.1038/aps.2013.24.

[44]Rocksén D,Ekstrandhammarstr?m B,Johansson L,et al.Vitamin E reduces transendothelial migration of neutrophils and prevents lung injury in endotoxin-induced airway inflammation[J].Am J Respir Cell Mol Biol,2003,28(2):199–207.

[45]Sittipunt C,Steinberg K P,Ruzinski J T,et al.Nitric oxide and nitrotyrosine in the lungs of patients with acute respiratory distress syndrome[J].Am J Respir Crit Care Med,2001,163(2):503–510.

[46]Li H,Sun B.Toll-like receptor 4 in atherosclerosis[J].J Cell Mol Med,2007,11(1):88–95.

[47]戴國(guó)華,吳傳新,龔建平.Kupffer細(xì)胞與膽道感染[J].世界華人消化雜志,2008,16(24):2746–2750.doi:10.3969/j.issn.1009–3079.2008.24.011.Dai GH,Wu CX,Gong JP.Role of Kupffer cells in the infection of biliary tract[J].World Chinese Journal of Digestology,2008,16(24):2746–2750.doi:10.3969/j.issn.1009–3079.2008.24.011.

[48]Clements W,Mccaigue M,Erwin P,et al.Biliary decompression promotes Kupffer cell recovery in obstructive jaundice[J].Gut,1996,38(6):925–931.

[49]Osnes T,Sandstad O,Skar V,et al.beta-Glucuronidase in common duct bile,methodological aspects,variation of pH optima and relation to gallstones[J].Scand J Clin Lab Invest,1997,57(4):307–315.

[50]孫韶龍,吳碩東,戴顯偉,等.內(nèi)毒素調(diào)節(jié)肝臟β-葡萄糖苷酸酶mRNA的表達(dá)[J].世界華人消化雜志,2007,15(17):1887–1892.doi:10.3969/j.issn.1009–3079.2007.17.003.Sun SL,Wu SD,Dai XW,et al.Endotoxin regulates the expression of hepatocyte β-glucuronidase mRNA[J].World Chinese Journal of Digestology,2007,15(17):1887–1892.doi:10.3969/j.issn.1009–3079.2007.17.003.

[51]Putra AB,Kosuke N,Ryusuke S,et al.Jellyfish collagen stimulates production of TNF-α and IL-6 by J774.1 cells through activation of NF-κB and JNK via TLR4 signaling pathway[J].Mol Immunol,2014,58(1):32–37.doi: 10.1016/j.molimm.2013.11.003.

[52]Whiting JF,Green RM,Rosenbluth AB,et al.Tumor necrosis factor-alpha decreases hepatocyte bile salt uptake and mediates endotoxin-induced cholestasis[J].Hepatology,1995,22(4 Pt 1):1273–1278.

[53]周徽,彭健.胃癌術(shù)后膽石癥發(fā)病相關(guān)因素的Meta分析[J].中華肝膽外科雜志,2015,21(2):117–121.doi:10.3760/cma.j.issn.1007–8118.2015.02.012.Zhou H,Peng J.Related factors of gallstone occurrence after gastrectomy for gastric cancer: a Meta-analysis[J].Chinese Journal of Hepatobiliary Surgery,2015,21(2):117–121.doi:10.3760/cma.j.issn.1007–8118.2015.02.012.

[54]Greenburg G,Hay ED.Epithelia suspended in collagen gels can lose polarity and express characteristics of migrating mesenchymal cells[J].J Cell Biol,1982,95(1):333–339.

[55]Kalluri R,Weinberg RA.The basics of epithelial-mesenchymal transition[J].J Clin Invest,2009,119(6):1420–1428.doi: 10.1172/JCI39104.

[56]Xie G,Diehl AM.Evidence for and against epithelial-tomesenchymal transition in the liver[J].Am J Physiol Gastrointest Liver Physiol,2013,305(12):G881–890.doi: 10.1152/ajpgi.00289.2013.

[57]Glaser SS,Gaudio E,Miller T,et al.Cholangiocyte proliferation and liver fibrosis[J].E Expert Rev Mol Med,2009,11:e7.doi:10.1017/S1462399409000994.

[58]王麥建,楊雪峰,周廷梅,等.LPS刺激SD大鼠膽管上皮細(xì)胞表型轉(zhuǎn)化的動(dòng)物實(shí)驗(yàn)研究[J].重慶醫(yī)科大學(xué)學(xué)報(bào),2010,35(11):1662–1665.Wang MJ,Yang XF,Zhou TM,et al.Reseach of epithelialmesenchymal transitions in bile duct epithelial cells of SD rats induced by LPS[J].Journal of Chongqing Medical University,2010,35(11): 1662–1665.

[59]Sung R,Lee SH,Ji M,et al.Epithelial-mesenchymal transitionrelated protein expression in biliary epithelial cells associated with hepatolithiasis[J].J Gastroenterol Hepatol,2014,29(2):395–402.doi: 10.1111/jgh.12349.

[60]易世杰,趙禮金.TLR4及其作用的研究進(jìn)展[J].蛇志,2013,25(2):183–187.doi:10.3969/j.issn.1001–5639.2013.02.045.Yi SJ,Zhao LJ.Research progress in TLR4 and its actions[J].Journal of Snake,2013,25(2):183–187.doi:10.3969/j.issn.1001–5639.2013.02.045.

[61]顧進(jìn).TLR4-snail信號(hào)通路在LPS誘導(dǎo)的人膽管上皮細(xì)胞EMT中作用初步研究[D].遵義: 遵義醫(yī)學(xué)院,2015.Gu J.The role of TLR4-snail signal pathway in the EMT of human biliary epithelial cells induced by LPS[D].Zunyi :ZunYi Medical College,2015.