Biliary clonorchiasis

Introduction to biliary clonorchiasis Clonorchiasissinensis of bileduct, commonly known as liver fluke, was first discovered in the bile duct of an overseas Chinese in Calcutta, India in 1874 and confirmed in China in 1908. In 1975, the clonorchiasis eggs were found in the ancient corpses of the Western Han Dynasty and the tombs of the Warring States tombs in Jiangling County, Hubei Province, which proved that the disease was prevalent in China for at least 2,300 years. Clonorchis sinensis is found throughout the world, mainly in China, Japan, North Korea, South Korea, Vietnam and other Asian countries. At present, there are 26 provinces, municipalities, autonomous regions and special administrative regions in China. The disease is caused or prevalent. Due to bad eating habits, the number of infected people in Guangdong Province is the highest, about 5 million, accounting for half of the total number of infected people in the country. Adults are parasitic in the biliary system, causing chonorchiasis of bile duct, which is asymptomatic, and causes cholecystitis, cholangitis, biliary calculi, biliary tract tumors, malnutrition and growth and development disorders. basic knowledge Sickness ratio: 0.0001% Susceptible people: no specific people Mode of infection: non-infectious Complications: acute cholecystitis

Causes of biliary clonorchiasis

(1) Causes of the disease

After the first intermediate host (freshwater snail) and the second intermediate host (freshwater fish prawn), the eggs of C. sinensis develop into cystic sputum. After the live sac is ingested, it is activated by bile and the larvae of the sac is broken. The wall emerges, and the bile duct enters the hepatic bile duct to develop into an adult. It can also reach the liver through the blood vessel or through the intestinal wall. Finally, the parasitic development in the liver and bile duct develops into an adult. The life span of the adult is generally 20 to 30 years, mainly parasitic in humans. Dogs, cats and pigs in the bile duct, when the number of insects can also migrate to larger bile ducts or even gallbladder, occasionally found in the pancreatic duct.

(two) pathogenesis

The hepatobiliary tube parasitized by adults is closely related to the number of infections of Clonorchis sinensis and the length of infection. If the number of infected insects is only 10 to dozens, there is no macroscopic lesion in the liver and bile duct. If the number of parasites exceeds 100 or even thousands, the worms are filled with intrahepatic bile ducts, gallbladder and pancreatic ducts, causing biliary obstruction, cholangitis, liver abscess, pancreatitis, etc. Intrahepatic small bile duct, due to mechanical clogging of the worm body and toxic effects of metabolites, causing cholestasis, bile duct saclike or cylindrical expansion, with the left marginal part of the left biliary epithelial cells shed and hyperplasia, bile duct wall Connective tissue hyperplasia and thickening, and a large number of glandular hyperplasia, lymphocytes and granulocyte infiltration; adjacent liver cells have fatty degeneration, atrophy and necrosis, eventually leading to biliary cirrhosis, death of Clonorchis sinensis The eggs and the detached bile duct epithelium can become the core of the formation of stones, and induce bile duct stones. It is reported that this disease is closely related to cholangiocarcinoma.

Biliary tract clonorchiasis prevention

1. Measures against infectious sources

(1) census and cure source: In popular areas, census work must be strengthened, and skin tests can be used for screening first, and positive ones for fecal tests. Drug-treated patients should be given a stool-tested egg-positive person.

(2) Management of animal infectious sources: Cats, dogs, pigs, etc. cannot be fed with raw fish and shrimp or fish viscera to avoid infection. The manure of these animals should also be managed to prevent manure from entering the ditch and fish ponds. Infected animals in livestock, and conditions are also given to deworming. The wild animal insectivorous host is hunted according to the situation.

2. Measures for the route of transmission

Do not eat uncooked fish and shrimp: Strengthen health publicity and education work, make the residents of the epidemic areas a household name, everyone understand the harmfulness of this disease and its transmission. Not eating uncooked fish or shrimp is the most effective measure to prevent this disease. Experiments have shown that 1mm thick fish containing cystic sputum is put into hot water at 98 °C, and it will die after 1s capsule, and die at 70 °C for 5s; if the fish containing cystic mites is 2~3mm thick, in water at 70 °C It takes 8s to die; therefore, the thicker the fish, the longer it takes to heat. Cysts are more resistant to condiments. In vinegar (about 3.36% of acetic acid), they die after 2 hours, and sodium chloride (19.3%) in soy sauce, and die after 5 hours. Therefore, uncooked fish have the potential to spread the disease. Be aware that kitchen knives and chopping boards must be cooked separately. Children must not eat grilled fish, baked fish, fish or raw fish.

Complications of biliary clonorchiasis Complications acute cholecystitis

1. Clonorchis sinensis with chronic or acute cholecystitis itself, damage to the bile duct epithelium, easily lead to biliary obstruction and bacterial infection, in the Pearl River Delta epidemic area of Guangdong Province, due to biliary tract disease hospitalized patients with clonorchiasis infection rate of 75 %, clinical manifestations of abdominal pain, gallbladder enlargement, chills, fever, a large number of worms cause obstructive jaundice.

2. The stones caused by the biliary tract clostridium are mostly polychromatic pigment stones in the intrahepatic bile duct, which is related to the parasitic mites in the small and medium biliary ducts. Among the 2214 cases of clonorchiasis reported in China, 93 cases of gallstones, 4.20%, and the control stone was only 0.31%.

3. Cholangiocarcinoma stenosis parasitic bile duct aneurysmal or polypoid hyperplasia, recurrent cholangitis, bile duct wall fibers thickening, leading to obstruction of bile duct stricture, this stenosis is more common in medium-sized intrahepatic bile duct, in When ERCP was performed on biliary obstruction caused by trematode, it was found that the nipple cannula encountered different degrees of difficulty. The benign papillary sphincter stenosis was 57.2% (8/14 cases), indicating that trematode can cause distal stenosis of the biliary tract.

4. The incidence of cholangiocarcinoma after cholangiocarcinoma infection is significantly higher than that of non-infected patients. It is characterized by: 1 In the bile duct surrounded by tumor or in the bile duct connected with the tumor, adult worm or adult worm 2; histological examination showed fibrosis around the bile duct, increased secretion of mucous membrane of bile duct epithelium, adenomatous hyperplasia, a group of 45 confirmed infections, 5 cases of cholangiocarcinoma, 1 case of duodenal papillary carcinoma, bile duct in Hong Kong The occurrence of cancer is also closely related to trematode infection.

5. Pancreatitis adults block the pancreatic duct.

Symptoms of biliary clonorchiasis Common symptoms biliary colic jaundice diarrhea abdominal pain chills high fever ascites gallbladder wall fibrosis

The incubation period is 1 to 2 months.

Mildly infected people are often asymptomatic, and only eggs are found in the feces.

More serious infections are repeated infections, slow onset, but non-endemic areas can cause acute onset. The clinical manifestations of acute phase mainly include gastrointestinal symptoms and allergic reactions, including loss of appetite, upper abdominal pain and fullness, liver Area pain, liver enlargement (especially the left lobe is obvious), and there are fever, fatigue, dizziness, insomnia, lack of energy, memory loss and other symptoms, even due to a large number of adults blocking the common bile duct and biliary colic Obstructive jaundice.

34.2% of patients with no obvious symptoms in the chronic phase, more common are fatigue, upper abdominal discomfort, abdominal pain, liver pain, dizziness, etc., followed by headache, insomnia, loss of appetite, diarrhea, etc., severe cases of chronic recurrent infection may have liver Hardening and portal hypertension, manifested as weight loss, anemia, edema, hepatosplenomegaly, ascites, jaundice, etc., severely infected children may have malnutrition and growth and development disorders, and may even cause dwarfism.

Some patients have sudden chills about 1 month after severe infection, high fever, liver with tenderness, mild jaundice, a small number of splenomegaly, lung infiltration, and acute symptoms disappear into a chronic phase after several weeks. For fatigue, indigestion, liver and tenderness.

Examination of biliary tract clonorchiasis

1. Eggs are found in the feces to find clonorchiasis, the detection rate is about 50%, the commonly used methods are direct smear method, water washing and precipitation method, modified Kato thick film smear method and aldehyde ether method The latter two methods have higher detection rate, and the eggs are directly inspected from the duodenal drainage fluid. The detection rate is close to 100%. Due to the troublesome operation, the patient's pain is increased, and it is not suitable for routine use.

2. Immunological examination enzyme-linked immunosorbent assay (ELISA) for the diagnosis of clonorchiasis, the seroprevalence rate of 89.7% ~ 100%, the method is simple, rapid, less blood sample, high sensitivity and specificity, judgment results Easy, is a widely used method, there are many commonly used methods, the positive rate of intradermal test is 92% ~ 95%, about 5% false negative, can be used for preliminary screening, serum immunology indirect hemagglutination The positive rate of the test (IHA) was 90%.

3. The blood picture may have an increase in the total number of white blood cells and an increase in eosinophils; an acute infection may cause anemia.

4. Liver function test showed little change in mild infection; severe infection mainly showed decreased serum total protein and albumin, albumin/globulin ratio could be inverted, ALP increased; serum ALT was normal or slightly elevated.

5. B-mode ultrasound examination in the severe infection often occurs in the intrahepatic bile duct dilatation, liver enlargement, dilated small bile ducts in a "jungle"-like distribution, around the dilated small bile ducts form a small light group or along with no sound shadow The branches of the portal veins are dotted with strong echoes, which are like "stars" scattered.

6. Cholangiography Percutaneous transhepatic cholangiography (PTC), retrograde cholangiopancreatography (ERCP) through duodenoscopy, ERCP is more common, cholangiography is characterized by: dilated bile duct is not "dendritic" from thick Thinning, but due to occlusion of the worm, the widened branch of the bile duct is suddenly cut off, showing a "bald-like" or "cystic" at the end, and a filamentous or elliptical translucent area is also visible in the dilated bile duct.

3. CT scan of the common bile duct caused by Clonorchis sinensis CT changes are the uniform expansion of the intrahepatic bile duct from the hepatic gate to the capsule, the diameter of the tube is similar, and the bile duct dilation caused by general obstruction is gradually from the hepatic gate to the surrounding There was a significant difference in the reduction, and the incidence of cystic or rod-like dilatation of the subcapsular bile duct was also high, reaching 90.8% (148/163 cases), and CT showed simultaneous lesions.

Diagnosis and differentiation of biliary tract clonorchiasis

In epidemic areas, because people generally have an understanding of this disease, it is easy to diagnose according to clinical manifestations, but it is easy to cause misdiagnosis in non-endemic areas. According to epidemiological data, clinical symptoms and signs, combined with laboratory examination and imaging examination. Can be clearly diagnosed.

Differential diagnosis

1. Viral hepatitis needs to be differentiated from the early manifestations of Clonorchis sinensis infection. Viral hepatitis can have jaundice in the early stage, diffuse enlargement of the liver, liver function damage, liver function test, serum immunological examination, and fecal egg test. Achieve a clear diagnosis.

2. Both dyspepsia have dyspepsia symptoms. According to the medical history, the fecal eggs are examined, and the immunological examination excludes the infection of Clonorchis sinensis.

3. Ameba liver abscess has a history of dysentery or diarrhea before the onset, then there is fever, liver pain, stool to find amoebic trophozoite, B-ultrasound or CT shows liquid occupying in the liver, liver puncture see typical chocolate Pus.

4. Fasciola hepatica is parasitic in the liver of herbivorous livestock and wild animals. The main terminal host is cattle, sheep, pigs, and people are accidentally infected, mainly eating the cysts. The aquatic plants, such as water celery or raw water contaminated with sacs, are similar to the clonorchiasis, and the identification mainly depends on the eggs.

5. Mixed infection of liver fluke and heterophysis (Hyperphysis) or infection with Alien trematode. It has been found in China that the life history of Heterodera is similar to the life history of Clonorchis sinensis, but this insect mainly parasitizes the intestinal mucosa. In the deep, it can invade other organs of the human body with blood flow, causing local embolism and ectopic damage. The morphology of the eggs of the worms and the clonorchiasis of the genus Clostridium is very similar, and should be distinguished.

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