Acute cholecystitis

Introduction to acute cholecystitis Acute cholecystitis is an acute suppurative inflammation of the gallbladder, 80% associated with gallstones, is one of the common acute abdomen. Common causes of this disease include: 1. Stones in the cystic duct incarceration caused by obstruction, gallbladder cholestasis, concentrated bile salts damage the gallbladder mucosa caused by inflammation. 2. Bacterial infections, common pathogenic bacteria are Escherichia coli, aerogens, Pseudomonas aeruginosa, etc., mostly from the biliary tract retrograde. 3. Chemical stimulation: High concentrations of bile salts stimulate acute inflammation of the gallbladder mucosa. Often occurs after trauma, or after some abdominal surgery unrelated to the biliary system. In recent years, with the changes in the eating habits of the Chinese people and the aging, the incidence of gallstones in urban people has increased significantly. Therefore, acute cholecystitis is more common in urban residents, the incidence rate of adults is higher, and the incidence rate of the elderly is higher. Obesity The incidence of women is high, according to statistics female: male is 2:1. Repeated episodes of acute symptoms of this disease can be converted to chronic cholecystitis. At present, the cure rate of surgical treatment of this disease is high. Mild simple cholecystitis can be treated with drugs; for suppurative or gangrenous cholecystitis should be treated promptly to avoid complications. basic knowledge The proportion of illness: 0.036% Susceptible people: adults, the elderly, obese women Mode of infection: non-infectious Complications: biliary peritonitis, liver abscess, gallstones, hyponatremia, malnutrition, diarrhea, hiccup, biliary bleeding, intestinal obstruction, jaundice

Cause of acute cholecystitis

Bile retention (30%):

This is a pioneering, basic factor in causing acute cholecystitis, and the reasons can be broadly divided into two categories:

Mechanical obstruction: It is generally believed that more than 90% of patients with acute cholecystitis have stones incarcerated in the gallbladder neck or cystic duct, resulting in bile retention; some authors believe that even if there is no stone in the gallbladder during surgery or autopsy, it can not be proved in the early stage of the lesion. Stones are present, and stones may have been drained to the common bile duct. In addition to stones, the connection between the cystic duct and the common bile duct may also be due to a small angle, the cystic duct itself is too tortuous, deformed, or abnormal blood vessels, peripheral inflammation adhesions, aphid drilling, and swelling of the lymph nodes cause obstruction and biliary retention. Functional disorders studies have confirmed that biliary muscles, neurological disorders, and normal emptying of the gallbladder are blocked, causing temporary bile retention. When there are lesions in the abdominal organs, such as stomach, duodenal ulcer, chronic appendicitis or periarteritis, the visceral nerve is transmitted to the cerebral cortex by pathological stimulation, causing dysfunction of the cortex, thereby causing the cystic duct reflexively. The sphincter and duodenal papillary sphincter dysfunction causes paralysis, resulting in retention of bile throughout the biliary system. Long-term bile retention and concentration in the gallbladder can stimulate the gallbladder mucosa, causing inflammatory lesions, and bacterial infection can form acute cholecystitis.

Bacterial infection (30%):

About 70% of bacteria causing acute cholecystitis are Escherichia coli, others include Klebsiella, Clostridium, Staphylococcus, Salmonella typhi, Paratyphoid, Staphylococcus, and pneumococcal. About 50% of patients with acute cholecystitis have positive bile culture. The path of bacterial invasion is usually through bile or lymphatic vessels, and sometimes it can be retrograde into the biliary tract or blood-borne dissemination through the intestine. In short, there are many paths for bacteria to reach the gallbladder.

Other reasons (10%):

There are a few cases in the clinic that have no bile retention or bacterial infection for other reasons. Mainly seen in trauma and pancreatic reflux. Trauma, including surgery, burns, etc., can lead to acute cholecystitis. In the case of trauma, bile viscosity increases due to pain, fever, dehydration, emotional stress, etc., and emptying slows down. In addition, when the pancreatic and bile ducts are obstructed, trypsin in the reflux pancreatic juice is activated by bile, which binds to bile acids and also activates phospholipase to convert lecithin to lysolecithin, both of which act on the gallbladder wall. , causing damage.

Acute cholecystitis prevention

To prevent acute cholecystitis, the following items should be done:

1, pay attention to diet, food is light, suitable for eating greasy and fried, grilled food.

2, keep the stool smooth.

3, to change the sedentary lifestyle, more walking, more exercise.

4, to raise sex, long-term family is not jealous, people with a bad mood can cause or aggravate the disease, to be broad-minded, comfortable.

Acute cholecystitis complications Complications biliary peritonitis liver abscess gallstone hyponatremia malnutrition diarrhea reversing biliary bleeding intestinal obstruction jaundice

1, acute emphysema cholecystitis: This is a special type of cholecystitis, mainly caused by Clostridium perfringens in anaerobic flora, often combined with streptococcus, Escherichia coli and other mixed infections The main cause of bacterial infection is due to the development of acute cholecystitis to a certain extent, empyema in the gallbladder, ischemic necrosis of the gallbladder wall, which not only causes a decrease in oxygen partial pressure in the tissue, anaerobic bacteria are easy to breed, and various bacteria continuously produce gas. Then, it spreads around the gallbladder. In recent years, domestic and foreign scholars believe that purulent bile in the gallbladder stimulates the gallbladder mucosa, releasing lysozyme, causing further damage to the gallbladder mucosa, and phosphatase A can also promote lecithin in bile. It is converted into lysolecithin, which promotes mucosal hemolysis and hemorrhage.

The clinical manifestations of the patient are similar to acute severe cholangitis. Sometimes the patient may have jaundice and melena. The jaundice is mainly caused by the enlarged gallbladder or stone compressing the bile duct. Most of the patients have obvious abdominal distension. If the gallbladder perforation is combined, bile may appear. Signs of peritonitis can cause multiple organ dysfunction syndrome in severe cases.

Acute emphysema cholecystitis on the abdominal X-ray film, after 24 to 48 hours of onset, the gallbladder wall thickens and accumulates gas. As the condition worsens, it can spread to the surrounding tissues of the gallbladder. If the gallbladder is necrotic, the underarm can appear. Free gas and ascites effusion, in the X-ray signs should pay attention to the identification of gallbladder gas in the gallbladder intestinal tract, B-ultrasound can be seen in the gallbladder wall and gallbladder cavity gas and acute cholecystitis ultrasound signs, due to the disease mortality rate Higher, the lesions develop rapidly, gallbladder gangrene and perforation can occur in the early stage, so early cholecystectomy or gallbladder ostomy should be performed, and abdominal drainage should be performed.

2, gallbladder perforation: acute cholecystitis perforation can have a variety of clinical manifestations:

(1) bile enters the abdominal cavity, causing biliary peritonitis;

(2) secondary liver abscess formation;

(3) adhesion to the surrounding tissue, eventually forming an abscess around the gallbladder;

(4) Forming internal hemorrhoids with adjacent tissues and organs, such as gallbladder gastroparesis, gallbladder duodenum or colon fistula, etc. Among them, the most common abscess around the gallbladder, followed by biliary peritonitis, the cause of gallbladder perforation is more complicated. The main cause is gallbladder wall blood circulation disorder, gallbladder gangrene, the time of perforation is affected by the pressure increase in the gallbladder, the thickness of the gallbladder wall and the degree of fibrosis, the swellability of the gallbladder, the mechanical compression of gallstones, the gallbladder and surrounding tissues. The degree of adhesion and other factors, due to the occurrence of gallbladder perforation, more complications, and a certain mortality rate, it is recommended for active surgical treatment.

3, gallbladder internal hemorrhoids: gallbladder internal hemorrhoids mainly cholecystitis, cholelithiasis as the main clinical manifestations, due to different parts of the sputum have different clinical manifestations, the most common is gallbladder gastrointestinal fistula, a few are gallbladder and renal pelvis, bladder The ovary or uterus forms internal hemorrhoids. Clinically, the gallbladder and the stomach, the duodenum, the colon and the common bile duct form the internal hemorrhoid. After the formation of internal hemorrhoids, the main clinical manifestations are recurrent biliary infection and reflux acute. Cholecystitis, gallstones discharged through the duodenal fistula, can occur duodenal obstruction, if running to the small intestine, can cause mechanical obstruction at the lower end of the small intestine, clinically known as gallstone intestinal obstruction, and gallbladder colon Patients with delirium often present with steatorrhea, hyponatremia, malnutrition, etc. Comprehensive domestic and international literature, patients with cholecystitis should consider the possibility of gallbladder internal hemorrhoids when they have the following clinical manifestations:

(1) sudden onset of biliary colic and fever, chills, jaundice, symptom relief after self or anti-inflammatory treatment.

(2) Long-term diarrhea, especially after eating greasy food.

(3) Hiccups. Vomiting bile.

(4) Biliary hemorrhage.

(5) Intestinal obstruction.

B-ultrasound has a higher diagnostic rate for gallstones, but it is difficult to detect internal hemorrhoids. CT scans after oral contrast media scans can be found in the gallbladder and high density of intestinal density. The diagnosis is established, barium meal and X-ray abdominal plain film. It is an important and practical clinical method for diagnosing gallbladder fistula. The former can directly diagnose the gallbladder gastrointestinal fistula. The latter can see gas filling in the gallbladder or bile duct. Individual stones can be seen in the intestine, but Oddi should be excluded. Sphincter relaxation, emphysema cholecystitis, cholangitis, biliary anastomosis and other factors, PTC shows clear biliary tract, if the contrast agent is found to enter the intestine with abnormal passage, diagnosis can be made, ERCP found in the duodenum Abnormal opening and bile overflow can be diagnosed.

4, liver abscess: more occurs in the liver V segment immediately adjacent to the gallbladder bed, a small number of other parts of the liver abscess, the cause may be acute suppurative cholecystitis gallbladder invasion to the liver tissue, with the cholecystitis relieve liver abscess appears and aggravated It can also invade the liver tissue essence for perforation of acute cholecystitis. The patient has high fever, chills, and liver CT examination shows low density and liquid dark areas in the liver V segment.

Acute symptoms of gallbladder symptoms Common symptoms Fever gallbladder wall thick abdominal pain bloating right back pain jaundice biliary colic gallbladder tenderness sign nausea little finger nails have depression

1, sudden upper right abdomen persistent cramps, radiation to the right subscapular area, accompanied by nausea, vomiting.

2, chills, fever, anorexia, abdominal distension.

3, 10% of patients may have mild jaundice.

4, in the past there was a similar medical history, fat meal diet is easy to induce, caused by gallstones, nighttime onset is a feature.

5, right upper abdominal muscle tension, tenderness or rebound tenderness, Murphy (Murphy) sign positive, 30% -50% of patients can reach the swelling of the gallbladder with tenderness.

Examination of acute cholecystitis

[Laboratory Inspection]

1, the total number of white blood cells and neutrophils: about 80% of patients with increased white blood cell count, the average is (10 ~ 15) × 10 ⁹ / L, the degree of elevation is related to the severity of the disease and the presence or absence of complications, if the total number of white blood cells At 20 × 10 ⁹ /L or more, the presence of gallbladder necrosis or perforation should be considered.

2, serum total bilirubin: clinically about 10% of patients have jaundice, but the serum total bilirubin increased by about 25%, the serum total bilirubin in patients with acute cholecystitis generally does not exceed 34mol / L, if more than 85.5mol /L should consider the presence of common bile duct stones; when combined with acute pancreatitis, blood, urine amylase content also increased.

3, serum aminotransferase: 40% of patients with serum transaminase is not normal, but most of them below 400U, rarely up to the level of acute hepatitis.

Film degree exam

1, B-mode ultrasound

B-ultrasound is a rapid and simple non-invasive examination method for acute cholecystitis. The main sonographic features are:

(1) The long diameter and the wide diameter of the gallbladder may be normal or slightly larger, and are often elliptical due to increased tension.

(2) The gallbladder wall is thickened and the outline is blurred; sometimes it is mostly double-ringed and its thickness is more than 3mm.

(3) The permeability of the gallbladder contents is reduced, and the echo spots scattered in the mist appear.

(4) The enhancement effect of the lower edge of the gallbladder is weakened or disappeared.

2, X-ray inspection

Nearly 20% of acute gallstones can be visualized in plain radiographs, suppurative cholecystitis or gallbladder effusions, and can also show enlarged gallbladder or inflammatory tissue mass shadows.

3, CT examination

B-ultrasound can sometimes replace CT, but patients who have complications and cannot be diagnosed must have CT examination. CT can show thickening of the gallbladder wall more than 3mm. If gallbladder stones are invaded in the cystic duct, the gallbladder is significantly enlarged, and the gallbladder subserosal layer Peripheral tissue and fat are low-density rings due to secondary edema. Perforation of gallbladder can be seen as a liquid-abscess abscess in the gallbladder fossa. For example, there are bubbles in the gallbladder wall or gallbladder, suggesting "emphysema cholecystitis". This patient often has gallbladder It has been gangrene, and the density of the inflammatory gallbladder wall is significantly enhanced when the scan is enhanced.

4, intravenous cholangiography

For refractory acute cholecystitis, if the serum bilirubin is within 3mg% (51mol/L), there is no serious damage to liver function. Intravenous cholangiography can be performed within 24 hours after admission (patients do not need preparation, use 30% biliary Glucamine 20ml), if the bile duct and gallbladder are developed, acute cholecystitis can be ruled out; only the gallbladder delayed development, can also exclude acute cholecystitis, bile duct development and gallbladder still does not develop after 4h, can be diagnosed as acute cholecystitis, gallbladder Most of the bile ducts are not developed, most of them are acute cholecystitis. At present, ultrasound imaging has become the first choice for biliary diseases. Oral and intravenous cholangiography has been rarely used.

5. Radionuclide imaging

Intravenous injection of 131I-rosin or 99mTc-dimethyliminodiacetic acid (99mTc-HIDA) was performed after liver and gallbladder scan. Generally, the gallbladder was not radioactive within 90 minutes after injection, suggesting that the cystic duct is unreasonable, mostly acute cholecystitis. Therefore, this method is safe and reliable, and the positive rate is high. Therefore, 99mTc-HIDA scintillation can be used as the first choice for acute cholecystitis.

Diagnosis and differentiation of acute cholecystitis

diagnosis

Sudden pain in the right upper quadrant, and radiation to the right shoulder and back, accompanied by fever, nausea, vomiting, physical examination of the right upper quadrant tenderness and muscle health, Murphy sign positive, white blood cell count increased, B ultrasound showed gallbladder wall edema, you can confirm the diagnosis For this disease, if there is a history of biliary colic in the past, the diagnosis is more certain.

It should be pointed out that 15% to 20% of cases have mild clinical manifestations, or some symptoms are relieved immediately after the onset of symptoms, but the actual condition is still progressing, which may increase the difficulty of diagnosis.

Duodenal drainage test does not help the diagnosis of acute cholecystitis, but it will promote the gallbladder contraction and aggravate abdominal pain, causing incarceration of gallstones. Therefore, in the acute phase of the disease, duodenal drainage should be regarded as contraindication.

Differential diagnosis

1, duodenal ulcer perforation: most patients have a history of ulcers, the degree of abdominal pain is more severe, showing continuous knife-cut pain, sometimes can cause the patient in shock state, abdominal wall tonicity is significant, often "plate-like", tenderness, The rebound pain is obvious; the bowel sounds disappear; abdominal X-ray examination can find free gas under the armpit, but only a few cases have no typical ulcer history, small perforation or chronic perforation is not typical, which can cause diagnostic difficulties.

2, acute pancreatitis: abdominal pain is mostly in the upper abdomen or left, the signs are not as obvious as acute cholecystitis, Murphy sign negative; serum amylase increased significantly; B-ultrasound shows pancreatic enlargement, unclear border, etc. without acute gallbladder Inflammation signs; CT examination is more reliable for the diagnosis of acute pancreatitis than B-ultrasound, because B-ultrasound is often unclear due to flatulence of the abdomen.

3, high acute appendicitis: metastatic abdominal pain, abdominal wall tenderness, abdominal muscle rigidity can be confined to the right upper abdomen, easily misdiagnosed as acute cholecystitis, but B ultrasound without acute cholecystitis signs and Rovsing (Ruo Benzene) sign positive (by The left lower abdomen can cause pain in the appendix. It helps to identify. In addition, the history of recurrent episodes of cholecystitis and the characteristics of pain are also useful for differential diagnosis.

4, acute intestinal obstruction colic in the lower abdomen, often accompanied by bowel sounds hyperthyroidism, "metal tone" or gas over water, abdominal pain is not radioactive, abdominal muscles are not nervous, X-ray examination shows that the abdomen has a fluid level.

5, right kidney stone fever is rare, patients with low back pain, radiation to the perineum, kidney area with sputum pain, gross hematuria or microscopic hematuria, X-ray abdominal plain film can show positive stones, B-ultrasound kidney Stone or with renal pelvis expansion.

6, right lobar pneumonia and pleurisy patients may also have right upper quadrant pain, tenderness and muscle health and acute cholecystitis mixed, but the disease often has high fever, cough, chest pain and other symptoms, chest examination lung breath sounds reduced, It can smell vocal or pleural friction, and X-ray can help diagnose.

7, coronary artery disease: angina pain can often involve the upper abdomen or right upper abdomen, if misdiagnosed as acute cholecystitis and anesthesia or surgery, sometimes can lead to the death of patients, therefore, all patients over the age of 50 have abdominal pain symptoms while If you have tachycardia, arrhythmia or high blood pressure, you must have an electrocardiogram to identify.

8, acute viral hepatitis: acute severe jaundice hepatitis may have similar cholecystitis right upper abdominal pain and muscle health, fever, white blood cell count and jaundice, but hepatitis patients often have loss of appetite, fatigue, low fever and other prodromal symptoms; physical examination often It can be found that the liver area is generally tender, the white blood cells generally do not increase, and the liver function is obviously abnormal, which is generally not difficult to identify.

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