Acute cholecystitis in pregnancy

Introduction to pregnancy with acute cholecystitis Acute cholecystitis is the second most common surgical disease after appendicitis. The incidence of cholecystitis is related to the blockage of bile duct and bacterial infection. Greenberger et al. (1998) reported that the incidence of acute cholecystitis, bacterial infection accounted for 50%~ 85%. Patients with cholecystitis have gallstones, called calculous cholecystitis, and non-calculous cholecystitis without gallstones. The main cause of the disease is bile duct obstruction and secondary bacterial infection. Bile drainage is easy to breed and cause infection. Common bacteria are Gram-negative bacilli, of which E. coli is the most common account of more than 70%, followed by Staphylococcus, Streptococcus and Anaerobic bacteria. It has also been reported that Helicobacter pylori is countercurrent to the biliary tract through the duodenal papilla. At the beginning of gallbladder inflammatory disease, cystic duct obstruction, gallbladder enlargement, elevated pressure, mucosal congestion and edema, exudation is called acute simple cholecystitis. If the obstruction is not relieved, inflammation is not controlled, the lesion can develop to the full thickness of the gallbladder wall. Thickening of the cyst wall and purulent exudate become acute suppurative cholecystitis. If the disease changes further, the pressure in the gallbladder continues to rise, and the tension of the gallbladder wall leads to blood circulation disorder. At this time, clinical gangrene, perforation complications, pus The fluid enters the bile duct, and the pancreatic duct can cause acute suppurative cholangitis and pancreatitis. If the bile duct obstruction is relieved during the course of the disease, the inflammation can gradually subside, and the recurrent episodes are chronic cholecystitis changes. basic knowledge The proportion of illness: 0.001% Susceptible population: pregnant women Mode of infection: non-infectious Complications: peritonitis gallstone intestinal obstruction acute suppurative cholangitis acute pancreatitis

Pregnancy with acute cholecystitis

(1) Causes of the disease

Choles deposition (20%):

More than 90% of cholestasis is caused by stone incarceration. Stones can cause obstruction of gallbladder outlet, increased gallbladder pressure, poor blood supply to the gallbladder wall, and ischemic necrosis. The accumulated bile can stimulate the gallbladder wall and cause chemical inflammation. Pancreatic juice reflux, pancreatic digestive enzymes erode the gallbladder wall and cause acute cholecystitis.

Bacterial infection (30%):

Due to cholestasis, bacteria can multiply, enter the gallbladder retrograde through the bloodstream, lymph or biliary tract, causing infection. The source of infection is Gram-negative bacilli, 70% is Escherichia coli, followed by Staphylococcus, Proteus and so on.

Pregnancy effects (10%):

During pregnancy, the progesterone is increased, the gallbladder wall muscle layer is thick, the gallbladder smooth muscle is relaxed, the gallbladder contractility is decreased, the gallbladder volume is increased by 2 times, the gallbladder emptying is delayed, and the cholesterol content in the bile is increased, and the ratio of cholesterol and bile salts is changed. Increased bile viscosity is prone to cholecystitis; increased uterus in the uterus can also cause cholecystitis.

Acute cholecystitis may be present alone or as part of acute suppurative cholangitis. Acute cholecystitis is caused by biliary tract obstruction of the cystic duct; common bile duct stones or biliary tract mites are often the cause of acute suppurative cholangitis.

(two) pathogenesis

In the past, because pregnant women should not do X-ray gallbladder examination, there is less information in this area. Ultrasound is used to evaluate the gallbladder dynamics of pregnant women. It is found that although the pregnant women did not increase the gallbladder in early pregnancy, the emptying rate was slightly decreased. After the gallbladder fasting volume increased to 15 ~ 30ml, the residual volume also increased, 2.5 ~ 16ml, gallbladder emptying rate decreased significantly.

The changes of gallbladder during pregnancy may be related to hormones. Estrogen reduces the regulation of sodium in the gallbladder mucosa and reduces the ability of the mucous membrane to absorb water, which will affect the concentration function of gallbladder. The slowing of gallbladder emptying is related to the increase of progesterone. During the process, cholecystokinin is released, and the gallbladder is contracted and emptied. Progesterone reduces the gallbladder's response to cholecystokinin, and at the same time inhibits the contraction of gallbladder smooth muscle and slows the emptying of the gallbladder.

Pregnancy also has an effect on bile composition and secretion. Bile salts, phospholipids and cholesterol are important chemical components of bile and maintain a certain proportion to form a colloidal solution. This ratio changes, especially bile acids, and phospholipids. Or increase in cholesterol, can make cholesterol from supersaturated bile crystallize, precipitate and form stones, pregnant women to pregnancy, the secretion of cholesterol in the bile increases, cholesterol saturation increases, and the volume of bile acid pool increases from early pregnancy, The proportion of chenodeoxycholic acid in bile acids decreased and the proportion of cholic acid increased. Contrary to the increase in the rate of synthesis of cholic acid, chenodeoxycholic acid and deoxycholic acid decreased. This ratio change affects cholesterol in colloidal solution. The solubility in the cholesterol makes the cholesterol easy to precipitate and crystallize, and the progesterone reduces the contractile force of the gallbladder, prolongs the emptying time of the gallbladder, increases the residual volume, and creates conditions for gallstone formation and bacterial reproduction, which may cause biliary infection.

Pregnancy with acute cholecystitis prevention

1. Pay attention to hygiene and prevent intestinal mites from infecting: develop good hygiene habits, wash hands before and after meals, eat raw fruits and vegetables, and do a good job in environmental sanitation. It is an effective measure to prevent tsutsugamushi disease. Preventing gallstones is also helpful.

2. Active treatment of intestinal ascariasis and biliary ascariasis: After the discovery of intestinal ascariasis, it is necessary to take anthelmintic drugs in time to prevent the mites from drilling into the biliary tract. In case of biliary ascariasis, it should be actively treated to prevent the occurrence of bile pigments. stone.

3, to maintain the contractile function of the gallbladder, to prevent long-term stasis of bile: patients with long-term fasting intravenous nutrition, should regularly use gallbladder contraction drugs, such as cholecystokinin.

Pregnancy with complications of acute cholecystitis Complications peritonitis gallstone intestinal obstruction acute suppurative cholangitis acute pancreatitis

Gallbladder perforation

Perforation occurs in the gallbladder wall at the bottom of the gallbladder or at the incarceration of the stone, causing biliary peritonitis. 50% of patients with gallbladder perforation are wrapped by the omentum and surrounding tissue to form an abscess around the gallbladder; 20% of patients in the gallbladder and its adjacent organs (stomach Intestinal) forms internal hemorrhoids; about 10% of patients can develop gallstone intestinal obstruction.

2. Acute suppurative cholangitis

Biliary obstruction and infection are the basic factors of the disease. Primary or secondary common bile duct stones, biliary ascariasis and biliary obstruction caused by common bile duct stricture are the pathological basis of acute suppurative cholangitis, cholestasis during biliary obstruction. Conducive to bacterial growth in bile, secondary bacterial infection after biliary mucosa congestion and edema, increased pressure in the biliary tract, aggravating the degree of biliary obstruction.

3. Biliary pancreatitis

The lower end of the common bile duct stone incarceration or Oddi sphincter spasm, or duodenal papillary edema, causing temporary obstruction of Vater ampulla and pancreatic duct, bile flow back to the pancreatic duct through the "common channel", induce acute pancreatitis.

Pregnancy with acute gallbladder symptoms Common symptoms Lazy gallbladder abdomen has local or wide... Nausea peritonitis cyst Sudden right upper quadrant colic jaundice chills abdominal muscle tension shock

Usually occurs after a full meal or excessive fatigue, more common at night, the pain is sudden, more common in the right upper abdomen, can also be seen in the middle of the upper abdomen or under the xiphoid, paroxysmal intensification, pain can be radiated to the right shoulder, right shoulder In the lower or right waist, a small number of patients can radiate to the left shoulder, 70% to 90% of patients may have nausea and vomiting; 80% of patients have chills and fever; 25% of patients with jaundice, shock can occur when severe infection .

The right upper abdomen has obvious tenderness. Under the right rib, the enlarged gallbladder can be touched. In the case of peritonitis, there may be abdominal muscle tension and rebound tenderness. In some patients, the Murphy sign is positive. In the third trimester, due to the enlarged uterus cover, the abdominal signs may not be obvious.

Examination of pregnancy with acute cholecystitis

1. The white blood cell count is increased, with the left side of the nucleus. If there is suppuration or gallbladder gangrene, the white blood cells can reach 20×10 ⁹ /L or more when perforated. This is not a very specific indicator based on the high white blood cells during pregnancy.

2. Serum alanine transferase (ALT) and aspartate transferase (AST) are slightly elevated, bilirubin is elevated when the common bile duct is obstructed, and alkaline phosphatase (ALP) is slightly elevated, but Because of the influence of estrogen during pregnancy, the latter does not help much.

Ultrasonography is the best diagnostic method during pregnancy, especially in the diagnosis of cholelithiasis, the false positive and false negative rate is 2% to 4%, under the ultrasound, gallbladder enlargement, wall thickness, most acute cholecystitis combined with gallstones, so it can be seen Gallstones and sound shadows, bile sediments and gallbladder contraction, when the common bile duct obstruction, the common bile duct dilatation, diameter > 0.8cm, sometimes visible in the common bile duct stones or aphid echo, Stuffer et al reported in 93 % of patients scan the gallbladder when not on an empty stomach, and about 95% of them find gallstones. Of course, the ideal is still 12h on an empty stomach.

Diagnosis and differential diagnosis of pregnancy complicated with acute cholecystitis

diagnosis

According to the typical medical history, sudden upper right abdominal cramps, paroxysmal aggravation, right upper abdominal gallbladder area tenderness, muscle tension, elevated body temperature, can be diagnosed, ultrasound see gallbladder wall thickness, systolic dysfunction, or combined with gallstone diagnosis More specifically, if you touch the gallbladder with a large tension or the body temperature is 39 ~ 40 ° C, the condition is not relieved, etc., the gallbladder necrosis should be considered, the risk of perforation is increased, and it may cause peritonitis.

Differential diagnosis

First of all, consider the diagnosis of life-threatening diseases such as myocardial infarction, acute fatty liver in pregnancy, severe hypertensive disorder complicating pregnancy and HELLP syndrome; and other diseases that are not life-threatening but very serious, such as right acute pyelonephritis, acute Identification of pancreatitis, pneumonia, etc.

Secondly, it should be differentiated from the acute appendicitis that requires the most timely surgery. The position of the appendix in pregnancy is often misdiagnosed as cholecystitis and delayed surgery.

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