Persistent severe pain in the right upper quadrant radiating to the right shoulder

Introduction Sustained severe pain in the right upper abdomen and radiation to the right shoulder is one of the symptoms of acute cholecystitis. Acute cholecystitis is inflammation of the gallbladder caused by cystic duct obstruction and bacterial invasion; its typical clinical features are paroxysmal cramps in the right upper quadrant with obvious tenderness and abdominal stiffness.

Cause

The cause of persistent severe pain in the right upper quadrant and radiation to the right shoulder:

(A) the cause of the disease: the gallbladder is a blind sac, through the curved, slender cystic duct and the bile duct. The main cause of this disease is cystic duct obstruction, bile retention and consequent bacterial infection or chemical cholecystitis due to various factors. In a few cases, there was no obvious retention of bile in the gallbladder. Bacterial infection seemed to be the only cause of acute cholecystitis.

1. Bile retention: This is a pioneering and basic factor in causing acute cholecystitis. The causes can be roughly divided into two categories: (1) Mechanical obstruction: It is generally believed that more than 90% of patients with acute cholecystitis have stones embedded in The gallbladder neck or cystic duct leads to bile retention; some authors believe that even if there is no stone in the gallbladder during surgery or autopsy, it can not be proved that there is no stone in the early stage of the lesion, and the stone may have been discharged 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.

2. Bacterial infection: About 70% of the bacteria causing acute cholecystitis are Escherichia coli, others include Klebsiella, Clostridium, Staphylococcus, Salmonella typhi, Paratyphoid, Streptococcus, and Pneumococci Wait. 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.

3. Other causes: 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.

(B) the pathogenesis: when the cystic duct or gallbladder neck is blocked due to sudden incarceration of stones or other reasons, because the gallbladder is a "blind sac, causing bile retention or concentration, concentrated bile salts stimulate and damage the gallbladder caused acute chemical gallbladder At the same time, bile retention and/or stone incarceration can release phospholipase A from the mucosal epithelium of the injured gallbladder, hydrolyzing lecithin in bile into lysolecithin, thereby changing the biofilm structure of the cells and causing acute gallbladder inflammation. Another author found that high concentrations of prostaglandins in the gallbladder wall of inflammation are considered to be a medium for causing acute cholecystitis. If the cystic duct obstruction is not released in time, the pressure in the gallbladder cavity is continuously increased, the gallbladder wall is blocked by blood and lymphatic reflux, and the congestion and edema cause ischemia. The ischemic gallbladder wall is prone to secondary bacterial infection, thereby aggravating the progression of acute cholecystitis. As a result, gallbladder gangrene or perforation is complicated; for elderly people, patients with diabetes and arteriosclerosis are more likely to develop ischemic necrosis of the gallbladder. Gallbladder ischemia, increased inflammation, gangrene at the bottom of the gallbladder, clinically more common in the second week of onset, if not treated in time, it will soon be complicated by perforation and peritonitis. Such as simple cystic duct obstruction without blood supply barrier and bacterial infection of the gallbladder wall, it develops into gallbladder effusion.

According to the severity of inflammation and the length of the disease, the pathological manifestations of acute cholecystitis can vary greatly.

1. Simple cholecystitis: belongs to the lightest type. It is characterized by mild enlargement of the gallbladder, congestion of the cyst wall, mucosal edema, slightly thickening of the cyst wall; visual observation of bile is more viscous, slightly turbid or no abnormality, leukocyte infiltration under the microscope, mucosal epithelial shedding, but bacterial culture often Negative.

2. Suppurative cholecystitis: the gallbladder is obviously enlarged due to obstruction of the cystic duct, blue-green or gray-red, the hyperemia of the cystic wall is extremely significant, the vasodilation of the serosa layer; the surface of the gallbladder often has purulent cellulose precipitate, and the mucosa can be An ulcer is formed and the entire gallbladder is filled with pus. Inflammatory exudation of the gallbladder wall can cause adjacent peritoneal adhesions and lymphadenopathy. At this time, the bacterial culture of bile is mostly positive. Microscopically, a large number of mononuclear cells infiltrated, bilirubin calcium precipitated, and cholesterol crystallized.

3. Gangrenous cholecystitis: When the condition is serious, sometimes the gallbladder is swollen too much, the blood supply of the cyst wall is blocked, causing ischemic gangrene of the cyst wall; the stones in the gallbladder can be invaded in the neck of the gallbladder, causing compression and necrosis of the capsule wall. These changes can eventually lead to perforation of the gallbladder, and even the formation of internal hemorrhoids between the gallbladder and the duodenum. In addition to inflammatory cell infiltration, cystic wall edema, oozing, localized or extensive necrosis, ischemia, and even perforation can be seen; sometimes small arteriosclerosis with luminal stenosis.

an examination

Related inspection

Chest B-ultrasound CT examination

Examination of the upper right abdomen with persistent severe pain and radiation to the right shoulder:

Clinical manifestations:

1. Sudden onset of persistent upper right abdomen, radiation to the right scapular region, accompanied by nausea and vomiting.

2. chills, fever, anorexia, and bloating.

3.10% of patients may have mild jaundice.

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

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

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

Differential diagnosis

Sustained severe pain in the right upper abdomen and identification of confusing symptoms to the right shoulder:

Paroxysmal cramps in the upper right abdomen of children: This symptom occurs in children and should be suspected as biliary ascariasis. Because the mites have the characteristics of oxalic acid and drilling, they are affected by the surrounding environment (inappropriate insects, indigestion, etc.) and turbulence occurs. They move upwards and break into the biliary tract, causing sudden upper right abdominal cramps in children and to the right. Lumbar radiation. Children often have vomiting and spit out bile and aphids.

Sudden right upper quadrant colic: biliary ascariasis is a common clinical complication, and the invasion site of the worm is mostly in the common bile duct. The main symptom is sudden upper right abdominal cramps and is radiated to the right shoulder, back and lower abdomen.

Right upper abdominal pain: generally the liver, gallbladder, biliary tract, pancreas, duodenum, right kidney, right segment of the large intestine. The right upper quadrant pain was paroxysmal cramps and radiated to the right shoulder, mostly cholecystitis and cholelithiasis. Right upper quadrant pain, it is probably due to liver problems, inflammation of the liver will cause upper right abdominal pain, it is best to check the two pairs of hepatitis B, whether or not you have hepatitis B. Accompanied by diarrhea may be inflammation of the intestine; constipation may be obstruction of feces; vomiting should consider intestinal obstruction or inflammation; changes in bowel habits may be caused by large intestine; symptoms of jaundice, fever, etc. may be bile duct or liver lesions; frequent urination In the case of dysuria, nocturia, etc., it is necessary to consider problems such as the bladder and urethra. These accompanying different symptoms can help distinguish the real cause of abdominal pain.

Paroxysmal abdominal pain: abdominal pain, accompanied by diarrhea, etc., symptoms are not like dysentery. Such abdominal pain and diarrhea symptoms can also be called summer paroxysmal abdominal pain. Also common in intestinal fistula, is the most common case of acute abdominal pain in children. In small babies, the onset of intestinal fistula is mainly characterized by persistent, difficult to appease crying. The main manifestations are crying and uneasiness, which may be accompanied by vomiting, cheek flushing, tumbling, and distortion of both lower extremities. When crying, the face is flushed, the abdomen is inflated and tense, and the legs are lifted up. The attack can be terminated by the child's exhaust or defecation. In small babies, it can be repeated and self-limited.

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