Gallbladder tenderness

Introduction The Murphy sign refers to the patient lying on his back and knees. The doctor puts the left palm flat on the lower part of the patient's right rib. First, use the moderate pressure on the left thumb to press the lower biliary point of the right rib. The patient slowly inhales deeply. In the inflamed gallbladder when deep inhalation, the pain is caused by the thumb pressed by the force. The phenomenon that the patient suddenly breathes because of the pain is called the Murphy sign positive, also known as the gallbladder tenderness sign, which is found in acute cholecystitis. Acute cholecystitis is a gallbladder inflammation caused by cystic duct obstruction and bacterial invasion. Its typical clinical features are paroxysmal cramps in the right upper quadrant, accompanied by obvious tenderness and abdominal stiffness. About 95% of patients have gallstones, called calculous cholecystitis; 5% of patients have no gallstones, called acalculous cholecystitis.

Cause

(1) Causes of the disease

The gallbladder is a blind sac that communicates with the bile duct through a curved, elongated cystic 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, basic factor in causing acute cholecystitis. The reasons can be broadly divided into two categories:

(1) 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 cannot be proved. There are no stones in the early stage of the lesion, and stones 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.

(two) pathogenesis

When the cystic duct or gallbladder neck is obstructed due to sudden incarceration of stones or other reasons, because the gallbladder is a "blind sac, causing bile to remain or concentrate, concentrated bile salts stimulate and damage the gallbladder to cause acute chemical cholecystitis. At the same time, bile retention and/or stone incarceration can release phospholipase A from the mucosal epithelium of the damaged gallbladder, and hydrolyze lecithin in the bile into lysolecithin, thereby changing the biofilm structure of the cells and leading to acute cholecystitis. 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. , eventually complicated by gallbladder gangrene or perforation. For the elderly, 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, and a slight thickening of the cyst wall. Visual observation of bile was more viscous, slightly turbid or no obvious abnormality. Leukocyte infiltration was observed under the microscope, and mucosal epithelium was shed, but bacterial culture was often negative.

2. Suppurative cholecystitis: the gallbladder is obviously enlarged due to obstruction of the cystic duct, showing a blue-green or gray-red color. The wall of the cystic wall is extremely hypertrophic and the vascular layer of the serosa is dilated. There is often a purulent cellulose deposit on the surface of the gallbladder, an ulcer can form on the mucosa, 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 wall is blocked, causing ischemic gangrene of the wall. The stones in the gallbladder can be invaded in the neck of the gallbladder, causing compression and necrosis of the wall of the capsule.

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

MRI examination of liver, gallbladder, pancreas and spleen

Diagnosis of acute cholecystitis:

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

Clinical manifestations of acute cholecystitis:

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. When the Murphy's sign is examined, the doctor asks the patient to lie flat, the doctor stands on the right side of the patient, the left thumb is placed on the gallbladder, and the other four fingers are placed in front of the right chest. The patient is asked to take a deep breathing action. When the inflamed gallbladder is in contact with the thumb, the patient may be diagnosed as positive for Murphy's sign if the patient feels pain and suddenly breathes. 30%-50% of patients can reach the swelling of the gallbladder with tenderness.

Differential diagnosis:

1. Duodenal ulcer perforation: Most patients have a history of ulcers. The degree of abdominal pain is severe, showing continuous knife-cut pain, sometimes causing the patient to be in a state of shock. Abdominal wall rigidity is significant, often "plate-like", tenderness, rebound tenderness, bowel sounds disappear, abdominal X-ray examination can be found under the armpits with free gas. In a few cases, there is no history of typical ulcers, and the perforation is small or the chronic perforation is atypical, which can cause diagnostic difficulties.

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

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. However, B-ultrasound has no signs of acute cholecystitis and Rovsing (Ruosing Benzene) sign positive (according to the left lower abdomen can cause pain in the appendix). In addition, the history of recurrent episodes of cholecystitis and the characteristics of pain are also useful for differential diagnosis.

4. Acute intestinal obstruction: The colic of intestinal obstruction is mostly located in the lower abdomen, often accompanied by bowel sounds, "metal sound" or gas over water, abdominal pain without radioactivity, abdominal muscles are not nervous. X-ray examination showed that the abdomen had a fluid level.

5. Right kidney stones: 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 films can show positive stones. B super visible kidney stones or with renal pelvis expansion.

6. Right lobar pneumonia and pleurisy: patients may also have right upper quadrant pain, tenderness and muscle spasm and mixed with acute cholecystitis. However, in the early stage of the disease, there are many symptoms such as high fever, cough, chest pain, chest lungs, lung sounds, and vocal or pleural friction. X-ray chest is helpful for diagnosis.

7. Coronary artery disease: Pain in angina often involves the middle of the upper abdomen or the right upper abdomen. If it is misdiagnosed as acute cholecystitis and anesthesia or surgery, it can sometimes lead to death. Therefore, patients over the age of 50 who have symptoms of abdominal pain and have tachycardia, arrhythmia or hypertension, must be electrocardiogram examination to identify.

8. Acute viral hepatitis: Acute severe jaundice hepatitis may have upper right abdominal pain and muscle spasm similar to cholecystitis, fever, increased white blood cell count, and jaundice. However, patients with hepatitis often have proactive symptoms such as loss of appetite, fatigue, and low fever. Physical examination often reveals that the liver area is generally tender, white blood cells generally do not increase, liver function is obviously abnormal, and it is generally difficult to identify.

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