Gallbladder empyema

Introduction Since the gallbladder neck tube causes obstruction, the water in the gallbladder does not circulate, and the stagnant water is like the stagnant water in the pool. It is easy to cause bacteria to breed and multiply and infect, thus forming gallbladder empyema. The bile becomes a stinky pus. Afterwards, the pressure in the gallbladder gradually increases, affecting the blood and lymph circulation of the gallbladder wall mucosa, and gradually causing ulceration and necrosis on the gallbladder wall mucosa. In severe cases, large necrosis and perforation may occur. Cholecystitis is a relatively common disease with a high incidence. According to its clinical manifestations and clinical experience, it can be divided into two types, acute and chronic, often combined with cholelithiasis.

Cause

The incidence of acute cholecystitis is closely related to biliary stasis and bacterial infection. The main pathogens of cholecystitis are Escherichia coli (60% to 70%), Gram-negative bacteria such as Klebsiella and Anaerobacter, and most of them are retrogradely enter the gallbladder through the common bile duct, and a few pass the portal system to the liver. Then flow into the gallbladder with bile.

Part of chronic cholecystitis is delayed by acute cholecystitis, but most of them have no history of acute attacks. About 70% of patients are accompanied by stones. Due to the stimulation of gallstones, and on the basis of long-term chronic inflammation, there have been repeated acute attacks, which can cause atrophy of the gallbladder or hyperplasia of the fibrous tissue of the cyst wall, resulting in a narrowing of the cystic cavity and loss of function. If the cystic duct is completely blocked by stones, inflammatory adhesions or scars, bile can not flow into the gallbladder, and the original bile in the gallbladder is gradually absorbed by the bile pigment, and the mucous membrane still secretes colorless watery mucus (white bile). The formation of gallbladder water; when secondary infection, it evolved into gallbladder empyema.

an examination

Related inspection

Oral gallbladder laparoscopic

Laboratory examination

(1) blood routine

In acute cholecystitis, white blood cell counts are slightly elevated and neutrophils are increased. If the white blood cell count exceeds 20 × 109 / L, and there are nuclear left shift and toxic particles, it may be complications such as gallbladder necrosis or perforation.

(2) Duodenal drainage

In chronic cholecystitis, such as increased mucus in bile; white blood cells piled up, bacterial culture or parasite test positive, which is very helpful for diagnosis.

2. Other auxiliary inspections

(1) Acute cholecystitis:

1 Ultrasound examination: B-ultrasound found that gallbladder enlargement, wall thickness, intracavitary bile viscosity, etc. can often make a timely diagnosis.

2 Radiological examination: The positive findings of the diagnostic significance of the abdominal plain film are: stones in the gallbladder area, enlarged gallbladder shadow, calcified plaque in the gallbladder wall, and gas and liquid level in the gallbladder cavity. Cholecystography: oral method: the gallbladder is generally not developed; intravenous injection, the diagnosis of acute cholecystitis.

3 radionuclide examination: sensitivity to the diagnosis of acute cholecystitis is 100%, specificity is 95%, also has diagnostic value.

(2) chronic cholecystitis: 1 ultrasound examination: if gallbladder stones, gallbladder wall thickening, reduction or deformation, have diagnostic significance.

2 abdominal X-ray film: If chronic cholecystitis, gallstones, gallbladder gallbladder, gallbladder calcification spots and gallbladder milky opaque shadows can be found.

3 gallbladder angiography: can be found in gallstones, gallbladder shrinkage or deformation, gallbladder enrichment and systolic dysfunction, gallbladder development and other images of chronic cholecystitis. When the gallbladder is not developed, if it is caused by damage to liver function or abnormal liver function, it may be chronic cholecystitis.

4 cholecystokinin test: such as gallbladder contraction amplitude is less than 50%, and biliary colic, a positive reaction, expressed as chronic cholecystitis.

5 fiber laparoscopy: If the liver and swollen gallbladder are found under direct vision, it is green, greenish brown or greenish black. It is suggested that jaundice is an extrahepatic obstruction; if the gallbladder loses its smooth, translucent and azure appearance, it becomes grayish white, and there is gallbladder shrinkage and obvious adhesion, and gallbladder deformation, etc., suggesting chronic cholecystitis.

6 small laparotomy: small laparotomy is a newly proposed method for diagnosing difficult hepatobiliary diseases and jaundice in recent years. It can not only make a clear diagnosis of chronic cholecystitis, but also understand the liver performance.

Differential diagnosis

Differential diagnosis of gallbladder empyema:

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 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 fever similar to cholecystitis, 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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