What is Cholecystitis?

Cholecystitis is a more common disease with a higher incidence. According to its clinical manifestations and clinical experience, it can be divided into two types of acute and chronic, often coexisting with cholelithiasis. The upper right abdomen is severely painful or colic, which is more common in acute cholecystitis caused by stone or parasite incarceration and obstruction of the neck of the gallbladder. The pain often occurs suddenly, very severely, or colic-like. In the case of non-obstructive acute cholecystitis of the gallbladder, the pain in the right upper quadrant is generally not severe, and the pain is usually persistent. As the inflammation of the gallbladder progresses, the pain can be aggravated and the pain is radioactive. The most common radiation sites are the right shoulder and Right scapula inferior corner and so on.

Basic Information

English name

cholecystitis

Visiting department

Gastroenterology

Common causes

Sudden obstruction of gallbladder stones, incarcerated gallbladder duct

Common symptoms

Severe right or upper abdominal pain

Causes of cholecystitis

Acute cholecystitis caused by sudden obstruction or incarceration of the gallbladder stones in the gallbladder can also cause acute cholecystitis due to twisting, narrowing of the gallbladder tube, and obstruction of biliary ascaris or bile duct tumors. In addition, during the aging process, the gallbladder wall gradually becomes hypertrophic or atrophic, and the contractile function decreases, causing bile stasis, concentration and formation of bile salts; the end of the common bile duct and the sphincter of Oddi become loose, prone to retrograde infection; systemic arteries Atherosclerosis and increased blood viscosity can increase gallbladder arterial ischemia. After obstruction of the gallbladder duct or gallbladder neck, the bile stagnated in the gallbladder is concentrated to form bile acid salt, which stimulates the gallbladder mucosa and causes chemical cholecystitis (early stage); meanwhile, bile retention keeps increasing the pressure in the gallbladder, which affects the gallbladder first. Venous and lymphatic reflux of the gallbladder wall, hyperemia and edema in the gallbladder. When the internal pressure of the gallbladder is> 5.39kPa (55cmH ₂ O), the arterial blood flow of the gallbladder wall is blocked, and the gallbladder ischemic. Infection exacerbates the process of cholecystitis, eventually resulting in gallbladder gangrene or perforation. If the gallbladder tube is obstructed without blood circulation disorders and bacterial infections of the gallbladder wall, it develops into a gallbladder effusion. Recent studies have shown that phospholipase A can be released from damaged gallbladder epithelium due to bile stasis or stone incarceration, and hydrolyze lecithin in the bile to lyso-lecithin, which in turn changes the integrity of mucosal epithelial cells and causes acute gallbladder. inflammation.

Clinical manifestations of cholecystitis

Acute cholecystitis

The clinical manifestations of acute calculus cholecystitis are basically the same as those of acute calculi-free cholecystitis.

(1) Symptoms Pain in the upper right abdomen or colic, which is mostly acute cholecystitis caused by stone or parasite infestation obstructing the neck of the gallbladder; pain often occurs suddenly, is very severe, or presents as colic, which mostly occurs in After eating high-fat food, it usually occurs at night; general pain in the right upper quadrant is seen in non-obstructive acute cholecystitis of the gallbladder. Generally, the pain in the right upper quadrant is not severe, and most are persistent pain. With the progress of gallbladder inflammation, the pain It can also be aggravated, and the pain is radioactive. The most common radiation sites are the right shoulder and the lower angle of the right scapula, which are caused by gallbladder inflammation that stimulates the right sacral nerve endings and peripheral abdominal wall nerves. Nausea and vomiting are the most common symptoms, such as nausea, stubbornness or frequent vomiting, which can cause dehydration, collapse, and electrolyte disturbances, which are more common when stones or maggots obstruct the gallbladder duct. Chills, chills, and fever Light cases often have chills and low fevers ; severe cases can have chills and high fevers , the heat can reach above 39 ° C, and mental symptoms such as slang and delirium can occur. Jaundice is rare. If jaundice is generally mild, it means that the infection has spread to the liver through the lymphatic vessels, causing liver damage, or inflammation has invaded the common bile duct.

(2) Main signs Abdominal examination shows abdominal muscle tension, tenderness, rebound pain, and positive Murphy sign in the right upper abdomen and middle upper abdomen. With gallbladder empyema or abscess around the gallbladder, a tender mass or markedly enlarged gallbladder can be palpated in the right upper abdomen. When abdominal tenderness and abdominal muscle tension spread to other areas of the abdomen or the entire abdomen, gallbladder perforation is indicated. Or have acute peritonitis. 15% to 20% of patients due to cystic duct edema, gallstone compression and cystic inflammation caused liver damage, or inflammation involving the common bile duct, causing Oddi sphincter spasm and edema, leading to bile drainage disorders, mild jaundice may occur. If jaundice is significantly deepened, it means that the common bile duct with stone obstruction or concurrent cholangitis may be caused. In severe cases, signs of peripheral circulatory failure may appear. Blood pressure is often low, and septic shock may even occur. This is especially the case in severe cases of pyogenic gangrene.

2. Chronic cholecystitis

(1) Symptoms of persistent dullness or discomfort in the right upper quadrant; nausea, belching, acid reflux, abdominal distension, and heartburn; dyspepsia in the right lower scapular region; symptoms worsened after eating high-fat or greasy food; long duration After the onset of the disease, there are alternating characteristics of acute exacerbation and remission. The symptoms of acute gallbladder are the same as in acute exacerbation, and sometimes there are no symptoms during the remission period.

(2) Signs There may be mild tenderness and throbbing pain in the gallbladder area, but there is no rebound pain; cases of cholestasis can swell to the enlarged gallbladder; in the acute episode, there may be muscle tension in the right upper abdomen, normal body temperature or low fever, occasionally Jaundice can occur. The gallbladder tenderness point is at the intersection of the right rectus abdominis muscle and the costal arch, the thoracic spine tenderness point is near the 8-10 thoracic spine, and the right phrenic nerve tenderness point is between the two lower corners of the right sternocleidomastoid muscle of the neck.

Cholecystitis examination

Laboratory inspection

(1) Blood routine In acute cholecystitis, the white blood cell count is slightly increased and neutrophils are increased. If the white blood cell count exceeds 20 × 10 ⁹ / L, and there are left shifts of the nucleus and toxic particles, then complications such as gallbladder necrosis or perforation may occur.

(2) Duodenal drainage In chronic cholecystitis, such as increased mucus in the bile; white blood cells pile up, and bacterial culture or parasite tests are positive, which is very helpful for diagnosis.

2. Other auxiliary inspections

(1) Acute cholecystitis Ultrasound examination of B-ultrasonography reveals that the gallbladder is enlarged, the thickness of the wall, and the bile in the cavity are often diagnosed in time. Radiographic examination The positive findings of abdominal plain film with diagnostic significance are: stones in the gallbladder region; enlarged gallbladder shadows; calcified spots on the gallbladder wall; gas and fluid levels in the gallbladder cavity. Cholecystography: oral method: the gallbladder is generally not visualized; intravenous injection method is of diagnostic significance for acute cholecystitis. The radionuclide test has a sensitivity of 100% and a specificity of 95% for the diagnosis of acute cholecystitis, and has diagnostic value.

(2) Chronic cholecystitis Ultrasound examination If gallbladder stones, thickening, shrinkage or deformation of the gallbladder wall are found, it has diagnostic significance. Plain X-ray film of the abdomen If it is chronic cholecystitis, gallstones, swollen gallbladder, gallbladder calcified plaque and milky opaque shadow of the gallbladder can be found. Cholecystography An image of chronic cholecystitis such as gallstones, shrinkage or deformation of the gallbladder, poor gallbladder concentration and contractile function, and weak development of the gallbladder can be found. When the gallbladder does not develop, it can be chronic cholecystitis if it can exclude the liver damage or liver metabolic dysfunction. Cholecystokinin test If the gallbladder contraction amplitude is less than 50% and biliary colic occurs, it is a positive reaction, which is indicated as chronic cholecystitis. Fiber laparoscopy If the liver and swollen gallbladder are found to be green, green-brown or green-black under direct vision. It suggests that jaundice is extrahepatic obstruction; if the gallbladder loses its smooth, translucent and sky-blue appearance, becomes grayish-white, with gallbladder shrinkage and obvious adhesion, and gallbladder deformation, it indicates chronic cholecystitis. Small laparotomy is a new method to diagnose difficult liver and gallbladder diseases and jaundice, which is newly promoted in recent years. It can not only make a clear diagnosis of chronic cholecystitis, but also understand the performance of the liver.

Cholecystitis diagnosis

Acute cholecystitis

Eat greasy food as an inducement. Sudden severe pain in the right upper abdomen with paroxysmal aggravation, which can be radiated to the right scapula, often with nausea, vomiting and fever. There was tenderness and muscle tension in the right upper abdomen, Murphy's sign was positive, and jaundice was seen in a few cases. Increased white blood cell and neutrophil counts may increase serum jaundice index and bilirubin. Ultrasound of the gallbladder showed that the gallbladder was enlarged, the wall of the gallbladder was thickened or rough, there were floating light spots in the capsule, and stones were visible when there were stones. X-ray examination: plain film of the abdomen of the gallbladder area may have gallbladder enlargement shadow.

2. Chronic cholecystitis

Persistent dullness or discomfort in the right upper quadrant, or pain in the right scapular region. Have indigestion symptoms such as nausea, belching, acid reflux, bloating and stomach burning, which will worsen after eating greasy food. The disease course is long, and the symptoms are alternated between acute attack and remission. The gallbladder area may have mild tenderness and throbbing pain. Mucus in bile increased, white blood cells piled up, and bacterial culture was positive. B-ultrasound gallbladder stones, gallbladder wall thickening, gallbladder shrinkage or deformation. Gallbladder angiography shows gallstones, shrinkage or deformation of the gallbladder, poor contraction of the gallbladder, or weak development of the gallbladder.

Differential diagnosis of cholecystitis

Acute cholecystitis

It should be distinguished from the diseases that cause abdominal pain (especially upper right abdominal pain), mainly including: acute pancreatitis, lower right pneumonia, acute diaphragmatic pleurisy, early herpes zoster, abdominal myocardial infarction, and acute appendicitis.

2. Chronic cholecystitis

Attention should be paid to the identification of peptic ulcer, chronic gastritis, gastric dyspepsia, chronic viral hepatitis, gastrointestinal neurosis and chronic urinary tract infection. In chronic cholecystitis, nausea and discomfort or pain in the right upper abdomen often increase after eating greasy foods. In this case, gastrointestinal diseases are rare. In addition, it can be identified with the help of barium meal angiography, fiber gastroscopy, liver function and urine examination.

Cholecystitis treatment

General treatment

Actively prevent and treat bacterial infections and complications, pay attention to food hygiene, prevent the occurrence of biliary parasitic disease, and actively treat intestinal ascariasis. Moderate daily living, pay attention to the combination of work and rest, appropriate cold temperature, maintain optimism and smooth stool. If the disease has stones or frequent attacks, surgery can be considered. should choose a low-fat meal to reduce bile secretion and reduce the burden of the gallbladder.

2. Drug treatment

(1) Acute cholecystitis Antispasmodic and analgesic Intramuscular injection of atropine, nitroglycerin sublingualization, pethidine (duolidine), etc. can be used to relieve Oddi sphincter spasm and pain. Antibacterial treatment Antibiotics are used to prevent bacteremia and purulent complications. Ampicillin (ampicillin), clindamycin (clindamycin) and aminoglycosides are usually used in combination, or a second option is used. Substitute cephalosporins such as Cefmendol (ceftizole) or cefuroxime. Antibiotic replacement should be based on blood culture, bile culture during surgery and bacterial culture of the gallbladder wall, and the results of drug sensitivity tests. Cholesterol medicine 50% magnesium sulfate orally (not for those with diarrhea), dehydrocholic acid tablets orally, bile acid tablets orally.

(2) Chronic cholecystitis Cholesterol drugs 50% magnesium sulfate, dehydrocholic acid tablets, etc. can be taken orally. Deworming therapy Deworming for the cause. stone- dissolving therapy such as those caused by cholesterol stones, can be treated with chenodeoxycholic acid dissolving stones. It is reported in the literature that the effective rate of dissolved stone can reach about 60%. After the end of the course of treatment, maintenance doses should be taken to prevent recurrence.

(3) Reasonable selection of proprietary Chinese medicine Jindan Tablet Function: anti-inflammatory and choleretic. For acute and chronic cholecystitis. Qinggan Lidan Oral Liquid Function: Qingli liver and gallbladder damp heat. Indications: Daze, pain, fatigue, fatigue, yellow urine, greasy fur, pulse string, liver stagnation and stagnation, liver and gallbladder dampness and heat, etc.

3. Surgical treatment

Cholecystectomy is the fundamental treatment for acute cholecystitis. Indications for surgery: Gallbladder gangrene and perforation with diffuse peritonitis; Repeated acute episodes of acute cholecystitis with clear diagnosis; Those who continue to develop and worsen after active medical treatment; have no contraindications to surgery and can withstand Subject. Chronic cholecystitis with gallstones; once the diagnosis is established, cholecystectomy is a reasonable radical treatment. If the patient has serious diseases such as heart, liver, lung, or systemic conditions can not tolerate surgery, medical treatment can be given.

Cholecystitis prognosis

The fatality rate of acute cholecystitis is 5% to 10%, almost all of which are caused by concurrent purulent infection and those with other serious diseases. Acute cholecystitis complicated with localized perforation can achieve satisfactory results through surgery; concurrent free perforation has a poor prognosis and a mortality rate of up to 25%.