Geriatric cholecystitis
Cholecystitis is one of the more common diseases with a high incidence. According to its clinical manifestations and clinical course, it can be subdivided into two types, acute and chronic, with the common coexistence of cholelithiasis. Gallstone disease is one of the most important diseases that threaten the health of the elderly.
Disease description
Cholecystitis is one of the more common diseases with a high incidence. According to its clinical manifestations and clinical course, it can be subdivided into two types, acute and chronic, with the common presence of cholelithiasis in combination. In recent years, the detection of cholelithiasis and cholecystitis has increased year by year due to the clinical application of modern detection techniques, such as B-mode ultrasound scanning, retrograde cholangiopancreatography via fiberoptic duodenoscopy, percutaneous hepatic puncture cholangiography, radionuclide scintigraphy, computerized X-ray tomography, and magnetic resonance imaging. As the average life expectancy of human beings increases, the number of cholelithiasis and cholecystitis among the elderly has also increased significantly. The increased incidence of cholelithiasis and cholecystitis in the elderly is related to certain anatomical and physiological changes in the biliary system in the elderly.
The diameter of the common bile duct changes with age, from 6.8 mm at age 12 to 9.2 mm at age 70, and more importantly, the physiological narrowing of the end of the common bile duct becomes narrower with age, which increases the resistance to bile discharge. As the contractile function of the gallbladder decreases with age, bile stagnation occurs in the gallbladder, and the viscosity of bile increases, making it easier to produce gallstones. The above factors may be the underlying factors for the increasing incidence of cholelithiasis and cholecystitis with age in the elderly. The incidence of gallstones in patients with acute cholecystitis is more than 90%, and it is the second most common surgical emergency abdomen.
Symptoms and signs
Acute cholecystitis The clinical manifestations of acute calculous cholecystitis are basically the same as those of acute non calculous cholecystitis.
(1) Symptoms.
Pain: severe pain or colic in the right upper abdomen, mostly acute cholecystitis caused by stones or parasites embedded in the obstructed gallbladder neck, the pain is often sudden onset, very intense, or presenting colic-like, occurring mostly after a full meal characterized by eating high-fat food, mostly occurring at night, general pain in the right upper abdomen, seen in the gallbladder duct non-obstructive acute cholecystitis, the pain in the right upper abdomen is generally not severe, mostly persistent distension, with the gallbladder As the inflammation of the gallbladder progresses, the pain can be aggravated, and the most common radiating sites are the right shoulder and the subscapular angle of the right scapula.
Nausea and vomiting: are the most common symptoms. If nausea and vomiting are stubborn or frequent, they can cause dehydration, deficiency and electrolyte disturbance, mostly seen when stones or roundworms obstruct the gallbladder duct.
Chills, chills, and fever: Chills and low-grade fever are often present in light cases (those with catarrhal inflammation); in heavy cases (those with acute septic gangrene), chills and hyperthermia may be present, with fever up to 39°C or higher, and psychiatric symptoms such as delirium and delirium may occur.
Jaundice: Rarely, if any jaundice is generally mild, indicating that the infection has spread to the liver via the lymphatics, causing liver damage, or that the inflammation has invaded the common bile duct.
(2) Main features.
Abdominal examination reveals right upper abdomen and middle epigastric abdominal muscle tension, pressure pain, rebound pain, and positive Murphy’s sign. In cases with pus accumulation in the gallbladder or peribiliary abscess, a mass with pressure pain or an obviously swollen gallbladder can be found in the right upper abdomen. When abdominal pain and abdominal muscle tension extend to other regions of the abdomen or the whole abdomen, it suggests gallbladder perforation. Or there may be acute peritonitis. Mild jaundice may occur in 15% to 20% of patients due to peripheral edema of the gallbladder duct, gallstone compression and liver damage from pericholangitis, or inflammation involving the common bile duct, causing spasm and edema of the Oddi sphincter and resulting impaired bile drainage. If the jaundice increases significantly, it indicates the possibility of obstruction of the common bile duct with stones or complications of cholangitis. Severe cases may show signs of peripheral circulatory collapse. Blood pressure is often low, and infectious shock may occur, especially in severe cases of septic gangrene. There may also be depression, poor appetite, weakness and constipation.
(3) The main features of acute cholecystitis in the elderly: the body is weakly responsive in elderly patients, and although it is an acute inflammatory disease, some patients have a slow and atypical onset. Some patients present with symptoms similar to those outside the gastrointestinal tract such as right hypopneumonia, myocardial infarction, and right-sided pyelitis. Clinical manifestations such as abdominal pain, fever, and palpable enlarged gallbladder and mass in the abdomen are often absent or less severe than in younger patients. Even if there are comorbidities such as gallbladder gangrene and perforation, the abdominal manifestations are not typical, and even after perforation, the gallbladder contents flow upward into the colonic space, which can appear as acute appendicitis or acute colonic diverticulitis, which is very confusing to diagnose. However, some older patients have an acute onset and rapid changes in their condition. Gallbladder gangrene, perforation, peritonitis, and shock are often the initial clinical manifestations of acute cholecystitis. Elderly patients with cholecystitis are mostly accompanied by common bile duct stones, so the incidence of jaundice is higher (about 59%) and the degree is heavier than in young and middle-aged patients. In addition, the evolution of acute cholecystitis in the elderly is also atypical. In young adults, they often rely on the severity of pain, fluctuations in body temperature and white blood cells to evaluate changes in the condition of cholecystitis, but in elderly patients, especially those with a weak body, it is unreliable to use these indicators to observe the evolution of cholecystitis. It is very important to grasp these characteristics of acute cholecystitis in the elderly in order to make a correct judgment of the condition.
2.Chronic cholecystitis
(1) Symptoms: persistent dull abdominal pain or discomfort in the right upper abdomen; indigestion symptoms such as nausea, belching, acid reflux, abdominal distention and burning in the stomach; pain in the right lower scapular region; worsening of symptoms after eating high-fat or fatty foods; long duration of disease, alternating acute attacks and remission, with acute attacks with acute cholecystitis symptoms, and sometimes without any symptoms during remission.
(2) Signs: mild pressure and percussion pain in the gallbladder area, but no rebound pain; distended gallbladder may be found in cases of cholestasis; muscle tension in the right upper abdomen during acute attacks, normal temperature or hypothermia, and occasional jaundice; hepatosplenomegaly may be present in viral cholecystitis. Clinical examination: positive pressure points with diagnostic significance are found. The gallbladder pressure point is at the intersection of the right rectus abdominis muscle outer edge and the rib arch, the thoracic pressure point is next to the 8-10 thoracic vertebrae, and the right phrenic nerve pressure point is between the two lower corners of the right sternocleidomastoid muscle in the neck.
Disease etiology
Acute cholecystitis is commonly caused by sudden obstruction of stones in the gallbladder or by an embedded cystic duct, and can also be caused by torsion of the cystic duct, stenosis, and obstruction by biliary roundworms or biliary tumors. In addition, during the aging process, the gallbladder wall gradually becomes hypertrophic or atrophic, and the contraction function is reduced, resulting in bile stagnation, concentration and formation of bile salts; the end of the common bile duct and the Oddi sphincter become relaxed, making it easy for retrograde infection to occur; systemic atherosclerosis and increased blood viscosity can aggravate gallbladder artery ischemia. These pathophysiological changes are the reasons why the incidence of cholecystitis and cholelithiasis is higher in the elderly than in the young, and why acute gangrenous cholecystitis and gallbladder perforation are more common in elderly patients. After obstruction of the gallbladder duct or gallbladder neck, the stagnant bile in the gallbladder concentrates and forms bile acid salts, which stimulate the gallbladder mucosa and cause chemical cholecystitis (early stage); at the same time, bile retention increases the pressure in the gallbladder, and the swollen gallbladder firstly affects the venous and lymphatic reflux of the gallbladder wall, and the gallbladder becomes congested with blood and edema. The ischemic gallbladder is prone to secondary bacterial infection, aggravating the process of cholecystitis and eventually complicating gallbladder gangrene or perforation. In case of obstruction of the cystic duct without blood circulation disorders and bacterial infection of the gallbladder wall, gallbladder effusion develops. Recent studies have shown that phospholipase A can be released from the damaged gallbladder mucosa epithelium due to bile stasis or stone impaction, causing hydrolysis of lecithin in the bile to lysolecithin, which in turn causes changes in the integrity of the mucosal epithelium causing acute cholecystitis.
Pathophysiology
1. Western etiology and pathology
(1) Acute cholecystitis: the pathogenesis of this disease is still poorly understood. Historically, it is thought to be related to bile stasis, mucosal injury, gallbladder ischemia and bacterial infection after obstruction of the gallbladder duct stones.
Gallbladder duct obstruction: It is usually believed that obstruction of the gallbladder duct by stones or parasites can cause acute cholecystitis for the following reasons: bile salt irritation, gallbladder wall ischemia, secondary infection, and pancreatic reflux erosion. It is also believed that mechanical and vascular factors may be more important in the pathogenesis of acute cholecystitis than irritation due to increased bile salt concentration.
Infection: This includes bacterial and parasitic infections. The main bacterial infections are in Enterobacteriaceae, E. coli, S. typhi, S. paratyphi, Staphylococcus, Streptococcus, Pneumococcus and Bacillus pneumoniae. The ways of infection are: hematogenous infection (bacteria enter the gallbladder with the blood stream), biliary infection (bacteria in the intestinal tract enter the liver after the fine portal vein and are not destroyed to infect the gallbladder, bacteria in the liver enter the gallbladder through the lymphatic vessels), epithelial infection (biliary roundworms carry intestinal bacteria into the bile duct to cause obstruction and inflammation of the gallbladder), erosive infection (when the tissues and organs adjacent to the gallbladder are inflamed, bacteria can erode and spread to the gallbladder). . Schistosoma chinensis and pear-shaped flagellates can cause cholecystitis, especially Schistosoma chinensis is particularly close to the biliary tract infection.
Neurological and psychiatric factors: Any factor that causes hypotonia of the vagus nerve is likely to cause acute cholecystitis or is an important additional factor in the development of cholangitis. According to the literature, mental factors such as pain, fear and anxiety can invite the development of acute cholecystitis and affect the emptying of the gallbladder leading to bile stasis.
Hormonal factors: Cholecystokinin increases bile secretion, gallbladder contraction and relaxation of the common bile duct sphincter to maintain normal bile secretion and drainage. When there is an increase in the concentration of bile salts and amino acids and fats in the intestinal cavity, the gallbladder can stop contracting and become dilated, so bile stasis can occur. In addition, after trauma, burns or surgery, acute cholecystitis can sometimes occur, which may be related to dehydration caused by bleeding, anesthesia, fever, low food intake secondary to infection, etc., because dehydration can increase the viscosity of bile, resulting in delayed emptying of the gallbladder.
(2) Chronic cholecystitis: chronic cholecystitis is both the basis for the occurrence of gallstones and the consequence of gallstone formation. It reflects the long-term process of mutual influence of gallbladder and stones, and its mechanism is roughly the same as that of acute cholecystitis. Chronic cholecystitis is a chronic and prolonged process, characterized by repeated acute attacks, and is much more frequent than acute cholecystitis.
Stone factor: commonly known as stone cholecystitis. About 70% of chronic cholecystitis is caused by this factor, which is due to inflammation of the gallbladder wall caused by long-term irritation of gallstones, on top of which bacterial infection can also develop.
Bacterial infection: Commonly known as bacterial cholecystitis, bacteria also infect the gallbladder through direct spread of inflammation in the blood, lymph or adjacent tissues and organs, as well as through the opening of the duodenal papilla up to the gallbladder.
Viral infection: commonly known as viral cholecystitis. It often occurs in the presence of viral hepatitis and may be related to direct or indirect hepatitis virus invasion of the gallbladder.
Chemical factors: Commonly known as chemical cholecystitis. It is caused by excessive concentration of bile salts or reflux of pancreatic digestive enzymes into the gallbladder.
Parasitic factors: Commonly known as parasitic cholecystitis. The common ones are Schistosoma chinensis, intestinal pear-shaped flagellates, schistosomes and roundworms.
It comes as a sequel to acute cholecystitis.
In conclusion, regardless of the etiology, the common pathological features are hyperplasia of the fibrous tissue of the gallbladder, thickening of the cystic wall, narrowing and atrophy of the cystic cavity due to contraction of the scar tissue, and adhesion of the gallbladder to the surrounding tissues leading to complications such as pyloric obstruction. If the inflammation invades the cystic duct causing obstruction, the gallbladder may also be distended and the wall may be thinned.
Diagnostic tests
Diagnosis
(1) Acute cholecystitis
Mostly triggered by consumption of greasy food.
Sudden onset of severe and persistent pain in the right upper abdomen with paroxysmal aggravation, which may radiate to the right scapula, often with nausea, vomiting and fever.
There is pressure pain and muscle tension in the right upper abdomen, Murphy’s sign is positive, and jaundice is seen in a few cases.
White blood cell and neutrophil counts are elevated, and serum jaundice index and bilirubin may be elevated.
Ultrasound shows enlarged gallbladder, thickened or gross gallbladder wall, floating light spots in the gallbladder, and stone images in the presence of stones.
X-ray examination: abdominal plain film of the gallbladder area may have enlarged gallbladder shadow.
(2) Chronic cholecystitis
Persistent dull pain or discomfort in the right upper abdomen, or with pain in the right scapular region.
There are indigestion symptoms such as nausea, belching, acid reflux, abdominal distension and heartburn, which are aggravated after eating fatty food.
The duration of the disease is long, and the course of the disease is characterized by alternating acute attacks and remissions.
Percussion pain with mild pressure may be present in the gallbladder area.
There is increased mucus in the bile, piles of white blood cells, and positive bacterial cultures.
Ultrasound reveals gallbladder stones, thickening of the gallbladder wall, and shrinkage or deformation of the gallbladder.
Cholecystography may show gallstones, shrinkage or deformation of gallbladder, poorly contracted gallbladder, or a thinly developed gallbladder.
Laboratory tests
Acute cholecystitis blood count: In acute cholecystitis, the total white blood cell count is mildly increased (usually between 12,000 and 15,000/mm3) and the number of classified neutrophils is increased. If the total leukocyte count exceeds 20×10E9/L with significant nuclear left shift and neutrophilic granules, the gallbladder may be necrotic or have complications such as perforation.
Duodenal drainage in chronic cholecystitis: if there is an increase in mucus in the bile of the B-tube; leukocytes in piles and positive bacterial culture or parasite examination, it is very helpful for diagnosis.
Other auxiliary tests
1.Acute cholecystitis
Ultrasonography: B-ultrasound findings of enlarged gallbladder, thick wall and viscous bile in the lumen can often make a timely diagnosis. B-mode ultrasonography is simple and easy to perform, and can determine the size of the gallbladder and the thickness of the wall, especially for the detection of gallstones, and is the preferred method of imaging for acute cholecystitis, and is also one of the indicators for observing the evolution of the disease in the elderly.
Radiographically, the positive findings of the abdominal plain film that are of conclusive significance are
Stones in the gallbladder area.
Enlarged gallbladder shadow.
Calcified spots in the gallbladder wall.
Gas and fluid level in the gallbladder cavity.
Cholecystogram.
Oral method: the gallbladder is usually not visualized.
Intravenous method: apply 60% sodium pantothenate, the dosage is calculated by 2.2ml/kg, mixed with an equal amount of 5% glucose solution, rapid intravenous drip, if the gallbladder shows a circular arc or ring-shaped shadow, it has diagnostic significance for acute cholecystitis.
Radionuclide examination: Radionuclide biliary scan has 100% sensitivity and 95% specificity for the diagnosis of acute cholecystitis, and is also of diagnostic value. If there is no radioactive material in the gallbladder area within 90 min after intravenous injection of 131 tetraiodotetroxide fluorescence 99mTc, it means that there is obstruction of the gallbladder duct and acute cholecystitis can be considered.
2.Chronic cholecystitis
Ultrasound examination: If gallbladder stones, thickening, shrinking or deformation of gallbladder wall are found, it has diagnostic significance.
Abdominal X-ray: If it is chronic cholecystitis, gallstones, distended gallbladder, gallbladder calcification spots and gallbladder milky opaque shadow can be found.
Cholecystography: Gallstones, shrunken or deformed gallbladder, poorly concentrated and contracted gallbladder, and thin gallbladder shadowing can be detected in chronic cholecystitis. When the gallbladder is not visualized, it may be chronic cholecystitis if it is not due to liver impairment or malfunction of liver color metabolism.
Cholecystokinin test: after the use of oral cholecystography contrast agent to visualize the gallbladder, C.C.K is injected intravenously, and the gallbladder film is taken continuously in 15 min, if the amplitude of gallbladder contraction is less than 50% (indicating poor gallbladder contraction) and biliary colic occurs, it is a positive reaction, indicating chronic cholecystitis.
Fiberoptic laparoscopy: Under direct visualization if the liver and distended gallbladder are found to be green, greenish-brown or greenish-black. Then it suggests jaundice as extrahepatic obstruction; if the gallbladder loses its smooth, translucent and sky-blue appearance and turns grayish-white with shrinking gallbladder and obvious adhesions, as well as gallbladder deformation, it suggests chronic cholecystitis.
Microdissection: Microdissection is a new method advocated in recent years to diagnose difficult hepatobiliary diseases and jaundice, which can make a definite diagnosis of chronic cholecystitis as well as to understand the performance of the liver.
Differential diagnosis
Acute cholecystitis should be differentiated from diseases that cause abdominal pain These diseases include: acute pancreatitis, right lower pneumonia, acute diaphragmatic pleurisy, early herpes zoster in the chest and abdomen, acute myocardial infarction and acute appendicitis. All of the above diseases have their own clinical characteristics and special examination methods. As long as a detailed medical history is taken, the condition is analyzed meticulously, and changes in the condition are observed dynamically, the differentiation is generally not difficult.
Chronic cholecystitis should be distinguished from peptic ulcer, chronic gastritis, gastric dyspepsia, chronic viral hepatitis, gastrointestinal neurological disorders and chronic urinary tract infections. In chronic cholecystitis, there is often nausea and increased discomfort or pain in the right upper abdomen after eating fatty foods, which is rare in digestive tract diseases. In addition, barium meal imaging, fiberoptic gastroscopy, liver function and urinalysis can be used to differentiate.