What is meant by cholecystitis?
Acute cholecystitis and chronic cholecystitis attacks are both acute purulent inflammation of the gallbladder. The cause of their onset is stones embedded in the neck of the gallbladder or in the gallbladder duct, which distends the gallbladder and prevents the discharge of concentrated bile inside. As a result of bacterial attack, the gallbladder wall becomes edematous and inflamed, which in turn can cause disorders in the blood supply to the gallbladder wall, thus further worsening the inflammation of the gallbladder wall dramatically.
The onset of acute cholecystitis is often related to satiety, eating fatty food, exertion and mental factors, etc. It often develops suddenly, with right upper abdominal cramps at the beginning, increasing in paroxysms and radiating to the right shoulder or chest and back, accompanied by nausea and vomiting. In the early stage of the disease, there may be no chills and fever, but when there is septic infection of the gallbladder, chills and fever may appear. Some patients may also develop yellow sclera of both eyes. When the inflammation spreads to the periphery of the gallbladder, the condition becomes increasingly severe, and the abdominal pain becomes more severe and extensive than before. At this time, the right upper abdomen cannot be touched, and the pain is more unbearable with slight pressure. Sometimes the pain can be aggravated by deep breathing, turning over or coughing, causing the patient to lie still and not dare to move. In about 1/3 to 1/2 of the patients, a slightly elevated, egg-sized enlarged gallbladder can be felt in the right upper abdomen, and the pain increases when pressure is applied. In most patients, these symptoms can be gradually relieved after active and effective treatment, but in a small number of patients, especially elderly patients with arteriosclerosis, gallbladder gangrene and perforation can occur. At this time, the patient’s abdominal pain is severe, the condition develops rapidly, and symptoms such as dehydration, shock and peritonitis appear, which can be life-threatening in severe cases.
It is generally believed that small gallbladder stones tend to obstruct the cystic duct and cause acute cholecystitis, while larger stones often do not have obvious abdominal cramps, but cause chronic cholecystitis. Chronic cholecystitis refers to chronic inflammation of the gallbladder, and the most common cause of chronic inflammation is the presence of stones in the gallbladder. It can be said that almost all patients with stones in the gallbladder have chronic cholecystitis. Chronic cholecystitis can be a sequel to an episode of acute cholecystitis. Patients almost inevitably develop chronic cholecystitis after an episode of acute cholecystitis. However, most acute cholecystitis is actually an acute episode of chronic cholecystitis, and a significant proportion of chronic cholecystitis occurs unknowingly, without a previous history of acute cholecystitis.
The clinical manifestations of chronic cholecystitis are mostly atypical and not obvious. Usually, there may be frequent indigestion symptoms such as vague pain in the right upper abdomen, bloating, belching, nausea and aversion to greasy food, while some patients feel vague pain under the right scapula, right quarter rib or right waist, which is more obvious after standing, exercise and cold bath. Ultrasound examination reveals a shrinking or enlarged gallbladder and dysfunctional emptying. The diagnosis can be confirmed when oral cholecystography agent reveals the presence of stones.
Why is the gallbladder easily inflamed?
1, the gallbladder is the enlarged part of the end of the gallbladder duct, which can hold 30-60ml of bile. Bile entering the gallbladder or discharging from the gallbladder has to pass through the gallbladder duct, which is about 3-4cm long and 2-3mm in diameter. After embedding, the bile in the gallbladder can not be discharged, so that the excess bile accumulates in the gallbladder, stagnates for a long time and is too concentrated, which directly stimulates the gallbladder mucosa and causes inflammation.
When the way out of the gallbladder is blocked, the mucous membrane of the gallbladder continues to secrete mucus, causing the pressure in the gallbladder to increase continuously, causing the gallbladder to swell and accumulate water, and the blood vessels in the wall of the gallbladder are pressurized and become ischemic and necrotic. When the gallbladder is ischemic, the resistance of the gallbladder decreases, and bacteria can easily grow and multiply, taking advantage of the opportunity to move and occur cholecystitis.
The gallbladder has the function of storing and concentrating bile, so the contact time between the gallbladder and bile is longer than other bile ducts, and the concentration of bile in contact is also high, so when there are bacteria in the bile ducts, infection will occur, and the chances of forming cholecystitis will certainly increase.
What tests are needed for biliary tract diseases?
After the initial diagnosis, the physician chooses a variety of tests based on the patient’s clinical presentation and physical signs. At present, the following tests are commonly used in hospitals
1, blood biochemical tests: such as liver function, serum transaminases, serum amylase, which help to identify obstructive and non-obstructive jaundice and liver function, pancreatic function.
2.X-ray abdominal plain film: about 10%-15% of gallstones contain more calcium salts, which cannot pass through X-ray during X-ray examination, so the shadow of stones is shown on the film. This type of stone is called positive stones by doctors. However, most gallstones contain less calcium salts, such as cholesterol stones, which can pass through X-rays and do not show a shadow on the film with ordinary X-ray examination methods. Such stones are called negative stones by doctors. X-ray abdominal plain film examination, therefore, is only a preliminary examination for patients with gallstone disease. Patients should make the following preparations when doing X-ray abdominal plain film examination: do not take preparations containing iron, iodine, barium, bismuth, calcium, etc. for three days before the examination, so as not to affect the X-ray development; take activated carbon tablets two days before, with the purpose of adsorbing the gas in the intestine; take senna 3-6g or castor oil 20ml the night before the examination to help empty the stool; fast in the morning of the examination, and try to clear the stool.
3. Oral cholecystography: oral iodine-containing contrast agent (iodophanic acid) that is impervious to X-rays is taken to set off the shadow of stones that are permeable to X-rays (negative stones). The morphology of the gallbladder is observed and the contractile function of the gallbladder is determined. Oral cholecystography patients need to be aware that
(1) It is advisable to eat a high-fat diet (such as 1 to 2 fried eggs) for lunch the day before the examination because a high-fat diet can induce the contraction of the filled gallbladder and empty the bile so that the contracted state of the gallbladder can be observed.
(2) It is advisable to eat a light and less oily diet (such as pickled vegetables) at night in order to observe the filling of the gallbladder during this period of time the next day and to obtain the best conditions for contrast during imaging.
(3) Correctly grasp the time to take the drug: in order to ensure a good concentration for the next morning examination, so that the gallbladder can be visualized, generally one hour after dinner can begin to swallow the contrast agent with sugar boiled water, every 5 minutes to take a piece (0.5g) a total of 6 tablets, a total of 3 g. Do not take the 6 tablets at once.
(4) Breakfast fasting on the day of examination: The first film examination can be performed 12 to 14 hours after taking the drug. Depending on the situation, you may need to eat a fatty meal again. Often encounter some patients do not like to eat fatty food, in order to achieve the effective purpose, I hope you can overcome a little, as required by the doctor to eat a fatty meal, so that the examination is correct.
(5) Intravenous cholecystography: A contrast agent called “cholestyramine” is injected into the intravenous vessels and then X-ray is performed. This allows the stones in the gallbladder to be seen, and the stones in the bile ducts to be accurately visualized. The patient should be aware that a high-fat dinner is recommended the day before the examination. On the day of the examination, breakfast is fasted. An allergy test to the contrast agent must be done before the examination.
(6) Ultrasound: Ultrasound is a high-frequency sound wave inaudible to the ear, which can be seen on the TV screen during the examination, and can help diagnose stones in the bile duct and their size and location with an accuracy rate of over 90%. The test is painless, easy to perform, repeatable, and has no contraindications. The patient must fast for at least 8 hours before the test. If the patient eats before the examination, especially after eating food containing a lot of protein and fat, the gallbladder will contract and discharge bile to help digestion, so that the volume of the gallbladder will shrink and the wall of the gallbladder will thicken, making the ultrasound observation inaccurate and easy to cause misdiagnosis. Therefore, when ultrasound examines the biliary tract, the gallbladder and bile ducts must be filled with bile, so fasting is also very important. The specific practice is: after dinner on the day before the examination that is, fasting, the next morning fasting examination, such as appropriate drinking water or allowed. Some patients are also subjected to barium x-ray or X-ray contrast examination. Since barium is a strong reflecting and absorbing agent of ultrasound, if there is barium remaining in the gastrointestinal tract near the gallbladder and bile duct, it will affect the ultrasound examination and hinder the visualization. Cholangiographic contrast agents also have some influence on the normal physiological state of the bile duct. In order to exclude these interferences, the patient should generally schedule an ultrasound examination first, or perform an ultrasound examination 3 days after the barium X-ray and 2 days after the cholangiography.
(7) Duodenal drainage: A catheter is inserted into the duodenum of a person through the mouth, and magnesium sulfate is injected with a syringe to relax the sphincter at the mouth of the bile duct, while causing the gallbladder to contract and expel bile, and then bile is withdrawn through the catheter. The concentration, color, presence of pus cells, crystals, worm eggs and bacteria of bile are examined by scientific methods. It is used to determine whether there is obstruction, stones, inflammation and parasites in the biliary tract. It has a reference value for the diagnosis of biliary tract diseases.
(8) Computed tomography (CT): It is not a routine test, but can be used for complex gallstone disease. CT is more sensitive to determine the amount of calcium in stones than general X-ray, and can provide a more valuable reference for the choice of lithotripsy.
(9) Endoscopy and transendoscopic cholangiography: This is an extremely valuable test for bile duct stones. If the imaging is successful, it can provide clear images of the bile ducts inside and outside the liver and the gallbladder.
(10) Others: X-ray gallbladder tomography, transhepatic percutaneous cholangiography. Each of these methods has its own advantages and shortcomings.
Which Chinese and Western medical methods can treat cholelithiasis?
1.Lithotripsy: In 1972, American physicians first applied goose deoxycholic acid to treat gallbladder cholesterol stones. 1978, Japanese Makino and others introduced ursodeoxycholic acid to the treatment of gallstones. After more than ten years of practice, its indications, pharmacology and side effects have been basically clarified, and the evaluation of its efficacy has gradually become consistent. It has been proved to be an effective treatment method, with an efficiency of 44% to 80% in different countries, but the majority of those with reduced stones and 20% to 30% of those with complete disappearance. Secondly, the use of the drug must have strict indications, only for cholesterol stones with good gallbladder function, gallstone diameter below 2 cm and no calcification. Again, the dose of the drug must be adequate, the duration of continuous administration must be long-lasting, and the stones can recur after stopping the drug. Therefore, the effect of lithotripsy treatment cannot be considered satisfactory yet. Oral lithotripsy must be administered under the guidance of a physician, otherwise it will result in a waste of time and financial resources. Currently, the commonly used litholytic drugs are goose deoxycholic acid, ursodeoxycholic acid and ursodeoxycholic acid, whose main function is to increase the solubility of cholesterol in bile, which can dissolve cholesterol stones and stop their formation.
2.Lithotripsy: i.e. extracorporeal shock wave lithotripsy. This new treatment was first applied in Federal Germany in 1983 and introduced in Japan and China since 1987, creating a non-surgical treatment for human stones in the history of human medicine. Through the patient’s oral cholecystography agent, the gallbladder can be displayed under the X-fluorescent screen. If there are 1 to 2 stones with a diameter of 1 to 2 cm in the gallbladder, and the X-ray plain film shows that they are gallbladder stones and stones in the common bile duct and the left and right hepatic ducts, in those who have good liver function, no serious heart disease, bleeding disease, active ulcer, and no obstruction in the lower end of the common bile duct, they can be treated with lithotripsy by applying extracorporeal shock wave lithotripter through ultrasonic localization. During lithotripsy, B ultrasound is used for positioning, and the image of the whole treatment process is clear, so the stone form can be clearly observed, so it is targeted lithotripsy treatment.
3.Endoscopic bile duct extraction: It is suitable for residual bile duct stones, and can be done via “T” duct sinus bile duct, and endoscopic papillary sphincter can be used to extract stones by papillotomy, etc. The effect is ideal, but special equipment and skilled technique are required.
4, surgical treatment: surgical treatment is still a major asset in the treatment of cholelithiasis, all those who are not suitable for lithotripsy, lithotripsy and herbal treatment should be included in the indications for surgical treatment. Selecting the right time for surgery, deciding the right way of surgery and making good care before and after surgery are the important conditions to improve the effect of surgical treatment.
5.Chinese herbal lithotripsy soup: rhubarb, mucuna pruriens and heliotrope are the main ingredients. According to the literature, the effect of lithotripsy can reach 90% for gallstones with a diameter of 1 cm (the size of a soybean) or less. Its effects are roughly threefold: increasing the secretion and excretion of bile to prevent the enlargement of stones; facilitating the discharge of gallstones; and clearing heat and reducing inflammation. However, under the same medical conditions, some people can succeed and a few will fail, which is a matter of the choice of indications. For bile duct stones, Chinese herbal medicine is more effective; for gallbladder stones, it is less effective; for gallbladder stones larger than 0.5cm in diameter and for bile duct stones larger than 1cm in diameter, it is less likely to be expelled; for smooth stones, it is easier to be expelled than for rough and uneven stones; for narrowing of the lower end of the common bile duct or for adhesions between gallstones and mucosa, it is more difficult to be expelled.
What are the causative factors of acute cholecystitis?
Acute cholecystitis is a common clinical condition that occurs mostly in the gallbladder with stones, but can also be secondary to diseases such as bile duct stones and bile duct ascariasis. The disease is mostly triggered by factors such as chemical irritation and bacterial infection.
1, gallbladder outlet obstruction: more than 90% of cholecystitis is accompanied by gallstone disease, and less than 5% without stones. In addition to gallstones, ascaris, Toxoplasma gondii and pear-shaped flagellates can also cause obstruction of the gallbladder outlet.
2, bacterial infection: the early onset of acute cholecystitis is not a bacterial infection, due to ischemia, injury and reduced resistance of the gallbladder, after 1 year of onset, more than 50% of patients can develop secondary bacterial infections, mostly intestinal parasitic flora. The pathways of infection are: pathogenic bacteria flow into the gallbladder with blood (hematogenous); intestinal bacteria reflux from the portal vein to the liver, then spread to the gallbladder via lymphatic vessels or drain into the gallbladder with bile, and also due to trauma to the gallbladder site, so that bacteria invade the gallbladder from the wound.
3, the influence of sex hormones: women in pregnancy, due to the influence of sex hormones, can delay the emptying of the gallbladder, gallbladder dilation, bile stasis and lead to acute cholecystitis.
4, neurological and mental factors: After vagus nerve block, the influence of neurological and mental factors such as pain, fear and anxiety can also cause gallbladder emptying disorder, which leads to bile stasis and chemical stimulation of the cyst wall and cause cholecystitis.
What are the causes of gallbladder stones?
Under normal circumstances, stones do not occur in the gallbladder because there is a certain percentage of bile salts and lecithin in the normal bile to keep the cholesterol dissolved and not precipitated. In order for stones to form, there must be certain stone formation conditions, i.e., the anti-nucleation factor in the gallbladder bile decreases and the nucleation factor increases, so that cholesterol can easily precipitate out and form stones. Common factors that can form stones are.
1, long-term high-protein, high-fat, high-calorie diet increases cholesterol in the body or increases the amount of cholesterol synthesized by the liver, resulting in cholesterol supersaturation in bile.
2, certain intestinal diseases due to the loss of bile salts, but also make cholesterol in a relatively supersaturated state.
3.Inability to eat on time, and bile is retained in the gallbladder for too long.
4.Biliary tract infection, inflammation of the gallbladder wall, and its contraction function is reduced.
5.Some hemolytic diseases or hepatic sclerosis can also lead to gallbladder stones, but most of these stones are black stones.
6.Biliary stagnation caused by pregnancy and imbalance of the nervous system can also cause gallbladder stones.
7, Long-term fasting and intravenous nutrition can lead to bile stagnation in the gallbladder and stone formation.
8.After most of the gastric resection or vagus nerve stem cutting, it can also delay the emptying of gallbladder and facilitate the formation of gallstones.
What are the symptoms of acute and chronic cholecystitis?
The symptoms of acute cholecystitis include right upper abdominal pain, nausea, vomiting and fever. Acute cholecystitis causes pain in the upper right abdomen, which is initially very similar to biliary colic, but the abdominal pain caused by acute cholecystitis tends to last longer and the pain is often aggravated by breathing and changing position, so the patient prefers to lie down on the right side to relieve the abdominal pain. Some patients experience nausea and vomiting, but the vomiting is usually not severe. Most patients also have a fever, usually between 38.0°C and 38.5°C, and high fever and chills are uncommon. A few patients also have mild yellowing of the whites of the eyes and skin.
When the physician examines the patient’s abdomen, pressure pain in the right upper abdomen and abdominal muscle tension can be found, and an enlarged gallbladder can be felt in about 1/3 of the patients. Ultrasound examination may reveal an enlarged gallbladder with a thickened wall and a stone blocked in the neck of the gallbladder.
Based on the above symptoms, physical examination and various auxiliary examinations, doctors can usually make the diagnosis of acute cholecystitis in a timely manner.
Chronic cholecystitis is the most common type of gallbladder disease, and patients usually have gallstones at the same time, but patients with chronic cholecystitis without stones are not uncommon in China. Chronic cholecystitis can sometimes be a sequel to acute cholecystitis, but most patients have not had acute cholecystitis in the past. Due to long-term inflammation of the gallbladder, the wall of the gallbladder can become fibrous thickened and scarred and contracted, resulting in atrophy of the gallbladder, and the cystic cavity can be completely closed, leading to decreased or even complete loss of gallbladder function.
After suffering from chronic cholecystitis, patients will mainly have the following two groups of symptoms.
1, stones momentarily block the gallbladder duct, causing episodes of biliary colic, the pain is mostly located in the upper abdomen or right upper abdomen, lasting from several minutes to several hours, the pain may involve the back or right shoulder blade, and may be accompanied by nausea and vomiting.
2. There are often a series of symptoms of indigestion such as abdominal distension, epigastric or right upper abdominal discomfort, heartburn, belching, acid swallowing, etc. Eating fried or fatty foods often aggravates these symptoms. Therefore, some patients may not have an attack of biliary colic, but only feel some symptoms of indigestion such as epigastric discomfort, belching and acid swallowing, often mistaking themselves for suffering from “stomach disease”. Although the “symptoms” of these patients are in the “stomach”, the “root” of the disease is in the “bile”. “Although they have been treated as “stomach disease” for a long time, they have not been able to eliminate the “root” of the disease, so their condition has not been cured for a long time.
Cholecystography and B-ultrasound hepatobiliary scan are valuable tests to diagnose chronic cholecystitis. In addition to detecting gallstones and changes in the shape of the gallbladder, ultrasonography can also reveal signs of thickening and thickening of the gallbladder wall. Patients with the above symptoms should seek medical attention in a timely manner, and the diagnosis of chronic cholecystitis can generally be clarified through the above tests.
What are the treatment principles of acute and chronic cholecystitis?
1, for patients with acute cholecystitis, generally by non-surgical treatment, most of the symptoms can be relieved, and then elective surgery will be performed later.
Non-surgical treatment includes bed rest, fasting, fluid infusion, correction of water and electrolyte disorders, application of antibiotics and vitamins, and gastrointestinal decompression if necessary. Antispasmodics and analgesics, such as atropine and dulcolax, can be given in case of abdominal pain, while changes in the condition should be closely observed. Emergency surgery should be performed after a short period of preparation with symptomatic treatment in the following cases.
(1) The clinical symptoms are heavy and not easily relieved, and the gallbladder is enlarged and under greater tension with the possibility of perforation.
(2) Those with significant abdominal pressure pain, abdominal muscle tonicity, and peritoneal irritation, or whose abdominal signs worsen during observation and treatment.
(3) Purulent cholecystitis with chills, high fever, and significantly elevated white blood cells.
(4) General acute cholecystitis with failure to relieve symptoms or worsening of the condition under non-surgical treatment.
(5) Elderly patients, the gallbladder is prone to gangrene and perforation, early surgery should be performed on those with severe symptoms.
After chronic cholecystitis, the function of the gallbladder is mostly damaged, and patients often feel pain in the upper abdomen or right upper abdomen, as well as symptoms of indigestion such as epigastric fullness, acid reflux and belching, nausea and vomiting. Some patients will have acute cholecystitis attacks, and a few patients will have gallbladder cancer. There is no drug that can cure chronic cholecystitis, and various antibiotics that are antiseptic and anti-inflammatory are not effective in treating chronic cholecystitis. Therefore, once chronic cholecystitis is clearly diagnosed, surgical removal of the diseased gallbladder should be appropriate. After cholecystectomy, the majority of patients will achieve satisfactory results and their symptoms will disappear, and complications such as acute cholecystitis and gallbladder cancer will be avoided.
For patients with mild symptoms, no stones in the gallbladder, and only mildly reduced concentration and contraction of the gallbladder, they can be treated with cholestatic drugs, such as oral deoxycholic acid, sodium cholate or anti-inflammatory and cholestatic tablets. The diet of these patients generally does not require special restrictions. Some doctors believe that a certain amount of fat in the diet can promote the contraction of the gallbladder, which is instead helpful in the treatment of chronic cholecystitis. Of course, the amount of fat in the diet should not be too much to avoid causing discomfort to the patient.
Does the removal of the gallbladder affect the digestive function of the body?
The main function of the gallbladder is to store bile. After eating, the gallbladder contracted, so that the stored bile is discharged into the duodenum to help digestion and absorption of food. So, once the gallbladder is removed due to gallbladder pathology, will it affect the digestive function and health of the body?
In fact, although this concern is somewhat justified, it is not entirely correct, because the gallbladder is not an indispensable organ in the body, and many higher animals, such as horses, deer, elephants, whales, etc., are born without gallbladders, and their lives are not very different from some animals with gallbladders. There are a few people who are born without a gallbladder due to abnormal embryonic development of the gallbladder, but they continue to live the same life as normal people. After cholecystectomy, the patient’s original symptoms disappear immediately. Although the gallbladder loses its function of concentrating and storing bile, there is no major impact on the patient’s digestive and absorption functions.
Scientific experimental studies have shown that the digestive and absorption functions of patients after cholecystectomy do not differ much from those of normal people. In patients with cholesterol stones, after removal of the gallbladder, the content of bile acids in the bile will slowly increase so that the supersaturated bile before surgery can gradually become normal bile. Therefore, cholesterol stones will not recur as long as the bile duct stones have been completely removed at the time of gallbladder removal. Therefore, there is no need to worry about the adverse effects on health and digestion and absorption after gallbladder removal.
Furthermore, after gallbladder removal, the wall of bile duct will be thickened and the mucus glands of bile duct will be increased. If the body consumes too little fat, it will not be beneficial to the body, but rather detrimental to human health. Of course, the recovery of the body after surgery and the establishment of compensatory functions should be a process, the intake of animal fat and eggs should not be too much, and the fat content in food should be gradually increased, so that the body has a gradual adaptation process.
What should be noted in the daily diet of patients with cholecystitis and cholelithiasis?
1, cholecystitis in the acute phase, avoid eating fried, fried food, eggs, broth and alcohol; food should be limited to low-fat, low protein, a small amount of easily digestible liquid or semi-liquid food, as the disease subsides can gradually add a small amount of fat and protein food, such as lean meat, fish, eggs, milk and fruits and fresh vegetables.
2, chronic cholecystitis patients, weekday diet should be light, easy to digest food, should enter a large number of drinks (1500 ~ 2000ml) to dilute the bile. Eat once every 2 to 3 hours to stimulate bile secretion. Eat easily digestible protein, 50g per day. do not eat animal brain, kidney, egg yolk, fried food, spicy products.
3, cholecystitis, gallstone patients, in terms of dietary rules, it is appropriate to regular ration, eat less and more meals, should not be too full. In the diet structure, strictly control fat and cholesterol-containing food, such as fatty meat, fried food, animal offal, etc., because the formation of gallstones is related to high cholesterol and metabolic disorders in the body. Do not drink alcohol and eat spicy food, it is advisable to eat more radish, green vegetables, beans, soy milk and other side dishes. Radish has a biliary effect and can help digestion and absorption of fat; green vegetables contain a lot of vitamins and fiber; beans are rich in vegetable protein. In addition, some fruits and juices should be supplemented to compensate for the loss of fluid and vitamins caused by inflammation.
4, cholecystitis, gallstone patients It is generally advisable to enter a low-fat, low-cholesterol diet. Fatty meats, fried foods, dried fruits, nuts and egg yolks that contain a lot of fat, animal brains, liver, kidneys and fish roe should be strictly controlled. The diet should be easy to digest and less dregs to avoid gas. All alcohol, stimulating foods, strong condiments can promote gallbladder contraction, so that the biliary sphincter can not be relaxed in time, resulting in bile outflow, thus causing an acute attack of cholecystitis, so they should be avoided. In acute attacks, low-fat, easily digestible semi-liquid or liquid food is recommended; in severe cases, fasting, gastrointestinal decompression and intravenous rehydration should be given.