What is cholecystitis?
Cholecystitis is an inflammatory lesion of the gallbladder caused by bacterial infection or chemical irritation (bile). It is a common clinical condition. The incidence is higher in obese, prolific, and women around 40 years of age.
There are two types of cholecystitis, acute and chronic.
Acute cholecystitis is an acute inflammation of the gallbladder caused by obstruction of the cystic duct or common bile duct, chemical irritation and secondary bacterial infection, mainly manifested by fever, right upper abdominal pain and pressure, with nausea, vomiting, jaundice and increased white blood cells.
Chronic cholecystitis is a chronic inflammatory disease of the gallbladder caused by stones, chronic infection, chemical irritation and repeated episodes of acute cholecystitis, which may manifest as chronic recurrent epigastric vague pain and dyspepsia.
How is cholecystitis caused?
Most cases of cholecystitis occur due to the presence of stones in the gallbladder, which block the cystic duct and cause poor bile drainage, followed by bacterial infection, resulting in cholecystitis. In some patients, there are no stones in the gallbladder, but bacteria enter the gallbladder from the intestine or from the bloodstream, resulting in cholecystitis.
Why are women more likely to develop cholecystitis than men?
Women are more likely to have delayed gallbladder emptying and poorer contraction than men due to sex hormones. Female hormones also affect the composition of bile and have a mild biliary stasis effect, causing the liver to produce less bile acids. These factors contribute to the fact that women are more likely to develop cholecystitis than men. This gender difference between men and women is less pronounced after the age of 50.
What are the manifestations of cholecystitis?
The clinical manifestations of acute cholecystitis and chronic cholecystitis are different.
Many patients with acute cholecystitis develop it in the middle of the night after a greasy dinner because a high-fat diet can cause the gallbladder to contract more, and lying down makes it easier for small gallstones to slip into the cystic duct and become embedded. The main manifestations are persistent pain in the right upper abdomen with paroxysmal intensification, radiating to the right shoulder and back; often accompanied by fever, nausea, vomiting, chills are rare, jaundice is light. Abdominal examination reveals right upper abdominal fullness, abdominal muscle tension, obvious pressure pain and rebound pain in the gallbladder area.
Symptoms and signs of chronic cholecystitis are atypical. Many patients with chronic cholecystitis can continue for years without symptoms, called painless cholecystitis. Most of them are found during physical examination. Most patients present with biliary dyspepsia, aversion to fatty foods, epigastric distention, belching, and burning in the stomach; sometimes the attack can be acute due to stone obstruction of the gallbladder duct, but it improves rapidly when the stone moves and the obstruction is removed. On examination, there may be mild pressure pain or percussion pain in the gallbladder area; if the gallbladder is waterlogged, a round, smooth cystic mass can often be found in the right upper abdomen.
What are the risks of cholecystitis?
Acute cholecystitis can cause serious complications if left untreated: gallbladder gangrene and perforation, biliary bleeding, bile duct stenosis, biliary peritonitis, peri-gallbladder abscess, biliary liver abscess, endoleaks, portal phlebitis and biliary pancreatitis. The mortality rate of acute cholecystitis is about 5% to 10%, and it almost always occurs in elderly people with septic infection and other serious diseases.
The long-term chronic stimulation of chronic cholecystitis is related to the occurrence of gallbladder cancer, especially porcelain gallbladder and chronic atrophic cholecystitis are closely related to gallbladder cancer.
What are the common examination methods of cholecystitis?
1.Blood routine and liver function: peripheral blood leukocyte count is mostly 10.0×109～15.0×109/L. Liver function test ALT is mildly elevated, and when serum bilirubin is significantly elevated with high alkaline phosphatase, it indicates the possibility of secondary common bile duct stones.
2.B ultrasound examination: simple, easy to perform, non-invasive, safe, high accuracy, its accuracy rate can reach 96%, often as the first choice; visible enlarged gallbladder, gallbladder wall thickening, gallbladder stones, fluid around the gallbladder, etc.
3, abdominal plain film: 10%-15% can show positive gallbladder stones, enlarged gallbladder, acute emphysematous cholecystitis can appear as pneumatosis in the gallbladder wall, and gas and fluid in the gallbladder. It can also help to exclude other causes of abdominal pain, such as intestinal obstruction or perforation.
4, intravenous cholangiogram: If the bile ducts are visualized and the gallbladder is not, the diagnosis of cholecystitis can be made; if both the gallbladder and bile ducts are visualized, acute cholecystitis can be excluded.
5.CT and MRI examination: In acute cholecystitis, the gallbladder is enlarged, the gallbladder wall is thickened, and the inflammation is exuded and edematous.
Radionuclide scan: It is a very effective method to diagnose cholecystitis, mainly used to diagnose cholecystitis without stones, especially for patients with clinical suspicion of cholecystitis and uncertain ultrasound results. However, the operation is tedious and radioactive, so it is mostly used for scientific research and not commonly used in clinical practice.
Ultrasound endoscopy (EUS): EUS requires endoscopy, and body surface ultrasound has a high sensitivity for the diagnosis of cholecystitis and gallbladder stones, and its advantage is that it can detect microscopic stones in the gallbladder, so it is only considered when there is a high clinical suspicion of gallbladder stones and body surface ultrasound is negative.
8. Percutaneous cholecystocentesis: Gallbladder puncture can be performed under ultrasound guidance to drain bile or pus, and bile bacterial culture can be performed, which is beneficial to the diagnosis and treatment of the disease.
How to diagnose cholecystitis?
The diagnosis of acute cholecystitis is mostly clear based on symptoms, physical signs, ultrasound, X-ray and other examinations. When the clinical manifestations are atypical, the diagnosis of acute cholecystitis must be differentiated from cholangitis, pancreatitis, appendicitis, peptic ulcer and pleurisy.
In patients with fatty diet intolerance, abdominal distension and recurrent postprandial epigastric distension and discomfort, chronic cholecystitis can be diagnosed by ultrasound examination showing gallbladder stones, cystic wall thickening, gallbladder atrophy and reduced contraction and emptying function of the gallbladder. It should be distinguished from diseases related to dyspepsia such as esophagus, stomach, intestine and pancreas.
What is bile heart syndrome and bile heart reflex?
The heart is innervated by the T2-8 spinal nerves, while the gallbladder and common bile duct are innervated by the T4-9 spinal nerves, and they cross at the T4-5 spinal nerves. When there is inflammation in the bile duct and the pressure in the bile duct increases, the reflexes of T4-5 nerves cause the coronary artery to constrict and the blood flow to decrease, triggering the dysfunction of heart activity. This is known as bile heart syndrome.
The biliary heart reflex refers to the slowing of the heart rate and decrease in blood pressure or even cardiac arrest caused by pulling the gallbladder or probing the bile duct during biliary surgery. The biliary heart syndrome is a clinical syndrome in which the coronary artery supply is not adequate and the heart activity is abnormal due to biliary tract disorders. The two are fundamentally different but intrinsically closely related, both occurring on the basis of the bile heart reflex arc.
What is Mirizzi’s syndrome?
Mirizzi’s syndrome is a clinical syndrome of obstructive jaundice, biliary colic and cholangitis due to stone impaction in the cervical duct of the gallbladder or the cystic duct and/or other benign lesions compressing the common hepatic duct, which is a rare complication of cholecystitis. Because of its non-characteristic clinical presentation, the syndrome is difficult to diagnose preoperatively, and improper intraoperative management can lead to biliary tract injury.
Can jaundice be caused even without gallstones and cholecystitis?
Jaundice can occur without gallstones and cholecystitis. The causes of jaundice include: damage caused by harmful substances from infection through venous return or lymphatic drainage to the liver; spasm and edema of the sphincter of Oddi caused by inflammation of the gallbladder involving the common bile duct; and obstructive jaundice caused by edema of the bile duct tissue pressing on the common hepatic duct.
Can chronic cholecystitis cause gallbladder cancer?
Chronic cholecystitis can cause nodular thickening of the gallbladder wall, glandular epithelial hyperplasia, heterotypy, and finally hypertrophic adenocarcinoma. Clinically, it is often found that gallbladder cancer patients with combined stones have a history of chronic recurrent cholecystitis.
How to treat and prevent cholecystitis?
Acute cholecystitis: Approximately 85% of patients with acute cholecystitis are in remission after non-surgical treatment. Non-surgical treatment in internal medicine includes.
1. General treatment: bed rest and fasting should be given within 48h of onset. Those with nausea, vomiting and abdominal distension can be given gastrointestinal decompression and intravenous supplementation of nutrition, water and electrolytes. When the condition improves, a low-fat semi-liquid diet can be considered.
2, antispasmodic and analgesic drug therapy: atropine 0,5mg or 654-2 5mg intramuscularly; nitroglycerin 0,3-0,6 mg, sublingually; vitamin K3 8-16mg, intramuscularly; analgesia such as dulcolax or equimethoprim, morphine should not be used.
3, antibacterial treatment: acute cholecystitis with fever, high white blood cells, and gangrene perforation trend or complications, the application of antibiotics is particularly important to control the spread of infection and improve symptoms. Ampicillin, ciprofloxacin and metronidazole can be used; aminoglycosides or cephalosporin antibiotics can also be used, and it is best to choose antibiotics with higher concentration in blood and bile according to the results of bacterial culture and drug sensitivity test.
4.Chinese medicine treatment: The principle of treatment is to regulate qi, activate blood, pass through the lining and attack, and identify the evidence for treatment. Shuchitong, anti-inflammatory and biliary tablets or liver-clearing and biliary oral liquid should be applied only after the attack is relieved.
5.Surgical treatment: If active medical treatment is ineffective or necrosis, septicemia, perforation or embedded stones occur, surgical treatment should be performed in time, such as cholecystectomy or cholecystostomy. For combined common bile duct obstruction, the stone can be removed by ERCP papillotomy, and for tumor-induced obstruction, a stent can be placed to reduce the pressure.
Chronic cholecystitis: medical treatment includes low-fat diet, oral cholagogic drugs such as magnesium sulfate, anti-inflammatory and cholagogic tablets, liver-clearing and cholagogic oral liquid, and biliary health care. For chronic cholecystitis with frequent attacks and symptoms, especially those with gallstones, cholecystectomy is the only effective treatment to relieve symptoms and prevent cancer. Surgery is usually performed 2 months after the onset of cholecystitis to reduce the adhesions around the gallbladder and gallbladder edema.
What kind of acute cholecystitis requires surgery?
For acute cholecystitis after medical treatment, surgery should be considered if the symptoms worsen and the following conditions occur.
① chills, fever, and a white blood cell count of 20 x 109 or more.
② aggravation of jaundice.
(iii) Significant enlargement of the gallbladder.
④ significant pressure pain, rebound pain and muscle tension in the right upper abdomen.
⑤ Complicated with signs and symptoms of acute pancreatitis.
⑥People aged 60 years or older.
What should be noted in the diet of cholecystitis?
1, eat less high-fat food, pork, beef, lamb, cream, butter, fried food (especially fried eggs), animal offal, roe, and oily pastries, etc., are high-fat food, these foods can stimulate the gallbladder to contract strongly, thus causing acute attacks of cholecystitis.
2, appropriate intake of high quality protein, long-term low protein diet can lead to varying degrees of protein and other nutrient deficiencies and malnutrition, resulting in decreased resistance, prone to disease, more detrimental to the recovery of patients with cholecystitis. Therefore, the proper intake of high-quality protein is completely necessary. The lean meat, chicken and duck meat, fish, eggs, soy products, etc. are rich in high-quality protein.
The actual fact is that you can find a lot of people who are not only in the market, but also in the marketplace.
4, regular eating, avoid overeating.
What is “gallstone disease”?
Gallstone disease is commonly referred to as “gallstones” and is often called gallstone disease. It refers to stones that occur anywhere in the biliary system. Depending on where the stones occur, gallstone disease can often be classified as gallbladder stone disease, common bile duct stone disease, hepatobiliary stone disease, or a combination of these. Gallstones can cause inflammation in the area where they are located, resulting in a number of clinical symptoms. There are also cases of gallstone disease without any symptoms. Gallstones are crystals formed by certain components of the bile, ranging from small stones like fine sand to large stones up to several centimeters in size.
Why do gallbladder stones form?
The causes are very complex and are a combination of factors. The basic factor is a change in the composition and physicochemical properties of the bile, resulting in supersaturation of cholesterol in the bile or a decrease in the synthesis of bile salts and lecithin, which leads to the precipitation and crystallization of cholesterol.
What imaging tests can be used for the diagnosis of gallstones?
(1) Ultrasound, which is the preferred method of gallstone examination, can detect 2mm diameter stones. It can not only detect stones, determine the size and number of stones, but also clarify the location and distribution of stones, and understand the condition of the bile duct and gallbladder, whether there is dilatation, stricture, atrophy, function, and whether other lesions occur. In addition, it is possible to determine whether there is atrophy, sclerosis, abscesses, etc. in the lobe of the liver where the stones occur. However, failure of ultrasound to detect stones does not exclude the presence of stones.
(2) CT, which is a common test for gallstone disease, is more advantageous for hepatic bile duct stones, lower bile duct stones, combined bile duct and liver lesions, in addition to achieving the above-mentioned purposes.
(3) MRI and MRCP, in addition to achieving the above-mentioned purposes, can also be used to display the biliary tree using biliary imaging technology, which can replace PTC or ERCP examinations to a certain extent.
(4) PTC or ERCP, with minimal trauma, can clearly show stones, dilatation, and strictures in the bile duct through the imaging of the bile duct, and can indicate the presence of bile duct variants and malformations.
Is abdominal radiography valuable for the diagnosis of gallbladder stones?
No. Only 13% to 17% of gallstones contain enough calcium to prevent the passage of radiation. The pathologies that need to be differentiated from gallstones on X-ray are gallbladder calcification, calcium bile, urinary stones, intrahepatic calcified foci and other calcified images.
Do I need surgery if I have gallbladder stones?
About 20-40% of patients with gallbladder stones are asymptomatic for life, called resting gallbladder stones, and asymptomatic gallbladder stones may be left untreated in healthy adults. However, since gallbladder stones may lead to complications such as biliary colic, acute cholecystitis or even gallbladder gangrene at any time, and since gallbladder stones are associated with gallbladder cancer, patients with static gallbladder stones should be followed up regularly and, if necessary, undergo elective surgery. Patients with combined diabetes mellitus or those requiring long-term intravenous nutrition can undergo prophylactic cholecystectomy. For patients with recurrent attacks, cholecystectomy should be performed as early as possible.
What are the main methods of non-surgical treatment of gallbladder stones?
1.Lithotripsy therapy
(1) Oral drug lithotripsy: Goose deoxycholic acid or ursodeoxycholic acid can be taken orally, the latter has stronger and faster effect with less side effects. It is suitable for non-calcified cholesterol stones and is contraindicated for pregnant women. Because of the poor efficacy of lithotripsy (5%-13% efficiency), long duration of use, and high recurrence rate after discontinuation of the drug, it is not much used clinically.
(2) Direct contact lithotripsy: direct drug lithotripsy by percutaneous transhepatic gallbladder placement, which is not recommended clinically because of its trauma and side effects.
(2) Lithotripsy: including extracorporeal shock wave lithotripsy, laser lithotripsy and electrohydraulic lithotripsy treatment.
Can extracorporeal shock wave lithotripsy be used to treat gallbladder stones?
It is only suitable for single stone with good gallbladder function and diameter less than 2CM, but due to the difference of anatomical structure and stone composition, the effect of lithotripsy treatment is poor, and the recurrence rate of stone is high, and it is also easy to have complications such as stone impaction and biliary obstruction, so this method is rarely used now.
What are the contraindications and complications of laparoscopic cholecystectomy?
Contraindications include severe cardiopulmonary insufficiency, bleeding disorders, various hernias, extensive abdominal adhesions, psychiatric patients or those who are unable to cooperate and those who are more than 3 months pregnant.
The minimal invasiveness of laparoscopic surgery does not mean that its surgical risks are also minimal. In addition to the same complications that can occur with traditional open surgery, laparoscopic surgery can also result in complications specific to the laparoscopic technique. Complications associated with pneumoperitoneum include subcutaneous emphysema, pneumothorax, pneumopericardium, gas embolism, hypercapnia and acidosis, cardiac rhythm disturbances, lower extremity venous stasis and thrombosis, intra-abdominal ischemia, and decreased body temperature. Complications associated with laparoscopic cholecystectomy include injury to the common bile duct or hepatobiliary duct, bile leak, vascular injury, poke hole bleeding and abdominal wall hematoma, poke hole infection, abdominal wall necrotizing fasciitis and poke hole hernia.