Gallbladder stones are the most common risk factor for chronic cholecystitis, with chronic calculous cholecystitis accounting for 90-95% of all chronic cholecystitis; chronic non-calculous cholecystitis is less common, accounting for 4.5%-13% of all chronic cholecystitis.
Main etiology and pathogenesis
Etiology and pathogenesis of chronic calculous cholecystitis
1. Gallbladder stones: stones lead to recurrent cystic duct obstruction and cause damage to the gallbladder mucosa, recurrent inflammatory reaction of the gallbladder wall, scar formation and gallbladder dysfunction. Studies in elderly patients with chronic cholecystitis showed that the severity of inflammatory response was positively correlated with the maximum diameter of stones and negatively correlated with the number of stones and age, and that isolated large stones were a high risk predictor of chronic cholecystitis.
2. Bacterial infection: normal bile should be sterile, and when stones are embedded and obstructed in the gallbladder or bile duct, it may lead to retrograde infection with intestinal bacteria. The pathogenic bacteria of chronic cholecystitis mainly originate from retrograde infection of intestinal bacteria, and the species of pathogenic bacteria are basically the same as intestinal bacteria, mainly Gram-negative bacteria, accounting for 74.4%, mainly including Escherichia coli, Bacillus immobilis, and Aspergillus chimaera. Recent studies suggest that H. pylori infection may be associated with the development of chronic cholecystitis.
The etiology and pathogenesis of chronic non-lithotropic cholecystitis
1, abnormal gallbladder dynamics: biliary stasis is an important cause of chronic non-lithotripsy cholecystitis. However, this examination method is rarely carried out in China.
2, gallbladder ischemia: common causes are severe diseases, such as sepsis, shock, severe trauma, burns, use of vasoconstrictor-boosting drugs, and large non-biliary surgery, which may cause mucosal ischemia and local inflammatory reaction and necrosis of the gallbladder.
3. Other: viral and parasitic infections are one of the few causes of cholecystitis. Dietary factors are also involved in the occurrence of chronic nonstone cholecystitis, such as chronic hunger, overeating, and overnutrition.
Diagnosis and evaluation
Clinical manifestations
1. Abdominal pain: It is the most common symptom of most chronic cholecystitis, with an incidence of 84%. The occurrence of abdominal pain is often associated with a high-fat, high-protein diet. Patients often show episodes of biliary colic, mostly located in the right upper abdomen, or a dull pain that can radiate to the back and last for several hours and then resolve.
2, indigestion: is a common manifestation of chronic cholecystitis, accounting for 56%, also known as biliary dyspepsia, manifested as belching, fullness, bloating, nausea and other indigestion symptoms.
Physical examination: About 34% of patients with chronic cholecystitis have detectable right upper abdominal pressure pain on physical examination, but most patients may not have any positive signs.
4, common complications: when there is an acute attack of chronic cholecystitis and biliary pancreatitis, the corresponding symptoms and signs of acute cholecystitis and acute pancreatitis can be observed; Mirizzi’s syndrome is similar to common bile duct stones and is non-specific; gallstone intestinal obstruction is dominated by the performance of intestinal obstruction.
5. Asymptomatic gallbladder stones: With the wide application of ultrasound technology, gallbladder stones can often be detected incidentally during routine health checkups, and patients have neither obvious symptoms nor positive signs, but some patients may develop symptoms in the future.
Diagnostic imaging
Ultrasonography: Ultrasonography is the most common and valuable test for diagnosing chronic cholecystitis, showing thickening of the gallbladder wall, fibrosis, and stones in the gallbladder. The ultrasound features of chronic cholecystitis are mainly gallbladder wall thickening (≥3 mm) and grossness; if combined with gallbladder stones, strong echogenicity and posterior acoustic shadowing in the gallbladder are present, and if there is a laminar distribution of punctate hypoechogenicity in the gallbladder with no posterior acoustic shadowing, it is often an image of bile sludge in the gallbladder. The diagnosis also requires attention to differentiate cholesterol crystals from polyps. If the ultrasound examination shows fixed strong echogenicity in the gallbladder that does not move with body position and no posterior acoustic shadow, it is mostly diagnosed as polyps-like lesions in the gallbladder.
CT: With a sensitivity of 79%, specificity of 99%, and accuracy of 89%, CT provides good visualization of gallbladder wall thickening and possible stones, and can assess dystrophic calcification of the gallbladder and help exclude other diseases that need to be differentiated.
Magnetic resonance imaging: MRI is superior to CT in assessing gallbladder wall fibrosis, gallbladder wall ischemia, peri-gallbladder hepatic tissue edema, and peri-gallbladder fat accumulation, and is mainly used to differentiate between acute and chronic cholecystitis. In addition, magnetic resonance cholangiopancreatography (MRCP) can detect small stones in the gallbladder and common bile duct that are not easily detected by ultrasound and CT.
Treatment: For patients with chronic cholecystitis and gallbladder stones, treatment should be individualized according to the presence or absence of symptoms and the presence or absence of complications. The goals of treatment are symptom control, prevention of recurrence, and prevention and control of complications.
Treatment of asymptomatic chronic cholecystitis and gallbladder stones: For patients with asymptomatic chronic cholecystitis and gallbladder stones, the treatment principles are dietary adjustment, symptomatic treatment with bile when symptoms are present, and continued observation. For some high-risk patients, prophylactic cholecystectomy can be adopted.
Indications for prophylactic cholecystectomy.
1, high-risk groups prone to gallbladder cancer.
2.Patients who are immunosuppressed after organ transplantation.
3, patients with rapidly declining body mass.
4. Patients with increased risk of gallbladder cancer due to “porcelain” gallbladder.
Treatment of symptomatic chronic cholecystitis and gallbladder stones: The treatment is based on symptom control and elimination of inflammatory response.
Antispasmodic and analgesic: It is used for biliary colic during acute attacks of chronic cholecystitis. Available nitroglycerin vinegar 0.6mg sublingual, 1 time/3-4h, or atropine 0.5mg intramuscular injection, 1 time/4h, can be used simultaneously with isoprostanes 25mg intramuscular injection; analgesic pethidine 50-100mg intramuscular injection, combined with antispasmodics can enhance the analgesic effect. It should be noted that these drugs do not change the disease regression and may mask the condition, so once they are ineffective or the pain recurs, they should be discontinued promptly.
Relief of biliary dyspepsia: The prevalence of inflammatory irritation and chronic fibrosis of the gallbladder wall in chronic cholecystitis predisposes patients to dyspepsia symptoms. In patients with dyspepsia with definite gallbladder stones, 10%-33% of symptoms can be relieved after cholecystectomy. However, because biliary dyspepsia also has a pathogenesis of extra-biliary digestive system dysfunction (possibly related to biliary dynamics and sphincter of Oddi tone), drugs that help improve symptoms of biliary dyspepsia, such as compound azinomide or other pancreatic enzymes, need to be applied early in the onset of dyspepsia to increase the concentration of pancreatic enzymes in the digestive tract, enhance digestion, and improve bloating symptoms and nutrition levels .
Anti-infection treatment: According to the bile culture results of patients with chronic cholecystitis, the severity of infection in patients, antibiotic resistance and antibacterial spectrum, as well as the underlying diseases of patients, especially for liver and kidney function with damage, the rational application of antibiotics in the treatment of biliary tract infection in chronic cholecystitis is important. For chronic cholecystitis and gallbladder stones with acute attacks, piperacillin/tazobactam and cefoperazone/sulbactam should be recommended for treatment, while the use of metronidazole class for anaerobic bacteria also has a better effect. In contrast to acute cholecystitis attacks, patients with chronic cholecystitis can wait for bile culture and bacterial drug sensitivity test results to be perfected before choosing to use antibiotics to avoid resistance due to blind application.
The place of surgical treatment in the treatment of chronic cholecystitis and gallbladder stones.
Chronic cholecystitis and gallbladder stones require consideration of surgical treatment if, on the basis of medical treatment, the following symptoms and manifestations occur.
1. no relief of pain or recurrent attacks that affect life and workers
2. gradual thickening of the gallbladder wall to 4 mm and above
3, gallbladder stones increase and enlarge year by year, combined with gallbladder dysfunction or impairment.
4. Ceramic-like changes in the gallbladder wall.
Common complications and management principles: In case of acute attack of chronic cholecystitis or complications such as acute peritonitis, acute gallbladder perforation, severe acute pancreatitis and other acute abdominal conditions, a surgeon should be consulted and dealt with in a timely manner. If surgery is temporarily unsuitable or contraindicated, ultrasound or CT-guided cholecystocentesis and drainage or endoscopic retrograde cholangiopancreatography can be considered.
Acute cholecystitis with acute peritonitis: When acute cholecystitis attacks, it will lead to bile stagnation in the gallbladder and combined with infection. If the inflammatory reaction is early or limited, laparoscopic cholecystectomy can be considered; if the inflammatory reaction is prolonged, the adhesions around the gallbladder are severe or the gallbladder is perforated, cholecystectomy or cholecystostomy is required for caesarean section. Non-calculous cholecystitis also often results in acute cholecystitis attacks due to impaired blood flow, and gangrene of the gallbladder wall often occurs, which also requires surgical resection.
Biliary pancreatitis: gallstone disease (including biliary microstones), hypertriglyceridemia, and ethanol are three common causes of acute pancreatitis, and biliary pancreatitis is still the main cause of acute pancreatitis in China. For the treatment of patients with acute biliary pancreatitis, in addition to routine fasting, inhibition of pancreatic enzyme secretion, antispasmodic and analgesic and rehydration support therapy, internal medicine also requires the selection of appropriate antibacterial drug therapy based on the results of blood and bile cultures + drug sensitivity tests. For patients with acute biliary pancreatitis with common bile duct obstruction and cholangitis, ERCP, percutaneous percutaneous hepatobiliary drainage or surgery is appropriate.
Mirizzi’s syndrome: The anatomical factors of its formation are the excessive length of the cystic duct with the common hepatic duct or the low confluence of the cystic duct and the common hepatic duct. The clinical features are recurrent episodes of cholecystitis and cholangitis with marked obstructive jaundice. Mirizzi’s syndrome accounts for 0.3-3.0% of patients undergoing cholecystectomy and increases the risk of bile duct injury during cholecystectomy. The risk of bile duct injury during cholecystectomy is increased. Laparoscopic cholecystectomy is not recommended for these patients, and open surgery is recommended.
Stone intestinal obstruction: It accounts for 1% of all small bowel obstruction and is caused by the formation of a fistula between the gallbladder injury and the intestine, through which stones enter the intestine, mostly in the narrow ileocecal region causing mechanical obstruction. Mild cases often present as incomplete obstruction. Unless the stone is significantly calcified, it is difficult to detect on abdominal X-ray, but CT reveals pneumatization in the gallbladder, shrinkage of the gallbladder, and stones at the site of obstruction. Treatment is based on surgical intervention to relieve the obstruction.
Traditional Chinese medicine and acupuncture treatment: Traditional Chinese medicine has a long history in the treatment of cholecystitis, and biliary herbs can be selected according to the patient’s clinical performance. Commonly used acupuncture points for acupuncture treatment are Gallbladder Yu, Gallbladder, Yanglingquan, Periodic Gate, Foot Sanli, etc.