Cholecystitis, includingacute cholecystitisandchronic cholecystitis , is byGallstoneOr other reasonsgallbladderA disease in which inflammation occurs.The disease is mainly caused byBiliary obstruction、CholestasisInfection caused,Biliary calculiIt is the main cause of biliary obstruction.Cholecystitis is a common digestive system disease. The high-risk population is mainly middle-aged and elderly people, and it is related to gender, eating habits and other factors.The incidence of acute cholecystitis is higher in women.
The main symptoms of cholecystitis include pain in the right upper abdomen, which may be accompanied by nausea, vomiting, anorexia and constipation.Among them, acute cholecystitis develops rapidly and may occur when the disease worsensGallbladder perforationAnd other serious complications.Cholecystitis is not infectious.
Treatment of cholecystitis mainly includes drug treatment and surgical treatment.Drug treatment mainly includes spasmolysis, analgesia, anti infection and cholagogue.Cholecystectomy should be considered when the disease is serious or the symptoms cannot be relieved by drug treatment at the initial stage of the disease.The prevention of cholecystitis is mainly to maintain good eating habits and avoid taking orally drugs that lead to the formation of gallstones, such ascefatriaxone, contraceptives, etc.
The latest research results show that the occurrence of cholecystitis is related to the body's immune system, the patient's eating habits, drug intake and other factors.This discovery provides a new idea for the prevention and treatment of cholecystitis.
TCM disease name
cholecystitis
Alias
acute cholecystitis、chronic cholecystitis
Visiting department
Gastroenterology Department, General Surgery Department, Emergency Department
Multiple population
Women are more likely to get sick, especially before the age of 50, and the elderly are seriously ill
Main causes of cholecystitisBiliary obstruction、CholestasisIt is caused by secondary infection, and the main cause of obstruction is biliary stones. Repeated infection can promote the formation of stones, which further aggravate biliary obstruction and form a vicious circle.
Acute Calculous Cholecystitis
The initial inflammation may be caused by the direct damage to the mucosa of the pressure part caused by the stone, while the later bacterial infection occurs under the condition of cholestasis.The main causes of the disease are cystic duct obstruction (leading to obstruction of bile discharge, cholestasis and concentration, forming high concentration of bile, which is cytotoxic and will damage the mucosa), bacterial infection (pathogenic bacteria can retrogress from the intestinal tract togallbladderIn the environment of cholestasis, pathogenic bacteria are more likely to proliferate rapidly).
Acute acalculous cholecystitis
The cause of the disease is not clear at present. It usually occurs in the elderly and critically ill patients. Some studies believe that the disease is a complication of long-term parenteral nutrition and AIDS.The main pathogenic factors are cholestasis and ischemia. The disease develops very quickly, so it is more likely to cause gallbladder gangrene and perforation.
Chronic calculous cholecystitis
GallstoneIt is the main cause of chronic cholecystitis.Stones can causeCystic ductRepeated obstruction causes gallbladder mucosa damage, repeated inflammation of gallbladder wall, scar formation and gallbladder dysfunction.
Bacterial infection: normal bile should be sterile. When the gallbladder or bile duct has stone incarceration or obstruction, it may lead to enterogenous bacterial infection, that is, intestinal bacteria can pass through the bile duct to the gallbladder, or from blood orlymphThe route reaches the gallbladder.
Others: low fiber, high energy diet can increase the content of cholesterol in bile, which is easy to form stones;Some drugs can cause gallstones to form easily, such as ceftriaxone, contraceptives, etc;The rapid reduction of body weight, such as unreasonable weight loss, may also lead to the formation of gallstones.
Chronic acalculous cholecystitis
Infection: Enterogenic bacterial infection is the main cause.parasite、viral infectionIt is the cause of a small number of chronic cholecystitis, such as roundworm, pyriform flagellate and human immunodeficiency virus (HIV).
Gallbladder emptying disorder: Gallbladder emptying disorder leads to the prolongation of the time for the gallbladder to discharge bile to the intestinal tract, cholestasis in the gallbladder, gallbladder enlargement, and gradually gallbladder wall fibrosis and chronic inflammatory cell infiltration.
Gallbladder ischemia: vascular disease of gallbladder wall, large non biliary surgery, as well as severe diseases such as septicemia, shock, and severe trauma may cause long-term gallbladder mucosal ischemia, local inflammatory reaction, and necrosis.
Metabolic factors: When bile acid metabolism is impaired due to some reasons, long-term chemical stimulation of bile salts and pancreatic juice reflux can also cause chemical chronic gallbladder inflammation.
symptom
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The symptoms of acute and chronic cholecystitis are different. The symptoms of mild cholecystitis are limited to the upper abdomen, while those of severe cholecystitis can affect the whole body;70% of cholecystitis patients have no symptoms.
early symptom
A sudden onset of severe colic in the right upper abdomen and radiating to the right shoulder and back is often an early symptom of cholecystitis, which often occurs after eating a lot of fat or at night.
Typical symptoms
Acute Calculous Cholecystitis
It often occurs at night. At the beginning, only epigastric distension and discomfort gradually develop to paroxysmal colic;
When the pain is severe, it will radiate to the right shoulder, shoulder blade and back;
Eating rich and greasy food often induces sudden attacks;
If the disease develops, the pain will be continuously and paroxysmally aggravated;
Generally, it is associated with mild to moderate fever. Once there is shivering and high fever, it indicates that the condition is very serious;
There is pain when pressing the right upper abdomen. Some patients have very obvious pain. The whole abdominal muscles are tense and stiff. When pressing down, it is painful, and when lifting the hand, it is more painful;
Often accompanied by nausea, vomiting, anorexia, constipation and other gastrointestinal symptoms;
A few patients may have jaundice of varying degrees, that is, yellow staining of skin and eyes, and yellow deepening of urine.
Acute acalculous cholecystitis
The symptoms are similar to those of acute cholecystitis, but it is more likely to cause severe conditions such as gallbladder gangrene and perforation, which are manifested by chills, high fever and severe abdominal pain.
chronic cholecystitis
The symptoms are generally atypical. Most of them suffer from abdominal distention and pain after eating a full meal and greasy food. The degree of abdominal pain varies from person to person, and may involve the right shoulder and back. Fever, jaundice, nausea, vomiting and other symptoms are rare.
Chronic cholecystitis caused by gallstones often has biliary dyspepsia, which is manifested asBelching, fullness, abdominal distension and nausea after meals.
Medical treatment
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Due to the rapid onset of acute cholecystitis, and a few serious cases can endanger life, once the upper abdomen paroxysmal colic occurs, it is necessary to seek medical advice immediately.
Chronic cholecystitis is a chronic disease. If the disease is not controlled in time in the early stage, gallbladder fibrosis, adhesion with surrounding tissues and dyspepsia may occur, and a few patients will eventually suffer from complete loss of gallbladder function.Therefore, patients with persistent and repeated epigastric pain should seek medical advice in time.
Diagnostic basis
The doctor will inquire about the patient's medical history to see if there is any possibility of cholecystitis diagnosis.Then, the doctor will recommend that the patient receive physical examination, blood examination, ultrasound, CT, MRI and other imaging examinations to further confirm the diagnosis.
Determine whether the patient's abdominal pain and other discomfort are caused by cholecystitis;
Determine whether the patient has cholelithiasis at the same time;
Determine the priority of the patient's condition and the overall condition of the patient, so as to develop a treatment plan;
In most cases, patients go to the gastroenterology department for medical treatment due to epigastric pain and discomfort, or accompanied by nausea, vomiting, anorexia, constipation and other gastrointestinal symptoms.When the diagnosis and treatment of the gastroenterology department determines that surgery is needed, it will be transferred to the general surgery department.
Some patients with chronic cholecystitis have a better understanding of their own conditions and can go directly to the general surgery department according to their previous medical experience.
If the patient has rapid onset and severe symptoms, he should go to the emergency department of the local hospital as soon as possible.
Relevant inspection
Medical history and physical examination
Detailed collection of medical history and physical examination is the clinical basis for diagnosis of cholecystitis.The patient needs to answer the following questions from the doctor:
Basic information: including the patient's age, occupation, smoking, drinking, marriage and family health.
Time of onset: The doctor needs to know whether there are obvious inducements and regularity of the onset of the disease, so as to assist in diagnosis.
Conscious symptoms: the doctor will ask the patient whether he has abdominal distension and pain, whether the pain radiates to other parts, whether he has other digestive system discomfort, whether he has fever, chills and other symptoms, and understand the characteristics of each symptom, so as to provide a basis for making a diagnosis.
Physical examination: The doctor will conduct a comprehensive physical examination of the patient's whole body. Because of the obvious abdominal symptoms, the doctor will focus on the abdominal examination.Gallbladder tenderness sign (also known as positive) is a typical sign of acute cholecystitis, which can be used as a diagnostic basis.
Special attention: for patients with critical, severe trauma and long-term parenteral nutrition support, once there is pain in the right upper abdomen accompanied by fever, they should be alert to the occurrence of acute acalculous cholecystitis.
Imaging examination
Acute calculous cholecystitis: Ultrasound can observe gallbladder enlargement, cystic wall thickening, bilateral signs can be seen when edema is obvious, stones show strong echo, followed by sound shadow.CT、MRIInspections can assist in diagnosis.99mTc EHIDA can be used for patients with atypical symptoms.
Acute acalculous cholecystitis: It is not easy to make a diagnosis with ultrasonic examination at the early stage of the disease. CT examination is helpful, and nuclide scanning of the hepatobiliary system can also help.
Chronic cholecystitis: typical abdominal ultrasound examination shows that the gallbladder wall is thickened (wall thickness ≥ 3mm) and rough, and with gallstones, it can show strong echo in the gallbladder and posterior acoustic shadow.Gastrointestinal barium meal, gastroscope, abdominal CT, urography and other examinations can be used for differential diagnosis.
differential diagnosis
It is briefly introduced here that different types of cholecystitis need to be differentiated from other diseases. However, the differential diagnosis must be carried out by professional doctors, and patients and their families should carefully speculate to avoid unnecessary disease delay and wrong treatment.
Acute Calculous Cholecystitis
It should be differentiated from acute pancreatitis, peptic ulcer perforation, high appendicitis, liver abscess, gallbladder cancer, colon liver flexure cancer or small intestinal diverticulum perforation, as well as right pneumonia, pleurisy, hepatitis and other diseases.
Acute acalculous cholecystitis
The typical symptoms of abdominal pain are often covered up because of other serious diseases associated with the patient, so it is easy to be misdiagnosed and delayed treatment. Doctors will conduct more inquiries and examinations for careful identification.
chronic cholecystitis
The symptoms of chronic cholecystitis are often similar to those of chronic digestive tract diseases. Doctors may arrange gastrointestinal barium meal, gastroscopy, abdominal CT, urography and other examinations for differential diagnosis.
treatment
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The treatment of cholecystitis requires the combination of medical medication and surgery. The optimal treatment scheme is determined according to the patient's condition and comprehensive situation.If surgical treatment is selected, laparoscopic cholecystectomy is currently commonly used.
Acute treatment
In case of acute cholecystitis, if there are no other complications, fasting water, spasmolysis and pain relief, intravenous nutrition support, anti infection treatment, etc. can be considered. After the condition is relieved, please ask the surgeon to assess whether surgery is needed.
If the condition is critical and not relieved, or it has been confirmed that there is suppurative cholecystitis or gangrenous perforated cholecystitis, emergency surgery should be considered as soon as possible.
Indications for emergency surgery
Within 48-72 hours after onset;
Non operative treatment is ineffective or the condition worsens;
Complicated by gallbladder perforation, diffuse peritonitis, or acute suppurative cholangitis or acute necrotizing pancreatitis.
For acute acalculous cholecystitis, it is very easy to deteriorate and gangrene and perforation occur. Once diagnosed, surgery should be carried out as soon as possible.
General treatment
On the basis of medical treatment, if patients with chronic cholecystitis have the following symptoms, it is necessary to consider inviting surgeons for consultation to decide whether surgery is necessary:
No relief or recurrent pain, affecting life and work;
The examination showed that the gallbladder wall was gradually thickened to 4mm or more, or the gallbladder wall was locally thickened or irregularly suspected of gallbladder cancer;
The examination showed that the gallbladder wall showed ceramic like changes;
According to the professional doctor's assessment, the number of gallstones increases year by year, or the stone in the neck of the gallbladder is incarcerated, which is associated with gallbladder dysfunction or disorder.
For asymptomatic patients or those whose abdominal pain may be caused by other coexisting diseases, surgical treatment should be cautious.Patients who cannot tolerate surgery can choose non-surgical treatment, including oral litholytic drugs, organic litholytic agents directly puncture gallbladder litholysis, extracorporeal shock wave lithotripsy, etc., and can also limit the intake of greasy food and take anti-inflammatory and cholagogic drugs, bile salts, Chinese medicine and other treatments.
medication
acute cholecystitis
Treatment of spasmolysis and analgesia: availableatropineIntramuscular injectionPethidine(meperidine), etc., so as to relieve spasm and relieve pain.
Anti infection treatment: in order to prevent bacteremia and suppurative complications, antibiotics can be used, and aminobenzylpenicillin, clindamycin and aminoglycosides can be used together, or cefazol or cefuroxime can be used for treatment.The change of antibiotics should be determined according to the clinical symptoms of blood culture, bile culture, bacterial culture of gallbladder wall and drug sensitivity test.
Cholagogue drugs: take 50% magnesium sulfate orally. It should not be used for people with diarrheaDeoxycholic acid tabletEtc.
chronic cholecystitis
Cholagogues: 50% magnesium sulfate, dehydrocholic acid tablet, etc.
Litholytic therapy: cholecystitis caused by cholesterol stones can be treated with ursodeoxycholic acid or chenodeoxycholic acid.After the end of the course of treatment, continued treatment for a period of time can prevent recurrence.
Chinese patent medicine
The Chinese patent medicine for clearing liver and gallbladder can clear away the dampness and heat of liver and gallbladder, help to diminish inflammation and promote gallbladder, and is mainly used for treatmentStupidity, hypochondriac pain, yellow urine, greasy furPulse string, fatigue and fatigue, liver depression and qi stagnation, liver and gallbladder dampness and heat are not clear and other symptoms.Both acute and chronic cholecystitis can be used.
surgical treatment
This article briefly introduces some surgical methods. In actual surgery, surgeons need to consider comprehensively according to the patient's general condition and hospital technical conditions and other factors.
Cholecystectomy: Minimally invasive laparoscopic cholecystectomy is often performed, and open cholecystectomy may be required in medical institutions where conditions do not permit;
Partial cholecystectomy: For patients with difficulty in separating the gallbladder bed or possible bleeding, part of the gallbladder wall of the gallbladder bed can be retained and the rest of the gallbladder can be removed.
Cholecystostomy: For high-risk patients, especially the elderly with other basic diseases, the first operation can be performed for decompression and drainage, and cholecystectomy can be performed 3 months later.
Ultrasound guided percutaneous transhepatic gallbladder drainage (PTGD): This method can reduce the internal pressure of the gallbladder, and the operation will be performed when the acute stage has passed.PTGD is suitable for patients with severe suppurative cholecystitis who are not suitable for surgery.
TCM treatment
Traditional Chinese medicine has a long history in the treatment of chronic cholecystitis, which can be treated according to different clinical manifestations of patients, and can also cooperate with other Chinese medicine treatments, such as acupuncture, ear point therapy, drug application, etc.
prognosis
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Different types of cholecystitis have different prognosis, but most patients have good prognosis.
Individual recovery varies greatly, and most patients have a good prognosis, or even recover;The condition of a few patients worsens rapidly and becomes severe rapidly, which can endanger life.
The age over 80 years old is a risk factor for increased morbidity and mortality in patients with acute cholecystitis.
Under the premise of not accepting surgery, it will continue to exist and is difficult to cure, which may affect the quality of life and normal work of some patients.
It is necessary to be alert to the long-term existence of chronic cholecystitis, which can induce gallbladder cancer or other malignant diseases of liver, gallbladder and pancreas in a few patients, as well as its acute attack and rapid deterioration.
harmfulness
Cholecystitis may cause necrosis, suppuration or perforation of the gallbladder, which is dangerous and can endanger the patient's life in serious cases.
Chronic cholecystitis can persist, causing abdominal distension, greasy aversion, belching, epigastric pain, fever and other symptoms for a long time, affecting the quality of life of patients.
If you have suffered from cholecystitis in the past, you need to limit the intake of lipids to a certain extent daily to prevent recurrence, which will have a certain impact on the quality of life of patients.
This is a serious complication. For patients with acute biliary pancreatitis with common bile duct obstruction and cholangitis, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage or surgery should be performed as soon as possible.For patients with acute gallstone pancreatitis and cholecystitis, cholecystectomy should be performed as early as possible to prevent recurrence of acute pancreatitis.
Mirizzi syndrome is related to the shape and length of some congenital gallbladder and cystic duct, which leads to repeated inflammatory reactions, and may lead to the common bile duct fistula of gallbladder, the disappearance of cystic duct, and partial or complete obstruction of common bile duct by stones.The treatment of Mirizzi syndrome is mainly surgery.
Lithiasis ileus
Calculous intestinal obstruction accounts for about 1% of all intestinal obstruction, which forms a fistula between the gallbladder and the intestine. The most common one is cholecystoduodenal fistula, which accounts for 68%.More ileocecal ileus occurs because stones enter the intestine through fistula.Surgical intervention is the main treatment for calculous intestinal obstruction.
Gallbladder cancer is the most serious complication of chronic cholecystitis and gallstone.In addition to clinical manifestations (such as right costal pain, mass, jaundice, etc.) and laboratory examinations, the diagnosis of gallbladder cancer mainly depends on imaging examinations, including abdominal ultrasound, CT, MRI and endoscopic ultrasound.Due to the poor prognosis of gallbladder cancer, patients with high suspicion of gallbladder cancer should be prophylactically removed regardless of whether there are symptoms.
