Biliary Ascariasis
Introduction
Introduction to biliary ascariasis Biliary ascariasis is a retrograde intestine from the small intestine into the biliary tract, causing bile ducts and Oddi sphincter spasm, with the main clinical features of sudden upper abdominal pain in patients. After the mites enter the biliary tract, most of them stay in the common bile duct. Because of the large angle between the cystic duct and the common bile duct, the mites rarely enter the gallbladder, but can be drilled into the left and right hepatic bile ducts. Children and young people are more common and have no gender differences, and rural areas are more common. Improper handling can cause a variety of complications, which is one of the causes of primary bile duct stones. basic knowledge The proportion of illness: 0.0035% Susceptible people: more common in children and young adults Mode of infection: non-infectious Complications: liver abscess biliary bleeding septic shock sepsis
Cause
Causes of biliary ascariasis
Locust parasitic (85%):
The adult mites are parasitic in the small intestine, the lower part, and occasionally enter the upper digestive tract. The mites have boreholes. Therefore, the mites entering the duodenum often penetrate the biliary tract through the common bile duct opening. Clinical observations note that sometimes the mites can pass through The mouth spits out or climbs out, the patient is often accompanied by high fever, hunger, diarrhea or deworming with the mountain road and the amount of drug is insufficient. Therefore, considering the change of the living environment of the aphid may be the cause of the movement of the upper digestive tract.
Aphids drill into the biliary tract (5%):
There are more than one aphids drilled into the biliary tract, but there are also a dozen or even more than a hundred. Aphids rarely enter the gallbladder, and most of them stay in the bile duct system, including extrahepatic and intrahepatic bile ducts. During the passage of the mites through the Oddi sphincter, the sphincter is paralyzed by stimulation, causing severe pain.
Biliary tract stimulation (5%):
After the mites withdraw from the biliary tract or completely enter the biliary tract, the stimulation of the sphincter disappears, the severe pain caused by sputum is relieved, and the mites can cause paroxysmal pain in the biliary tract. It is also due to the activity of the mites that the passage of bile is not Completely blocked, so there is generally no jaundice, intestinal bacteria with the worm into the biliary tract, can cause biliary tract infection, causing acute inflammation of the gallbladder, bile duct, resulting in liver abscess, biliary bleeding, septic shock and sepsis, etc. disease.
Prevention
Biliary tsutsugamushi disease prevention
Prevention of reducing or eliminating intestinal mites infection can reduce the incidence of biliary ascariasis. To this end, it is necessary to strengthen health promotion, do a good job of harmless management of feces, pay attention to food hygiene, not eat cold and unclean food, to cut off the source of infection, reduce The rate of intestinal mites infection, regular census of feces, positive eggs, should be treated as deworming.
Complication
Complications of biliary ascariasis Complications liver abscess biliary bleeding septic shock sepsis
After the mites enter the biliary tract, complications do not occur immediately. Only when the body's resistance is reduced, the biliary tract is obstructed, and bile drainage is not smooth, complications may occur. Common complications are as follows:
1, biliary tract infection, suppurative cholangitis, accounted for 40%; cholecystitis, accounting for 40%; septic shock, accounting for 6%, at this time, patients in addition to right upper quadrant colic, often accompanied by chills, high fever, skin sclera yellow stain, Abdominal swelling is intensified, the range of tenderness in the right upper quadrant is enlarged, and muscle tension is present. If there is biliary obstruction, the gallbladder can be swollen and swollen. When acute cholecystitis occurs, the Murphy sign is positive.
2, the incidence of biliary bleeding is 3.5%, often occurs on the basis of biliary tract infection, first fever, abdominal pain, etc., followed by hematemesis, melena.
3, liver abscess on the basis of intrahepatic cholangitis, secondary hepatitis, liver abscess, liver abscess often for a number of scattered small abscess, abscess ulceration, may appear under the armpit empyema or empyema.
4, the incidence of acute pancreatitis is 3.5%, due to aphid stimulation of Oddi sphincter spasm and worm blockage, resulting in poor drainage of bile and pancreatic juice, so that infected bile and / or pancreatic juice flow back into the pancreatic duct and activate pancreatic enzyme, causing acute Pancreatitis; worm body into the pancreatic duct can cause necrotizing pancreatitis; insect eggs deposited in the pancreatic duct cause inflammation, fibrosis, can cause chronic pancreatitis, which is a special cause of pancreatitis in China in early years.
5, the incidence of biliary calculus is about 19%, the mites in the biliary tract debris or residual keratin can be used as the core of the stone, forming stones, such stones are mostly bile pigmented stones, in addition, female mites produce a large number of worms per day Eggs can also become the core of the stone.
6, other common bile duct perforation rate <1%, gallbladder perforation <1%, peritonitis accounted for 6%, empyema accounted for 2% to 6%, bile duct stricture accounted for 1% to 3.5%.
Symptom
Symptoms of biliary ascariasis common symptoms abdominal pain jaundice upper abdominal pain cold war pain nausea nails similar to mica intrahepatic duct obstruction mites infection
Biliary tsutsugamushi is common in children and young adults, and women are more common. Most patients have intestinal ascariasis, wormworm or wormworm history, and some patients have had recent deworming treatment.
1. Abdominal pain Abdominal pain is the main symptom of this disease. It is often located in the middle and upper abdomen under the xiphoid process. It is a paroxysmal drill-like severe cramping. The patient is tossing and turning, sitting and restless, sweating, and the patient often takes a bent knee position. With your hands on the abdomen, both hands are intended to tear the clothes, and the pain usually lasts for a few minutes or more than 10 minutes. This is the case when the worms quit or the whole worm enters the bile duct or temporarily quiet and does not wiggle. After the onset of remission, the patient may be asymptomatic as a normal person or mild right upper abdomen pain. This kind of episode is unbearable and the interval is as obvious as the normal person. It is one of the characteristics of this disease. Often accompanied by nausea, vomiting, or retching, vomit is stomach contents and bile, about one-third of patients spit out aphids, the latter has special value for the diagnosis of this disease, and in some cases the whole body can enter the bile duct without pain.
2, no or only mild jaundice is another characteristic of this disease, because the worm's smooth activity, it is not easy to completely block the biliary tract, if the secondary infection and inflammation caused by bile duct obstruction may be accompanied by obvious jaundice, which is seen in 20% of cases.
3, chills, fever often occurred in the biliary tract infection after 24 hours of onset.
4, abdominal signs of the disease in the early stage of the xiphoid or right upper abdomen only slightly fixed tenderness, no rebound pain and muscle health, severe symptoms, slight signs are another feature of the disease, the skin sclera may have a slight yellow stain If the range of tenderness is widened, it is necessary to be alert to the possibility of complications.
Examine
Examination of biliary ascariasis
Laboratory inspection
1, blood: peripheral blood leukocytes increased slightly, the proportion of eosinophils increased, such as increased white blood cells, suggesting a combined bacterial infection.
2, looking for eggs: stool eggs can be found in the eggs, if you do not find the eggs, you can not rule out the disease, some patients can find aphid eggs in the duodenal drainage.
Film degree exam
1. B-ultrasound examination: It can clearly show the liver and the outer bile duct, and it is convenient and easy to repeat. After the mites enter the common bile duct, the B-ultrasound can be seen in the bile duct, the internal echo is uneven, and the living worm body It can also be seen that its peristalsis, such as the dead or calcified worm, is a strong echo of the strip.
2, ERCP examination: can clearly understand the presence or absence of aphids in the bile duct and its location, shape and quantity, as well as the treatment of insects under endoscopic direct vision, in addition, can directly observe the vicinity of the duodenal nipple area No mites.
3, intravenous cholangiography: the presence of biliary tract development or no development, duodenal hypotonography can not diagnose the complete worm into the biliary tract, so the current two methods are less applied.
If you suspect a combination of liver, gallbladder, and pancreatic complications, you can check accordingly.
Diagnosis
Diagnosis and identification of biliary ascariasis
diagnosis
The diagnosis is based on:
1, paroxysmal cramps in the right upper abdomen or xiphoid, especially accompanied by "drilling pain", the remission period is as common as anyone.
2, abdominal pain accompanied by nausea, vomiting, a small number of patients have a history of spit or aphid.
3, the symptoms of heavy physical signs, only under the xiphoid and right quarter rib tenderness.
4, ultrasound examination can be seen dilated bile ducts, there are line-like swimming insects.
5, ERCP shows mites in the biliary tract, or under the endoscope under the direct view of the duodenal nipple with aphid incarceration.
Differential diagnosis
If there are complications, it should be differentiated from cholecystitis cholelithiasis, acute adenitis, acute perforation of gastroduodenal ulcer, intestinal ascariasis, urinary calculi, intestinal fistula, etc., as long as the identification of the above diseases, as long as careful Asked about the characteristics of the "symptoms of inconsistency" in the early stage of biliary ascariasis and the sudden and sudden occurrence of colic, and if it is characterized by complications, it can be diagnosed correctly because of the complications.
