chronic cholecystitis
Introduction
Introduction to chronic cholecystitis Chronic cholecystitis (chronic cholecystitis) refers to chronic inflammatory lesions of the gallbladder, mostly chronic calculous cholecystitis, accounting for 85% to 95%, a small number of non-calculous cholecystitis, such as typhoid carriers, the disease can be recurrent by acute cholecystitis Prolonged, can also be chronic onset, clinical manifestations are non-specific, common in the right upper abdomen or heart and socket pain, after eating, full of discomfort, suffocation, after eating greasy food can have nausea, occasional vomiting, in the elderly, No clinical symptoms, called asymptomatic cholecystitis. basic knowledge The proportion of illness: 0.3% Susceptible people: more common in the elderly Mode of infection: non-infectious Complications: cholelithiasis
Cause
Causes of chronic cholecystitis
Repeated episodes of acute cholecystitis (25%):
Chronic calculous cholecystitis is the same as acute cholecystitis, because the gallbladder stones cause repeated small episodes of acute cholecystitis, that is, chronic cholecystitis and acute cholecystitis are manifestations of different stages of the same disease.
Chronic atrophic cholecystitis with stones (15%):
Chronic atrophic cholecystitis with stones, also known as porcelain-like gallbladder, inflammation and stimulation caused by stones, leading to the formation of gallstone wall calcification, calcification can be confined to the mucosa, muscle layer or both, to female patients over 65 years old More common.
Other (15%):
Chronic acalculous cholecystitis This type of case accounts for 2% to 10% of all patients with gallbladder disease at autopsy or surgery. Yellow granulomatous cholecystitis is relatively rare, accounting for 0.7% to 1.8% of cholecystitis, which is caused by the inflammatory reaction of bile lipids into the connective tissue of the gallbladder cavity.
(two) pathogenesis
1. Chronic calculous cholecystitis Chronic cholecystitis due to connective tissue hyperplasia and tissue edema, thickening of the gallbladder wall, lymphocytic infiltration between the whole layer, mucus in the gallbladder, visible sediment, gallstone or stone; The layer is replaced by fibrous tissue, the gallbladder wall is scarred, the cystic duct is obstructed by fibrous mass, and the bacterial culture of bile is often negative.
2. Chronic acalculous cholecystitis
(1) Metabolic disorder: due to the disorder of cholesterol metabolism, cholesterol ester is deposited in the gallbladder mucosa and causes mild inflammation. About half of them may have the formation of cholesterol stones, and the appearance of the gallbladder is not abnormal, and the wall of the capsule may be slightly thickened. The color is slightly pale; the gallbladder mucosa is obviously hyperemia and hypertrophy, and there are numerous yellow-white cholesterol ester precipitates on the mucosa, which are shaped like strawberries, so this disease is also called "strawberry gallbladder".
(2) Infection: bacteria can come from the intestines and biliary tract, up to the gallbladder; in sepsis, bacteria can reach the gallbladder via blood or lymphatic pathway, about 1/3 of patients have bile culture with bacterial growth, and chronic cholecystitis can also be due to virus Infection caused, about 15% of patients have a history of hepatitis, fungal, parasitic infections can also lead to chronic cholecystitis.
(3) Motor dysfunction: biliary tract movement and/or duodenal papillary sphincter dysfunction can gradually evolve into organic lesions, and after vagus nerve ablation, gallbladder tension and dynamic variability, emptying time, gallbladder enlargement Large, gradually appearing fibrosis of the gallbladder wall, thickening with chronic inflammatory cell infiltration.
(4) vascular factors: due to gallbladder wall vascular disease can lead to gallbladder mucosal damage, gallbladder enrichment function is reduced or lost, eventually leading to gallbladder wall fibrosis.
3. Chronic atrophic cholecystitis with stones can be normal size or small, even if the thumb is large, the thickening of the gallbladder wall is grayish white, the cystic stone can be one or more, or even the entire gallbladder, the mucosa is Fine granules or still smooth but with gallstones, bile at the bottom or body of the gallbladder, bile in the gallbladder, microscopic gallbladder mucosa, atrophy and significant fibrosis, thick muscle layer; few inflammatory cells, only a few lymphoplasmacytes And macrophages, can also be seen in granulomatous foreign body giant cell reaction, giant cells have cholesterol crystals, gallbladder wall blood vessels can have occlusive peripheral arteritis, porcelain bottle-like gallbladder gallbladder cancer incidence is higher, has its pathological significance.
4. At the beginning of yellow granulomatous cholecystitis, due to acute cholecystitis and obstruction, bile enters the stroma through the ulcer surface or ruptures the Aschoff-Rokitanky sinus. The phagocytosis is concentrated in the site of inflammation, digestion Lipids form large, round, pale yellow tumor cells that cause localized or diffuse destructive inflammation. The naked eye sees a yellow mass on the gallbladder wall, thickens the gallbladder wall, and adheres to adjacent organs. The gallbladder can have perforations, and the gastrointestinal tract. The formation of the tract is difficult to distinguish from the gallbladder cancer.
Prevention
Chronic cholecystitis prevention
1. Pay attention to diet, food should be light, eat less greasy and fried, grilled food.
2. Keep the stool clear, six to use, liver and gallbladder dampness, when the stool is secret, the symptoms are aggravated, it is very important to keep the stool smooth.
3. To change the sedentary lifestyle, move more and exercise more.
4. To support, long-term family is not jealous, people with a bad mood can cause or aggravate the disease, to be broad-minded and comfortable.
Complication
Chronic cholecystitis complications Complications cholelithiasis jaundice
1. Gallbladder hydrops: In chronic cholecystitis, the gallbladder mucosal epithelium secretes excessive mucus. When the gallstones are blocked in the cystic duct, the increasing mucus makes the gallbladder slowly and painlessly gradually expand (such as rapid expansion will cause pain), if No acute inflammation occurs, the bile is sterile. At this time, the right upper abdomen can lick a painless enlarged gallbladder. The gallbladder water should be differentiated from the gallbladder expansion caused by slow obstruction of the common bile duct. The latter is not because of expansion. Mucus secretion is caused by jaundice, and gallbladder water is not accompanied by jaundice.
2. White bile: When the gallbladder accumulates water for several weeks, the bile pigment is decomposed, and after absorption, the bile becomes colorless and transparent.
3. Lime milk bile: Paste or milky, colloidal limestone deposited in the gallbladder called lime milk bile, 1.3% to 3.4% of patients with cholelithiasis can be seen with lime milk bile, male to female ratio of 1:2.7, 1911 Since Churchman reported the first case of lime milk bile, he has a deep understanding of the disease.
4. Porcelain-like gallbladder: The so-called porcelain-like gallbladder is calcified in the gallbladder wall, which is hard and brittle like porcelain. The gallbladder-like gallbladder is seen in 0.06%-0.8% gallbladder removal. The ratio of male to female is 1:3, and the average age of onset is 54. At the age of, the cancer rate is greater than 25%.
Symptom
Chronic gallbladder inflammation symptoms common symptoms jaundice nausea abdominal discomfort indigestion palpitations anorexia qi biliary colic biliary syndrome gallbladder tenderness
The age and gender of onset of patients with chronic cholecystitis are similar to those of patients with acute cholecystitis. The clinical manifestations may vary greatly among different patients, and they are often inconsistent with actual pathological changes. Sometimes patients may be asymptomatic, and post-mortem autopsy is It was found that the gallbladder had obvious chronic lesions; sometimes patients had a history of severe biliary colic, but gallbladder lesions were not severe during surgery.
The symptoms of the patient can obviously appear from the first episode of acute cholecystitis, and the symptoms can be concealed. The symptoms are mild, and the symptoms are not observed until the diagnosis is confirmed. It can have irregular recurrent episodes. Symptoms are the same as acute cholecystitis; if the episode is not attacked, the clinical symptoms are blurred, similar to chronic "stomach disease"; there can be no acute episodes and only manifested as frequent upper abdominal pain and indigestion, and sometimes can be asymptomatic. The difference in symptoms is mainly due to the different degrees of inflammation of the gallbladder, with or without gallstones, and the degree of reflex sphincter spasm varies. Therefore, the functional status of the gallbladder is also different.
Patients usually have bloating, belching and anorexia greasy. After eating, they often feel abdominal discomfort, and unlike duodenal ulcers, they can relieve pain after eating. Patients often feel right under the scapula, right rib under or right. Waist and other pains in the waist, more obvious after standing, exercise or cold water bath, due to frequent pain and discomfort, the patient rarely exercise, the weight is often reduced, once there is an acute attack due to stone incarceration, the right upper abdomen will have frequent blunt Pain, and paroxysmal aggravation, and 80% of patients may have nausea and vomiting (but nausea and vomiting are rare), and 25% of patients with gallstones have mild jaundice at the onset, such as stone entry The incidence of common bile duct and jaundice can be as high as 60%. Therefore, deep jaundice occurs after severe biliary colic. Most of them indicate that there is calculus in the common bile duct, but sometimes there may be stones without pain or jaundice. Patients with chronic cholecystitis can also have two special manifestations:
1 rheumatic joint pain, especially in the neck, back and other joints, is said to be a special chronic poisoning phenomenon;
2 heart symptoms, such as precordial pain, palpitations, shortness of breath, etc., sometimes very similar to angina pectoris, these two special manifestations can be improved or cured after cholecystectomy, so this situation is not a contraindication to surgery, and is an operation Indications.
Examine
Chronic cholecystitis examination
Duodenal drainage collects bile for examination, and it can be found that there are pus cells in the bile, cholesterol crystals, bilirubin calcium precipitation, parasite eggs, etc., and pathogenic bacteria can be found in bile culture.
1. B-ultrasound has the most diagnostic value, showing the size of the gallbladder, the thickness of the cyst wall, the intra-capsular stones and the gallbladder contraction.
2. Radiological examination of the abdominal X-ray film can show signs of positive stones, gallbladder calcification and gallbladder expansion; gallbladder angiography can show signs of stones, gallbladder size, shape, gallbladder contraction and concentration.
3. Oral, venous cholangiography in addition to showing stones, gallbladder size, gallbladder calcification, gallbladder swelling signs, can also observe the common bile duct morphology and common bile duct stones, aphids, tumors and other signs, have a great diagnostic value for this disease Retrograde cholangiopancreatography is better when conditions are available, not only reliable, but also duodenoscopy.
Diagnosis
Diagnosis and identification of chronic cholecystitis
diagnosis
Physical examination except for mild tenderness in the right upper abdomen, generally no other positive symptoms, a small number of patients with cystic duct obstruction and gallbladder enlargement, occasionally can find a round mass in the right upper abdomen, and some can also find patients with slightly skin and Mild yellow staining of the sclera suggests that the lesion is in the biliary system, and in a few cases there is tenderness in the right side of the 8th to 10th thoracic vertebrae, or tenderness between the lower and lower sternocleidomastoid muscles. The latter is especially diagnostic. .
The general diagnosis of patients with chronic cholecystitis is not difficult, because most patients have one or more cases of colic and dyspepsia in the right upper abdomen, but sometimes the symptoms are not typical, and can be associated with chronic appendicitis, chronic ulcer disease, chronic gastritis, colon cancer , chronic pancreatitis and pyelonephritis are confused, the correct diagnosis depends on:
1 gallbladder X-ray film photography.
2 gallbladder angiography.
3B super or CT, MRI, etc.
Differential diagnosis
Because the clinical symptoms of chronic cholecystitis are not typical, the clinical often misdiagnosed, the following diseases are often misdiagnosed as chronic cholecystitis, so should pay attention to identification.
1. Peptic ulcer symptoms Atypical peptic ulcer is easily confused with chronic cholecystitis, and such diseases often coexist with chronic cholecystitis. In addition to careful medical history, upper gastrointestinal barium meal examination and B-ultrasound examination are helpful for identification.
2. Chronic gastritis The symptoms of various chronic gastritis have similarities with chronic cholecystitis. Fiber gastroscopy is an important method for the diagnosis of chronic gastritis. After the diagnosis is clear, if the symptoms are improved, it can be differentiated from chronic cholecystitis.
3. Esophageal hiatal hernia The common symptoms of this disease are upper abdominal or two-season rib discomfort. The typical manifestation is post-sternal pain, which occurs 0.5 to 1 h after a full meal. After a meal, the supine weight is increased, and the standing or semi-recumbent position is relieved. There may be belching and nausea, and chronic cholecystitis is mostly in the right rib. It is aggravated after meals and has nothing to do with body position. Because about 20% of patients with hiatal hernia have chronic cholecystitis, the clinical symptoms often coexist. The check can be identified.
4. In the era of primary liver cancer without B-ultrasound, some primary liver cancers are diagnosed as chronic cholecystitis, because early liver cancer, small liver cancer and subclinical liver cancer have no symptoms, once the right upper abdomen appears Discomfort or dull pain, more is advanced, B-ultrasound and CT examination can be identified.
5. Gallbladder cancer The early symptoms of this disease are similar to chronic cholecystitis. In this case, B-ultrasound examination can be differentiated from chronic cholecystitis, and can have better therapeutic effects, such as the development of the disease, jaundice and right upper quadrant mass, mostly late .
