acute suppurative cholangitis
Introduction
Introduction to acute suppurative cholangitis Acute suppurative cholangitis, also known as acute obstructive suppurative cholangitis, refers to acute suppurative biliary tract infection caused by obstruction. It is the most important and direct cause of death in patients undergoing biliary surgery. Most of them are secondary to bile duct stones and biliary tract mites. disease. The disease occurs in 40 to 60 years old, and the mortality rate is 20% to 23%. The mortality rate of the elderly is significantly higher than that of other age groups, and can be as high as 70% in non-surgical cases. Abdominal pain is more common, the first symptom of this disease. There is often a history of recurrent episodes. The pain is usually in the lower part of the xiphoid and/or in the upper right abdomen. It is exacerbated by persistent pain and can be radiated to the right shoulder and back. Fever is the most common symptom. basic knowledge The proportion of illness: 0.004%, more secondary to gallstones Susceptible people: good for 40 to 60 years old Mode of infection: non-infectious Complications: jaundice bacteremia peritonitis
Cause
Causes of acute suppurative cholangitis
Cause
Most of them are secondary to bile duct stones and biliary ascariasis, but lesions such as bile duct stricture and biliary tumors can sometimes be secondary to these diseases. These diseases cause bile duct obstruction, cholestasis, and secondary bacterial infections. The pathogens are almost all from the intestines. The biliary tract can be retrogradely entered through the ampulla or biliary anastomosis. Bacteria can also enter the biliary tract through blood or lymphatic channels. The pathogens are mainly Escherichia coli, Klebsiella, Streptococcus faecalis and some anaerobic bacteria. bacteria.
Prevention
Acute suppurative cholangitis prevention
Acute suppurative cholangitis is a serious complication of hepatolithiasis and biliary ascariasis. Therefore, the primary prevention of this disease is mainly for the prevention and treatment of hepatolithiasis and biliary mites.
1. Prevention and treatment of hepatolithiasis, the key to prevention of hepatolithiasis is to prevent and eliminate pathogenic factors. Patients who have been diagnosed with hepatolithiasis should be highly alert to the occurrence of this disease, especially in the case of concurrent biliary infections. Early use of high-dose sensitive antibiotics to fight infection, pay attention to water, electrolytes and acid-base balance, strengthen systemic support for the treatment of biliary tract infections. As soon as the general condition allows, surgery should be performed as soon as possible to remove stones and smooth drainage, so as to prevent the occurrence of AOST.
2, prevention and treatment of biliary ascariasis. When the mites enter the biliary tract, they cause different degrees of obstruction of the biliary tract, which increases the pressure of the biliary tract. When a bacterial infection occurs, AOST can be induced. In addition, biliary ascariasis is also an important factor in the formation of hepatolithiasis. Therefore, prevention and treatment of biliary ascariasis is an extremely important aspect of preventing AOST. Mainly pay attention to drinking water, food hygiene, prevention and treatment of intestinal ascariasis. Once the diagnosis is diagnosed, if it is diagnosed as biliary ascariasis, it should be treated as soon as possible. Give analgesia, relieve phlegm, control infection, and prompt the mites to withdraw from the biliary tract. In addition, duodenal endoscopy can be performed, and a part of the mites entering the common bile duct can be pulled out of the body by a snare. Surgical treatment is considered when treatment is ineffective.
Complication
Acute suppurative cholangitis complications Complications jaundice bacteremia peritonitis
1, some patients with bacteremia may have signs of bacteremia of high fever and chills.
2, the incidence of jaundice accounts for about 80%. The presence or absence of jaundice and the degree of jaundice depend on the location of the biliary obstruction and the duration of the obstruction.
3, peritonitis patients with inflammatory exudation, there may be signs of right lower peritonitis.
Symptom
Acute suppurative cholangitis symptoms Common symptoms Abdominal pain, fever and jaundice bile excretion blocked nausea, irritability, bile duct fracture, gallbladder dyskinesia, high fever, blood pressure, jaundice shock
The onset is often rapid, sudden severe pain under the xiphoid or right upper quadrant, generally persistent, followed by chills and relaxation type hyperthermia, body temperature can exceed 40 ° C, often accompanied by nausea and vomiting, most patients have jaundice, but jaundice The depth of the disease can be inconsistent with the severity of the disease. Nearly half of the patients have irritability, disturbance of consciousness, lethargy, and even coma, and other central nervous system inhibition, and often blood pressure decline, often suggesting that the patient has septicemia and septic shock, is the condition A manifestation of critical illness, elevated body temperature, pulse rate can be increased more than 120 beats / min, pulse is weak, under the xiphoid and right upper abdomen have obvious tenderness and muscle tension, such as gallbladder unremoved, often sputum and swelling and The tender gallbladder and dirty, white blood cell count is significantly increased and right shift, up to 20,000 to 40,000 / mm3, and can appear toxic particles, serum bilirubin and alkaline phosphatase values, and often GPT and r - GH value increases and other liver function damage, blood culture often has bacterial growth.
Examine
Examination of acute suppurative cholangitis
Laboratory inspection
1. White blood cell count: In 80% of cases, the white blood cell count is significantly increased, and the neutrophils are elevated with the left shift of the nucleus. However, in severe cases or secondary biliary sepsis, the white blood cell count can be lower than normal or only nuclear left shift and poisoning particles.
2, bilirubin determination: serum total bilirubin, combined bilirubin determination and urinary bilirubin, urinary bilirubin test, are characterized by obstructive jaundice.
3. Serum enzymology determination: serum alkaline phosphatase was significantly elevated, and serum transaminase was slightly elevated. If the biliary obstruction is longer, the prothrombin time can be prolonged.
4, bacterial culture: in the chills, fever, blood collection for bacterial culture, often positive. Bacterial species are consistent with bile. The most common bacteria are Escherichia coli, Klebsiella, Pseudomonas, Enterococcus and Proteus. Anaerobic bacteria such as Bacteroides fragilis or Clostridium perfringens can be seen in about 15% of bile samples.
Other auxiliary inspection
1, cholangiography: more PTC, with the dual role of diagnosis and treatment. The location and cause of dilated bile ducts and obstruction can be found, but it is generally inappropriate for patients with severe shock to perform this test immediately.
2, CT and MRI examination: When there is a high degree of suspicion of intrahepatic and extrahepatic bile duct obstruction and B-ultrasound examination failed to establish a diagnosis, CT or MRI examination is feasible. CT or MRI is better than B-ultrasound for clear obstruction and obstruction, and its accuracy is over 90%.
3, ultrasonic inspection B-ultrasound: has become the preferred method of inspection. The diagnostic coincidence rates for exploration of gallstones, common bile duct stones, and intrahepatic bile duct stones were 90%, 70% to 80%, and 80% to 90%, respectively. The bile duct and/or intrahepatic bile duct can be found in the obstruction of the stone, and the size of the gallbladder, the size of the liver, and the presence or absence of hepatic abscess can be known.
Diagnosis
Diagnosis and differentiation of acute suppurative cholangitis
diagnosis
According to the clinical manifestations of typical abdominal pain, chills and high fever and jaundice triad, namely Charcot, and clinical manifestations of central nervous system depression and hypotension in the development of the disease, the diagnosis of acute suppurative cholangitis, Generally not difficult. In only a small number of patients, such as acute suppurative cholangitis complicated by intrahepatic bile duct stones, the diagnosis may be delayed due to atypical symptoms such as no abdominal pain and jaundice. At this time, by special examination methods, such as B-ultrasound for non-invasive examination, often can show intrahepatic or extrahepatic bile duct dilatation, multiple small abscesses in the liver, and intra-biliary calculus, thereby inferring intraductal bile duct The presence of obstructive lesions, combined with clinical manifestations to make a diagnosis. Occasionally, tests such as PTC or ERCP can be used to aid diagnosis.
Differential diagnosis
For typical cases, it is generally easier to make a diagnosis, but it should be differentiated from the following diseases.
1. Peptic ulcer perforation: The patient has a history of ulceration, the abdominal muscles are plate-shaped, the liver dullness area is reduced or disappeared, and there is free gas under the armpit to confirm the diagnosis.
2, underarm abscess B-ultrasound: can find the location and size of the abscess, CT can be reliably located, and can see the relationship between abscess and surrounding organs.
3, acute pancreatitis blood, urine amylase or serum lipase increased. B-ultrasound can be found that the pancreas is limited or diffusely enlarged, and if necessary, CT examination can be used to further determine the location and extent of the lesion.
4, liver abscess B ultrasound, CT and other imaging examinations and acute suppurative cholangitis easy to identify.
5, right lower bacterial pneumonia can be diagnosed by its typical symptoms, signs and chest X-ray examination.
