Biliary Ascariasis and Hepatic Ascariasis
Introduction
Introduction to biliary ascariasis and hepatic ascariasis Biliary tsutsugamushi disease and liver tsutsugamushi disease are two diseases that are closely related and distinct from each other, and are derived from intestinal mites. In 1932, the British doctor Mure performed the first case of common bile duct incision for aphid in China. In 1942, Huaxi Medical University implemented the second case of common bile duct incision for aphid, thus uncovering a new page of oriental biliary surgery. Since the discovery of biliary mites, the disease has been ravaged for at least half a century in China and has become an important cause of primary hepatolithiasis until the late 1970s, with the continuous improvement of people's living standards and sanitary conditions. Gradually improved, the incidence of biliary ascariasis began to show a significant downward trend. basic knowledge The proportion of sickness: 0.01% Susceptible people: no specific people Mode of infection: non-infectious Complications: biliary bleeding acute pancreatitis
Cause
Biliary tsutsugamushi disease and the cause of liver tsutsugamushi disease
(1) Causes of the disease
The following factors occur in the occurrence of biliary ascariasis:
1 Aphids can be used for swinging, twisting, flipping, folding, etc., and can swim in the intestines;
2 Under normal circumstances, aphids in the intestine head to the stomach end, sucking food slag and intestinal fluid, aphids have the characteristics of anaerobic acid, low stomach acid is one of the incentives for ascaris, studies have shown that the average gastric acid value of patients with biliary mites is low, children And the higher incidence of pregnant women may also be related to their low stomach acid;
3 Aphids have drilling habits. When they are ascending to the duodenum, they can enter the biliary tract through the duodenal papilla Oddi sphincter;
4 systemic or local disease caused by gastrointestinal dysfunction, intestinal environment changes, such as fever, nausea, vomiting, diarrhea and pregnancy, can enhance the activity of aphids, promote their upward;
5 Oddi sphincter pathological or physiological relaxation caused by various reasons, easy to drill aphid, such as after eating greasy food, surgical stimulation (cholecystectomy, Oddi sphincter incision and stone removal);
6 improper use of aphid drugs, such as insufficient dose can stimulate the aphid to stimulate the blind, easy to enter the biliary tract.
After the mites enter the biliary tract, most of them stay in the common bile duct. There are few people who enter the gallbladder. Because the cystic duct is thin and has a spiral Heiste mucosal flap to prevent the mites from entering, the mites can further ascend to the common hepatic duct or the left and right hepatic ducts, or even enter In the intrahepatic bile duct.
The number of aphids entering the biliary tract is 1 in most cases, generally no more than 10, but there are also reports of dozens to hundreds of aphids causing biliary ascariasis.
The survival time of aphids in the biliary tract is generally 1 week to 1 month, and the longest survival time is 14 days in the fresh bile of isolated humans.
Aphids can sometimes exit when they enter the biliary tract, mostly in the following situations:
1 The part of the worm enters the biliary tract, and part of it stays in the duodenum. The drug stimulation or the peristaltic wave can push it to curl and pull it out of the biliary tract;
2Oddi sphincter relaxation, when the pressure in the duodenum is low, the excretion of bile can discharge smaller aphids;
3 When the biliary tract is dilated, the mites can be exhaled by themselves;
4 After the mites die and are discharged with the bile, the mites remain in the biliary tract and often cause serious symptoms.
(two) pathogenesis
When the mites penetrate into the biliary tract, they cause strong convulsions of the Oddi sphincter and typical biliary colic. With the entry of aphids, intestinal bacteria, mainly Gram-negative bacilli and anaerobic bacteria are brought into the biliary tract, which can cause acute suppurative cholangitis. Even the infection spreads up to cause capillary biliary hepatitis or liver abscess. At the same time, due to the mites stimulating Oddi sphincter spasm, biliary tract obstruction, bacterial bile refluxing into the pancreatic duct, or the worm directly blocking the pancreatic duct opening to induce acute pancreatitis, when the infection involves Liver and intrahepatic bile ducts can erode blood vessels in the portal area and cause biliary tract bleeding. Because the mites are smooth and cylindrical, and they are constantly moving, the obstruction of the bile ducts is incomplete. Obstructive jaundice is rare, but the mites and eggs can become At the core of the stone, the literature reports that the aphid fragments or eggs are the core of the stone, accounting for 36.5% to 65.5% of gallstones. It can be seen that biliary aphids are one of the important causes of hepatolithiasis.
The pathological changes of hepatic tsutsugamushi are mainly aphid-like liver abscess and liver worm granuloma. Aphid-like liver abscess is caused by aphid going through the intrahepatic bile duct. It can be single or multiple, and the abscess contains mites and eggs. Is characterized by liver abscess can be diffused into the abdominal cavity to cause diffuse peritonitis; can also penetrate the thoracic cavity to the right empyema, necrotic liver tissue and eggs in the abscess can still flow into the hepatic vein caused by hepatic vein inflammation and thrombosis, and even Entering the lung through the right heart, causing pulmonary infarction and suppuration symptoms, liver aphid granuloma is invaded into the liver, caused by massive spawning, early is eosinophilic abscess, and later forms granuloma, the literature is caused by hepatic aphid granuloma Reports of biliary tract hemorrhage, in addition, sputum invasive intrahepatic bile duct can lead to liver necrosis in the corresponding area and later localized fibrotic lesions.
Prevention
Biliary tsutsugamushi disease and prevention of liver tsutsugamushi disease
It is necessary to mobilize the whole society to do a good job in water prevention and control, such as water control and tube dung, and actively promote it. Everyone must develop good hygiene habits, not eating unclean fruits and vegetables, and preventing diseases from entering the mouth. In the case of intestinal ascariasis, regular sputum treatment is given. If biliary ascariasis is obtained, it should be thoroughly treated according to the doctor's advice to prevent gallstones and worms from causing gallstones in the biliary tract.
Complication
Biliary tsutsugamushi disease and complications of liver tsutsugamushi Complications biliary bleeding acute pancreatitis
The risk of biliary ascariasis is that it can cause more serious complications. These complications can reach more than 10 kinds, among which liver abscess is the first, and the rest have bile duct and gallbladder purulent inflammation, biliary tract hemorrhage, biliary perforation, acute Pancreatitis, toxic shock, chronic cholecystitis, biliary calculi, cirrhosis, etc.
1. Liver abscess: biliary aphids enter the intrahepatic bile duct or the infection of the bacteria they carry can form intrahepatic cholangitis, inflammation further develops through the bile duct to form abscess, and the worm-dissolved tissue toxin after the death of aphid accelerates the formation and development of liver abscess The clinical manifestations are similar to those of other causes of liver abscess. There are pain in the liver area, chills and fever, liver enlargement, tenderness and suffocation in the liver area, increased white blood cell count, etc. When there is aphid in the liver abscess, it can penetrate into the abdominal cavity to form suppurative. Peritonitis, or perforation of the diaphragm to form a bile duct trachea, aphids can enter the chest or excreted by the trachea.
2. Cholangitis and cholecystitis: Intestinal pathogens are brought into the biliary tract by aphids, which can induce acute suppurative cholangitis and cholecystitis. In addition to paroxysmal cramps of biliary ascariasis, there may be persistent pain. Chronic fever, jaundice, mental symptoms and toxic shock performance, if not acute suppurative infection, can prolong the development of chronic cholangitis and cholecystitis.
3. Acute pancreatitis: Aphids enter the duodenal papilla, Oddi sphincter spasm, edema, bile pancreatic juice discharge blocked, infectious bile reflux can activate pancreatic enzyme-induced acute pancreatitis, mild pancreatic edema, severe pancreatic hemorrhage and necrosis, etc. In a small number of cases, aphids directly enter the pancreatic duct, causing obstruction, bacterial infection, and acute pancreatitis.
4. Biliary hemorrhage: the mechanism of cholangitis and the mechanical damage of aphids can be caused. When cholangitis affects the liver portal area, the branches of the hepatic artery and portal vein become vulnerable due to infection. Inflammation and aphid movement can cause Rupture, bleeding into the biliary tract, biliary tract bleeding often precedes chills and high fever and other symptoms of biliary tract infection, right upper quadrant cramps, followed by hematemesis or accompanied by melena, blood loss can be self-coagulation when blood pressure is significantly decreased, blood pressure gradually returns to normal, but infection Uncontrolled can cause bleeding again, so biliary bleeding can occur periodically and repeatedly, usually between 1 and 2 weeks.
5. Biliary stones: Corrupted fragments of mites in the biliary tract can be excreted with bile, but the horny skin contained in the horns is more prone to spoilage, and the locust eggs are deposited in the biliary system, which can be used as the core of the stone and interact with other stone-forming factors. Causes bile pigment, cholesterol deposition, formation of intrahepatic bile duct stones, gallstones, most reports indicate that the core of gallstones is a large proportion of aphid fragments or aphid eggs. Some scholars have placed aphids or eggs into the bile duct of the dog, in the gallbladder. It is found that the surface forms bile pigment or calcium salt deposition, which is prone to stone formation. After the formation of biliary stones, it may be a seizure Charcot triad, or simply painless jaundice.
Symptom
Biliary tsutsugamushi disease and symptoms of liver tsutsugamushi Common symptoms biliary ascaria granulomatosis mites infection abdominal pain peritonitis jaundice lung infection gallbladder wall fibrosis
1. Biliary tsutsugamushi is characterized by its typical abdominal pain. Sudden onset of scabbard under the xiphoid process, sudden and intermittent, the interval is as usual (so it is described as: it is like a blue sky, when it goes, it disappears) Can be accompanied by vomiting aphids, severe symptoms and mild signs, the disease is generally not accompanied by fever and jaundice.
2. Hepatic tsutsugamushi disease often occurs after the symptoms of biliary ascariasis and stormy rain. Compared with the latter, the clinical manifestations of hepatic tsutsugamushi disease are more complicated and diverse, mainly manifested as liver abscess and its complications (such as biliary bleeding, Peritonitis, empyema and lung infections, etc.) Symptoms and signs, liver mites granuloma can be complicated by biliary tract bleeding, while liver mites cause chronic cholangitis and peribiliary inflammation can occur in liver area pain and jaundice, a few can cause aphid liver Hardening performance.
Examine
Examination of biliary ascariasis and liver tsutsugamushi
Blood routine test: early white blood cell and neutrophil counts are normal or slightly elevated, significantly increased in the presence of comorbidities, increased eosinophils, vomit, duodenal drainage, bile or fecal mites Checking positives is helpful for diagnosis.
1. B-ultrasound: simple, non-invasive, visible bile duct dilatation, and sometimes can also find the sound of mites in the common bile duct.
2. Duodenal barium meal angiography: the initial symptoms of pain, when the mites have not fully entered the biliary tract, there is a cord-like filling defect (aphid shadow) at the duodenal papilla.
3. Intravenous cholangiography: visible bile duct dilatation, there is a cord-like filling defect in the intrahepatic or extrahepatic bile duct.
4. Endoscopic retrograde cholangiopancreatography (ERCP): In recent years, more applications at home and abroad, angiography can also divert bile to check eggs, such as diagnosis can be done at the same time to take insects, irrigation, injection and other treatment.
5. Percutaneous liver puncture bile drainage eggs examination.
The above auxiliary examination methods can be selected according to the patient's condition and medical conditions. It should be noted that do not excessively pursue the detection of eggs in the bile, and actively treat and relieve the patient's pain while checking.
Diagnosis
Diagnosis and diagnosis of biliary ascariasis and liver tsutsugamushi disease
According to the age of biliary ascariasis, susceptible population and clinical manifestations, combined with imaging examination, 90% of the clinical diagnosis of biliary ascariasis can be established.
Differential diagnosis
Biliary tsutsugamushi disease can sometimes be confused with the following diseases:
1. Acute pancreatitis: abdominal pain is often persistent severe pain. It is located in the upper abdomen or the left side. It radiates to the lower back and has no feeling of drilling. After the onset, the whole body condition deteriorates rapidly, and the serum amylase increases obviously, but attention should be paid to the biliary aphid. The disease is associated with acute pancreatitis.
2. Acute cholecystitis, gallstones: the onset is relatively slow, abdominal pain is gradually intensified, mostly persistent, paroxysmal aggravation, located in the right quarter of the rib area or under the xiphoid, the pain is not as serious as biliary ascariasis, vomiting is relatively Less occurs, the upper right abdomen tenderness is obvious when the abdomen is examined, and there may be muscle tension and rebound tenderness.
3. Peptic ulcer perforation: the onset is also rapid, but the upper abdomen pain can quickly spread to the whole abdomen, for persistent pain, check the abdominal muscle tension, tenderness and rebound tenderness is significant, X-ray standing examination is more common Free gas.
4. Acute gastroenteritis: may have paroxysmal abdominal cramps, and nausea, vomiting, mites may be spit when there is intestinal tsutsugamushi, but the pain is not as severe as biliary tsutsugamushi, and the position is mostly in the umbilical cord or partial On the top, there are many diarrhea, abdominal examination: no abdominal muscle tension, no tenderness, percussion can have flatulence drum sound, auscultation of bowel sounds hyperthyroidism.
