cholecystitis in the elderly
Introduction
Introduction to cholecystitis in the elderly Cholecystitis is one of the more common diseases with a higher incidence. According to its clinical manifestations and clinical experience, it can be divided into two types, acute and chronic. Common cholelithiasis is present. basic knowledge The proportion of illness: 0.002% Susceptible people: the elderly Mode of infection: non-infectious Complications: shock
Cause
The cause of cholecystitis in the elderly
(1) Causes of the disease
Sudden obstruction of the gallbladder stones or incarceration of the cystic duct is a common cause of acute cholecystitis. The cystic duct torsion, stenosis and biliary aphid or biliary obstruction can also cause acute cholecystitis. In addition, during the ageing aging process, the gallbladder wall gradually changes. Get hypertrophy or atrophy, shrinking function, causing bile stasis, concentration and formation of cholate; end of common bile duct and Oddi sphincter becomes slack, prone to retrograde infection; systemic atherosclerosis, increased blood viscosity can aggravate gallbladder Arterial ischemia, these pathophysiological changes are the cause of the incidence of cholecystitis cholelithiasis in the elderly is higher than in young people, but also acute gangrenous cholecystitis, gallbladder perforation is more common in elderly patients.
After cystic duct or gallbladder neck obstruction, the bile in the gallbladder is concentrated to form bile salts, which stimulate the gallbladder mucosa to cause chemical cholecystitis (early); at the same time, bile retention causes the gallbladder pressure to increase continuously, and the inflated gallbladder first affects Venous and lymphatic drainage of the gallbladder wall, congestion and edema of the gallbladder. When the internal pressure of the gallbladder is >5.39 kPa (55 cmH2O), the blood flow of the gallbladder wall is blocked, the ischemic injury of the gallbladder, and the ischemic gallbladder is prone to secondary bacterial infection. Increase the course of cholecystitis, eventually complicated with gallbladder gangrene or perforation. If the cystic duct obstructs without blood circulation disorder and bacterial infection of the gallbladder wall, it develops into gallbladder effusion.
Recent studies have shown that phospholipase A can be released from the damaged gallbladder mucosal epithelium due to bile stasis or stone incarceration, so that lecithin in bile is hydrolyzed into lysolecithin, which in turn causes changes in the integrity of mucosal epithelial cells to cause acute gallbladder. inflammation.
(two) pathogenesis
1. Western medicine etiology and pathology
(1) Acute cholecystitis: The pathogenesis of this disease is still not enough. It has been considered to be related to bile stasis, mucosal injury, gallbladder ischemia and bacterial infection after obstruction of cystic duct stones.
1 cystic duct obstruction: It is generally believed that the cystic duct can cause acute cholecystitis after being blocked by stones or parasites. The reasons are: bile salt stimulation, gallbladder wall ischemia, secondary infection, pancreatic juice reflux erosion, and some people think that in acute cholecystitis In terms of onset, mechanical and vascular factors may be more important than stimuli caused by increased bile salt concentrations.
2 Infection: including bacterial infection and parasitic infection. The infected bacteria are mainly in Enterobacter, E. coli, Salmonella typhi, Paratyphoid bacillus, Staphylococcus, Streptococcus, Pneumococcal and Aerobacteria. The infection routes are as follows: Blood-borne infection (bacteria enters the gallbladder with blood flow), biliary infection (intestinal bacterial portal vein into the liver is not destroyed after infection of the gallbladder, liver bacteria enter the gallbladder through the lymphatic vessels), ascending infection (biliary aphid carrying the intestine Intra-bacterial drilling into the biliary tract causes obstruction and gallbladder inflammation), erosive infection (inflammation of the tissues and organs adjacent to the gallbladder, bacteria can erode and spread to the gallbladder), and clonorchiasis and pear-shaped flagellates can cause cholecystitis. In particular, Clonorchis sinensis is particularly closely related to biliary tract infections.
3 nerves, mental factors: any factors that can cause vagal tone reduction, may occur an important additional factor in the pathogenesis of acute cholecystitis or cholangitis, according to the literature, pain, fear and anxiety and other mental factors can lead to acute gallbladder The occurrence of inflammation affects the emptying of the gallbladder leading to cholestasis.
4 Hormone factors: cholecystokinin can increase bile secretion, gallbladder contraction and common bile duct sphincter relaxation, in order to maintain the normal secretion and discharge of bile, where there are factors such as elevated bile salt concentration and increased amino acid and fat in the intestinal lumen. Gallbladder can stop contraction in the state of expansion, so cholestasis and disease; sex hormones: women in pregnancy, due to the effects of sex hormones, gallbladder emptying delay, gallbladder dilatation, cholestasis often prone to acute cholecystitis.
In addition, acute cholecystitis may occur after trauma, burns or surgery. This may be related to dehydration caused by bleeding, anesthesia, fever, low food intake, secondary infection, etc. Dehydration may increase bile viscosity and cause gallbladder emptying. Delayed.
(2) Chronic cholecystitis: Chronic cholecystitis is the basis of gallstone formation and the consequence of gallstone formation. It embodies the long-term process of interaction between gallbladder and calculus. The mechanism is roughly the same as acute cholecystitis, and the condition of chronic cholecystitis is Chronic prolonged menstruation, clinically repeated episodes and other characteristics, the disease is far more acute than acute cholecystitis.
1 stone factors: commonly known as calculous cholecystitis, about 70% of chronic cholecystitis caused by this factor, is due to long-term stimulation of gallbladder wall inflammation caused by gallstones, on this basis can also be secondary bacterial infection.
2 bacterial infection: commonly known as bacterial cholecystitis, bacteria also through the blood, lymph or adjacent tissue inflammation direct spread, and through the duodenal nipple opening up to the gallbladder and other ways to infection.
3 virus infection: commonly known as viral cholecystitis, often occurs in the case of viral hepatitis, may be directly or indirectly related to hepatitis virus invasion of the gallbladder.
4 chemical factors: known as chemical cholecystitis, due to excessive concentration of bile salts or pancreatic digestive enzymes into the gallbladder caused by gallstones, usually caused by gallstone stimulation caused by hepatic and pancreatic abdomen sphincter spasm.
5 parasitic factors: commonly known as parasitic cholecystitis, common clonorchiasis, intestinal prairie, schistosomiasis and aphids.
6 acute cholecystitis came after.
In short, regardless of the cause, the common pathological features are gallbladder fibrosis, thickening of the cyst wall, contraction of the gallbladder due to scar tissue, and narrowing and atrophy of the cyst, adhesion of the gallbladder to the surrounding tissue and pyloric obstruction. If the inflammation invades the cystic duct and causes obstruction, the gallbladder can also swell and thin the wall of the capsule.
2. Chinese and Western etiology and pathogenesis
(1) Unhealthy diet: If the diet is not good, if you want to eat greasy, you can take the spleen and stomach, resulting in impaired transport, wet and turbid endogenous, wet and turbid spleen and stomach can hinder the liver and gallbladder, and the liver and gallbladder, and then Then the qi stagnation heat or qi stagnation blood stasis heat, liver and gallbladder stagnation heat and spleen and stomach wet turbidity steaming, it promotes cost disease.
(2) mites on the mites: tsutsugamushi patients can cause spleen and stomach deficiency due to various factors, because the mites have the habit of warming and aversion to cold, when the cold is turbulent, disturbing into the "sputum", hindering the liver and gallbladder venting, Hepatobiliary qi stagnation, that is, qi stagnation heat or qi stagnation and blood stasis and heat, its heat and spleen deficiency caused by the wet steam, can cost the disease.
(3) Emotional stimulation: liver loss and stagnation, sexual hi-bar, gallbladder attached to the liver, liver and gallbladder meridians and other genus for the table, to smooth the smooth and smooth, if the emotional stimulation, resulting in poor liver and gallbladder On the one hand, the liver and gallbladder are spleen, on the one hand, the spleen is reversed, on the one hand, the qi stagnation and the heat or qi stagnation and blood stasis and heat, the heat of the liver and gallbladder and the wetness of the spleen and stomach are caused by the disease.
In short, the pathogenesis of acute cholecystitis is characterized by qi stagnation of the liver and gallbladder, qi stagnation and blood stasis, phlegm and heat, heat and spleen and dampness become a syndrome of liver and gallbladder dampness, gallbladder is nowhere, pain, bile reversing the skin Yellowing, if the heat accumulation does not disperse, it becomes a purulent inflammation, and the hot poison blazes into the blood of the camp. It can cause, "dead yin", "dead yang", the disease characteristic of chronic Mauritius bursitis is liver and gallbladder stagnation, stomach loss and drop.
Prevention
Cholecystitis prevention in the elderly
Appropriate participation in exercise, participation in sports and recreational activities, reasonable arrangements according to the condition and physical condition, study and rest, enhance physical fitness, to promote the recovery of chronic cholecystitis.
Complication
Cholecystitis complications in the elderly Complications
Complications include toxic shock, gallbladder gangrene, and gallbladder perforation.
Symptom
Cholecystitis symptoms in the elderly Common symptoms Frail abdominal tenderness Indigestion severe pain Low heat nausea Qi pain Abdominal pain Lazy gallbladder pain
Acute cholecystitis
The clinical manifestations of acute calculous cholecystitis are basically the same as those of acute acalculous cholecystitis.
(1) Symptoms:
1 Pain: severe pain or cramping in the right upper abdomen, mostly for stones or parasitic incarceration. Obstruction of the gallbladder neck caused by acute cholecystitis. The pain often occurs suddenly, very intense, or shows colic-like symptoms. After eating high-fat foods, most of them occur at night, general pain in the right upper quadrant. When seen in non-obstructive acute cholecystitis of the cystic duct, the pain in the right upper quadrant is generally not severe, and most of them are persistent pain. As the gallbladder inflammation progresses, Pain can also be aggravated, and the pain is radioactive. The most common radiation sites are the right shoulder and the lower scapula of the right scapula. It is caused by inflammation of the right phrenic nerve and peripheral nerve of the abdominal wall.
2 nausea, vomiting: is the most common symptoms, such as nausea, vomiting stubborn or frequent, can cause dehydration, collapse and electrolyte imbalance, more common in the stone or aphid obstruction of the cystic duct.
3 chills, chills, fever: mild cases (inflammation is catarrhal type) often have chills and low fever; severe cases (acute pus gangrene type) can have chills and high fever, heat up to 39 ° C or more, and There are slang, sputum and other mental symptoms.
4 Astragalus: Less common, if the jaundice is generally mild, it means that the infection spread to the liver through the lymphatic vessels, causing liver damage, or inflammation has invaded the common bile duct.
(2) Main features: Abdominal examination can be seen in the right upper abdomen and upper abdomen, abdominal muscle tension, tenderness, rebound tenderness, Murphy sign positive, with gallbladder empyema or peribiliary abscess, in the right upper abdomen can be licked and tender mass Or obvious swelling of the gallbladder, when abdominal tenderness and abdominal muscle tension extend to other areas of the abdomen or the whole abdomen, it suggests perforation of the gallbladder, or acute peritonitis, 15% to 20% of patients due to cystic ductal edema, gallstone Compression and inflammation around the gallbladder cause liver damage, or inflammation involving the common bile duct, causing Oddi sphincter spasm and edema, leading to bile discharge disorders, mild jaundice may occur, such as jaundice significantly deepening, indicating common bile duct obstruction or concurrent choledochitis The possibility is that severe cases may have signs of peripheral circulatory failure, blood pressure is often low, and even septic shock may occur. This situation is particularly common in severe cases of sputum and sputum type, but also may have mental wilting, anorexia, fatigue and constipation. .
(3) The main features of senile acute cholecystitis: the elderly patients have weak body reaction ability, although acute inflammation, but some patients have slow onset, and are not typical, and some patients have similar right lower pneumonia, myocardial infarction, right renal pelvis Symptoms other than gastrointestinal tract, such as abdominal pain, fever, abdominal swelling and gallbladder and mass, compared with younger patients, often lack or slight, even if there are complication of gallbladder gangrene and perforation, the abdomen The performance is also not typical. Even after perforation, the contents of the gallbladder flow up to the interstitial space, and the appearance of acute appendicitis or acute colonic diverticulitis may occur. It is easy to confuse the diagnosis, but some old patients have an acute onset, the condition changes rapidly, and the gallbladder is gangrene. Perforation, peritonitis, shock, etc., are often the initial clinical manifestations of acute cholecystitis. Patients with senile cholecystitis are often associated with common bile duct stones, so the incidence of jaundice is higher (about 59%), and the degree is heavier than young adults. In addition, after the elderly suffer from acute cholecystitis, the evolution of the disease is also not typical. In young adults, they often rely on the severity of pain, body temperature and fluctuations of white blood cells. The change of the price of cholecystitis, but in elderly patients, characterized by the elderly patients with weak body, it is very unreliable to use these indicators to observe the evolution of cholecystitis. Mastering these characteristics of acute cholecystitis in the elderly is the correct condition. Judgment is very important.
2. Chronic cholecystitis
(1) Symptoms: persistent upper right abdomen blunt abdominal pain or discomfort; nausea, belching, acid reflux, bloating and stomach burning dyspepsia; pain in the right lower scapular region; increased symptoms after eating high-fat or greasy food; Long, the condition is characterized by an acute attack and remission. The acute attack is the same as acute cholecystitis. Sometimes there is no symptom during the remission period.
(2) Signs: There may be mild tenderness and snoring pain in the gallbladder area, but no rebound pain; cases of cholestasis may cause swelling of the gallbladder; acute exacerbation may have muscle tension in the right upper abdomen, normal temperature or low fever, Occasionally, jaundice may occur; viral cholecystitis may have hepatosplenomegaly.
Clinical examination: found a positive tender point that is meaningful for diagnosis. The gallbladder tenderness point is at the intersection of the right rectus abdominis rim and the rib arch. The thoracic tenderness point is 8 to 10 thoracic vertebrae, and the right phrenic nerve tender point is at the right side of the neck. Lock the mastoid muscle between the lower corners.
Examine
Examination of cholecystitis in the elderly
Acute cholecystitis
Blood routine: In acute cholecystitis, the total number of white blood cells is slightly increased (usually between 12,000 and 15,000/mm3), and the classification of neutrophils increases, such as the total number of white blood cells exceeds 20 × 109 / L, and there is a significant nuclear left For migrating and toxic particles, complications such as gallbladder necrosis or perforation may occur.
2. Chronic cholecystitis
Duodenal drainage: such as increased mucus in B tube bile; white blood cell piles, bacterial culture or parasite test positive, a great help for diagnosis.
3. Acute cholecystitis
(1) Ultrasound examination: B-ultrasound found that gallbladder enlargement, wall thickness, intracavitary biliary viscosity and so on can often make a timely diagnosis. It is worth mentioning that the clinical manifestations of the elderly are often required to be diagnosed by B-ultrasound and other imaging examinations. B-mode ultrasonography is simple and easy to perform. It can measure the size of the gallbladder and the thickness of the cyst wall. It is especially accurate for detecting gallstone. It is the first choice for the imaging examination of acute cholecystitis and one of the indicators for observing the evolution of the elderly.
(2) Radiological examination: The positive findings of the abdominal plain film have the meaning of: 1 gallstone in the gallbladder area; 2 enlarged gallbladder shadow; 3 calcified plaque in the gallbladder wall; 4 gas and liquid level in the gallbladder cavity (see those caused by gas-producing bacterial infection) , gallbladder angiography: 1 oral method: gallbladder is generally not developed; 2 intravenous injection method: the application of 60% sodium diatrizoate, the amount is calculated according to 2.2ml / kg, mixed with an equal amount of 5% glucose solution, fast Intravenous drip, such as the gallbladder showing arc or ring development, has diagnostic significance for acute cholecystitis.
(3) Radionuclide examination: The sensitivity of radionuclide biliary scanning for the diagnosis of acute cholecystitis is 100%, the specificity is 95%, and it also has diagnostic value. Within 90 minutes after intravenous injection of 131 IV iodine fluorescence 99mTc, If there is no radioactive substance in the gallbladder area, it means that there is cystic duct obstruction, which can be considered as acute cholecystitis.
4. Chronic cholecystitis
(1) Ultrasound examination: If gallstones are found, the gallbladder wall is thickened, reduced or deformed, and has diagnostic significance.
(2) Abdominal X-ray film: If chronic cholecystitis is found, gallstones, enlarged gallbladder, gallbladder calcification spots and gallbladder milky opaque shadows can be found.
(3) gallbladder angiography: gallstones can be found, gallbladder shrinkage or deformation, but cystic concentrating and systolic dysfunction, gallbladder development and other images of chronic cholecystitis, when the gallbladder is not developed, if the liver function damage or liver color metabolism can be excluded Due to malfunction, it may be chronic cholecystitis.
(4) Cholecystokinin (CCK) test: After oral gallbladder contrast agent is used to develop gallbladder, CCK is injected intravenously, and the gallbladder tablets are continuously taken in 15 minutes, such as gallbladder contraction amplitude is less than 50% (indicating poor gallbladder contraction). And biliary colic, a positive reaction, expressed as chronic cholecystitis.
(5) Fiber laparoscopy: If the liver and the enlarged gallbladder are found to be green, greenish brown or greenish black under direct vision, it indicates that the jaundice is blocked outside the liver; if the gallbladder loses its smooth, translucent and azure appearance, it becomes Grayish white, with gallbladder shrinkage and obvious adhesion, as well as gallbladder deformation, etc., suggest chronic cholecystitis.
(6) Small laparotomy: Small laparotomy is a newly proposed method for diagnosing difficult hepatobiliary diseases and jaundice. It can not only make a clear diagnosis of chronic cholecystitis, but also understand the liver performance.
Diagnosis
Diagnosis and identification of cholecystitis in the elderly
Diagnostic criteria
Acute cholecystitis
(1) It is more to induce greasy food.
(2) sudden onset of severe upper right abdomen with paroxysmal aggravation, can be radiated to the right scapula, often nausea, vomiting, fever.
(3) There is tenderness in the right upper abdomen, muscle tension, positive Murphy sign, and a small number of visible jaundice.
(4) The white blood cell and neutrophil counts are increased, and the serum jaundice index and bilirubin may increase.
(5) B superficial gallbladder enlargement, thickening or roughening of the gallbladder wall, floating spots in the capsule, and visible stone images with stones.
(6) X-ray examination: the abdominal plain film in the gallbladder area may have a gallbladder to increase the shadow.
2. Chronic cholecystitis
(1) Sustained right upper quadrant dull pain or discomfort, or pain in the right scapular region.
(2) There are symptoms of dyspepsia such as nausea, belching, acid reflux, bloating and burning of the stomach. After eating greasy food, it is aggravated.
(3) The course of the disease is long, and the condition is characterized by acute attack and remission.
(4) There may be mild tenderness in the gallbladder area.
(5) Mucus increased in bile, white blood cells piled up, and bacterial culture was positive.
(6) B superficial gallstones, gallbladder wall thickening, gallbladder shrinkage or deformation.
(7) gallstone angiography can be seen gallstones, gallbladder shrinkage or deformation, gallbladder contraction dysfunction, or gallbladder development is thin.
Differential diagnosis
1. Acute cholecystitis should be differentiated from diseases that cause abdominal pain (especially right upper abdominal pain). These diseases include acute pancreatitis, right lower pneumonia, acute hernia pleurisy, early chest and abdomen herpes, acute myocardial infarction and acute appendicitis. The above diseases have their own clinical characteristics and special examination methods. As long as the medical history is detailed, the condition is analyzed in detail, and the changes in the condition are dynamically observed. Identification is generally not difficult.
2. Chronic cholecystitis should be distinguished from peptic ulcer, chronic gastritis, gastric dyspepsia, chronic viral hepatitis, gastrointestinal neurological function and chronic urinary tract infection. In chronic cholecystitis, nausea and upper right often occur after eating greasy food. Abdominal discomfort or pain is exacerbated. In this case, digestive tract diseases are rare. In addition, it can be identified by gastrointestinal barium meal imaging, fiber gastroscopy, liver function and urine examination.
