cholelithiasis in the elderly
Introduction
Introduction to cholelithiasis in the elderly Cholelithiasis refers to stones that occur in any part of the biliary system. According to their location, they are divided into gallstones, extrahepatic bile duct stones, and intrahepatic bile duct stones. According to their composition, they are divided into cholesterol stones, bile pigment stones, and mixed stones. (cholesterol, bile pigment, calcium and other metal salts). basic knowledge The proportion of illness: 0.84% Susceptible people: the elderly Mode of infection: non-infectious Complications: jaundice, cholangitis, liver abscess, acute pancreatitis
Cause
The cause of cholelithiasis in the elderly
Abnormal cholesterol, bile salts and phospholipid metabolism (20%):
The main components in bile are bile salts, cholesterol and phospholipid bilirubin. The cholesterol in bile, the ratio of bile acid to phospholipid is very important for maintaining the dissolved state of cholesterol. When the amount of cholesterol is increased, the secretion of bile salts is reduced. These three abnormalities alone or together can lead to an increase in the amount of bile secretion, which can make cholesterol into a supersaturated state. In 1954, Isaksson et al. proposed that the gelatinous grains formed by bile salts and lecithin maintain cholesterol in the bile. The dissolution, but in the late stage, there is still a cholesterol carrier and a large bubble of phospholipids. The macrobubble is mainly composed of phospholipids and cholesterol, and is present in all bile. Usually, the ratio of cholesterol to phospholipid in the macrobubble is 1:1. Up to 5:2, and the ratio of cholesterol to phospholipid in the micelle is 1:2 to 1:5. The macrobubble can carry more cholesterol than the microcapsule, when the ratio of cholesterol to phospholipid is increased, such as in a large bubble. The ratio is 3:2, and when the ratio of the micelles is 1:3, the carrier capacity exceeds the metastable limit concentration, and cholesterol tends to precipitate.
Facilitating nucleation and anti-nuclear factor imbalance (20%):
The first step in the formation of the stone is nucleation, in which the cholesterol molecules are polymerized into a solid block of a considerable size. Once the solid block and the core are formed, the crystal growth of the cholesterol can occur, and then more molecules are deposited in the crystal fissure. The formation of stones, the current hypothesis has been recognized and endorsed by most scholars, in addition, some scholars believe that there are nucleation factors and nucleation inhibitors in the bile of normal people and gallstone patients, whether it can be nucleated, depending on two The proportional relationship between the two, if the proportional relationship is out of balance, the nucleation factor predominates to promote the occurrence of nuclear, and vice versa can not nucleate, the normal bile nucleation time is long and the biliary nucleation time of patients with cholelithiasis is very short, It is suggested that there is a factor of cholesterol precipitation in the bile. On the other hand, in the experimental model system, the cholesterol precipitate is much faster than the cholesterol in the bile containing the same lipid component, indicating that the bile contains an anti-nucleating factor.
Abnormal function of the gallbladder (20%):
The gallbladder has the function of concentrating, storing and excreting bile. If these functions are abnormal, it will promote the formation of gallstones. Especially the formation of cholesterol gallstones in the gallbladder is closely related to gallbladder dysfunction. The normal gallbladder mucosa secretes H+ water and electrolytes. This effect can acidify bile, reduce the pH of bile, reduce the precipitation of calcium ions in the gallbladder and dilute the bile, accelerate the discharge of bile in the gallbladder, increase the viscosity when the bile is concentrated in the gallbladder, and decrease the bile emptying in the starvation state. There is bile storage, mechanical and inflammatory stimuli cause cholestasis, and when the above effects are weakened, it can lead to the formation of gallstones. In addition, when the contractile function of the gallbladder is reduced, the emptying function of the gallbladder is beneficial to the formation of gallstones in the gallbladder. Factors that have so far been considered to affect gallbladder systolic dysfunction are:
1 Continued total parenteral nutrition for more than 6 weeks, long-term fasting after abdominal surgery, endogenous CCK (cholecystokinin) decreased, leading to reduced gallbladder contractile function.
2 After the partial resection of the stomach, the high vagus nerve was removed.
3 peptide hormones such as intestinal vascular polypeptide, somatostatin and pancreatic polypeptide can inhibit CCK.
4 sex hormones, high levels of estrogen and progesterone, and oral contraceptives can relax the gallbladder and empty, increasing the risk of stone formation.
5 prostaglandins, can reduce the gallbladder contraction, aspirin has been shown in animal experiments, because it can inhibit the formation of certain compounds required for the synthesis of prostaglandins to prevent the formation of stones, 6 other factors such as diabetes, cirrhosis and obesity can make the gallbladder The contraction is weakened.
Increased unbound bilirubin content in bile (10%):
Glucuronidase produced by bile and biliary infections in mammals can hydrolyze bound bilirubin to unbound bilirubin. Unbound bilirubin binds to calcium ions to form bilirubin and precipitates. The formation of biliary pigment calcium stones, the formation of bilirubin calcium and biliary tract infections, bacterial or parasitic infections, eggs, residual sutures are closely related, inflammation of the epithelium, bacteria, mites and eggs often form the core of gallstones, In particular, biliary tract mites are the main cause of cholelithiasis in China. In addition, chronic hemolytic anemia and cirrhosis cause excessive accumulation of bilirubin in bile due to excessive destruction of red blood cells, which is easy to form melaninous stones.
Other (10%):
The formation of gallstones is also related to gender, environment, soil, eating habits, family, ethnicity, and genetic factors. China has been the most common with bile pigment stones and mixed stones, but with the improvement of living standards and dietary habits, the incidence of cholesterol stones has increased significantly in recent years.
Pathogenesis
Under normal physiological conditions, the main components of gallstones, cholesterol and bilirubin, are solute in bile and transport with bile. Studies have shown that most of the water-insoluble cholesterol can pass through the form of micelles and vesicles ( The vesicle form is "dissolved" in the bile solution. The cholesterol, bile salts and phospholipids are combined in a certain ratio to form micelles with a diameter of 50-60A. Since the hydrophilic groups are arranged on the surface, the cholesterol can be "dissolved". In bile, the imbalance of cholesterol, bile salts and phospholipids can cause cholesterol to precipitate and crystallize. The vesicles are composed of phospholipids and cholesterol. They are 10 to 20 times larger than the microcapsules. They are hollow, spherical and soluble. The cholesterol in the micelles and vesicles can be transformed and in a dynamic equilibrium. In short, the formation of cholesterol stones is based on the supersaturation of cholesterol itself, crystallization, precipitation nucleation as the basis, and bile stasis, gallbladder emptying disorders. The kinetic angle provides a condition for the sediment to aggregate and grow into a stone. About 99% of the bilirubin in the bile is bound to glucuronic acid, and only 1% is unconjugated bilirubin and not In water, calcium precipitation is easy to form when calcium ions are present. Under normal physiological conditions, bile salts ionize unbound bilirubin to avoid contact with calcium. In addition, bile salts can also combine with calcium to reduce free calcium. Concentration, under pathological conditions, increased ratio of unbound bilirubin or insufficient bile salts can produce bilirubin precipitation and become the basis of bile pigment stones.
Prevention
Elderly cholelithiasis prevention
Third-level prevention
Prevention of disease is extremely important and meaningful because of the atypical nature of cholelithiasis and the complexity of seizures.
Primary prevention (cause prevention): taking various measures to control or eliminate health risk factors, and the main cause of cholesterol stones due to supersaturation of cholesterol, so the elderly should eat cholesterol-rich foods such as brain and liver. Kidney, fish eggs, egg yolk, etc. should be eaten less; in addition, active activities such as exercise, running, walking, etc. should be actively emphasized to promote cholesterol metabolism in the body. In addition, the formation of nucleation factors should be actively prevented, and personal hygiene should be noted. Prevent the occurrence of intestinal parasites and intestinal infections, and actively prevent biliary infections.
Secondary prevention (clinical prevention): Early detection, early diagnosis and early treatment in the early stage of clinical disease, so that the disease may be cured or not aggravated early, and cholelithiasis generally has a process of chronic development, 60% to 80%. The patients with gallstones are asymptomatic at a certain time, and the rate of progression from asymptomatic to symptomatic stones varies greatly. In the first 5 years, about 2% of patients have various symptoms every year, so the high-risk areas and special diseases People such as obesity, women, old age, multiple pregnancies and family history of genetic disease should pass the census, key screening or regular health check, take non-invasive and convenient examination, early detection, early diagnosis, and can actively adopt diet, dissolution and drive Insects, anti-inflammatory, and promote the early treatment of gallbladder contraction and other positive means.
Tertiary prevention (clinical prevention): Take timely and effective treatment measures for patients with diseases to prevent the deterioration of the disease, prevent complications, prevent and treat disability, promote rehabilitation and prolong life, and adopt different treatment measures for different conditions of patients. In the case of acute biliary infection, a broad-spectrum antibiotic with high concentration and sensitivity in bile should be selected; fasting should be given when the pain is obvious, and necessary analgesia and sedative measures should be given in addition to gastrointestinal decompression; surgery can be performed if necessary. Treatment and endoscopic stone removal to prevent exacerbations, life-threatening cardiovascular and cerebrovascular diseases and other systemic complications.
2. Risk factors and interventions
(1) Dietary factors: the formation of gallstones is related to the lack of fiber in the diet, which increases the content of bile acids such as deoxycholic acid in the bile; in addition, high cholesterol diet can also increase the cholesterol content of biliary tract; hunger makes the bile empty Reduced, and bile storage can cause the formation of gallstones; therefore, a reasonable daily diet, adjust the diet structure to eat more vegetables, reduce cholesterol intake.
(2) Infectious factors: biliary tract infection, intestinal infection, parasitic eggs, worm body and other factors can promote the formation of gallstones, so it should actively prevent infection, pay attention to personal hygiene and food hygiene.
(3) Obesity factors: Obese people are more likely to suffer from cholelithiasis. Some data indicate that 50% of obese patients with gallstones are found in surgery, so they should actively participate in physical exercise and control their body weight within the normal range.
(4) Gender and fertility factors: Women with cholelithiasis are more likely to be present than men. Women with more births are more likely to have stones than women who are not. Women with oral contraceptives have a high rate of stone disease, so family planning and birth control surgery should be promoted.
(5) Age and genetic factors: The incidence of cholelithiasis increases with age, and members with cholelithiasis are more susceptible to cholelithiasis.
(6) Other disease factors: such as chronic hemolytic anemia, cirrhosis, patients after partial gastrectomy are also the predisposing factors of cholelithiasis, and should actively treat the primary disease.
3. Community intervention
The implementation of the community intervention plan must have a complete organizational system to ensure, including the government's policy support, and the community medical institutions to assist, first through the health education, personnel training, environmental changes and other measures to carry out special intervention projects. It is the reduction of risk factors for the population, so that the elderly have an optimistic spirit, a good living environment, carry out various forms of health education, enjoy medical insurance and other benefits, reasonable nutrition, carry out physical exercise, and on the other hand, pass on patients with cholelithiasis. Early diagnosis and treatment, reduce the incidence rate, rational use of drugs, for the elderly detoxification and poor detoxification, prone to adverse reactions, etc., sputum strict medication, do not use and random withdrawal.
Complication
Elderly cholelithiasis complications Complications jaundice cholangitis liver abscess acute pancreatitis
Common biliary obstruction, secondary cholangitis and obstructive jaundice, gallbladder gangrene and perforation, liver abscess, acute pancreatitis.
Symptom
Symptoms of cholelithiasis in the elderly Common symptoms Upper abdominal pain Skin itching biliary colic Abdominal tenderness Gallbladder hydrocephalus Bile excretion obstructed Face pale pale cold sweat Digestive chills
Typical symptoms
(1) biliary colic or upper abdominal pain: About 75% of patients with symptomatic stones seek medical treatment for biliary colic. biliary colic is a kind of visceral pain, mostly due to temporary obstruction of the cystic duct by stones. Mainly manifested as paroxysmal upper abdominal pain, often located in the right upper abdomen or upper abdomen, severe cases of colic, pain often radiated to other parts of the abdomen or back, shoulder area and right shoulder, pain can be aggravated by eating, more than night The seizures are mostly 15min or gradually aggravated after 1h, and if the pain persists for 5-6 hours, it suggests cholecystitis. When the gallstones move from the gallbladder to the cystic duct or common bile duct, or from the dilated common bile duct to the ampulla. Incarceration often occurs, due to gallbladder or common bile duct smooth muscle relaxation or spasm, resulting in biliary colic, this biliary colic is mostly changed in body position, induced by body bumps, pain often persistent dull pain, more severe, unbearable, The patient often sits restless, bends, rolls, presses the abdomen with his fists, presses his abdomen with his fists, and even cries, with sweat and pale, when the gallstones retreat into the gallbladder or enter the duodenum, pain Can disappear completely.
(2) chills and fever: when accompanied by acute cholecystitis, often chills, fever, when the gallbladder water secondary bacterial infection forms gallbladder empyema or gangrene perforation, chills and fever is more significant, 75% of the common bile duct Patients with stones, after the onset of biliary colic, due to biliary bacterial infection caused by chills, high fever, body temperature can reach 40 ° C, and can even lead to systemic infections, high fever in the elderly can often make a variety of diseases worse, the occurrence of consciousness, spirit Symptoms, shortness of breath, hypoxemia, myocardial ischemic changes, if the cause can not be relieved in a timely and effective manner, it will be difficult to treat. If it is treated in time, it can be turned into safety.
(3) digestive tract symptoms: most patients with gallstones may be accompanied by nausea, vomiting, vomiting, biliary colic, often with a certain degree of relief; gallbladder or intra-biliary stones, such as bile ducts into the intestine It can cause mechanical obstruction of intestinal lumen as gallstone intestinal obstruction, clinical manifestations of intestinal obstruction; in addition, it often shows symptoms of dyspepsia, often excessive hernia, abdominal distension, postprandial fullness and early satiety, heartburn symptoms, And intolerance to fats and other foods.
(4) Astragalus: simple gallstones do not cause jaundice, about 75% of patients with common bile duct stones, because the stones embedded in the abdomen of the ampulla can not be loosened or the obstruction of the common bile duct can not be relieved, in the upper abdominal pain, chills, After 12 to 24 hours after high fever, jaundice can occur. The severe ones are often accompanied by itchy skin. The urine is dark brown, and the stool is light or terracotta. After the stones move into the duodenum, the jaundice is relieved in about 1 week. Therefore, jaundice appears intermittently or when it is deep and shallow. Generally, intrahepatic bile duct stones do not cause jaundice. Only when the bile ducts of bilateral or bilobal ducts are blocked by stones, jaundice occurs.
(5) biliary syndrome: biliary colic with simultaneous myocardial ischemia, angina pectoris or myocardial infarction is called biliary heart syndrome, more common in elderly patients, patients with coronary artery often without organic lesions, the mechanism is due to gallstone Symptoms, biliary obstruction, increased intra-biliary pressure, through spinal nerve reflex (the gallbladder and the spinal nerve innervation of the myocardium, crossing the thoracic 4 to 5 spinal nerves), and the visceral-visceral nerve reflex pathway, causing coronary vasoconstriction, reduced blood flow, coronary The functional changes of the arteries are also closely related to factors such as the toxins of the water-electrolyte imbalance in the biliary tract infection, and the symptoms of the heart often disappear after cholecystectomy.
(6) Mirizzi syndrome: continuous incarceration or compression of larger gallstones in the abdomen and neck of the gallbladder, can cause common hepatic stenosis or cystic duct fistula, recurrent cholecystitis cholangitis and obstructive jaundice called Mirizzi syndrome, clinical Repeated mild or moderate right upper abdominal pain with fever and jaundice.
(7) clinical manifestations of acute suppurative cholangitis: immediate bile duct obstruction can not be relieved accompanied by severe intra-biliary infection often lead to acute suppurative cholangitis, manifested as clinical manifestations of systemic poisoning such as hypotension, toxic shock and sepsis.
2. Asymptomatic
Biliary stones are almost inevitable symptoms, and about 50% of patients with simple gallstones can have no clinical symptoms. Some of them are inadvertently found in gallbladder stones on X-ray and B-ultrasound.
3. Atypical symptoms
Older patients have slow response, poor physiological function, and poor clinical response. The clinical manifestations are often atypical. The abdominal pain is not severe and often has no colic. Even the main abdominal discomfort is complained. Some severe biliary infections have no chills and high fever, and a few even body temperature. Does not rise, when the body temperature is below 36 °C, suggesting a poor prognosis, some patients with pain from the left upper abdomen or upper abdomen and then transferred to the right upper abdomen similar to the progression of appendicitis, there are also patients with cholelithiasis only mild epigastric discomfort With gastric acid symptoms such as acid reflux, clinicians should pay attention to the patient's atypical symptoms to prevent missed diagnosis and misdiagnosis.
4. Typical signs
Some patients with simple gallbladder stones, there may be light pressure in the right upper abdomen during physical examination; in the case of acute cholecystitis, there is obvious tenderness in the right upper abdomen, muscle tension, sometimes touching the enlarged gallbladder, positive Murphy sign, positive sputum pain in the liver area; Liver enlargement is often found in intrahepatic bile duct stones.
5. Atypical signs
Some elderly patients with cholelithiasis have no obvious tenderness in the upper abdomen, only mild discomfort, and even severe infection. There is no obvious muscle tension and rebound tenderness in generalized peritonitis, sometimes when the signs of peritonitis are not obvious. In the case of toxic shock, the blood pressure is decreased, the pulse is fast and weak, the mind is indifferent or restless, and the clinical attention should be given enough attention, otherwise it may be life-threatening.
The diagnosis of this disease often depends on X-ray examination. In 10% to 15% of cases of cholelithiasis, the gallstones contain more calcium salts and are not transparent to X-rays. Only ordinary plain film photography (Fig. 1) can show shadows. Positive stones), if there is no positive detection in the plain film, X-ray gallbladder can be further taken orally with an X-ray-containing iodine-containing control agent such as iodoalphionic acid (priodax) or iopanoic acid (telepaque). Contrast angiography to illuminate the light-transmitting stone shadow (negative stone) (Fig. 2). If multiple contrast or contrast dose is increased, the gallbladder is still not developed, and 50% biligrafin can be injected simultaneously. 20ml, 2 to 3 days before the angiography into the high-fat meal, so that the bile in the gallbladder is empty, easy to enter the gallbladder, or use gallbladder tomography, etc., can increase the chance of development during gallbladder angiography, to improve the negative The detection rate of stones, because of X-ray cholecystography can not clearly show the bile duct, can be used intravenous or intravenous infusion of choledochalin for X-ray cholangiography, not deep in jaundice (bilirubin <3mg / dl) In cases where liver function damage is not severe, the bile duct can be displayed and gallstones are displayed (Fig. 3); 40% meglumine (meglumine) 10 ~ 30ml, intravenous injection within 10min, can also show bile duct and gallbladder in serum bilirubin > 7mg / dl; in cases after cholecystectomy, cholangiography is more valuable, However, in cases of severe liver damage or high obstructive jaundice, intravenous cholangiography often fails to develop.
Examine
Elderly cholelithiasis examination
Blood test: When biliary obstruction and biliary tract infection occur in patients with cholelithiasis, bilirubin metabolism, liver function, blood routine and serum enzymology may be abnormal.
Bilirubin metabolism
In the case of bile duct obstruction, serum total bilirubin is increased, which is mainly due to the increase of bilirubin. The ratio of bilirubin to total bilirubin is usually greater than 35% in 1min. When the bile duct is completely obstructed, the ratio can be greater than 60%. The increase in erythropoietin, the reduction or disappearance of urinary bile, and the reduction or disappearance of jejunal.
2. Multiple serum enzyme abnormalities
At the time of obstruction, alkaline phosphatase increased significantly, often three times higher than normal, -glutamyl transpeptidase was also significantly increased, serum transaminase was mild to moderately elevated, and lactate dehydrogenase was generally slightly elevated.
3. Blood routine
When combined with cholecystitis, there may be a slight increase in white blood cells and an increase in neutrophils. When developing acute suppurative gangrenous cholecystitis or gallbladder perforation, white blood cells may rise above 20×109/L, and neutrophils may increase to More than 0.90 and poisoning particles appear, a few cases can occur leukemia-like changes, white blood cells can rise to 40 × 109 / L.
4. Prothrombin time measurement
When bile duct obstruction, the prothrombin time is prolonged. After the application of vitamin K, the prothrombin time can be restored to normal. If the liver function is severely damaged due to long-term obstruction of the bile duct, even if vitamin K is injected, the prothrombin time will not return to normal. Hepatocytes produce a disorder in the production of prothrombin.
5. Determination of serum iron and copper content
The ratio of serum iron to serum copper in normal people is 0.8-1.0. When biliary obstruction occurs, the increase of serum copper often makes the iron/copper ratio less than 0.5.
6. Duodenal drainage
The three parts of bile that are drained can not only see the inflammatory cells produced by the infection, but also the cholesterol and bilirubin calcium crystals and eggs, suggesting the possibility of gallstones. If there is no such discovery, then Support for the diagnosis of gallstones, or the presence of obstruction at the distal end of the common bile duct.
7. Imaging examination
Imaging methods for cholelithiasis mainly include X-ray film, ultrasonography, X-ray computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic biliary tract. Contrast (PTC) and intraoperative cholangiography, choledochoscopy, and postoperative T-tube cholangiography are now described as follows:
(1) X-ray film: simple cholesterol stones and bile pigment stones can not be developed on X-ray film, only calcium-containing mixed stones can be developed on X-ray film, so the accuracy of diagnosis of gallstones is only 50%~ 60%, oral gallbladder angiography can achieve a development rate of 80%, because the X-ray cholecystography can not clearly show the bile duct, can be used for choledochalin with intravenous X-ray cholangiography, in the case of cholecystectomy for bile duct Contrast is more valuable, but significant liver function damage, or high obstructive jaundice, venous cholangiography often can not be developed.
(2) Ultrasound examination: Ultrasound examination has the advantages of convenient examination, non-invasiveness, repeated multiple times, and high diagnostic accuracy. It has become the first choice for diagnosis of cholelithiasis. The type A ultrasound system can detect whether the gallbladder or bile duct is dilated. B-ultrasound can well display intrahepatic and extrahepatic bile ducts, whether the gallbladder is dilated, enlarged and with or without stones, but its accuracy is often affected by gas in the gastrointestinal tract of the patient, the experience of the examiner and the conditions of the B-ultrasonic instrument. The impact of multiple factors.
(3) X-ray computed tomography and magnetic resonance imaging: CT accuracy of diagnosis of stones is 80% to 90%, high sensitivity to calcium-containing stones, often showing small stones with a diameter of 2mm, for the diagnosis of biliary tract The location of obstruction and the cause of obstruction are significantly better than B-ultrasound. The images of MRI diagnosis of cholelithiasis and biliary obstruction are basically the same as CT images, but the soft tissue structure is better than CT, but the cost of CT and MRI is better. High, so CT and MRI are usually only selected if ultrasound cannot be diagnosed.
(4) Endoscopic retrograde cholangiopancreatography: Retrograde cholangiopancreatography by fiberoptic duodenoscopy is an angiography method that directly injects contrast agent into the gallbladder, which can clearly develop the entire bile duct system and gallbladder and diagnose common bile duct stones. The positive rate can reach about 95%. If the bile duct is narrow and the obstruction factor can only show the image of the bile duct below the obstruction, the bile duct above the obstruction shows poor or no development.
(5) Percutaneous transhepatic cholangiography (PTC): PTC is a traumatic examination, which can clearly show the whole biliary system inside and outside the liver. It is important to determine the location of hepatolithiasis and extrahepatic bile duct stones and the presence or absence of obstruction of bile duct. Diagnostic value.
(6) intraoperative: postoperative cholangiography and choledochoscopy, in the gallbladder surgery, the contrast agent can be directly injected into the cystic duct or common bile duct, the intrahepatic and extrahepatic bile duct images can be clearly seen, after the biliary tract surgery, the T tube is pulled out Pre-retrograde angiography can show whether there is stenosis, obstruction and residual stones. In biliary tract surgery, inserting fiber choledochoscopy from the incision of the common bile duct to understand the lower end of the common bile duct without stones and other diseases, avoid blindness. Check the duodenum for damage.
8. Nuclide check
The radionuclide 99mTc-EHIDA or 99Tc-trimethyl bromide (mebrofenin) is intravenously injected after fasting for 2 to 14 hours, and then used gamma photography for intrahepatic scintigraphy, showing liver, gallbladder and biliary tract, when cholelithiasis with acute gallbladder Inflammation due to cystic duct obstruction, gallbladder is not developed, 95% of patients can be excluded from cholecystitis.
Diagnosis
Diagnosis and diagnosis of cholelithiasis in the elderly
Diagnostic criteria
Real-time ultrasound scanning is a non-invasive method for biliary tract. It can well display intrahepatic and extrahepatic bile ducts. The presence or absence of gallbladder expansion, enlargement and presence or absence of stones is a commonly used diagnostic method.
Nuclear 99mTc-EHIDA or 99mTc-trimethyl bromide (mebrofenin) can be used to show liver, gallbladder, biliary tract and intestinal tract after intravenous injection, such as gallbladder not developing, suggesting obstruction of cystic duct; Or poorly developed, suggesting extrahepatic biliary obstruction.
Retrograde cholangiopancreatography (ER-CP) by fiberoptic duodenoscopy: diagnosis of cholelithiasis with no positive findings on general X-ray examination, extrahepatic and intrahepatic obstructive jaundice, biliary tract cancer, pancreatic cancer, etc. And differential diagnosis basis.
Percutaneous transhepatic cholangiography (PTC): It can clearly show the bile ducts at all levels, which is helpful to determine the location and cause of obstructive jaundice, especially extrahepatic obstruction. It is also an effective method for the diagnosis of intrahepatic bile duct stones.
Computerized tomography (CT): It is also a good non-invasive method for biliary tract.
Duodenal drainage: Collection of gallstones in bile and feces has diagnostic value in some cases.
Differential diagnosis
At the same time as or after the onset of epigastric pain, fever and jaundice, accompanied by leukocytosis, ALP and GGT are significantly increased, biliary colic is very likely, renal colic often begins at the waist or flank, to the inside of the thigh or External genital radiation, accompanied by dysuria and hematuria and other symptoms, intestinal colic is diffuse, especially in the umbilical cord, lead poisoning abdominal cramps, the patient's occupation, gingival lead line, red blood cells basophilic spot color Urinary brown pigment and lead quantitative examination are the main points for identification. Acute pancreatitis is persistently severe pain in the upper abdomen, often accompanied by banded traction pain. Serum amylase and its isoenzyme determination are helpful for diagnosis, biliary aphid Symptoms are often severely cramped under the sword, which can be accompanied by a feeling of drilling. The intermittent period can be completely painless. The abdomen is soft and the pain is not obvious. The pain of acute myocardial infarction can sometimes be radiated to the right upper abdomen or the middle upper abdomen. Differential diagnosis depends on ECG.
In the past, the gallbladder that emphasized the case of common bile duct stones often shrinks due to chronic inflammation, and in the case of obstructive jaundice caused by pancreatic cancer, the gallbladder is often accessible due to swelling, and is used as a biliary obstruction and cancerous obstruction. One of the identification points, but according to reports in recent years in China, about half of the cases of common bile duct stones have no inflammation and contraction, and the gallbladder can be touched during physical examination.
