Acute cholecystitis during pregnancy
Introduction
Introduction to acute cholecystitis during pregnancy Under the action of progesterone during pregnancy, gallbladder and biliary smooth muscle relaxation causes slow gallbladder emptying and cholestasis; estrogen reduces the regulation of sodium in gallbladder mucosa, so that the ability of the gallbladder mucosa to absorb water decreases and affects the gallbladder concentrating function; plus cholesterol in bile Increased composition, reduced secretion of bile salts and phospholipids, is conducive to the formation of gallstones. Pregnancy is an important cause of gallstones. During pregnancy, the number of estrogen and progesterone increased, the muscle layer of the gallbladder wall was thick, the gallbladder smooth muscle was relaxed, the gallbladder contractility decreased, the gallbladder volume increased by 2 times, and the gallbladder emptying was delayed. In addition, the cholesterol content in the bile is increased, the ratio of cholesterol and bile salts is changed, and the viscosity of bile is increased, so cholecystitis is prone to occur. Increasing the gallbladder in the uterus of pregnancy can also cause cholecystitis. basic knowledge The proportion of illness: 0.0021% Susceptible population: pregnant women Mode of infection: non-infectious Complications: biliary peritonitis gallstone intestinal obstruction acute pancreatitis
Cause
Causes of acute cholecystitis during pregnancy
Choles deposition (20%):
More than 90% of cholestasis is caused by stone incarceration. Stones can cause obstruction of the gallbladder outlet, increased intracoronary pressure, poor blood supply to the gallbladder wall, and ischemic necrosis. The deposited bile can stimulate the gallbladder wall, causing chemical inflammation, such as pancreatic juice reflux, pancreatic digestive enzymes eroding the gallbladder wall, causing acute cholecystitis.Bacterial infection (20%):
Due to cholestasis, bacteria can multiply and enter the gallbladder retrogradely through the bloodstream, lymph, or biliary tract, causing infection. The source of infection is Gram-negative bacilli, 70% is Escherichia coli, followed by Staphylococcus and Proteus.Pregnancy effects (10%):
During pregnancy, the number of estrogen and progesterone increased, the muscle layer of the gallbladder wall was thick, the gallbladder smooth muscle was relaxed, the gallbladder contractility decreased, the gallbladder volume increased by 2 times, and the gallbladder emptying was delayed. In addition, the cholesterol content in the bile is increased, the ratio of cholesterol and bile salts is changed, and the viscosity of bile is increased, so cholecystitis is prone to occur. Increasing the gallbladder in the uterus of pregnancy can also cause cholecystitis. Acute cholecystitis may be present alone or as part of acute suppurative cholangitis. Acute cholecystitis is caused by biliary tract obstruction of the cystic duct. Common bile duct stones or biliary tract mites are often the cause of acute suppurative cholangitis.Prevention
Prevention of acute cholecystitis during pregnancy
To prevent acute cholecystitis, the following items should be done:
1. Pay attention to diet, food should be light, eat less greasy and fried, grilled food.
2. Keep the stool clear.
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
Complications of acute cholecystitis during pregnancy Complications biliary peritonitis gallstone intestinal obstruction acute pancreatitis
1. Gallbladder perforation occurs in the gallbladder wall at the bottom of the gallbladder or at the incarceration of the stone, causing biliary peritonitis. 50% of patients with gallbladder perforation were wrapped by the omentum and surrounding tissue, forming an abscess around the gallbladder; 20% of patients in the gallbladder and its adjacent organs (gastrointestinal tract) formed internal hemorrhoids; about 10% of patients can have gallstone intestinal obstruction.
2. Acute suppurative cholangitis biliary obstruction and infection are the basic factors of the disease. Primary or secondary choledocholithiasis, biliary ascariasis and biliary obstruction caused by common bile duct stricture are the pathological basis of acute suppurative cholangitis. When cholestasis occurs, it is beneficial to the bacteria in the bile. After the bacterial infection, the biliary mucosa congestion and edema increase the pressure in the biliary tract, which increases the degree of biliary obstruction.
3. Biliary pancreatitis in the lower end of the common bile duct stone incarceration or Oddi sphincter spasm, or duodenal papillary edema, resulting in temporary obstruction of Vater ampulla and pancreatic duct, bile flow back to the pancreatic duct through the "common channel" Induced acute pancreatitis.
Symptom
Pregnancy with acute gallbladder symptoms common symptoms right upper quadrant pain sudden upper right abdominal cramps high fever cold war chills abdominal muscles gallbladder volume shrinking jaundice
Generally, it is more common in the night after a full meal or excessive fatigue. The pain is more common in the sudden right upper abdomen. It can also be seen in the middle of the upper abdomen or under the xiphoid process. The pain can be radiated to the right shoulder, the lower shoulder, or the right lower waist. A small number of patients can radiate to the left shoulder. 70% to 90% of patients can have nausea and vomiting; 80% of patients have chills and fever; 25% of patients with jaundice . Shock can occur in severe infections. The right upper quadrant tenderness is obvious. The right gallbladder can be swollen under the ribs and the peritonitis can be accompanied by abdominal muscle tension and rebound tenderness. Some patients have positive Murphy sign. In the third trimester of pregnancy, due to the enlarged uterus cover, the abdominal signs may not be obvious.
Examine
Examination of acute cholecystitis during pregnancy
1, leukemia count increased, with nuclear left shift: If there is suppuration or gallbladder gangrene, perforation, white blood cells are significantly elevated, based on the high white blood cells of pregnancy, so this is not a very specific indicator.
2. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were slightly elevated. When the common bile duct is obstructed, bilirubin is elevated. Alkaline phosphatase (ALP) is mildly elevated, but the latter is less helpful because of the effects of estrogen on pregnancy.
3, ultrasound examination is the best diagnostic tool for pregnancy, especially in the diagnosis of cholelithiasis, the false positive and false negative rate is 2% - 4%. Under the ultrasound, gallbladder enlargement and wall thickness can be seen. Most of the acute cholecystitis combined with gallstones, so the gallstones and sound shadows, bile deposits and gallbladder contraction. When the common bile duct obstruction, the common bile duct dilatation can be seen, and the diameter is >0.8cm. Sometimes the echoes of stones or mites in the common bile duct are visible. Stuffer et al reported that gallbladder was scanned in 93% of patients without an empty stomach, and about 95% found gallstones. Of course, it is best to still check on an empty stomach for 12 hours.
Diagnosis
Diagnosis and differentiation of acute cholecystitis during pregnancy
diagnosis
According to the typical medical history, sudden upper right abdominal cramps, paroxysmal aggravation, right upper abdominal gallbladder area tenderness, muscle tension, elevated body temperature, can be diagnosed. Ultrasound see gallbladder cyst wall thickness systolic or combined with gallstones and other diagnoses are more clear. If you touch the gallbladder with a large tension or the body temperature is not relieved at 39 ~ 40 °C, you should consider the risk of gallbladder necrosis and perforation, which may cause peritonitis.
Differential diagnosis
First of all, consider the identification of life-threatening diseases such as myocardial infarction, acute fatty liver in pregnancy, severe hypertensive disorder complicating pregnancy and HELLP syndrome; and other diseases that are not life-threatening but very serious, such as right acute pyelonephritis, acute Identification of pancreatitis and pneumonia. Secondly, it should be differentiated from acute appendicitis that requires the most timely surgery. Upward shift of the appendix during pregnancy is often misdiagnosed as cholecystitis and delayed surgery.
