Biliary peritonitis

　　One, Pathogenesis

　　1. Biliary peritonitis is an acute or chronic secondary peritonitis caused by bile directly flowing into or leaking into the peritoneal cavity due to various causes. The causes are as follows:

　　(1) Gallbladder perforation is most commonly seen in

　　①Acute cholecystitis: causes include calculous, non-calculous, and typhoid cholecystitis.

　　②Trauma: including penetrating and blunt.

　　③Tumor: invasion by gallbladder cancer, gastric or transverse colon cancer.

　　④Penetrating peptic ulcer.

　　⑤Crohn's disease.

　　⑥Idiopathic.

　　⑦Thrombotic thrombocytopenic purpura, etc.

　　(2) Liver/bile duct system injury, common in

　　①Liver biopsy.

　　②Percutaneous liver bile ductography.

　　③Postoperative complications.

　　④T-tube displacement.

　　⑤Trauma: including penetrating and blunt.

　　(3) Spontaneous biliary gallbladder perforation occurs in:

　　①Children are developmental.

　　②Adults: 75% have choledocholithiasis, bile duct cyst rupture, bile duct infection, and bile duct diverticulum.

　　(4) Idiopathic.

　　①Gallbladder perforation is the most common cause of biliary peritonitis. About 10% of patients with acute cholecystitis will progress to gallbladder perforation. Gallbladder perforation can be divided into 3 types: Type I: Free perforation, accounting for 30%. It most commonly occurs at the gallbladder base, due to the lack of protective adhesions in the local area, leading to the entry of bile into the peritoneal cavity, forming a bile peritonitis. Type II: Localized perforation, accounting for 50%. Bile溢出至邻近器官 (such as liver, stomach, duodenum, colon, or small intestine), and the omentum wraps or adheres to it, leading to localized abscess. Type III: Chronic perforation, accounting for 20%. It usually progresses slowly to form a gallbladder-enteric fistula.

　　② Biliary surgery or abdominal trauma is also a common cause of biliary peritonitis. In surgical operations, biliary peritonitis can be caused by direct injury to the gallbladder or bile duct, or by the fall of the ligature at the residual end of the gallbladder or bile duct surgery, or leakage at the anastomosis, or injury by the displacement of the drainage tube, etc. Since the introduction of laparoscopic cholecystectomy, the incidence of bile duct injury has increased, and in a large series of case studies, the incidence can reach 0.5%, while open cholecystectomy is only 0.2%.

　　③ Biliary peritonitis is a rare complication of liver biopsy, percutaneous liver biliary tract angiography, percutaneous liver biliary tract drainage, etc. It is mainly caused by injury or puncture of the gallbladder or biliary tract system during liver puncture, especially in patients with mechanical obstruction of the intrahepatic and extrahepatic biliary tract systems, leading to bile duct dilation. It is often seen in patients with liver biopsy, percutaneous liver biliary tract angiography, percutaneous liver biliary tract drainage, etc. It is mainly caused by injury or puncture of the gallbladder or biliary tract system during liver puncture, especially in patients with mechanical obstruction of the intrahepatic and extrahepatic biliary tract systems, leading to bile duct dilation.

　　2. Spontaneous perforation of the biliary tract is an extremely rare cause of adult biliary peritonitis. The etiology may be related to the following factors:

　　(1) Increased pressure within the bile duct due to spasm of the Oddi sphincter, stone obstruction, narrowing at the duodenal papilla, etc.

　　(2) Partial compressive necrosis of the wall due to obstruction of the hepatic duct or common bile duct by stones.

　　(3) Infection within the wall of the bile duct due to bile duct inflammation.

　　(4) Diverticula or cysts in the biliary tract.

　　(5) Partial necrosis of the bile duct due to thrombosis of the intramural blood vessels of the common hepatic duct or bile duct.

　　(6) Liver retraction due to liver cirrhosis.

　　(7) Reflux of pancreatic juice through the common channel opening of the pancreatic duct and bile duct, resulting in digestion and erosion of the common bile duct tissue.

　　(8) Anatomical structural characteristics, such as insufficient arterial blood supply to the common bile duct at the entrance of the cystic duct.

　　Second, pathogenesis

　　Biliary peritonitis is usually caused by the leakage of sterile bile into the peritoneal cavity, due to the stimulation and chemical toxicity of bile salts. If the bile is contaminated or the primary disease has an infection, it can lead to secondary bacterial peritonitis. The most common infected bacteria are Escherichia coli, Streptococcus, Enterococcus, Klebsiella pneumoniae, and Bacteroides fragilis, etc., with bacterial content often > 105/ml.

　　1. Early complications:Metabolic changes in multiple systems, hypokalemia, shock, DIC, intestinal obstruction, acute renal failure, adult respiratory distress syndrome, pulmonary function failure, sepsis, etc. In the early stage of peritonitis, due to metabolic changes and fluid leakage into the peritoneal cavity, it can lead to electrolyte and water disorders. When intestinal obstruction occurs, it also increases the entry of fluid into the intestinal lumen. These changes promote the large entry of intracellular potassium into extracellular fluid, while sodium moves towards the intracellular fluid, resulting in hypokalemia. The levels of serum corticosteroids, aldosterone, and catecholamines are often elevated. The level of catecholamines is elevated.

　　2. Late complications:Formation of intra-abdominal abscesses (within the pelvis, subdiaphragmatic space, mesenteric spaces, etc.), formation of fistulas (due to anastomotic rupture, adhesion, intestinal obstruction, etc.).

　　The clinical symptoms and signs of biliary peritonitis depend on whether the extravasated bile is localized or diffused within the peritoneal cavity, whether it is contaminated by bacteria, and the variability of symptoms can be mild abdominal pain, or severe and intense abdominal pain, intestinal obstruction, abdominal mass, fever, oliguria, and shock, among other serious symptoms; it can occur suddenly or develop slowly, and abdominal pain and peritoneal irritation signs may temporarily alleviate due to the rapid accumulation and dilution of bile salts and their chemical toxicity after the peritoneum is stimulated, which is more pronounced during fluid therapy. Due to the stimulating effect of bile salts, not only does it increase the peritoneal exudate, but also a large amount of plasma渗入腹腔内, the abdomen can be percussed with a mobile dullness, and abdominal pain can change with the position, especially from a head-down supine position to a horizontal position, the pain can shift from the upper right abdomen to the lower right abdomen, and intestinal sounds may decrease or disappear.

　　For patients using gastrointestinal decompression after surgery, adults need to supplement 40ml of fluid per kilogram of body weight per day, plus the amount of drainage fluid. Therefore, the usual daily infusion volume is 2500 to 3000ml, which should be completed on schedule and in the correct amount to avoid water and electrolyte imbalance and metabolic disorders. For those with significant blood loss, plasma and fresh blood should be supplemented. For critically ill patients with difficulty in intravenous injection, deep venous catheterization, such as external jugular vein catheterization, can be used to maintain a longer duration. Note for deep venous catheterization:

　　1. Keep the local area clean by disinfecting with new germol solution and changing the dressing daily.

　　2. Flush the silicone tube with 10ml of normal saline before and after each infusion to prevent blockage.

　　3. It is not advisable to draw blood or inject other drugs into the deep venous catheter, as the former may cause blockage of the silicone tube, and the latter may lead to the injection of drug fluid into the right atrium, causing serious complications such as arrhythmia.

　　4. After the infusion is complete, plug the needle hub tightly and then wrap it with a sterile gauze bandage, securing it properly around the neck.

　　5. Instruct patients to cooperate so that the tube does not slip out or the plug falls off, causing massive bleeding. Generally, intestinal peristalsis recovers within 48 to 72 hours, and the gastric tube can be removed to relieve gastrointestinal decompression. Diet is usually resumed according to different conditions, starting with fluids and then gradually increasing in quality.

　　6. Prevent pulmonary complications: Pay attention to keeping warm, expose only the necessary parts when treating or nursing patients, and instruct patients to perform deep breathing twice a day, each for 5 to 10 minutes, if the condition permits. During the evening care, help patients with back tapping to assist coughing, or perform nebulizer inhalation to ensure smooth expectoration and good gas exchange in the lungs.

　　7. Regularly maintain oral and skin care.

　　1. Patients often have an elevated white blood cell count, increased levels of blood bilirubin and alkaline phosphatase, and sometimes may exhibit blood thickening.

　　2. Puncture of the abdominal cavity is a diagnostic test for biliary peritonitis. The aspirate from the abdominal cavity can reveal a deep yellowish fluid, with a bilirubin level often ≥102.6μmol/L (6mg/dl), and the ratio of bilirubin in ascites to serum bilirubin is greater than 1.0.

　　17. During laparoscopic examination, surgical operation, or autopsy, the sign of peritoneum being stained by bile is the golden test for diagnosing biliary peritonitis. If 131I-tetraiodotetrachlorofluorescein is injected intravenously and the substance is found in the peritoneal fluid, it helps to diagnose whether the patient has active bile leakage.

　　16. During ERCP or intraoperative biliary tract造影术, if the contrast agent infiltrates the peritoneal cavity, it helps to find the location of bile leakage or biliary tract perforation.

　　15. Abdominal X-ray examination is non-specific and can be used to rule out abdominal pain caused by other reasons. In addition, CT, ultrasound, MRI, and other imaging examinations are helpful in differential diagnosis of abdominal masses.

　　12. Dietetic recipes for biliary peritonitis

　　11. Taro (peeled), ginger, etc., in equal amounts. Mash the taro into a paste, grind the ginger into juice, mix it with the taro, add an appropriate amount of flour, stir into a paste, spread it on a cloth according to the size of the affected area, and apply it to the affected area (if it is winter, it needs to be warmed before applying), change once a day (this medicine must be prepared on the same day). It can treat pleurisy, peritonitis, appendicitis, and other conditions.

　　10. bittercress turnip soup. Take 100 grams of bittercress, 20 grams of honeysuckle, 25 grams of dandelion, and 200 grams of green radish. Boil all the ingredients together, remove the medicine after boiling, eat the radish and drink the soup. Take one dose daily, which has the effect of clearing heat and detoxifying. Honeysuckle has varying degrees of inhibitory effects on various bacteria such as staphylococcus, streptococcus, pneumococcus, E. coli, Pseudomonas aeruginosa, and skin fungi, and is very effective for the treatment of peritonitis.

　　9. honeysuckle melon seed and honey decoction. Take 20 grams of melon seed, 20 grams of honeysuckle, 2 grams of coptis, and 50 grams of honey. First decoct the honeysuckle, remove the dregs and take the juice, then add the melon seed and honey after decocting the melon seed for 15 minutes. Take one dose daily for one week.

　　8. Peony root and safflower tea. Take 10 grams of green peel and 10 grams of safflower. After drying the green peel and cutting it into strips, add it to the pot with safflower and soak in water for 30 minutes, then boil for 30 minutes. Filter with clean gauze, remove the dregs, and take the juice to make tea for frequent drinking.

　　Two, what foods are good for biliary peritonitis?

　　6. Patients with peritonitis need to fast, especially for those with peritonitis caused by gastrointestinal perforation, who must be absolutely fasting to reduce the continued leakage of gastrointestinal contents. Generally, patients can start eating after the intestinal peristalsis (or排气) recovers and with the consent of the physician. It is recommended to drink some plain water first. If there is no choking or other discomfort, you can start eating some fluid and light foods, such as congee, vegetable soup, lotus root starch, egg flower soup, and noodles.

　　5. In addition to liquid foods, it also includes congee, plain noodles, plain noodles, vegetarian wontons, bread, biscuits (low in oil), and a small amount of chopped soft vegetables.

　　4. When the body is recovering, eat more nutritious foods such as fish, lean meat, protein, tofu, etc.

　　Three, what foods should be avoided for biliary peritonitis?

　　1. Do not eat greasy foods to avoid stimulating the secretion of bile, which can worsen reflux and the condition.

　　2. Avoid eating cold and raw foods. Excessive consumption of cold and raw foods can lead to stomach and abdominal coldness, blood and Qi stasis, vomiting of clear or sour water, and increased stomach pain. Avoid drinking carbonated drinks, cola, and eating spicy and刺激性 foods.

　　3. Avoid smoking, drinking, and spicy irritant foods.

　　4. Avoid moldy, fried, smoked, and salted foods.

　　5. Avoid hard, sticky, and indigestible foods.

　　1. Drug Treatment

　　Active parenteral nutrition therapy should be adopted to supplement calories, fluids, electrolytes, etc., to maintain blood pressure and urine output. Intestinal intubation for decompression is required in cases of paralytic intestinal obstruction.

　　Use broad-spectrum antibiotics to prevent and treat secondary infections, especially those that are effective against the main bacteria in the intestines, have high concentrations in bile, and low toxicity. Currently, it is considered that cephalosporin antibiotics are the most suitable choice. Because of their higher concentration in the bile duct, the concentration order of cephalosporin antibiotics in bile is third-generation cephalosporins > second-generation cephalosporins > first-generation cephalosporins. Cefoperazone (Cefobid) has a higher concentration in the bile duct and is relatively stable to beta-lactamase, but has no significant effect on bacteroides. When used in combination with metronidazole or other drugs, it can achieve significant effects. Other antibiotics with high concentrations in bile include penicillin family, tetracycline family, chloramphenicol, etc., but they are sometimes prone to resistance. Piperacillin (Oxazolinic penicillin) is a broad-spectrum penicillin that has a therapeutic effect on bacteria in the bile duct, is excreted in bile, has no nephrotoxicity, and can be selected. In addition, ciprofloxacin also has a high concentration in liver bile. After administering 200mg of ciprofloxacin, the average concentration in liver bile is (56.7±21.6) μg/ml, which is 40 times the average serum value.

　　2. Surgical Treatment

　　Cholecystitis with peritonitis usually requires timely surgical treatment, but the indication for surgery should be individualized. If the patient's clinical symptoms deteriorate rapidly, immediate consideration should be given to surgical treatment. Surgical treatment mainly involves repairing the damaged bile duct, abdominal drainage or lavage, etc. If the leaked bile is encapsulated and localized, or if it is a bile cyst, it can be drained through the skin puncture. After cholecystectomy, cystic bile duct leakage can be treated with endoscopic sphincterotomy or placement of a stent above the sphincter of Oddi to reduce the intraductal pressure, promote bile drainage, and allow bile to enter the duodenum through the sphincter of Oddi, thereby healing the bile duct leakage.