Biliary tract infection

　　Recurrent attacks of biliary tract infection are important pathogenic and triggering factors for the formation of gallstones.
　　1. Acute cholecystitis: Acute cholecystitis is an acute chemical and (or) bacterial inflammation of the gallbladder. About 95% of patients have gallstones, known as calculous cholecystitis; 5% of patients do not have gallstones, known as non-calculous cholecystitis.
　　Chronic cholecystitis
　　Chronic cholecystitis is the result of recurrent attacks of acute cholecystitis, with about 70% to 95% of patients having gallstones. Due to repeated stimulation by inflammation, stones, etc., the gallbladder wall shows varying degrees of explosive cell infiltration, fibrous tissue proliferation, wall thickening, and adhesion to surrounding tissues, all of which are manifestations of chronic inflammation. In severe cases, scar formation in the gallbladder wall can lead to varying degrees of atrophy, with the gallbladder reduced to the size of a thumb, closely adhering to the liver bed and completely losing its function. Chronic cholecystitis is often atypical, with most patients having a history of biliary colic, followed by symptoms such as aversion to fatty foods, abdominal distension, belching, and digestive symptoms. There may be hidden pain in the upper right quadrant of the abdomen and the shoulder blades, but there are rarely symptoms such as chills, high fever, and jaundice. During physical examination, there may be mild tenderness and discomfort in the right upper quadrant of the abdomen over the gallbladder area, and Murphy's sign may be positive.
　　3. Acute obstructive suppurative cholangitis
　　The basic pathological changes of acute obstructive suppurative cholangitis are complete obstruction of the bile duct and suppurative infection within the bile duct. The site of obstruction can be in extrahepatic and/or intrahepatic bile ducts. Normally, a small amount of bacteria entering the liver through the portal vein system from the intestines can be engulfed by the liver's mononuclear-phagocytic system. Occasionally, due to the failure of the normal defense mechanism to prevent bacteria from entering bile, or bacteria from the intestines refluxing into the bile duct, if the biliary tract system is intact and bile flow is sufficient to clear bacteria from bile, the bacteria in the bile will multiply and lead to cholangitis. After biliary obstruction, the pressure in the bile duct increases, the bile duct above the obstruction dilates, the wall thickens, the bile duct mucosa becomes congested and edematous, inflammatory cells infiltrate, the mucosal epithelium erodes and falls off, forming ulcers. The liver becomes congested and enlarged. In the late stage of the disease, large areas of liver cells die, bile ductules may rupture to form bile duct-portal vein fistulas, which can form multiple abscesses within the liver and cause biliary bleeding. Liver sinusoids dilate, endothelial cells swell, containing bile pigment granule thrombi (also known as bile sand thrombi), a large number of bacteria and toxins can enter the systemic circulation through the hepatic veins, causing systemic suppurative infection and multi-organ dysfunction.
　　

　　Biliary tract infections are mainly caused by bacterial infections, followed by parasitic infections. If not treated promptly and effectively, complications such as gangrenous cholecystitis, perforation, biliary bleeding, liver abscess, and toxic shock can occur.

　　Symptoms of biliary tract infection:

　　1. Acute cholecystitis

　　Clinical manifestations of acute calculous cholecystitis:

　　Gallbladder diseases are more common in women, and the incidence of gallbladder diseases in men and women changes with age. Before the age of 50, the ratio of men to women is 1:3, and after the age of 50, it is 1:1.5. Most patients have had symptoms of gallbladder disease before the onset. The typical onset process of acute attacks is characterized by sudden, severe, right upper quadrant colicky pain, often occurring after a heavy meal, eating greasy food, or at night. The pain often radiates to the right shoulder, scapula, and back. Accompanied by gastrointestinal symptoms such as nausea, vomiting, and anorexia. If the condition progresses, the pain may become persistent and exacerbated. Almost every patient with an acute attack has pain, and the absence of pain can basically exclude the disease. Patients often have a slight fever, usually without chills. If there is a significant chill and high fever, it indicates that the condition is worsening or complications have occurred, such as cholecystic effusion, perforation, or combined with acute cholangitis. 10% to 25% of patients may have mild jaundice, which may be due to bilirubin entering the circulation through the damaged gallbladder mucosa, or due to spasm of the Oddi sphincter caused by adjacent inflammation. Or if jaundice is severe and persistent, it may indicate the possibility of common bile duct stones and obstruction.

　　Clinical manifestations of acute non-calculous cholecystitis:

　　Acute non-calculous cholecystitis is more common in males, with a male-to-female ratio of 1.5:1. The clinical manifestations are similar to those of acute calculous cholecystitis, but the pain and other symptoms and signs are often more common in patients with acute non-calculous cholecystitis, with only 50% of patients receiving correct diagnosis before surgery. Overeating and fatty foods can trigger an acute attack of the disease. Increasing awareness and vigilance of acute non-calculous cholecystitis is the key to early diagnosis. For all acute and critical patients, those with severe trauma, after surgery, and those with a long-term TPN, if there is pain in the upper right abdomen and fever of unknown cause, this disease should be considered.

　　Chronic cholecystitis

　　Chronic cholecystitis is often atypical, with most patients having a history of biliary colic, followed by symptoms such as aversion to fatty foods, bloating, belching, and other gastrointestinal symptoms, with pain in the upper right abdomen and shoulder and back, but there are few chills, high fever, and jaundice. During physical examination, there may be mild tenderness and discomfort in the gallbladder area of the upper right abdomen, and Murphy's sign may be positive.

　　3. Acute obstructive suppurative cholangitis

　　Patients often have a history of biliary tract disease attacks and biliary tract surgery. The disease onset is acute, and the condition progresses rapidly. In addition to the general triad of Charcot's syndrome (abdominal pain, chills and high fever, jaundice) in biliary tract infection, shock and depression of the central nervous system, that is, Reynolds' pentad, may also occur. Chills and fever appear at the onset of the disease, and in severe cases, there is obvious chills with a persistent rise in body temperature. The pain varies according to the site of obstruction, with external biliary obstruction being more obvious and internal biliary obstruction being less severe. The vast majority of patients can exhibit significant jaundice, but if there is only unilateral biliary duct obstruction, jaundice may not occur. The jaundice in patients who have undergone biliary-enteric drainage surgery is usually mild. Neurological symptoms are mainly manifested as apathy, drowsiness, confusion, and even coma; in cases of shock, it can also be manifested as restlessness and delirium. During physical examination, the patient's body temperature is often persistently elevated to 39-40°C or higher. The pulse is rapid and weak, reaching more than 120 beats per minute, and blood pressure decreases, presenting an acute serious appearance, with possible subcutaneous ecchymosis or cyanosis. There may be different ranges and degrees of tenderness or peritoneal irritation under the xiphoid process and in the upper right abdomen; there may be enlargement of the liver and tenderness in the liver area; sometimes, an enlarged gallbladder can be palpated.

　　Biliary tract infection refers to bacterial infection in the biliary tract, which can exist alone, but is often coexistent with cholelithiasis, with each being the cause and effect of the other. To prevent biliary tract infection, the following points should be noted:

　　1. Pay attention to strengthening nutrition in daily life, and eat high-sugar, high-protein, high-vitamin, low-fat, and easily digestible food.

　　2. When non-surgical treatment is adopted, attention should be paid to changes in the condition. If the body temperature exceeds 39 degrees, severe upper abdominal绞痛 should be reported to medical staff for treatment, and when taking traditional Chinese medicine, attention should be paid to observe whether there are stones excreted in the feces.

　　3. Acute patients should be fasting and receive intravenous fluid therapy, and pay attention to the location, nature, and presence of chills, high fever, shock, and other symptoms of abdominal pain at all times. Coordinate with preoperative skin preparation, blood matching, and other procedures.

　　4. When there is itching, pay attention to keep the skin clean and hygienic, take a bath and change clothes, and accept intramuscular vitamin K1 injection.

　　5. Actively treat biliary tract diseases, eat less high-fat and high-cholesterol foods.

　　Examination items for biliary tract infection:

　　1. Acute cholecystitis

　　Examination of acute calculous cholecystitis

　　Physical examination: There may be different degrees and ranges of tenderness, rebound tenderness, and muscle tension in the upper right abdomen, and Murphy sign is positive. Some patients may palpate an enlarged and tender gallbladder. If the gallbladder lesion develops slowly, the omentum can adhere and wrap the gallbladder, forming an unclear, fixed, tender mass; if the lesion develops quickly, the gallbladder may necrose or perforate, and diffuse peritonitis may occur.

　　Laboratory examination: 85% of patients have mild leukocytosis (1.2～1.5×10^9/L). Serum transaminase is elevated, AKP is elevated commonly, 1/2 patients have serum bilirubin elevation, 1/3 patients have serum amylase elevation.

　　Imaging examination: Ultrasound examination, can show gallbladder enlargement, thickening of the gallbladder wall, even with 'bilateral' sign, and gallbladder stones, the diagnostic accuracy rate for acute cholecystitis is 65%～90%.

　　In addition, such as Tc-EHIDA examination, acute cholecystitis due to bile duct obstruction, the gallbladder does not show up, its sensitivity is almost 100%; conversely, if there is gallbladder shadowing, 5% of patients can be excluded from acute cholecystitis.

　　Acute non-calculous cholecystitis

　　If there is tenderness and peritoneal irritation in the upper right abdomen, or palpation of an enlarged gallbladder, it is helpful for early diagnosis. Ultrasound, radionuclide liver and gallbladder system scanning, and CT examination are helpful for early diagnosis.

　　Chronic cholecystitis

　　Ultrasound examination can show gallbladder shrinkage, thickening of the gallbladder wall, decreased or absent emptying function. If there is a shadow of stones, it is more helpful for diagnosis. Oral cholecystography shows faint or no gallbladder shadowing, and reduced contraction function. If the gallbladder still does not show up with dosimetry cholecystography, it can be diagnosed definitively. However, it needs to be distinguished from peptic ulcer, gastritis, and other diseases. Fiberoptic gastroscopy and upper gastrointestinal barium meal examination are helpful for differential diagnosis.

　　Three, examination of acute obstructive suppurative cholangitis

　　Laboratory examination: White blood cell count is elevated, often >20×10^9/L, neutrophils are elevated, and toxic granules may appear in the cytoplasm. Platelet count is reduced, the lowest can reach (10～20)×10^9/L, indicating a serious prognosis; prothrombin time is prolonged, and liver function is damaged to varying degrees. Renal function damage, hypoxemia, dehydration, acidosis, and electrolyte disorders are also common, especially in the elderly and those with shock.

　　Imaging examination: Ultrasound is the most practical, which can be performed at the bedside and can timely understand the location and nature of biliary obstruction, as well as the expansion of intrahepatic and extrahepatic bile ducts, which is very helpful for diagnosis. If the patient's condition allows, CT examination can be performed when necessary.

　　(1) Eat more vegetables

　　Eat fresh vegetables, and you can also eat some apples, eggs, yogurt, fish, and sweet potatoes every day. Try to drink pure apple juice, pear juice is also good, and beet juice also has the effect of clearing the liver.

　　(2) Foods to avoid

　　Avoid various animal fats, meats, fried foods, spicy foods, artificial cream, sodas, coffee, sugar products, chocolate, etc. Alcoholic beverages and刺激性食物 or strong seasonings can all lead to the onset of gallstones and should be avoided as much as possible.

　　(3) Drink plenty of water

　　Increasing fluid intake can reduce blood viscosity and is also beneficial for bile secretion.

　　Conventional methods of Western medicine for treating biliary tract infection:

　　1. Acute cholecystitis

　　The ultimate treatment for acute calculous cholecystitis is surgical treatment. The timing and method of surgery should be determined according to the specific condition of the patient.

　　1. Non-surgical therapy: Including fasting, intravenous fluid therapy, correcting water, electrolyte, and acid-base metabolism imbalance, systemic supportive therapy; selecting broad-spectrum antibiotics or combined medication with effects on Gram-negative, Gram-positive bacteria, and anaerobic bacteria. Use vitamin K, antispasmodic analgesics, and other symptomatic treatments. Because the incidence is high in the elderly, it is necessary to detect and treat coexisting diseases of the heart, lung, kidney, and other organs in a timely manner to maintain the function of important organs. Non-surgical therapy can be used both as treatment and as preoperative preparation. During the period of non-surgical therapy, the patient's overall and local changes should be closely observed to adjust the treatment plan in time. Most patients can control their condition after non-surgical therapy and can undergo elective surgery later.

　　2. Surgical treatment

　　(1) Selection of the timing of surgery: Emergency surgery is applicable to: ① Patients with onset within 48-72 hours; ② Those who have failed non-surgical treatment and whose condition has worsened; ③ Patients with complications such as gallbladder perforation, diffuse peritonitis, acute empyema of the bile duct, acute necrotizing pancreatitis, etc. For other patients, especially high-risk patients who are elderly and weak, surgery should be performed when the patient's condition is at its best.

　　(2) Selection of surgical methods: Surgical methods include cholecystectomy and cholecystostomy. If the patient's overall condition and the pathological changes of the gallbladder and surrounding tissues allow, cholecystectomy should be performed to eliminate the lesion. However, for high-risk patients, or those with severe local inflammation, edema, adhesions, and unclear anatomical relationships, especially in emergency situations, cholecystostomy should be selected as a decompression and drainage method, and cholecystectomy can be performed after 3 months when the condition is stable. For elderly and weak patients with multiple organ diseases such as heart, lung, and kidney, some scholars have questioned whether cholecystectomy should be performed after gallstone removal and cholecystostomy.

　　Acute non-calculous cholecystitis, once diagnosed, should be treated with surgery as soon as possible. According to the patient's condition, cholecystectomy or cholecystostomy can be selected. For patients with severe illness who are difficult to tolerate surgical treatment, percutaneous cholecystostomy drainage surgery can be adopted. For those with mild illness, active non-surgical treatment can be carried out under strict observation. If the condition worsens, surgical treatment should be changed in a timely manner.

　　Chronic cholecystitis

　　All patients with gallstones should undergo cholecystectomy. For those without stones, with mild symptoms, and imaging shows no significant atrophy of the gallbladder with certain function, surgical treatment should be done with caution, especially for young female patients, who can be treated first with non-surgical methods such as anti-inflammatory and bile-promoting agents and acid-suppressing agents. For elderly and weak patients who cannot tolerate surgery, non-surgical treatment can be adopted, including restricting lipid intake, taking anti-inflammatory and bile-promoting drugs, and bile salts, etc., with integrated traditional Chinese and Western medicine treatment.

　　Treatment of acute obstructive suppurative cholangitis

　　The principle is to perform emergency surgery to relieve bile duct obstruction and drainage, and reduce the pressure in the bile ducts as soon as possible and effectively. Clinical experience has confirmed that in many critically ill patients, after the bile duct is opened and a large amount of purulent bile is drained during surgery, the patient's condition improves short-term as the pressure in the bile ducts decreases, and the blood pressure and pulse gradually tend to balance. This shows that only by relieving bile duct obstruction can bile duct infection be controlled and the progression of the disease be stopped.

　　1. Non-surgical treatment It is both a treatment method and can be used as preoperative preparation. It mainly includes: ① The joint use of a sufficient amount of effective broad-spectrum antibiotics. ② Correcting water and electrolyte disorders. ③ Restoring blood volume, improving and ensuring the good perfusion and oxygen supply of tissues and organs: including correcting shock, using adrenal cortex hormones, vitamins, and necessary vasoactive drugs; improving ventilation function, correcting hypoxemia, etc., to improve and maintain the function of the main organs. The non-surgical time should generally be controlled within 6 hours. For those with relatively mild conditions, after short-term active treatment, if the condition improves, treatment can continue under strict observation. For those with severe conditions or those whose conditions continue to worsen after treatment, emergency surgery should be performed. For those who still have shock, surgical treatment should also be performed while treating shock. ④ Symptomatic treatment: including cooling, supportive treatment, oxygen inhalation, etc.

　　2. Surgical treatment The primary purpose is to save the patient's life, and the operation should be simple and effective. The common methods are bile duct incision and decompression, and T-tube drainage. However, attention should be paid to the patency of intrapulmonary bile ducts, as some bile duct obstructions are multi-level. Multiple liver abscesses are a serious and common complication of the disease, and attention should be paid to the detection and simultaneous treatment of them. Cholecystostomy is often difficult to achieve effective bile duct drainage and is generally not recommended.

　　3. Non-surgical methods of bile duct decompression and drainage. Common methods include PTCD and endoscopic nasal bile duct drainage (ENAD). If the condition does not improve after treatment with PTCD or ENAD, it is necessary to change to surgical treatment in a timely manner.