Acute suppurative cholangitis

　　Mostly secondary to bile duct stones and ascaris lumbricoides disease. However, diseases such as bile duct stricture and bile duct tumors can also lead to this condition. These diseases cause bile duct obstruction, bile stasis, and secondary bacterial infection. The pathogenic bacteria are almost all from the intestines, entering the bile ducts through the Wirsung ampulla or through the bile-enteric anastomosis. Bacteria can also enter the bile ducts through the blood or lymphatic channels. The main pathogenic bacteria are Escherichia coli, Klebsiella, Streptococcus faecalis, and some anaerobic bacteria.

　　1. Bacteremia:The pathogenic bacteria reproduce in the human blood after entering the blood system and spread throughout the body with the blood flow, which has serious consequences.

　　2. Jaundice:This refers to the symptoms and signs of jaundice caused by an increase in serum bilirubin, leading to yellowing of the skin, mucous membranes, and sclera. The incidence rate is about 80%. Whether jaundice appears and the degree of jaundice depend on the location and duration of bile duct obstruction.

　　3. Peritonitis:The main clinical manifestations are abdominal pain, abdominal muscle tension, nausea, vomiting, and fever. In severe cases, it can lead to a decrease in blood pressure and systemic toxic reactions.

　　The onset is usually acute, with sudden severe pain under the sternum or in the upper right abdomen, usually persistent, followed by chills and remittent fever, with body temperature exceeding 40°C. Nausea and vomiting are common, and most patients have jaundice, but the depth of jaundice may not be consistent with the severity of the disease. About half of the patients may experience restlessness, disturbance of consciousness, drowsiness, and even coma, which are inhibitory manifestations of the central nervous system. At the same time, there may be a decrease in blood pressure, often indicating that the patient has sepsis and infectious shock, which is a manifestation of severe illness. The heart rate may increase to over 120 beats per minute, pulse may be weak, there may be marked tenderness and muscle tension under the sternum and in the upper right abdomen. In patients who have not had the gallbladder removed, a palpable, enlarged, and tender gallbladder and liver may be felt. The white blood cell count may significantly increase and shift to the right, reaching 20,000 to 40,000/mm3, and toxic granules may appear. Serum bilirubin and alkaline phosphatase levels may increase, and there may be elevated GPT and r-GT levels, indicating liver dysfunction. Blood cultures may show bacterial growth.

　　1. Prevention and treatment of gallbladder duct stones. The key to preventing gallbladder duct stones lies in preventing and eliminating pathogenic factors. For patients already diagnosed with gallbladder duct stones, they should be highly vigilant about the occurrence of the disease, especially when concurrent biliary infection occurs, and should actively prevent and treat it. Early application of high-dose sensitive antibiotics for infection control, attention to water, electrolyte, and acid-base balance, and strengthening systemic supportive treatment to control biliary infection are important. In cases where the general condition allows, surgery should be performed as soon as possible to remove the stones, ensure通畅引流, and thereby prevent the occurrence of AOST.

　　1. Prevention and treatment of biliary ascariasis. After the worms enter the bile duct, they cause varying degrees of obstruction in the bile duct, increasing the pressure in the bile duct. When concurrent bacterial infection occurs, it can trigger AOST. In addition, biliary ascariasis is also an important factor in the formation of gallbladder stones. Therefore, the prevention and treatment of biliary ascariasis is an extremely important aspect of preventing AOST. It mainly involves attention to drinking water and food hygiene, preventing intestinal ascariasis. Once diagnosed, treatment with vermifuge should be carried out immediately. If confirmed to be biliary ascariasis, treatment should be given as soon as possible. Analgesics, antispasmodics, and infection control are provided to promote the worms to spontaneously exit the bile duct. In addition, duodenoscopy can be performed, and the worms entering the common bile duct can be trapped and pulled out of the body with a snare. Surgical treatment should be considered only when treatment is ineffective.

　　1. Laboratory examination

　　1. White blood cell count

　　80% of the cases show a marked increase in white blood cell count, with neutrophils elevated and nuclear left shift. However, in severe cases or secondary cholestatic sepsis, the white blood cell count may be lower than normal or only show nuclear left shift and toxic granules.

　　2. Bilirubin determination

　　The determination of total bilirubin and conjugated bilirubin in serum and the test of urobilinogen and urobilin in urine all show the characteristics of obstructive jaundice.

　　3. Serum enzymatic determination

　　Serum alkaline phosphatase is significantly elevated, and serum transaminase is slightly elevated. If the bile duct obstruction lasts for a long time, the prothrombin time may be prolonged.

　　4. Bacterial culture

　　Blood cultures are often positive when blood is taken for culture during chills and fever. The types of bacteria are consistent with those in bile, with the most common bacteria being Escherichia coli, Klebsiella, Pseudomonas, Enterococcus, and Proteus, etc. Anaerobic bacteria such as Bacteroides fragilis or Clostridium perfringens can be found in about 15% of bile samples.

　　Second, other auxiliary examinations

　　1. Cholangiography

　　PTC is commonly used, which has both diagnostic and therapeutic effects. It can find dilated bile ducts and the site and cause of obstruction, but it is generally not advisable to perform this examination immediately for patients with severe shock.

　　2. CT and MRI examination

　　When there is a high suspicion of biliary obstruction inside and outside the liver while B-ultrasound examination fails to establish a diagnosis, CT or MRI examination can be performed. CT or MRI is significantly superior to B-ultrasound examination in identifying the site of obstruction and the cause of obstruction, with an accuracy rate of over 90%.

　　3. Ultrasound examination B-ultrasound examination

　　It has become the first choice for examination. The diagnostic accuracy of the examination for gallbladder stones, common bile duct stones, and intrahepatic bile duct stones is 90%, 70% to 80%, and 80% to 90% respectively. It can be found that the bile ducts at the site of stone obstruction and (or) intrahepatic bile ducts are dilated, and it can also be understood whether there is gallbladder enlargement, liver enlargement, and the formation of liver abscesses.

　　1. Minimize the intake of fat, especially animal fat, and avoid eating fatty meat and fried foods. Try to replace animal oil with vegetable oil as much as possible.

　　2. A considerable number of gallbladder inflammation and gallstone disease are indeed related to excessively high cholesterol levels and metabolic disorders in the body, so it is necessary to limit foods high in cholesterol such as fish roe, yolks of various eggs, and the livers, kidneys, hearts, and brains of various carnivorous animals.

　　3. Cooking should be done by steaming, boiling, stewing, and braising, and it is strictly forbidden to consume large amounts of fried, baked, grilled, smoked, or salted foods.

　　4. Increase the intake of foods rich in high-quality protein and carbohydrates such as fish, lean meat, dairy products, fresh vegetables, and fruits to ensure calorie supply, thereby promoting the formation of glycogen in the liver and protecting the liver.

　　5. Consume more foods rich in vitamin A such as tomatoes, corn, and carrots to maintain the integrity of gallbladder epithelial cells, prevent the shedding of epithelial cells to form the core of stones, and thus trigger stones or increase their size and number.

　　6. If possible, drink more fresh vegetable or melon juices such as watermelon juice, orange juice, and carrot juice, and increase the frequency and quantity of drinking water and eating to enhance the secretion and excretion of bile, and alleviate inflammation and bile stasis.

　　7. Eat less of foods rich in fiber such as turnips and celery to avoid increased peristalsis of the gastrointestinal tract due to difficult digestion, which may trigger biliary colic.

　　8. Quit smoking and drinking and eat less spicy and irritant foods, such as strong seasonings like wasabi oil, to avoid stimulating the gastrointestinal tract and triggering or aggravating the condition.

　　9. It is advisable to consume light, easy-to-digest, low-fiber, temperature-appropriate, non-irritating, and low-fat liquid or semi-liquid foods, and it is absolutely not advisable to indulge in eating and drinking for a moment of pleasure, as this may cause unnecessary trouble and even induce bile duct bleeding, which may endanger life.

　　The principle of treatment is to relieve bile duct obstruction by surgery, decompress the bile duct, and drain the bile duct. However, in the early stage of the disease, especially in acute simple cholangitis when the condition is not severe, non-surgical methods can be used first. About 75 percent of patients can achieve stable condition and control infection. For another 25 percent of patients, non-surgical treatment is ineffective, and the simple cholangitis develops into acute obstructive suppurative cholangitis, and surgical treatment should be changed in a timely manner. Non-surgical treatment includes antispasmodic analgesics and the application of bile duct drugs, among which 50 percent magnesium sulfate solution often has a good effect, with a dose of 30 to 50 ml taken at one time or 10 ml taken three times a day; gastrointestinal decompression is also often used; the combined use of high-dose broad-spectrum antibiotics is very important, although the concentration of antibiotics in bile cannot reach the therapeutic concentration during bile duct obstruction, it can effectively treat sepsis and septicemia. Commonly used antibiotics include gentamicin, chloramphenicol, ceftriaxone, and ampicillin, etc. Finally, it is necessary to adjust the appropriate antibiotics according to the blood or bile culture and drug sensitivity test.

　　If shock is present, active anti-shock treatment should be carried out. If there is no obvious improvement in the condition after 12 to 24 hours of non-surgical treatment, surgery should be performed immediately. Even if shock is difficult to correct, efforts should be made to achieve surgical drainage. For patients with severe conditions from the beginning, especially those with deep jaundice, timely surgery should be performed. The mortality rate of surgery is still as high as 25 to 30 percent. The surgical method should be as simple and effective as possible, mainly including bile duct incision, exploration, and drainage. It should be noted that the drainage tube must be placed near the site of bile duct obstruction; drainage on the side of the obstruction is ineffective and the condition cannot be relieved. If the condition allows, the inflamed gallbladder can also be removed, and the bile duct lesions can be thoroughly resolved after the patient has passed the critical period.