Cystic duct syndrome

　　First, etiology

　　The causes include both congenital and acquired factors, with acquired factors being more common. It has been confirmed that many structural abnormalities can lead to incomplete obstruction of the choledochal duct, such as inflammatory adhesions of the choledochal duct, torsion caused by elongated choledochal duct, acute angle of gallbladder-funnel connection caused by adhesions of the gallbladder with surrounding organs, localized stricture, and fibrosis of the choledochal duct. Due to partial obstruction of the gallbladder duct, the outflow of bile is obstructed, leading to bile stasis in the gallbladder and increased intragallbladder pressure, thus causing a series of clinical symptoms.

　　Second, pathogenesis

　　During laparotomy in patients with choledochal cyst syndrome, gallbladder enlargement and a certain degree of expansion can often be seen, and the gallbladder cannot be emptied after pressing with fingers. The gallbladder itself may not have any abnormalities, and the histopathological examination of the gallbladder duct tissue often shows mild to moderate inflammatory changes, thickening of the wall, or more typical proliferative changes.

　　In addition to general symptoms, it may also cause other diseases. This disease may be complicated with chronic inflammation of the choledochal duct, fibrosis, torsion of the choledochal duct, and band-like stricture of the choledochal duct, etc. Therefore, once found, active treatment should be carried out, and preventive measures should also be taken in daily life.

　　The prominent symptoms of this syndrome are pain, which can be located in the gallbladder or upper abdomen, occasionally radiating to the back. After a fatty meal, significant pain may be induced, so some patients may experience a sharp decrease in appetite and weight loss. Sometimes, severe pain may occur in paroxysmal attacks, which cannot be distinguished from biliary colic. Some patients may wake up in pain during sleep, with pain lasting for several hours. Nitroglycerin or anticholinergic drugs may relieve pain, but the effect cannot be completely guaranteed, and the onset time is also very short. Sometimes, there may be tenderness in the gallbladder area, but it is rarely possible to touch an enlarged gallbladder.

　　There are many causes of choledochal cyst syndrome (such as: inflammatory adhesions of the choledochal duct, torsion caused by elongated choledochal duct, fibrosis of the choledochal duct, etc.), therefore, the primary disease caused by acquired factors after treatment is the key to prevention,

　　1. Prevent the occurrence of gallbladder diseases, maintain a balanced diet, and pay attention to low-fat diet. The diet should be light, low in fiber, and easy to digest. Avoid spicy foods such as chili, onions, and radishes, which are strong in stimulation and contain rough fibers; avoid eating small meals with large quantities, and instead, eat small meals frequently, and drink more soup and water to promote the secretion and excretion of bile.

　　Maintain the contraction function of the gallbladder and prevent long-term stasis of bile: For patients with long-term fasting and intravenous nutrition, gallbladder contraction drugs should be used regularly.

　　I. Laboratory examination

　　The blood routine, classification, and liver function tests of patients with choledochal cyst syndrome are basically normal.

　　II. Imaging examination

　　The examination methods include various bile drainage methods, continuous cholecystography, cholecystokinin cholecystography, etc. If it can be confirmed that the gallbladder performs a strong but ineffective contraction to overcome resistance, it is helpful for the diagnosis, among which cholecystokinin cholecystography has better reliability.

　　1. Cholecystography:After taking oral cholecystographic agents, the gallbladder is well filled, but there is delayed emptying. 36 hours later, the gallbladder is still visible, and it also shows narrowing, twisting, and elongation of the gallbladder duct, faint or non-visible common bile duct shadow. The preparation before cholecystokinin cholecystography is the same as that for oral cholecystography, with a slow intravenous injection of 75U of CCK within 3 minutes. Since normal people may experience gallbladder neck contraction during rapid injection, slow injection is both for safety considerations and to avoid gallbladder neck contraction. The gallbladder volume of normal people decreases by 50% to 80% after injection compared to before injection, while gallbladder duct syndrome patients only have 5% to 45%, not exceeding 45%, and most patients have a more rounded gallbladder. In addition, most patients show gallbladder duct narrowing or contrast agent interruption during造影. An indispensable point for diagnosing gallbladder duct syndrome is that the patient will feel pain in the gallbladder area at the same time as CCK injection. Normal people may have mild diffuse pain or spasm-like pain in the abdomen after a slow CCK injection, which is due to stimulation of intestinal peristalsis, without localized pain in the gallbladder area.

　　2. Bile drainage examination:In duodenal bile drainage, bile appears delayed. After stimulation with cholecystokinin, bile flows out 6 to 20 minutes later, and the amount is small with a long duration; during bile drainage under CCK stimulation, if the time when dark bile (B bile) starts to appear is delayed, it is of the most diagnostic value. Patients of this type do not show B bile within 20 minutes after CCK injection, while normal people see B bile on average about 6 minutes after CCK injection. In addition, the amount of B bile in patients with this syndrome is also reduced, the time of discharge is prolonged, and the late stage is intermittent ejection. Bile drainage under CCK injection is helpful for the diagnosis of this syndrome, but it is not necessary to perform bile drainage examination for those who have undergone cholecystokinin cholecystography.

　　3. Radionuclide biliary system scan:The 99mTc-HIDA biliary system scan shows delayed gallbladder emptying for more than 4 hours. The diagnosis of choledochal cyst syndrome can be based on the following points: (1) There is postprandial biliary colic or discomfort in the upper right abdomen, but without chills and fever, jaundice, and elevated white blood cells. (2) Oral cholecystography or radionuclide biliary system scan shows good gallbladder filling, but with delayed emptying and changes in the gallbladder duct. (3) B-ultrasound, CT, MRI, X-ray cholecystography, and other examinations do not show gallbladder stones or space-occupying lesions. When the above methods still cannot make a diagnosis, other methods can be used to assist in diagnosis: ① Cholangiometry combined with cholangiography, ② During surgery, contrast medium is injected into the gallbladder, and the process of tracking the contrast medium to the duodenum under radiation is traced. Through this method, it is easy to determine the presence and location of the blockage.

　　After cholecystectomy, attention should be paid to diet: eat less and more frequently, eat nutritious food, less greasy, taste appropriate, and easy to digest. Encourage patients to eat, as only by supplementing nutrition can the condition recover better and faster. Control foods high in cholesterol to reduce cholesterol metabolism disorders. Limit the intake of high-cholesterol foods such as animal organs, egg yolks, salted duck eggs, preserved eggs, fish roe, and crab roe.

　　With the development of surgery, the risk of death from the syndrome is decreasing day by day, so the prognosis is getting better and better.

　　Preparation before surgery, preoperative preparation for laparoscopic cholecystectomy:

　　1. Follow the general preoperative nursing routine of surgery.

　　2. Explain the purpose and advantages of the examination, and obtain the patient's cooperation.

　　3. Take senna leaves in decoction in the afternoon before surgery or use warm salt water enema at night.

　　4. No food for 12 hours before surgery.

　　5. Morning insertion of gastric tube on the day of the operation, traditional Chinese medicine treatment method for cholecystokinin syndrome.

　　Home remedies or dietary remedies:

　　1. Medicine: 10 grams of dahurian angelica, 15 grams of Sichuan pepper, 50 grams of Melia azedarach, 20 pieces of white scallion, 20 pieces of chive, 50 milliliters of white vinegar. Method: First, grind dahurian angelica and Sichuan pepper into fine powder, then crush the chive, white scallion, and Melia azedarach into paste. Mix the above medicine with white vinegar to make a paste. Apply the analgesic plaster to the surrounding area of the dry middle energizer point, cover with a transparent film, and then reinforce it with a cloth or abdominal band. Change the medicine once every 24 hours, and it can be applied for 2-4 times.

　　2. Medicine: 32 grams of umeboshi, 15 grams of Melia toosendan, 10 grams each of Sichuan pepper, costus, and amomum, 10 grams each. Method: Decoct and take the medicine.