Biliary tract diseases

　　The scope of biliary tract diseases is relatively broad, and their pathogenesis is not uniform. The following takes cholelithiasis and cholecystitis as examples to introduce the etiology.

　　I. Cholelithiasis

　　Different types of gallstones have different etiologies and pathogenesis. Currently, there are theories such as metabolic disorders, biliary tract infections, and foreign body cores, but many issues have not been fully clarified.

　　1. Abnormal liver cholesterol metabolism or biliary acid liver-intestinal circulation disorders: Normal bile contains bile acids, bile salts, and lecithin in a certain proportion to form micelles, which are in a dispersed and dissolved state. When the gallbladder has organic or functional lesions, the cholesterol content in bile is too high, or the concentration of bile salts and lecithin is reduced, disrupting the normal proportion of the three, resulting in bile that can cause stones.

　　2. Biliary infection: The gallbladder mucosa can produce inflammation due to the chemical stimulation of concentrated bile or refluxed pancreatic juice. On this basis, it is very easy to attract secondary infections and exacerbate inflammation. Bacteria can decompose bile acids into free bile acids, which have a poor ability to form micelles. Bacteria in infectious bile are mostly Escherichia coli. Bacterial β-glucuronidase can convert conjugated bilirubin into free bilirubin. The content of calcium ions in bile increases during biliary inflammation, and the secretion of calcium by the gallbladder mucosa is significantly increased, making bilirubin calcium more likely to precipitate and precipitate. In addition, remnants of parasites, eggs, shed epithelial cells, and mucus in the gallbladder can often constitute the core of gallstones, helping cholesterol crystals to continuously precipitate and form gallstones or biliary sand. Mucus can also increase the viscosity of bile, making it easier to capture cholesterol crystals and promote the growth of gallstones. In China, infections with biliary parasites (roundworms, Schistosoma japonicum) are quite common and have an important causal relationship with the occurrence of bilirubin calcium stones. However, this relationship is not absolute and necessary. It also involves individual differences or intrinsic factors.

　　3. Bile stasis: Biliary inflammation can cause spasm of the common bile duct, biliary obstruction, dysfunction of the bile duct orifice sphincter, gallbladder motility disorders, and prolonged inactivity or obesity, pregnancy can cause relaxation of the abdominal wall, descent of visceral organs, reduced gallbladder tension, and delayed emptying.

　　In addition, depression and tension can lead to dysregulation of the autonomic nervous system, affecting gallbladder function and causing bile stasis. Bile stasis in the gallbladder increases the reabsorption of water. Overconcentration of bile makes cholesterol, which is already at the critical saturation point, more likely to form an oversaturated state, stimulating the gallbladder mucosa to produce inflammation. The increase in bile alkalinity reduces the ability of bile salts to dissolve cholesterol, and the proportion of bile components is out of balance. Bile stasis and the changes in its physicochemical properties are internal factors that promote the formation of bilirubin stones.

　　4. Dietary factors: The formation of gallstones in tangerines is to some extent related to overnutrition, deficiency, or imbalance. For example, the Western diet is high in calories, animal fats, and refined sugars, but lacks dietary fiber, which becomes a dietary factor that triggers gallstone disease. Practice has proven that dietary fiber (such as bran) can combine with bile acids, increasing the solubility of cholesterol in bile. The change in bile composition can reduce the formation of gallstones. The diet of indigenous African residents is rich in dietary fiber and low in refined sugars, with the lowest incidence of gallstone disease. The intake of a large amount of refined sugar can increase the synthesis of cholesterol in the liver and inhibit the secretion of bile acids by the liver, reducing the bile acid metabolism pool. Overeating, underactivity, and excess caloric intake can lead to obesity, an increase in the synthesis and secretion of cholesterol in the liver, and provide favorable conditions for the formation of gallstones.

　　5. Estrogen: Estrogen directly affects the enzyme system of the liver, causing an increase in triglycerides and inhibiting the synthesis of bile acids, resulting in an increase in cholesterol concentration, exceeding saturation and precipitating crystals. It can also interfere with the tension and emptying of the gallbladder, causing bile stasis and promoting the formation of gallstones. Therefore, the incidence of cholesterol stones in adult women and those with multiple pregnancies is significantly higher than that in men and infertile women. The incidence of cholesterol stones in those who have long-term estrogen use is also high, indicating that estrogen may have a certain relationship with the formation of gallstones.

　　6. Genetics: Some individuals with hereditary 'gallstone constitution' have a low content of bile salts in congenital bile, which makes cholesterol prone to oversaturation and precipitation to form stones, showing the 'family clustering' of cholelithiasis.

　　7. Other diseases such as diabetes, nephritis, hypothyroidism, elevated cholesterol concentration in blood, and increased excretion of cholesterol in bile are more likely to occur cholesterol stones. Patients with hemolytic diseases have a high incidence of cholelithiasis. During hemolysis, a large amount of conjugated bilirubin is formed and cannot be completely reabsorbed, leading to an increase in bilirubin in bile and the formation of stones. Long-term use of drugs such as clofibrate and niacin can also increase the risk of this disease. In addition, some surgeries that destroy the gallbladder's emptying function can cause bile stasis and reduced reabsorption of bilirubin. Extensive resection of the distal small intestine can cause intestinal-hepatic circulation disorders, increasing the possibility of gallstone formation. Bile duct stenosis, chronic inflammation, catheter placement, or ligature caused by bile duct surgery may also promote the formation of gallstones.

　　Second, cholecystitis

　　Acute cholecystitis is a non-specific disease, which often occurs in gallbladders with stones, and can also be secondary to diseases such as bile duct stones and biliary ascaris. Bile duct obstruction and bacterial infection are common causes. The suppurative lesions of adjacent organs can also directly affect the gallbladder. In addition, the gallbladder mucosa can produce inflammation due to the chemical stimulation of concentrated bile or refluxed pancreatic juice, thereby causing secondary bacterial infection and aggravating inflammation. It generally occurs in people over 40 years old, especially in obese women with multiple children.

　　Chronic cholecystitis is often a sequelae of acute cholecystitis, and some people say that acute cholecystitis is an acute attack of chronic cholecystitis. Gallstones are the most common cause of chronic cholecystitis (gallbladder inflammation complicated with gallstones accounts for 65-75%). The obstruction of bile duct stones can cause infection, which can then affect the gallbladder. The thickening, atrophy, or hydrops of the gallbladder wall can also cause chronic cholecystitis. The loss of gallbladder function and the change in bile composition can also cause chronic cholecystitis. Before onset, there are often triggers such as improper diet, overwork, and mental stimulation.

　　Biliary diseases have different types of diseases and complications. Taking biliary ascariasis as an example, the following will explain and analyze the complications of biliary diseases. The entry of ascaris into the bile duct does not necessarily lead to complications immediately, but only when the body's resistance decreases, the bile duct is obstructed, and the bile drainage is not smooth may complications occur. Common extrahepatic complications are as follows:

　　1. Liver abscess

　　On the basis of intrahepatic bile duct inflammation, hepatitis and liver abscesses may occur. Liver abscesses are often multiple scattered small abscesses. When the abscesses rupture, subdiaphragmatic abscess or pleurisy may occur.

　　2. Acute pancreatitis

　　The incidence rate of acute pancreatitis is 3.5%. Due to the spasm of the Oddi sphincter caused by the stimulation of ascaris and the blockage of the worm body, bile and pancreatic juice drainage is not smooth, causing infected bile and (or) pancreatic juice to reflux into the pancreatic duct and activate pancreatic enzymes, leading to acute pancreatitis; the worm body drilling into the pancreatic duct can cause necrotizing pancreatitis; the egg deposition in the pancreatic duct can cause inflammation and fibrosis, leading to chronic pancreatitis, which is a special cause of pancreatitis in China in the early years.

　　The symptoms of biliary tract diseases are not the same. The following takes cholelithiasis and cholecystitis as examples for specific explanation:

　　1. Gallstones

　　Gallstones can recur repeatedly, sometimes lasting for decades. Gallbladder stones may be asymptomatic or have intermittent dull pain in the upper right abdomen. When stones block the gallbladder duct, pain occurs and radiates to the right shoulder. Nausea, vomiting, and fever are common, and they can trigger acute cholecystitis. Gallbladder enlargement is often palpable and tender. X-ray examination can show stones. In addition to the above symptoms, bile duct stones can also cause jaundice, pain, chills, and fever due to the obstruction of the common bile duct by stones. Suppurative cholangitis may occur, and acute pancreatitis may also occur. Severe damage to liver cells can affect the production of coagulation factors, leading to a tendency to bleed, and even fibrosis may lead to biliary cirrhosis. Biliary tract imaging can show the thickening of the common bile duct or a clear area.

　　2. Cholecystitis

　　The main symptoms of acute cholecystitis are persistent pain in the upper right abdomen, intermittent cramping pain, abdominal muscle tension or rigidity, and often radiation pain to the right shoulder. Nausea and vomiting are common, and when suppurative cholecystitis or inflammation spreads to the common bile duct, chills, high fever, and jaundice may occur. The tenderness in the gallbladder area is marked. The gallbladder mucosa becomes edematous and congested, and then spreads to the gallbladder wall, causing the gallbladder to swell. In severe cases, especially in elderly patients, the gallbladder wall may become suppurative, necrotic, and perforated, leading to shock. After the inflammation subsides, fibrotic scar lesions may form. Inflammation can affect the proportion of bile components, promoting the formation of gallstones. Gallstones can also cause poor bile duct drainage, promoting inflammation, and the two often coexist, causing each other. Due to acute cholecystitis caused by biliary tract stones obstruction, cholecystitis can gradually subside after the stones are excreted and the obstruction is relieved.

　　Some chronic cholecystitis cases may have no symptoms at all. Some may feel a hidden pain in the upper right abdomen, bloating, belching, and loss of appetite. After eating high-fat foods, there is significant indigestion. In addition to mild tenderness in the upper abdomen, there are no other positive signs.

　　To prevent biliary tract diseases, attention should be paid to dietary hygiene in daily life to prevent infection; when inflammation occurs, apply effective antibiotics in a timely manner; reasonably adjust the diet, avoid excessive consumption of foods rich in animal fats, such as fatty meat and animal oil; when there are intestinal worms (mainly ascaris lumbricoides), apply vermifuge drugs in a timely manner, with sufficient dosage to prevent insufficient medication, as ascaris are active and easy to drill into the bile duct, causing obstruction and leading to cholecystitis. The main methods for preventing and treating cholecystitis include:

　　1. It is necessary to do some physical activities regularly to activate the whole-body metabolism, especially for middle-aged people who are engaged in mental labor and sit for work all day. They should consciously do more physical labor to prevent excessive obesity, because obesity is an important predisposing factor for cholecystitis or gallstones.

　　2. Pay attention to dietary hygiene, avoid overeating and drinking, and moderately limit fatty foods. Because after eating fatty foods, it will reflexively cause the gallbladder to contract, and once the contraction is too strong, it can lead to an acute attack of biliary colic.

　　3. After the autumn cool, attention should be paid to keeping warm, especially when sleeping, cover the quilt well to prevent the abdomen from getting cold. Because after the abdomen gets cold, it will stimulate the vagus nerve, causing the gallbladder to contract strongly.

　　4. People who have been proven to have gallstones or intestinal parasitic diseases should seek treatment in a timely manner to avoid inflammation of the gallbladder.

　　5. Some traditional Chinese medicine can be taken, and the effect is also good.

　　For biliary tract diseases, blood tests, B-ultrasound, and liver and gallbladder function tests can be performed. The specifics are as follows:

　　1. White blood cells:Increased during acute cholecystitis and acute exacerbation of chronic cholecystitis.

　　2. Stool examination for ascaris eggs:Biliary ascariasis may be positive.

　　3. Duodenal drainage (DJT):If bile is not excreted, it indicates that the common bile duct is obstructed by a stone; if the viscosity of bile increases, it indicates inflammation of the gallbladder, bile duct, and cholelithiasis; if a large number of epithelial cells are found, it indicates inflammation of the bile duct and duodenitis; if a large number of white blood cells are found, it indicates the possibility of duodenitis and gallstones. DJT can also detect parasitic eggs, and culture can detect pathogenic bacteria. If Escherichia coli, Candida, and other pathogens are found, it has significant diagnostic significance.

　　4. Bilirubin measurement:It is commonly divided into total bilirubin (TBiL), direct bilirubin (DBiL), and indirect bilirubin (IBiL). An increase in all three indicates hepatocellular jaundice; gallstones, cholecystitis, biliary obstruction with jaundice are often obstructive jaundice, with increased TbiL and DbiL; if TbiL and IbiL increase, it often indicates hemolytic jaundice.

　　5. Alanine aminotransferase:Increased.

　　6. Aspartate aminotransferase:Increased in obstructive jaundice.

　　7. GGT:It is of great value for the diagnosis of malignant tumors in the liver and gallbladder system and biliary tract diseases.

　　8. Alkaline phosphatase:Increased.

　　9. Lipase:Increased.

　　10. Glucose-6-phosphate isomerase:Increased due to cholecystitis.

　　11. Leucine aminopeptidase:Increased.

　　12. Adenosine deaminase:Increased liver and gallbladder diseases.

　　Post-cholecystectomy, attention should be paid to diet, eat less and more frequently, ensure a nutritious diet, avoid greasy foods, keep the taste moderate, and ensure easy digestion. Encourage patients to eat, as only with adequate nutrition can the condition recover better and faster. Control foods high in cholesterol to alleviate cholesterol metabolism disorders, and limit the consumption of high-cholesterol foods such as animal organs, egg yolks, salted duck eggs, century eggs, fish roe, and crab roe.

　　Sea vegetables and seafood should be eaten in limited quantities, some yogurt can be consumed appropriately, moderate exercise can be done, and it is recommended to rest more after surgery. The specific cause of pain can be reviewed and consulted with your treating doctor. It is necessary to avoid smoking and drinking to prevent adverse effects on the condition. Generally speaking, within half a year after cholecystectomy, the diet should follow the principle of light, low in oil, high in protein (no egg yolk), and high in calories. It is advisable to adopt a method of eating small and frequent meals, especially not to eat too much animal fat at one time, such as: pork, pork feet. After a period of time (about half a year), when the body recovers well, fat foods can be added in small and gradual amounts, with the standard of not causing abdominal discomfort and diarrhea and other dyspepsia.

　　Patients should arrange their diet reasonably, mainly light in taste, eat more roughage foods, drink more water, which is beneficial to prevent hypertension, hyperlipidemia, habitual constipation, etc. Developing good living habits can prevent and effectively control the occurrence and development of many diseases.

　　Acute attacks of biliary tract diseases should be treated with non-surgical methods first, and further examination should be carried out after symptoms are controlled to clarify the diagnosis and select appropriate treatment methods according to the situation. If the condition is severe and non-surgical treatment is ineffective, timely surgical treatment should be performed.

　　First, non-surgical treatment

　　1. Indications:

　　(1) Young patients with a first attack;

　　(2) Symptoms quickly relieved after non-surgical treatment;

　　(3) Atypical clinical symptoms;

　　(4) The onset has exceeded three days, there are no urgent surgical indications, and symptoms have subsided under non-surgical treatment.

　　2. Acupuncture and traditional Chinese medicine treatment.

　　3. Common nonsurgical treatments include bed rest, dietary restriction or low-fat diet, intravenous fluid therapy, and necessary blood transfusions. Correct water, electrolyte, and acid-base imbalances, apply broad-spectrum antibiotics, especially antibiotics sensitive to Gram-negative bacilli and drugs against anaerobic bacteria (such as metronidazole), and it is most appropriate to use medication according to the results of bacterial culture.

　　4. Treatment for chronic cases can include choleretics such as dehydrocholic acid, sodium glycocholate, anti-inflammatory and choleretic tablets, choleretic, and bile joy, etc., while attention should be paid to dietary regulation, which can often control attacks. Literature reports that the use of deoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) for dissolution therapy can make some gallstones smaller or disappear, but the medication time is long (usually half a year to 1.5 years), and excessive use can damage the liver. Stones can recur after discontinuation of medication, so appropriate cases can be tried.

　　5. Percutaneous liver puncture bile duct drainage (PTD) can be performed for patients with severe bile duct obstruction or suppurative cholangitis, in order to drain bile ducts, reduce bile duct pressure, control infection, reduce mortality, and win time for surgery.

　　6. Endoscopic papillary切开术 (EPT) is indicated for common bile duct stones with a diameter less than 3 cm, stenosis of the papilla confirmed by ERCP with dilatation of the common bile duct and cholestasis. After surgery, stones can be excreted spontaneously or removed with stone retrieval instruments, and long引流tubes can be placed in the common bile duct for biliary-nasal drainage.

　　7. Extracorporeal shock wave lithotripsy has a poor effect on gallstones, although it can fragment the stones, it may not necessarily be able to completely remove them, and there is still a possibility of recurrent stones, and there are certain complications and it is expensive. Intrahepatic bile duct stones can be tried.

　　Second, Surgical Treatment

　　If there are obvious systemic toxic symptoms, peritoneal irritation signs, and deepening jaundice during the acute stage, emergency surgery should be performed. For patients with a long history, recurrent attacks, and obvious organic changes in the bile duct, such as calculous cholecystitis, large common bile duct stones, primary bile duct stones, significant symptoms of intrahepatic stones, recurrent bile duct stones with marked dilatation of the bile (liver) duct, and biliary tract infection with narrowing of the Oddi sphincter, elective surgery should be performed after the acute symptoms are controlled. The surgical method is:

　　1. Cholecystectomy is the main surgical treatment for gallstones and acute and chronic cholecystitis, which can completely eliminate the focus and achieve satisfactory surgical outcomes. However, the effect of cholecystectomy for non-gallstone cholecystitis is not as good as that for gallstone cholecystitis, so a cautious attitude should be taken. After cholecystectomy, the bile duct can compensatorily dilate, which has little impact on physiology, only slightly reducing the digestion of fats due to insufficient concentration of bile. Therefore, correct cholecystectomy is harmless to patients. There are two surgical methods: the so-called retrograde method starting from the gallbladder fundus and the anterograde method starting from the gallbladder neck. The former is generally used. This method can avoid injury to the bile duct, while the latter has less bleeding, but if there is severe inflammation and edema around the gallbladder, surgery is often difficult. For suitable cases recently, laparoscopic cholecystectomy (LC) can be used.

　　2. Cholecystostomy is not commonly used in recent years and is only indicated for patients with severe inflammatory adhesions around the gallbladder, where it is very difficult to remove the gallbladder, and there is a risk of injury to important structures such as the common bile duct; gallbladder abscess; gangrene, perforation, peritonitis of the gallbladder; critically ill patients; or elderly patients with systemic failure who cannot tolerate cholecystectomy. The purpose of this operation is to incise, decompress, and drain, remove the stones, get through the critical period, and then consider cholecystectomy according to circumstances. Therefore, patients may suffer from the pain of a second operation, and it should not be used excessively.

　　3. Cholangiography and drainage are the basic methods for treating bile duct stones.

　　4. Cholecystoenteric anastomosis.

　　7. Hepatectomy is indicated for patients with multiple intrahepatic bile duct stones localized in one lobe (segment) of the liver, where it is not possible to remove the stones completely by other surgical methods, or when the liver tissue has atrophied, and the diseased lobe (segment) should be resected to eliminate the focus.