Elderly Cholecystitis

　　First, Etiology

　　Sudden obstruction or impaction of gallstones in the gallbladder or blockage of the cystic duct by gallstones, torsion of the cystic duct, stricture, ascaris lumbricoides, or bile duct tumors can also cause acute cholecystitis. In addition, during the aging process, the gallbladder wall gradually becomes thickened or atrophic, the contraction function decreases, causing bile stasis, concentration, and formation of bile salts; the distal end of the common bile duct and the Oddi sphincter become relaxed, making it easy to occur retrograde infection; systemic atherosclerosis and increased blood viscosity can aggravate ischemia of the gallbladder artery. These pathophysiological changes are the reasons why the incidence of gallbladder calculi in the elderly is higher than that in young people, and why acute necrotizing cholecystitis and gallbladder perforation are more common in elderly patients.

　　After obstruction of the cystic duct or neck of the gallbladder, the stasis bile in the gallbladder becomes concentrated to form bile salts, which stimulate the gallbladder mucosa, causing chemical cholecystitis (early stage). At the same time, bile stasis causes the pressure in the gallbladder to continuously increase. The distended gallbladder first affects the venous and lymphatic return of the gallbladder wall, resulting in congestion and edema of the gallbladder. When the pressure inside the gallbladder > 5.39 kPa (55 cmH2O), the arterial blood flow in the gallbladder wall is blocked, causing ischemic injury to the gallbladder. Ischemic gallbladders are prone to secondary bacterial infection, which aggravates the course of cholecystitis, and eventually leads to gallbladder gangrene or perforation. If there is no circulation disorder of the gallbladder wall and bacterial infection in the gallbladder without obstruction of the cystic duct, it may develop into cholecystosis.

　　Recent studies have shown that phospholipase A can be released from damaged gallbladder mucosal epithelium due to bile stasis or stone impaction, causing lecithin in bile to be hydrolyzed into lysophosphatidylcholine, which then changes the integrity of mucosal epithelial cells, leading to acute cholecystitis.

　　Second, Pathogenesis

　　1. Etiology and Pathology of Western Medicine

　　(1) Acute cholecystitis: To date, the etiology of this disease is still not well understood. It has always been considered that it is related to bile stasis, mucosal injury, ischemia of the gallbladder, and bacterial infection after obstruction of the cystic duct by gallstones.

　　①Obstruction of the cystic duct: It is generally believed that obstruction of the cystic duct by gallstones or parasites can cause acute cholecystitis. The reason is: stimulation by bile salts, ischemia of the gallbladder wall, secondary infection, pancreatic juice reflux erosion. Some people also believe that in the pathogenesis of acute cholecystitis, mechanical and vascular factors may be more important than the stimulation caused by increased bile salt concentration.

　　②Infection: Includes bacterial infection and parasitic infection. The main bacteria causing infection are Escherichia coli, Paracolon bacteria, Salmonella typhi, Paratyphi bacteria, Staphylococcus, Streptococcus, Streptococcus pneumoniae, and gas-forming bacteria, etc. The infection routes include: hemogenic infection (bacteria enter the gallbladder with the blood flow), cholegenic infection (intestinal bacteria enter the liver via the portal vein after passing through the mesenteric veins and are not destroyed, leading to infection of the gallbladder, and the bacteria in the liver enter the gallbladder through the lymphatic vessels), ascending infection (ascaris lumbricoides carrying intestinal bacteria drills into the bile duct, causing obstruction and gallbladder inflammation), and invasive infection (when the tissues and organs adjacent to the gallbladder are inflamed, bacteria can erode and spread to the gallbladder). Clonorchis sinensis and Trichomonas梨形 flagellate and other parasites can all cause cholecystitis, especially the close relationship between Clonorchis sinensis and bile duct infection.

　　③ Nervous and mental factors: Any factor that can cause a decrease in vagal tone can be an important additional factor for the occurrence of acute cholecystitis or choledochitis. According to literature reports, factors such as pain, fear, and anxiety can cause the occurrence of acute cholecystitis, affecting gallbladder emptying and leading to bile stasis.

　　④ Hormonal factors: Cholecystokinin can increase bile secretion, promote gallbladder contraction, and relax the sphincter of the common bile duct to maintain normal secretion and excretion of bile. When there are factors such as increased bile salt concentration and increased amino acids and fats in the intestinal lumen, the gallbladder can stop contraction and remain in an expanded state, leading to bile stasis and disease. Sex hormones: Due to the influence of sex hormones during pregnancy, women's gallbladder emptying is delayed, the gallbladder is expanded, and bile stasis is prone to occur, leading to acute cholecystitis.

　　In addition, acute cholecystitis can occur after trauma, burn, or surgery, which may be related to dehydration caused by bleeding, anesthesia, fever, reduced intake of food, and secondary infection, as dehydration can increase the viscosity of bile, leading to delayed gallbladder emptying.

　　(2) Chronic cholecystitis: Chronic cholecystitis is both the basis for the occurrence of gallstones and the consequence after the formation of gallstones. It reflects the long-term process of mutual influence between the gallbladder and stones. The mechanism is roughly the same as that of acute cholecystitis. Chronic cholecystitis has a chronic and protracted course, with characteristics such as recurrent acute attacks, and there are more cases of this disease than acute cholecystitis.

　　① Stone factors: Commonly known as calculous cholecystitis, about 70% of chronic cholecystitis is caused by this factor, which is due to long-term stimulation of the gallbladder wall by gallstones, which can lead to secondary bacterial infection on this basis.

　　② Bacterial infection: Commonly known as bacterial cholecystitis, bacteria can also be infected through the blood, lymph, or direct spread from inflammation of adjacent tissues and organs, as well as through the duodenal papilla to the gallbladder.

　　③ Viral infection: Commonly known as viral cholecystitis, often occurs during viral hepatitis, which may be related to direct or indirect invasion of the gallbladder by hepatitis virus.

　　④ Chemical factors: Commonly known as chemical cholecystitis, caused by excessive concentration of bile salts or reflux of pancreatic digestive enzymes into the gallbladder, often occurs when the biliary tract sphincter is spasmodic due to the stimulation of gallstones.

　　⑤ Parasitic factors: Commonly known as parasitic cholecystitis, common ones include Clonorchis sinensis, Entamoeba histolytica, Schistosoma and Ascaris lumbricoides, etc.

　　⑥ Post-infection from acute cholecystitis.

　　In summary, regardless of the cause, the common pathological feature is the proliferation of gallbladder fibrous tissue, thickening of the gallbladder wall, narrowing and atrophy of the gallbladder cavity due to contraction of scar tissue, adhesion of the gallbladder with surrounding tissues leading to complications such as pyloric stenosis, etc. If inflammation invades the gallbladder duct and causes obstruction, the gallbladder can also become distended and the gallbladder wall can become thin.

　　2. Western and Chinese etiology and pathogenesis

　　(1) Unregulated diet: If the diet is not regulated and excessive intake of greasy food occurs, it can injure the spleen and stomach, leading to impaired transformation and transportation, endogenous dampness and turbidity, which can obstruct the dispersal of liver and gallbladder Qi, causing liver and gallbladder Qi stagnation. Further, Qi stagnation can transform into heat or Qi stagnation and blood stasis can transform into heat. When liver and gallbladder heat combines with spleen and stomach dampness and turbidity, it promotes the development of this disease.

　　(2) Tapeworm disturbance: Patients with tapeworm disease may develop spleen and stomach deficiency and coldness due to various factors. Since tapeworms have the habit of liking warmth and hating cold, they become restless and disturbed when exposed to cold, disturbing the 'diaphragm', obstructing the flow of liver and gallbladder qi, causing qi stagnation in the liver and gallbladder. Qi stagnation can lead to heat or heat due to blood stasis, and this heat combined with dampness caused by spleen deficiency can lead to the disease.

　　(3) Emotional stimulation: The liver loses its function of疏导, which likes to be smooth and unobstructed. The gallbladder is attached to the liver, and the meridians of the liver and gallbladder are interconnected, with the smooth and unobstructed flow as the normal state. If emotional stimulation leads to the unsmooth flow of liver and gallbladder qi, causing qi stagnation, on one hand, it invades the spleen, and on the other hand, the qi stagnation further transforms into heat or blood stasis, leading to heat due to liver and gallbladder, and dampness due to spleen deficiency. This results in the disease.

　　In summary, the pathogenesis of acute cholecystitis is characterized by the stagnation of liver and gallbladder qi, leading to blood stasis due to qi stagnation, which transforms into heat. The combination of heat and dampness in the spleen and stomach leads to the syndrome of damp-heat in liver and gallbladder. The blockage of bile qi leads to pain, and the reversed overflow of bile juice to the skin causes jaundice. If the heat is not dispersed, it can lead to abscess and inflammation. The virulent heat invades the营 blood, which can lead to 'loss of yin' and 'loss of yang'. The pathogenesis of chronic cholecystitis is characterized by the stagnation of liver and gallbladder qi, and the failure of the stomach to descend.

　　Complications include gallbladder hydrops, white bile, lime milk bile, porcelain-like gallbladder, gallbladder perforation, gallbladder fistula, liver abscess.
　　Gallbladder perforation: On the basis of gangrenous cholecystitis, perforation occurs at the bottom or neck of the gallbladder, usually occurring three days after onset, with an incidence rate of about 6-12%. After perforation, it can cause diffuse peritonitis, subdiaphragmatic infection, internal or external bile fistula, liver abscess, etc., but it is often wrapped by omentum and surrounding organs, forming a pericholecystic abscess, presenting signs of localized peritonitis. At this time, surgery is very difficult, and cholecystostomy must be performed.

　　One, acute cholecystitis

　　The clinical manifestations of acute cholecystitis with gallstones are basically the same as those of acute cholecystitis without gallstones.

　　1. Symptoms

　　(1) Pain: Severe or colicky pain in the upper right abdomen, mostly due to acute cholecystitis caused by gallstones or parasitic impaction and obstruction of the gallbladder neck. The pain often occurs suddenly and is very severe, or it may present as colicky pain, most often after a heavy meal, especially after eating high-fat foods. It often occurs at night. General pain in the upper right abdomen is seen in non-obstructive acute cholecystitis, where the pain is usually not severe and is mostly persistent, dull pain. As the inflammation of the gallbladder progresses, the pain may also increase. The pain is radiation, and the most common radiation site is the right shoulder and the lower angle of the scapula, which is due to the stimulation of the right phrenic nerve endings and peripheral nerves around the abdominal wall by gallbladder inflammation.

　　(2) Nausea, vomiting: The most common symptom, if nausea and vomiting are stubborn or frequent, it can cause dehydration, fainting, and electrolyte imbalance, which is more common in cases of gallbladder duct obstruction by stones or tapeworms.

　　(3) Chills, shivering, fever: In mild cases (catarrhal inflammation), there is often aversion to cold and low fever; in severe cases (acute purulent gangrene), there may be chills and high fever, with temperatures above 39℃, and symptoms such as delirium and delirium may occur.

　　(4) Jaundice: Less common, if jaundice occurs, it is usually mild, indicating that the infection has spread to the liver through the lymphatic vessels, causing liver damage, or the inflammation has invaded the common bile duct.

　　2. Main Characteristics

　　Abdominal examination may show muscle tension, tenderness, rebound pain, and positive Murphy sign in the upper right abdomen and the middle upper abdomen. In patients with gallbladder abscess or pericholecystic abscess, palpable masses with tenderness or明显肿大的胆囊 can be felt in the upper right abdomen. When abdominal tenderness and muscle tension extend to other abdominal areas or the entire abdomen, it suggests gallbladder perforation or acute peritonitis. In 15% to 20% of patients, liver damage may occur due to pericholecystic edema, bile stone compression, and pericholecystitis, or inflammation may involve the common bile duct, causing spasm and edema of the Oddi sphincter, leading to bile duct obstruction. This may cause mild jaundice. If jaundice becomes more severe, it may indicate obstruction of the common bile duct with stones or concurrent cholangitis. In severe cases, peripheral circulatory failure signs may appear, with low blood pressure, and even infectious shock may occur. This condition is particularly common in severe cases with purulent gangrene, with symptoms such as malaise, anorexia, fatigue, and constipation.

　　3. The main characteristics of elderly acute cholecystitis

　　Elderly patients have weak body response ability. Although it is an acute inflammation, some patients have a slower onset and atypical symptoms, such as symptoms similar to right lower lobe pneumonia, myocardial infarction, and right pyelonephritis, etc., outside the gastrointestinal tract. Clinical manifestations include abdominal pain, fever, palpation of an enlarged gallbladder and mass, and compared to young patients, these are often absent or mild. Even if complications such as gangrene and perforation of the gallbladder occur, the abdominal manifestations are atypical, and even after perforation, the contents of the gallbladder can flow upwards into the interspaces of the colon, causing symptoms of acute appendicitis or acute colonic diverticulitis. This is very easy to confuse with diagnosis, but some elderly patients have an acute onset and rapid progression of the disease, with complications such as gallbladder gangrene, perforation, peritonitis, and shock, which are often the initial clinical manifestations of acute cholecystitis. Elderly patients with cholecystitis often have common bile duct stones, so the incidence of jaundice is relatively high (about 59%), and the severity is greater than that of young and middle-aged patients. In addition, the evolution of the disease after acute cholecystitis in elderly patients is also atypical. In young and middle-aged patients, the changes in the condition of cholecystitis are often evaluated based on the severity of pain, fluctuations in body temperature, and white blood cell count. However, in elderly patients, especially those with weakened physical condition, it is very unreliable to use these indicators to observe the evolution of cholecystitis. Understanding these characteristics of elderly acute cholecystitis is very important for making correct clinical judgments.

　　Two, chronic cholecystitis

　　1. Symptoms

　　Persistent dull pain or discomfort in the upper right abdomen; symptoms of dyspepsia such as nausea, belching, acid regurgitation, abdominal distension, and burning sensation in the stomach; pain in the lower right scapular area; symptoms worsen after eating high-fat or greasy foods; the course of the disease is long, with alternating characteristics of acute attacks and remissions, with symptoms similar to acute cholecystitis during acute attacks, and sometimes no symptoms at all during remission periods.

　　2. Signs

　　There may be mild tenderness and percussion pain in the gallbladder area, but no rebound pain; in cases of bile stasis, an enlarged gallbladder can be palpated; during an acute attack, there may be muscle tension in the upper right abdomen, normal body temperature or low fever, and occasionally jaundice; in cases of viral cholecystitis, there may be enlargement of the liver and spleen.

　　Participating in appropriate exercise, sports, and cultural and recreational activities, and reasonably arranging work, study, and rest according to the condition of the disease and physical strength can enhance physical fitness and promote the recovery of chronic cholecystitis.

　　One, acute cholecystitis

　　Blood routine: in acute cholecystitis, the total white blood cell count is slightly increased (usually between 12,000 to 15,000/mm3), with an increase in neutrophils. If the total white blood cell count exceeds 20×10^9/L, with significant left shift and toxic granules, it may indicate gallbladder necrosis or perforation and other complications.

　　Two, chronic cholecystitis

　　Duodenal drainage: if there is an increase in mucus in the bile of B tube; a cluster of white blood cells, positive bacterial culture or parasitological examination, it is of great help to the diagnosis.

　　Three, acute cholecystitis

　　1. Ultrasound examination

　　B-ultrasound can often make a timely diagnosis due to the enlargement of the gallbladder, thickened wall, and thick bile in the cavity. It is worth mentioning that atypical clinical manifestations in the elderly often require imaging examinations such as B-ultrasound to make a diagnosis. B-ultrasound examination is simple and easy to perform, can measure the size of the gallbladder, wall thickness, especially reliable for detecting gallstones, and is the first choice for imaging examination of diagnosing acute cholecystitis, as well as one of the indicators for observing the evolution of elderly diseases.

　　2. Radiographic examination

　　The positive findings with diagnostic significance in abdominal flat film are: ① gallbladder area stones; ② enlargement of gallbladder shadow; ③ calcification spots on gallbladder wall; ④ gas and liquid levels in the gallbladder cavity (seen in cases caused by gaseous bacteria infection).

　　3. Radioisotope examination

　　The sensitivity of radioactive isotope scanning of the biliary system for diagnosing acute cholecystitis is 100%, and the specificity is 95%, which also has diagnostic value. Within 90 minutes after intravenous injection of 131 four-iodine tetraoxygen fluorescent 99mTc, if there is no radioactive material in the gallbladder area, it indicates that there is biliary duct obstruction, and it can be considered as acute cholecystitis.

　　Four, chronic cholecystitis

　　1. Ultrasound examination

　　If gallstones, thickened gallbladder wall, shrinkage or deformation are found, it has diagnostic significance.

　　2. Abdominal X-ray film

　　If it is chronic cholecystitis, gallstones, enlarged gallbladder, gallbladder calcification spots, and milky opaque shadows in the gallbladder may be found.

　　3. Gallbladder imaging

　　It can be found that gallstones, shrinkage or deformation of the gallbladder, but poor gallbladder concentration and contraction function, and faint gallbladder imaging due to chronic cholecystitis. When the gallbladder does not show up, if it can be ruled out that it is caused by liver dysfunction or liver color metabolism dysfunction, it may be chronic cholecystitis.

　　4. Cholecystokinin (C.C.K.) test

　　After taking oral gallbladder contrast agent and the gallbladder is imaged, intravenous injection of C.C.K. is performed, and the gallbladder film is taken in several doses within 15 minutes. If the gallbladder contraction amplitude is less than 50% (indicating poor gallbladder contraction) and there is biliary colic, it is a positive reaction, indicating chronic cholecystitis.

　　5. Fiberoptic laparoscopy

　　If the liver and the enlarged gallbladder are green, brown or black under direct vision, it indicates that jaundice is caused by extrahepatic obstruction. If the gallbladder loses its smooth, translucent and sky-blue appearance and becomes grayish-white, with shrinkage and obvious adhesions, and deformation of the gallbladder, it indicates chronic cholecystitis.

　　6. Laparoscopic exploration

　　Laparoscopic exploration is a new method proposed in recent years for diagnosing difficult liver and gallbladder diseases and jaundice. It can not only make an accurate diagnosis of chronic cholecystitis but also understand the liver's condition.

　　What should elderly cholecystitis patients not eat

　　1. Abstain from eating ice cream. Cholecystitis patients may experience severe liver pain and biliary spasm after eating ice cream, so it should be avoided.

　　2. Abstain from drinking milk. Milk contains a large amount of fat, which requires bile and lipase to be decomposed and digested after drinking, increasing the burden on the gallbladder, so it should be avoided.

　　3. Abstain from smoking, alcohol, strong tea, and coffee, as many substances contained in them can stimulate the gastric wall and cause excessive secretion of gastric acid, leading to the production of cholecystokinin, causing spasm of the bile duct orifice sphincter and obstruction of bile excretion, thus triggering biliary colic, so it should be avoided.

　　First, treatment

　　1. General treatment

　　(1) Actively prevent and treat bacterial infections and complications, pay attention to dietary hygiene, prevent the occurrence of biliary parasitic diseases, and actively treat enterobiasis.

　　(2) Regulate daily life and rest, pay attention to the combination of work and rest, moderate cold and heat, maintain an optimistic mood, and ensure smooth defecation.

　　(3) Maintain a left lateral position during interoffice visits, which is beneficial for bile excretion.

　　(4) If the disease is accompanied by stones or frequent attacks, surgical treatment can be considered.

　　(5) Low-fat diet should be chosen to reduce bile secretion and lighten the burden on the gallbladder.

　　2. Drug therapy

　　(1) Acute cholecystitis:

　　① Spasmolytic and analgesic: Atropine 0.5mg can be injected intramuscularly, nitroglycerin 0.6mg can be dissolved sublingually, pethidine (dolantin) and others can be used to relieve the spasm and pain of the Oddi sphincter.

　　② Antimicrobial therapy: The use of antibiotics is to prevent sepsis and suppurative complications. Usually, it is used in combination with ampicillin (aminobenzylpenicillin), clindamycin (chlorocycline), and aminoglycosides, or second-generation cephalosporins such as cefamandole (cefahydroxol) or cefuroxime for treatment. The change of antibiotics should be determined according to the results of blood culture, bile culture during surgery, and bacterial culture of the gallbladder wall, as well as drug sensitivity tests.

　　③ Cholagogue drugs: 10ml of 50% magnesium sulfate, 3 times a day, taken orally (not used for those with diarrhea), 0.25g of dehydrocholic acid tablets, 3 times a day, taken orally, 0.2g of bile acid tablets, 3 times a day, taken orally.

　　(2) Chronic cholecystitis

　　① Cholagogue drugs: Magnesium sulfate 50%, dehydrocholic acid tablets, and others can be taken orally.

　　② Vermifuge therapy: Vermifuge therapy is conducted according to the cause.

　　③ Litholysis therapy: If cholesterol stones are the cause, litholysis therapy with cholic acid can be used. According to literature reports, the effective rate of litholysis can reach about 60%, with a daily dose of 500-700mg, a course of 6 months to 2 years, and a maintenance dose (250mg per day) after the end of the course to prevent recurrence. Side effects: diarrhea and mild increase in serum transaminase.

　　(3) Rational selection of traditional Chinese patent medicines:

　　① Jin Dan Tablet: Function: Anti-inflammatory and cholagogic, used for acute and chronic cholecystitis. Dosage: 5 tablets, 3 times a day.

　　② Qinggan Lidan Oral Liquid: Function: Clearing the damp-heat of the liver and gallbladder, mainly for symptoms such as anorexia, hypochondriac pain, fatigue, jaundice, sticky coating, wiry pulse, liver depression and qi stagnation, and uncleaned damp-heat of the liver and gallbladder. Dosage: 20ml per time, 3 times a day.

　　3. Acupuncture and moxibustion therapy

　　(1) Acupuncture therapy.

　　(2) Auricular acupuncture therapy.

　　4. Surgical treatment

　　Gallbladder resection is the fundamental treatment for acute cholecystitis. Indications for surgery: ① Gangrene and perforation of the gallbladder, with concurrent diffuse peritonitis; ② Acute cholecystitis with recurrent acute attacks, with clear diagnosis; ③ After active medical treatment, the condition continues to worsen; ④ Without contraindications to surgery and able to tolerate surgery. Chronic cholecystitis with gallstones; once the diagnosis is established, gallbladder resection is a reasonable fundamental treatment method. If the patient has serious diseases such as heart, liver, and lung or systemic conditions that cannot tolerate surgery, medical treatment can be provided.

　　5. Rehabilitation treatment

　　(1) General activity: The rehabilitation of chronic cholecystitis takes a long time. In addition to medication and surgery, daily care also plays a certain role in the recovery of the disease. First, a scientific arrangement should be made for the patient's rest and work schedule. During the acute attack, in addition to necessary treatment, bed rest should be ensured; during the remission period, there should be appropriate outdoor activities, such as taking a walk after meals, practicing Tai Chi, etc., to adapt to the recovery of psychology and physical strength, while ensuring that the patient has sufficient sleep and rest to consolidate the effect of rehabilitation treatment.

　　(2) Diet: Actively promote the significance of diet in the treatment of chronic cholecystitis. On this basis, some bad eating habits should be given up, such as smoking and drinking. In the process of rehabilitation treatment, it is generally low in fat, low in cholesterol, and easy to digest. At the same time, avoid high-calorie, spicy, and cold foods. During the acute attack or cholecystalgia, it is advisable to fast temporarily to avoid stimulating the gastrointestinal tract and to provide appropriate nutrition intravenously.

　　(3) Psychological treatment: The disease is chronic and recurrent, with symptoms frequently recurring, causing patients to suffer from pain for a long time, which is easy to lead to pessimistic and negative emotions. Through psychological care, patients' psychological and emotional states can be improved, enabling them to be spirited, build confidence, adjust unhealthy lifestyles and behaviors, and cooperate with treatment in a positive attitude. Since patients often suffer from anxiety and fear due to a lack of knowledge about the disease, detailed explanations and explanations should be provided in psychological care to enable them to initially master the knowledge and laws of the disease, eliminate wrong views of the disease, maintain a cheerful spirit and pleasant mood, and thus promote the recovery of the disease. Especially before undergoing ERCP and extracorporeal shock wave lithotripsy, it is necessary to explain repeatedly to eliminate negative emotions and cooperate with the doctor's operation. In addition, it is also necessary to actively explain the characteristics and common triggering factors of chronic cholecystitis, such as improper diet and chronic infection can promote the recurrence of the disease, etc. Through these efforts, patients' self-protection ability can be greatly enhanced, the frequency of recurrence can be reduced, and the quality of life can be improved.

　　(4) Drug treatment: The medication for patients with chronic cholecystitis involves various types of drugs such as antibiotics, analgesics, and choleretics, with many characteristics in use, which directly relate to the efficacy of the medication. For example, when using antibiotics and antispasmodic choleretic drugs, it is necessary to use liver-protecting drugs and extend the duration of medication; when using drugs such as atropine and pethidine, attention should be paid to the occurrence of side effects.

　　(5) Family rehabilitation guidance:

　　① Maintain a good mood: Due to the long duration of the course of chronic cholecystitis and its tendency to recur, short-term hospital treatment and rehabilitation are far from solving the actual problems of patients. Nurses should provide emotional support and psychological guidance according to the actual psychological changes of patients at each stage of recovery, so that they can maintain a good mood in their future long-term life and work. When people are in a state of tension, anxiety, and fear, the regulatory ability of the cerebral cortex and the autonomic nervous system decreases, which can directly lead to gallbladder contraction movement disorders. Only when one has a broad mind and is full of spirit can the normal function of the gallbladder be maintained. In addition, it is necessary to mobilize the support of society and the family, which not only provides convenience for patients' lives but also makes them feel the warmth of the environment and strengthen their confidence in treating the disease.

　　② Correct understanding of the disease: Chronic cholecystitis patients often have many psychological concerns due to long-term treatment without cure or repeated attacks, and are worried about it. Some patients even compare it with 'cancer', which often makes patients bear a heavy psychological burden. Generally speaking, although the disease is difficult to be completely cured, the canceration rate is about 3%, so patients should enhance their confidence and actively treat the disease.

　　③ Reasonable diet arrangement: Improper diet is an important cause of chronic cholecystitis, therefore, reasonable diet is the foundation of treating chronic cholecystitis. Patients should be guided to recognize the importance of good eating habits, quit smoking and drinking, avoid high-fat, high-cholesterol, and high-calorie foods, control the amount of food per meal, and maintain a balanced diet. During acute attacks, it is even more important to control diet.

　　④ Regular follow-up examination: Chronic cholecystitis patients should go to the hospital for regular check-ups according to the severity of their condition, report their recent symptoms and medication to the doctor, accept the doctor's guidance, and undergo an ultrasound examination once a year to prevent early canceration.

　　II. Prognosis

　　The mortality rate of acute cholecystitis is 5% to 10%, almost all occurring in the elderly with purulent infection and other serious diseases. Acute cholecystitis with localized perforation can achieve satisfactory efficacy through surgical treatment; with free perforation, the prognosis is poor, and the mortality rate can reach 25%.