Acute cholecystitis during pregnancy

　　1、胆汁淤积90％以上的胆汁淤积由结石嵌顿引起，结石可引起胆囊出口梗阻，胆囊内压增高，胆囊壁血运不良，发生缺血性坏死；淤积的胆汁可刺激胆囊壁，引起化学性炎症，如胰液反流，胰消化酶侵蚀胆囊壁引起急性胆囊炎。

　　2、细菌感染由于胆汁淤积，细菌可繁殖，经血流、淋巴或胆道逆行进入胆囊，引起感染。感染源以革兰阴性杆菌为主70％为大肠杆菌，其次为葡萄球菌、变形杆菌等。

　　3、妊娠的影响妊娠期雌、孕激素大量增加，胆囊壁肌层肥厚，胆囊平滑肌松弛，胆囊收缩力下降胆囊容量增大2倍，胆囊排空延迟加之胆汁中胆固醇含量增高，胆固醇和胆盐的比例改变，胆汁黏稠度增加易发生胆囊炎；妊娠子宫增大压迫胆囊也可引起胆囊炎。急性胆囊炎可单独存在或为急性化脓性胆管炎的一部分。急性胆囊炎由胆道结石梗阻胆囊管引起；胆总管结石或胆道蛔虫常是急性化脓性胆管炎的病因。

　　过去因孕妇不宜做X线胆囊检查，故这方面资料较少。现用超声来评估孕妇胆囊动力学，发现孕妇在早期妊娠胆囊虽未增大，但排空率有轻度下降。妊14周后，胆囊空腹容积增大到15～30ml，残余容积亦增加，为2、5～16ml，胆囊排空率明显下降。妊娠期胆囊的变化可能与激素有关。雌激素降低了胆囊黏膜上皮对钠的调节而使黏膜吸收水分能力下降，势必影响胆囊的浓缩功能。胆囊排空减慢与孕酮增多有关食物在消化过程中引起胆囊收缩素（cholecystokinin）释放，使胆囊收缩排空。孕酮降低胆囊对胆囊收缩素的反应，同时又抑制胆囊平滑肌收缩而使胆囊排空缓慢。妊娠对胆汁成分和分泌也有影响。胆汁酸盐、磷脂和胆固醇是胆汁的重要化学成分并保持一定的比例，使形成一种胶态溶液。这种比例的改变特别是胆汁酸、磷脂的减少或胆固醇增多，均可使胆固醇从过饱和的胆汁中结晶、沉淀而形成结石鶒。孕妇到妊中末期胆汁中胆固醇的分泌增加，胆固醇饱和度增高。同时从早妊开始胆汁酸池容积增加胆汁酸中鹅去氧胆酸的比例下降而胆酸比例上升。继之与胆酸合成率增加相反，鹅去氧胆酸与去氧胆酸下降。这种比例改变影响了胆固醇在胶态溶液中的溶解度使胆固醇易析出结晶。加上孕酮降低胆囊收缩力，使胆囊排空时间延长，残余容积增多，为胆石形成与细菌繁殖创造条件而易致胆道感染。

　　1. Gallbladder perforation

　　It often occurs in the necrotic gallbladder wall at the bottom of the gallbladder or at the site of gallstone impaction, causing cholestatic peritonitis. 50% of patients have gallbladder perforation wrapped by omentum and surrounding tissues, forming a perigallbladder abscess; 20% of patients form internal fistulas with adjacent organs (gastrointestinal tract); about 10% of patients may develop biliary stone intestinal obstruction.

　　2. Acute suppurative cholangitis

　　Biliary obstruction and infection are the basic factors of the disease. Primary or secondary common bile duct stones, biliary ascariasis, and bile duct stenosis caused by bile duct obstruction are the pathological basis of acute suppurative cholangitis. Bile stasis during biliary obstruction is conducive to the proliferation of bacteria in bile, and secondary bacterial infection leads to congestion and edema of the biliary mucosa. The increased pressure in the biliary tract aggravates the degree of biliary obstruction.

　　3. Biliary pancreatitis

　　The occlusion of gallstones at the lower end of the common bile duct or spasm of the Oddi sphincter, or edema of the duodenal papilla, causes temporary obstruction of the Vater壶腹 and pancreatic duct. Bile refluxes through the 'common channel' into the pancreatic duct, triggering acute pancreatitis.

　　It usually occurs after a heavy meal or overexertion, and nocturnal occurrence is more common. The pain is usually sudden and occurs in the upper right abdomen, and may also occur in the middle of the upper abdomen or below the xiphoid process, with intermittent exacerbation. The pain can radiate to the right shoulder, the subscapular angle of the right shoulder, or the right腰部. A few patients may radiate to the left shoulder. 70% to 90% of patients may have nausea and vomiting; about 80% of patients may have chills and fever; about 25% of patients may have jaundice. Severe infection may lead to shock. There is significant tenderness in the upper right abdomen, and an enlarged gallbladder can be palpated under the right costal margin. Abdominal muscle tension and rebound pain may occur when cholecystitis is complicated by peritonitis. Some patients may have a positive Murphy sign. In the late pregnancy, due to the concealment of the enlarged uterus, the abdominal signs may not be obvious.

　　Bacterial infection due to cholestasis allows bacteria to multiply, and they can enter the gallbladder via blood flow, lymphatic or retrograde bile duct, causing infection. The source of infection is mainly Gram-negative bacilli, with 70% being Escherichia coli, followed by Staphylococcus, Proteus, and others. Therefore, attention should be paid to the prevention of hyperlipidemia, gallstones, and cholestasis to prevent infection.

　　1. Leukocyte count is increased with left shift: if there is purulent or gangrenous cholecystitis or perforation, the white blood cell count is significantly elevated. Based on the slightly elevated white blood cell count during pregnancy, this is not a very specific indicator.

　　2. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are slightly elevated. When there is obstruction of the common bile duct, bilirubin levels rise. Alkaline phosphatase (ALP) is slightly elevated, but due to the influence of estrogen during pregnancy, the latter is not very helpful.

　　3. Ultrasound examination is the best diagnostic method for pregnancy, especially in diagnosing cholelithiasis, with a false positive and false negative rate of 2% to 4%. Under ultrasound, gallbladder enlargement and thickened walls can be seen. Most acute cholecystitis is accompanied by cholelithiasis, so gallstone light spots and echoes, sedimentation in bile, and poor gallbladder contraction can be seen. When there is biliary duct obstruction, there is dilation of the common bile duct, with a diameter greater than 0.8 cm. Sometimes, echoes of gallstones or ascaris in the common bile duct can also be seen. Stuffer et al. reported that in 93% of patients, the gallbladder was scanned non-fasting, and about 95% were found to have gallstones. Of course, it is still better to perform a 12-hour fasting examination.

　　Firstly, diet

　　1. Choose foods rich in high-quality protein with relatively low cholesterol content, such as fish, lean meat, dairy products, and soy products, and control the intake of foods such as animal liver, kidney, brain, or fish roe.

　　2. Ensure the supply of fresh vegetables and fruits. Leafy vegetables can provide necessary vitamins and a certain amount of dietary fiber, which should be ensured. Foods such as yogurt, jujube, and brown rice are also beneficial to patients.

　　3. Reduce the intake of animal fats, such as fatty meat and animal oils, and increase the proportion of vegetable oils such as corn oil, sunflower seed oil, peanut oil, and soybean oil.

　　4. Avoid spicy foods such as chili, curry, and other strongly刺激性 foods, as well as coffee and strong tea.

　　Secondly, postoperative diet

　　On the 1st day after surgery: After the intestinal peristalsis is restored, you can drink water. If there is no discomfort such as bloating after drinking water, you can start consuming liquid food. Avoid milk and soy milk.

　　On the 2nd day after surgery: If there is no discomfort after consuming liquid food, you can eat light semi-liquid food for two days.

　　On the 4th day after surgery: After consuming light semi-liquid food without discomfort, you can start eating regular food (but focus on low-fat, low-cholesterol, and easy-to-digest foods, with moderate high-quality protein, and eat more bile-inducing foods and fruits rich in vitamin C).

　　Avoid spicy foods (as they can stimulate the secretion of cholecystokinin by the gastrointestinal tract, causing bile fistula after surgery). Avoid animal fats. For example: fatty meat, lard, pork head, pork feet, cream cakes. Avoid fried and oil-fried foods. For example: fried dough sticks, fried eggs, fried chicken legs. Avoid foods high in cholesterol: yolks, fatty meat, internal organs of animals, fish roe.

　　On the 8th day after surgery: The fat and protein content in the food can be gradually increased. After 1 month, the diet can be restored to normal levels.

　　Congee, lotus root starch, almond cream, and other foods. High-quality protein sources such as milk, lean meat, egg whites, and soy products. Bile-inducing foods such as spinach, green bamboo shoots, onions, and tomatoes. Fruits rich in vitamin C such as oranges. Easy-to-digest plant oils with low cholesterol content such as soybean oil, rapeseed oil, and peanut oil.

　　Light, semi-liquid foods such as rice porridge, vegetable porridge, soup, and dumpling soup. Low-fat, low-cholesterol diets such as chicken, Chinese hake, freshwater fish (carp, silver carp, grass carp, crucian carp), yellow croaker, lean pork, lean mutton, lean beef, and skimmed milk powder.

　　The treatment principle for acute cholecystitis complicated with pregnancy is conservative treatment, appropriate diet control, symptom relief, administration of antibiotics to prevent infection, elimination of complications, and surgical treatment when necessary.

　　First, conservative treatment

　　1. Diet control

　　Severe patients should be on a total fasting diet, and mild patients should avoid fatty diets during the acute phase of symptom onset. During the remission period, high-sugar, high-protein, low-fat, and low-cholesterol diets can be provided. Adequate fluid intake, vitamin supplementation, and correction of water and electrolyte imbalances should be provided.

　　2. Symptomatic treatment

　　Antispasmodic analgesics can be used, such as atropine intramuscular injection, or pethidine (Duocolding) intramuscular injection. Nitroglycerin, methadone, indomethacin (消炎痛) and other drugs also have antispasmodic analgesic effects and can be appropriately selected. During the symptom relief period, it is appropriate to take bile-promoting drugs, such as oral magnesium sulfate 50%, which can relax the Oddi sphincter and promote gallbladder emptying. Other bile-promoting drugs include dehydrocholic acid, ursodeoxycholic acid, and hydroxymethyl nicotinamide (bile acid).

　　3. Anti-infection treatment

　　Cephalosporins, a broad-spectrum antibiotic, should be chosen as the first choice as it has no adverse effects on the fetus. Among them, cefoperazone (Xianfengbi) has a concentration in bile that is 100 times higher than that in blood, and it is an effective antibiotic for treating severe biliary tract infections.

　　Second, surgical treatment

　　Surgical treatment is mainly suitable for patients with gradually worsening symptoms during treatment, failure of conservative treatment, or the occurrence of serious complications, such as obstructive jaundice, cholecystitis with purulent effusion, perforation of gangrenous cholecystitis, and pericholecystic abscess with diffuse peritonitis. Unless the condition is critical, surgery during the second trimester of pregnancy should be chosen. If the delivery date is approaching, it is best to wait until after delivery for surgical treatment. The main surgical methods include cholecystostomy drainage, common bile duct drainage, cholecystectomy, or local abscess drainage under laparoscopy, the latter has little effect on the fetus.