Pediatric acute cholecystitis

　　The main causes of acute cholecystitis and cholangitis are bile stasis and bacterial infection. Bile stasis is often caused by biliary obstruction, with common factors including congenital or inflammatory stricture of the bile duct, anastomotic stricture and reflux after biliary-enteric anastomosis, and biliary sphincter spasm caused by parasites. Bacteria can enter the gallbladder and bile ducts through the blood, lymph, intestines, or adjacent organs, causing inflammation. The bacteria responsible for inflammation are mainly Escherichia coli, accounting for about 70%, with other bacteria including Staphylococcus, hemolytic streptococcus, Proteus, and mixed infections may also occur.

　　At the beginning of the lesion of acute cholecystitis or cholangitis, the mucosa becomes congested and edematous, and then spreads to all layers of the gallbladder or bile duct wall, with thickening of the wall and fibroproteic exudate on the surface. In severe cases of infection, there are suppurative foci in the gallbladder wall, leading to suppurative cholecystitis or/and cholangitis. The younger the age, the more acute the progression of the lesion. Due to simultaneous spasm of the cystic duct or choledochal orifice sphincter, the gallbladder or common bile duct can become distended, leading to localized ischemia and gangrene, which can cause perforation, choleperitonitis. At this time, the child may exhibit signs such as confusion and toxic shock.

　　It can lead to complications such as gallstones, cholangitis, choleperitonitis, and even toxic shock. Common complications include cholecystocele, cholelithiasis, lime milk cholelithiasis, porcelain gallbladder, gallbladder perforation, gallbladder fistula, liver abscess. Gallbladder perforation: on the basis of gangrenous cholecystitis, perforation occurs at the fundus or neck of the gallbladder, usually occurring three days after the onset, with an incidence rate of about 6-12%. After perforation, it can lead to diffuse peritonitis, subdiaphragmatic infection, internal or external biliary fistula, liver abscess, etc., but is often encapsulated by omentum and surrounding organs, forming a pericholecystic abscess, presenting with localized peritonitis signs. At this time, surgery is very difficult, and cholecystostomy must be performed.

　　Diagnosis is not difficult in general, based on the history and physical signs of upper abdominal pain and tenderness in the upper right abdomen. In children seeking medical attention with toxic shock, the possibility of this condition should also be considered. With rapid progression of symptoms, physical signs, and course, accompanied by symptoms such as poor mental state, delirium, confusion, or coma, a diagnosis can be made. In cases with peritoneal effusion, peritoneal puncture can be performed, and if green effusion is aspirated, it can be diagnosed as choleperitonitis.

　　The onset is usually acute and abrupt, with most patients seeking medical attention within 1 day after the onset. The main symptoms are abdominal pain, high fever, and chills, with occasional jaundice. The upper abdominal pain is persistent or intermittent dull pain, bloating, or severe colicky pain. Nausea and vomiting are often accompanied. High fever can cause convulsions, or symptoms such as poor mental state, delirium, or coma. Jaundice is usually mild and transient.

　　Physical examination shows an acute illness appearance, with body temperature that can sustain above 38.5℃, reaching up to 41℃ at the highest. There is marked tenderness and abdominal muscle tension in the upper right abdomen, and sometimes an enlarged gallbladder can be palpated. In some severe cases, symptoms such as abdominal distension, generalized abdominal tension, and tenderness, which are signs of peritonitis, appear only after treatment for toxic shock.

　　Peripheral blood leukocyte count increased, and there may be an increase in neutrophil count, left shift, and toxic granules.

　　1. Pay attention to diet

　　Food should be light and avoid greasy and fried, roasted foods.

　　2. Keep the bowels smooth

　　The six bowels are used for their function of being unobstructed. When there is dampness and heat in the liver and gallbladder, constipation can worsen the symptoms, so maintaining smooth defecation is very important.

　　3. Change the sedentary lifestyle

　　More movement and exercise.

　　4. Cultivate one's temperament

　　Long-term family discord and people with poor mood can trigger or exacerbate this disease. It is important to maintain a broad mind and a pleasant mood.

　　Physical examination shows an acute illness appearance, with body temperature that can sustain above 38.5℃, reaching up to 41℃ at the highest. There is marked tenderness and abdominal muscle tension in the upper right abdomen, and sometimes an enlarged gallbladder can be palpated. In some severe cases, symptoms such as abdominal distension, generalized abdominal tension, and tenderness, which are signs of peritonitis, appear only after treatment for toxic shock.

　　Peripheral blood leukocyte count increased, and there may be an increase in neutrophil count, left shift, and toxic granules.

　　1. During the acute attack of biliary colic, fasting should be given, and nutrition can be supplemented intravenously.

　　2. After the remission of chronic or acute attacks, light fluid diet or low-fat, low-cholesterol, high-carbohydrate diet can be consumed. The daily fat intake should be limited to 45 grams, mainly limiting animal fats, and appropriate amounts of vegetable oil (with choleretic effect) can be supplemented. Cholesterol should be limited to less than 300 milligrams per day. Carbohydrates should be guaranteed at 300 to 30 grams per day. Protein should be moderate, excessive can stimulate bile secretion, and insufficient is not conducive to tissue repair.

　　First, traditional Chinese medicine treatment

　　Mainly for clearing heat and dampness, soothing the liver and regulating qi.

　　Prescription examples: Bupleurum 3g, Scutellaria 9g, Costus 3g, Citrus 9g, Curcuma 9g, Dandelion 15g, Rhubarb 6g, Artemisia 15g, Bupleurum 6g. For severe abdominal pain, add Yuanhu 9g, Melia toosendan 9g.

　　Second, surgical treatment

　　Surgical indications:

　　1. Biliary peritonitis

　　After diagnosis, it should be attempted to perform surgery as soon as possible;

　　2. High fever, toxic shock

　　No significant improvement or deterioration of the condition after short-term correction;

　　3. Complications during the treatment process

　　With liver abscess, pancreatitis, necrotic perforation of the gallbladder;

　　4. Biliary calculi

　　Scarring stenosis that cannot be relieved by surgery. The surgical principle is: to relieve the obstruction of the bile duct, fully drain and reduce the intrabiliary pressure. Preoperative preparation should be active, including blood transfusion, fluid replacement, intravenous administration of antibiotics, and correction of shock measures. If after 3 to 6 hours of active treatment, the symptoms have not improved, emergency surgery should be performed to avoid missing the opportunity for rescue.

　　The surgical method can be determined according to the general condition and local condition of the child. If it is purulent perforating or gangrenous cholecystitis, cholecystectomy should be performed. If the lesion is limited to the gallbladder and the child's general condition is poor, cholecystostomy can also be performed. If there is accompanying inflammation or perforation of the common bile duct, biliary drainage should be performed at the same time as peritoneal drainage.