Acute cholecystitis and cholangitis in children

　　One, Etiology

　　The main causes of acute cholecystitis and cholangitis are bile stasis and bacterial infection. Bile stasis is often caused by biliary obstruction, common factors include 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 duct through the blood, lymph, intestines, or adjacent organs, and the bacteria causing inflammation are mainly Escherichia coli, accounting for about 70%. Other bacteria include staphylococcus, hemolytic streptococcus, Proteus, etc., which can also be mixed infections.

　　Two, Pathogenesis

　　The gallbladder is a blind pouch, and the cystic artery is a terminal artery. During the acute phase, after obstruction of the cystic duct, the secretion of the gallbladder mucosa increases, and the absorption function decreases, leading to gradual increase in intracystic pressure. This can compress the lymph and blood vessels of the gallbladder wall, causing obstruction of lymphatic and blood return, and small arteries can become occluded due to inflammation, leading to focal ischemic lesions. The gallbladder mucosa may appear erosive, ulcerative, and necrotic, and in severe cases, it can cause large areas of necrosis in the gallbladder wall. 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 biliary duct wall, with thickening of the wall and a fibrinous exudate on the surface. In severe cases of infection, there are suppurative foci in the gallbladder wall, forming suppurative cholecystitis and/or 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 may become dilated, leading to localized ischemia and gangrene, causing perforation, and choleperitonitis. At this time, children may present with confusion, toxic shock, and other signs. According to the degree of pathological changes, it can be divided into 4 types:

　　1. Acute simple cholecystitis is more common in the early stage of acute inflammation, with increased intracystic pressure, inflammation and edema of the gallbladder mucosal layer, and varying degrees of inflammatory cell infiltration in the gallbladder wall. The 'gallbladder hydrops' in children belongs to this type.

　　2. Acute suppurative cholecystitis continues to develop inflammation to the muscular layer and serous layer of the gallbladder wall, the entire wall of the gallbladder thickens, blood vessels dilate, and exudation increases; the serosa can be covered by purulent exudate; the bile in the gallbladder becomes turbid and purulent.

　　3. Acute necrotizing cholecystitis leads to continued increase in intracystic pressure, exacerbation of cyst wall edema, which can cause inflammatory occlusion of blood vessels in the gallbladder wall, leading to necrosis of the gallbladder tissue. After necrosis, the gallbladder tissue can perforate slightly when intracystic pressure increases, resulting in purulent bile entering the abdominal cavity, which can cause localized or diffuse peritonitis. Chronic obstruction of the cystic duct can lead to gallbladder hydrops, after the absorption of bile pigments, it becomes chalky bile, calcium secretion increases, and calcareous bile similar to limewater may appear. Calcium deposition in the gallbladder wall can produce 'porcelain gallbladder'. In adults, 50% of such cases develop into gallbladder cancer.

　　1. Delirium belongs to changes in consciousness content:Its pathological basis is the impairment of the entire cortical function of the brain. Previous literature has also classified delirium or equated it with confusion, but delirium is a more severe type of consciousness disorder than confusion.

　　2. Gallbladder perforation:When the cystic duct is obstructed and acute cholecystitis occurs, the intracystic pressure increases, causing circulatory disorders in the gallbladder wall, leading to gallbladder gangrene and perforation.

　　3. Peritonitis:It is inflammation of the parietal peritoneum and visceral peritoneum of the abdominal cavity, which can be caused by bacterial, chemical, or physical injury, and can be divided into primary peritonitis and secondary peritonitis according to the pathogenesis. Acute purulent peritonitis involving the entire abdominal cavity is called acute diffuse peritonitis.

　　4. Early gallbladder cancer:There are no specific clinical manifestations, or only the symptoms of chronic cholecystitis. Early diagnosis is very difficult. Once symptoms such as persistent upper abdominal pain, mass, and jaundice appear, the disease has reached an advanced stage, and various examinations also show abnormalities. Therefore, for patients with discomfort or pain in the gallbladder area, especially middle-aged and elderly patients over 50 years old with gallstones, inflammation, or polyps, regular ultrasound examination should be performed to seek an early and clear diagnosis.

　　The onset is usually acute, with most patients seeking medical attention within 1 day of onset. The main symptoms are abdominal pain, high fever, chills, and occasionally jaundice. The upper abdominal pain is continuous or intermittent dull pain, distension, or severe colicky pain. It is often accompanied by nausea, vomiting, and high fever can cause convulsions, or poor mental state, delirium, and coma, with mild jaundice and a short duration.

　　1. Develop good eating habits, maintain a balanced diet, change eating habits, consume low-fat diet, eat less barbecue meat, eat more fiber-rich foods, and pay attention to intake of sufficient vitamin C, vitamin B, and vitamin E.

　　2. Prevent and treat malnutrition diseases by consuming appropriate amounts of protein and high vitamins; prevent and treat malnutrition diseases to enhance physical fitness.

　　3. Oranges can prevent cholecystitis; eating more fruits, especially oranges, can prevent and reduce the occurrence of cholecystitis.

　　4. Develop good hygiene habits and actively prevent intestinal parasitic diseases and gastrointestinal inflammatory diseases.

　　1. Physical examination shows an acute illness appearance, with body temperature that can sustain above 38.5℃, reaching up to 41℃. 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 of toxic shock appear after treatment, with abdominal distension, tension, and tenderness, and signs of peritonitis.

　　2. The peripheral blood leukocyte count is elevated, and there may be an increase in neutrophils, left shift, and toxic granules.

　　Develop good eating habits, balance the diet, low-fat diet, eat less grilled meat, eat more foods rich in fiber, and pay attention to adequate intake of vitamin C, vitamin B, and vitamin E.

　　First, Non-surgical Treatment

　　Acute cholecystitis can be treated with non-surgical methods, including antispasmodic, analgesic, and anti-infection treatment. Broad-spectrum antibiotics such as Ampicillin (Ampicillin), Gentamicin, Cephalosporins such as Ceftriaxone (Ceftriaxone Sodium), and Metronidazole (Metronidazole) are commonly used antibacterial drugs. Due to the inability to eat much, intravenous fluid replacement is also required to maintain nutrition and water.

　　Second, Traditional Chinese Medicine Treatment

　　Mainly for clearing heat and dampness, soothing the liver and regulating the qi. Example prescription: Bupleurum 3g, Scutellaria 9g, Costus 3g,枳壳9g, Curcuma 9g, Taraxacum 15g, Rheum 6g, Artemisia 15g, Bupleurum 6g. For severe abdominal pain, add Yuanhu 9g, and Melia toosendan 9g.

　　Third, Surgical Treatment Indications

　　1. Once gallbladder peritonitis is diagnosed, it should be attempted to perform surgery as soon as possible.

　　2. High fever, toxic shock, with no significant improvement or deterioration of the condition after a short period of correction.

　　3. Complications such as liver abscess, pancreatitis, and necrotic perforation of the gallbladder during the treatment process.

　　4. Cholangitis stones, stenosis that cannot be relieved without 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 measures to correct shock. If after 3-6 hours of active treatment, symptoms do not improve, 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 concurrent inflammation or perforation of the common bile duct, bile duct drainage and abdominal cavity drainage should be performed at the same time.