cholelithiasis
Introduction
Introduction to cholelithiasis Cholelithiasis refers to the occurrence of stones in any part of the biliary system (including the gallbladder and bile duct). The main symptoms are abdominal pain (pain or cramps, severe pain), nausea and vomiting, chills, fever and jaundice, and the types and components of stones. Not exactly the same, the clinical performance depends on whether the stones are caused by the location and extent of infection, biliary obstruction and obstruction. Cholelithiasis is a common disease worldwide, and China is no exception. In the natural population, the incidence of cholelithiasis is about 10%. The results of domestic autopsy report that the incidence of cholelithiasis is 7%, which is more common in female patients, especially in obese women, the ratio of male to female is about 1:2. basic knowledge The proportion of illness: 0.052% Susceptible people: no specific population Mode of infection: non-infectious Complications: acute cholecystitis, liver abscess, biliary bleeding
Cause
Cause of cholelithiasis
(1) Causes of the disease
The cause of gallstone formation has not yet been fully clarified. It may be a comprehensive factor. The components of gallstones include cholesterol, bile pigment, calcium salt, mucin and other organic and inorganic substances. According to the different stone composition, gallstone is usually classified into cholesterol. Stones, gallstones and mixed stones (cholesterol, bile pigment, calcium and other organic matter, mixed with inorganic substances) 3 types, years of research have proved that gallstones are affected by many factors, after a series of pathology Formed by physiological processes, these factors include changes in bile composition, supersaturated bile or cholesterol in supersaturation, precipitation of bile vesicles and cholesterol monocrystals, dysfunction of nuclear factor and anti-nucleating factor, abnormal gallbladder function, oxygen Participation of free radicals and biliary bacteria, parasitic infections, etc.
1. Causes of gallstones
(1) Metabolic factors: bile salts, lecithin and cholesterol in normal gallbladder bile coexist in a stable colloidal ion group. The ratio of cholesterol to bile salt is generally between 1:20 and 1:30. Some metabolic causes cause bile salts, lecithin to decrease, or increase the amount of cholesterol. When the ratio is less than 1:13, cholesterol precipitates and forms larger stones after polymerization, such as late pregnancy, the elderly, blood cholesterol. The content is obviously increased, so many pregnant and elderly people are susceptible to this disease; and if the liver function is impaired, the reduction of bile acid secretion is also easy to form stones, congenital hemolysis patients, due to long-term large amount of red blood cell destruction, can produce bile pigmentation stone.
(2) Biliary infection: A large number of literatures have recorded that typhoid bacillus, streptococcus, B. bulgaricus, actinomycetes, etc. have been cultivated from the core of gallstones, which shows that bacterial infection plays an important role in the formation of stones. In addition to inflammation, its colonies, exfoliated epithelial cells, etc. can become the core of the stone, and the protein component of the inflammatory exudate in the gallbladder can be a scaffold for the stone.
(3) Others: such as stasis of bile, low pH of bile, lack of vitamin A, etc., are also one of the reasons for the formation of stones.
2. Causes of bile duct stones
(1) secondary to gallstones and stones for some reasons gallbladder stones moved down to the common bile duct, called secondary bile duct stones, mostly in the case of long-term cholecystitis, expansion of the cystic duct, small stones, The incidence rate is 14%.
(2) Primary bile duct stones may be associated with biliary tract infection, bile duct stricture, and biliary parasitic infection (especially aphid infection). When biliary tract infection occurs, Escherichia coli produces -glucuronidase, which is highly active. The bound bilirubin in the bile is hydrolyzed into free bilirubin, which in turn combines with calcium ions in the bile to form water-insoluble bilirubin calcium, which becomes a biliary calcium calculus after precipitation, and is caused by biliary ascariasis. Biliary tract infection, more likely to occur such stones, this is due to mites, corneas, eggs and the bacteria they bring, inflammatory products can become the core of the stone, bile duct stenosis will affect the flow of bile, resulting in bile Retention, bile pigment and cholesterol are more likely to precipitate to form stones. When combined with chronic inflammation, the formation of stones is more rapid. In short, the infection of the biliary tract and obstruction in the formation of stones are mutually causal and mutually promoted.
(two) pathogenesis
1. The mechanism of gallstone formation The basic factors of gallstone formation are: changes in the physical and chemical state of bile, biliary stasis and infection, etc., often combined with two or more factors, and changes in the physicochemical properties of bile cause the secretion of bile pigment or cholesterol. Forming stones; bile stasis can cause excessive absorption of water in bile, excessive concentration of bile, increase of bile pigment concentration, hypersaturation of cholesterol, etc., can promote the formation of gallstone; bacterial infection can cause inflammatory edema, cell infiltration and chronic biliary tract Period of fibrosis, leading to thickening, narrowing or even occlusion of the biliary wall, causing bile stasis, cells exuded during inflammation or exfoliated epithelium, bacterial flora, aphid residues and eggs can also serve as the core of the stone, promoting gallstone formation .
(1) The formation mechanism of cholesterol stones: If the cholesterol content is too saturated in the bile, it is easy to precipitate to form cholesterol stones (such as long-term eating high-fat diet). Normally, certain concentrations of bile salts and lecithin in bile can be It is a mixture of cholesterol and protein, which is suspended in bile without precipitation. In some intestinal diseases, the loss of bile salts promotes the precipitation of cholesterol and forms stones.
(2) Mechanism of bilirubin stone formation: The concentration of free bilirubin in bile can be combined with calcium in bile to form insoluble bilirubin calcium, and bilirubin in normal bile is combined with glucuronic acid. Ester is not free, glucuronidase in intestinal bacteria such as Escherichia coli has the effect of decomposing the above esters to release bilirubin, so there are intestinal bacterial infections, intestinal ascariasis and biliary inflammation. It is easy to form bilirubin stones. In addition, the increase of bile pigment content (such as excessive red blood cell destruction), the increase of calcium in bile and the increase of acidity of bile can promote the formation of such stones.
2. The type of pathological gallstone can be divided into three categories according to its composition:
(1) Cholesterol stones: The main component of the stone is cholesterol, mostly oval (single-shot) or multi-faceted (multiple), the surface is smooth or slightly nodular, yellow or yellowish white, soft and soft, the profile is Radial line pattern, X-ray film is not developed, such stones are mostly in the gallbladder, often single, large in size, up to several centimeters in diameter. Such stones are less in Europe than in Europe and America, and their incidence is not more than gallstone. 20% of the disease.
(2) bile pigmented stones: the stone components are mainly bilirubin calcium, which may contain a small amount of cholesterol, mostly mud-like, soft and brittle, some like mud, some like sand, brown and black Or brownish red, the size varies, because there is less calcium, X-ray film is not more developed, sand grain size is 1 ~ 10mm, often more than one, mostly in the liver, in the outer bile duct.
(3) Mixed stones: separated by two or more main components such as cholesterol, bile pigment and calcium salt. They have different shapes and are multi-faceted particles with smooth surface, rounded edges, dark green or brown, and the cut surface is ring-shaped. Layered or like trunk trunks or radial, due to more calcium, sometimes developed on X-ray film (called positive stones), mostly in the gallbladder, also in larger bile ducts, size, number , often more than 20 to 30, the mixed cholelithiasis-based cholelithiasis is the most common in China, accounting for more than 90% of all cholelithiasis cases.
Characteristics of cholelithiasis in China:
1 gallstone type: mixed pigmented sand-like stones far more than cholesterol stones.
2 The location of the disease: the bile duct is more than the gallbladder, and the incidence of intrahepatic bile duct stones is also higher.
3 Causes: Previous statistics of biliary ascariasis played an important role in the formation of gallstones. In recent years, changes in dietary hygiene and nutritional levels have changed.
Prevention
Cholelithiasis prevention
1. The primary prevention of gallstones is mainly:
1 Because the formation of gallstones is related to the excessive saturation of cholesterol in bile, controlling excessive intake of cholesterol in the diet is an important means to maintain a certain stability of bile. In daily life, rationally adjust the dietary structure and eat less cholesterol. More fatty foods, foods rich in high protein, vegetables and fresh fruits, especially women in pregnancy should pay enough attention. In addition, appropriate physical exercise should be carried out to prevent excessive accumulation of fat in the body.
2 Regular physical examinations every year, including liver and gallbladder B-ultrasound, for early detection and early treatment.
2. Intrahepatic bile duct stones are mainly for secondary intrahepatic bile duct stones. Extrahepatic bile duct stones and biliary ascariasis are the main causes of intrahepatic bile duct stones. Therefore, the primary prevention of intrahepatic bile duct stones mainly includes the following: Two aspects: prevention and treatment of biliary ascariasis, biliary ascariasis is an important cause of hepatolithiasis, and its prevention and treatment can not be ignored.
Complication
Complications of cholelithiasis Complications, acute cholecystitis, liver abscess, biliary bleeding
The most serious complications of cholelithiasis are acute cholecystitis of varying severity, including gangrenous, emphysema cholecystitis, peribiliary abscess and perforation. Chronic calculous cholecystitis is also a common complication of gallstones. Complications of gallstones include pancreatitis, liver abscess, cholangitis, ascending hepatitis, portal venous inflammation, Mirizzi syndrome and gallbladder cancer, in addition to chronic cholecystitis (almost every patient with gallstones has chronic cholecystitis) In addition, approximately 20% of patients with gallstones develop complications, and with age, the incidence of complications increases significantly.
Mirizzi syndrome and confluence stones:
Mirizzi syndrome is a rare complication of cholelithiasis. It is a group of symptoms in which the gallstone is invaded in the neck of the gallbladder or the cystic duct compresses the common hepatic duct and causes the stenosis of the common hepatic duct. It is incarcerated in the three-tube confluence, called For the confluence of stones, the three main points for diagnosing Mirizzi syndrome are: gallstones incarcerated in the gallbladder neck; calculus compression and calculus itself stimulate inflammation of the incarcerated site, fibrosis leads to partial mechanical obstruction of the common hepatic duct; recurrent bile duct Inflammation or biliary inflammatory cirrhosis caused by obstruction, the clinical symptoms are mainly upper right abdominal pain, jaundice, fever and other manifestations of cholangitis, Mirizzi syndrome and confluent stones are not developed in gallbladder angiography (regardless of oral or intravenous), B-ultrasound The positive rate of CT diagnosis of gallbladder neck stones is low, so it is often diagnosed by direct cholangiography such as PTC and ERCP. Dietrich et al believe that Mirizzi syndrome may occur only when there is an anatomic abnormality parallel to the cystic duct and the common hepatic duct, but most scholars believe that it is not Thus, the surgical treatment of Mirizzi syndrome is often difficult, and sequelae such as bile duct stricture and fistula formation often remain after surgery.
Common complications of common bile duct stones are different degrees of cholangitis and bile duct bacterial infection, followed by gallstone pancreatitis, liver abscess, sepsis, biliary fistula and gallstone intestinal obstruction, etc., due to gallstone compression caused by common bile duct mucosal ulcer In addition, it is rare to cause stenosis of the common bile duct. In China, bile duct mucosal ulcers, necrosis and hemorrhage may be caused by gallstone compression. In western countries, biliary tract bleeding is rare in patients with common bile duct stones. In addition, long-term recurrent cholangitis is caused by common bile duct stones. Astragalus can be further developed into biliary cirrhosis.
Symptom
Symptoms of cholelithiasis Common symptoms Gallbladder hydrops extrahepatic bile duct stones cold sweat biliary colic biliary obstruction pigmentary gallstones sputum gas gallbladder empyema biliary obstruction bile excretion blocked
In general, when gallstones occur in different parts of the biliary tract, the symptoms are not exactly the same. The clinical manifestations of gallstones, extrahepatic bile duct stones and intrahepatic bile duct stones are described respectively.
1. Clinical manifestations of gallstones
(1) biliary colic or upper abdominal pain: biliary colic is a kind of visceral pain, mostly due to temporary obstruction of the cystic duct by stones. If the gallbladder has acute inflammation, the gallbladder wall may have different degrees of congestion. Pathological manifestations such as edema or thickening. In typical cases, patients often have recurrent epistatic pain in the upper abdomen, often located in the right upper abdomen or upper abdomen. The severe cases are colic, and the pain can be aggravated by eating; some cases of pain can be At night, colic attacks occur mostly in those who lack physical activity or lack of exercise (such as long-term bedridden). The typical episodes of biliary colic are mostly aggravated within 15min or 1h, and then gradually weakened; about 1/3 The pain of the patient may suddenly occur. In a few patients, the pain may be abruptly terminated. For example, if the pain lasts for 5-6 hours, it often indicates that there is acute cholecystitis. About half of the patients often have pain in the right scapular region, and the back is centered or right. On the shoulders, patients with biliary colic are often uncomfortable. The intermittent period of pain can be several days, weeks, months or even years. It is impossible to predict a characteristic of biliary colic in the time of attack.
(2) nausea and vomiting: Most patients with angina pectoris accompanied by nausea and vomiting, severe with cold sweat, biliary colic vomiting often have a certain degree of relief, vomiting duration is generally not very long.
(3) Indigestion: Indigestion is manifested as intolerance to fat and other foods, often manifested as excessive hernia or abdominal distension, postprandial fullness and early satiety, heartburn and other symptoms, dyspeptic symptoms may occur with the presence of gallstones Or coexist with cholecystitis and so on.
(4) chills, fever: when complicated with acute cholecystitis, patients may have chills, fever; when gallbladder water secondary bacterial infection forms gallbladder empyema or gangrene, perforation, chills, fever is more significant.
(5) Astragalus: simple gallstones do not cause jaundice, only when accompanied by common bile duct stones or inflammation (cholangitis), or gallbladder stones discharged into the common bile duct can cause jaundice, some patients with skin itching.
(6) Right upper abdomen tenderness: Some patients with simple gallstones may have tenderness in the right upper abdomen during physical examination. For example, when acute cholecystitis is complicated, the right upper abdomen is obviously tender, muscle tension, sometimes gallbladder and swollen gallbladder, Murphy sign positive. .
(7) biliary syndrome: due to biliary tract disease such as gallstones, reflex caused by cardiac dysfunction or heart rhythm changes, resulting in a group of clinical syndrome called biliary heart syndrome, and the patient's coronary artery or heart has no device Qualitative lesions, the mechanism of coronary heart disease-like symptoms caused by cholelithiasis is due to cholelithiasis, biliary obstruction, increased intra-biliary pressure, can be through the spinal nerve reflex (the gallbladder and the spinal nerve of the heart, intersect at the thoracic 4 to 5 spinal nerve) That is, the visceral-visceral nerve reflex pathway causes coronary vasoconstriction and blood flow is reduced. In severe cases, myocardial hypoxia may occur, and angina, arrhythmia or electrocardiogram changes may occur.
2. Clinical manifestations of extrahepatic bile duct stones
Extrahepatic bile duct stones refer to stones that occur in the common hepatic duct and common bile duct. The most common is common bile duct stones. About 15% of patients with gallstones can coexist with common bile duct stones, and they coexist with age. The proportion is increased. Conversely, about 95% of patients with common bile duct stones have gallstones and common bile duct stones. The stones are mostly located at the lower end of the common bile duct and the duodenum ampulla. When the gallstone causes obstruction of the common bile duct, typical symptoms can be produced. With physical signs, its clinical manifestations are mainly related to biliary obstruction, increased pressure in the bile duct, obstruction of bile excretion and bacterial infection of bile. Typical symptoms include biliary colic, chills, high fever and jaundice, which are called triple joints of common bile duct stones. Sign, that is, charcot sign.
(1) Upper abdominal pain or cramps: About 90% of patients with common bile duct stones have pain or cramps in the upper abdomen or upper right abdomen, which can be radiated to the right shoulder and back. The cause of colic is that the stones are invaded at the lower end of the common bile duct. After the ampulla, the common bile duct obstruction and stimulation of Oddi sphincter and bile duct smooth muscle, colic can be induced after eating greasy food, or position change, the body is induced by bumps, heavy can be accompanied by cold sweat, pale, nausea and vomiting And other symptoms.
(2) chills and high fever: about 75% of patients with common bile duct stones, after the onset of biliary colic, due to biliary bacterial infection caused by chills and high fever, body temperature up to 40 ° C, chills, high fever is caused by infection into the liver Retrograde spread, pathogenic bacteria and their toxins through the hepatic sinus, hepatic vein to the systemic circulation leading to systemic infection results, a small number of common bile duct stones, such as acute bile duct obstruction, accompanied by severe intra-biliary infection caused by acute suppurative inflammation When it is called acute suppurative cholangitis or severe acute cholangitis, there may be clinical manifestations of systemic poisoning such as hypotension, toxic shock and sepsis.
(3) Astragalus: About 70% of patients with common bile duct stones, jaundice can occur in the upper abdominal cramps, chills, and high fever after 12 to 24 hours. The mechanism of jaundice is because the stones are incarcerated in the abdomen and can not be loosened. Common bile duct obstruction can not be relieved, often accompanied by itchy skin, urine is dark brown, feces color is light or terracotta color, most patients with jaundice can be volatility, can be relieved in about 1 week, due to bile duct expansion The reason why the stones are loose or the stones are discharged into the duodenum through the loose sphincter, some scholars believe that the jaundice appears intermittently or as a characteristic of common bile duct stones.
(4) Upper abdominal tenderness: There is deep tenderness under the xiphoid process and right upper abdomen during physical examination. People with severe inflammation often have abdominal muscle tension, and the liver area may have snoring pain. For example, the cystic duct is smooth, and sometimes it can be swollen and swollen. The gallbladder.
3. Clinical manifestations of intrahepatic bile duct stones
The stones that originate in the upper part of the bifurcation of the left and right hepatic ducts are called intrahepatic bile duct stones. The stones can be widely distributed in the intrahepatic bile duct system, or scattered in a branch of the intrahepatic bile duct, or in a certain branch. In the bile duct of the liver lobe or liver segment, a large amount of data indicates that the stone is more common in the left hepatic bile duct. The main clinical manifestations are:
(1) Upper abdominal pain: The symptoms of intrahepatic bile duct stones are often atypical. Small stones scattered in the intrahepatic bile duct usually do not cause symptoms, or only persistent pain or dull pain in the right upper abdomen and chest and back. There is no colic.
(2) Astragalus: General intrahepatic bile duct stones do not appear jaundice, only when the bile ducts of bilateral or left and right lobe are blocked by stones, most of them may be accompanied by biliary colic or more severe pain. If you have a biliary infection, you can also have chills and high fever. In severe cases, you can develop acute suppurative cholangitis.
(3) upper abdominal tenderness: physical examination often touches the swollen liver and tenderness, a few may have liver sputum pain, most data show that intrahepatic bile duct stones often coexist with common bile duct stones, so when patients have cholelithiasis Typical symptoms (colic, chills and high fever, jaundice) are often symptoms of common bile duct stones.
Examine
Cholelithiasis examination
Laboratory inspection
1. Bilirubin metabolism: When gallstones cause bile duct obstruction, serum total bilirubin is increased, which is mainly combined with increased bilirubin, that is, the ratio of bilirubin to total bilirubin is often greater than 40%; Obstruction, the ratio can be greater than 60%, the urinary bilirubin content is significantly increased, while the urinary bile principle is reduced or absent, and the fecal biliary tract is also reduced or disappeared.
2. Serum enzymology: Alkaline phosphatase (ALP) was significantly increased in obstructive jaundice, often three times higher than normal; -glutamyltranspeptidase (-GT) was also significantly increased; Serum aminotransferase (ALT, AST) showed a mild to moderate increase; lactate dehydrogenase (LDH) generally increased slightly.
3. Prothrombin time measurement: prothrombin time prolonged when bile duct obstruction, prothrombin time can return to normal after application of vitamin K, but if the long-term obstruction of bile duct causes serious liver damage, even if injected with vitamin K, thrombin The original time will not return to normal, suggesting that the liver cells make the original barrier to thrombin.
4. Determination of serum iron and copper content: The ratio of serum iron to serum copper in normal people is 0.8-1.0. When the biliary tract obstructs, the serum copper content increases, making the ratio of iron to copper less than 0.5.
5. Duodenal drainage fluid examination: It has been used less frequently, mainly because the drainage fluid collection is troublesome and cannot be accepted by most patients. Currently, there are two methods for collecting duodenal juice, namely duodenal insertion. In the tube method and retrograde cholangiography, it is generally necessary to use the octapeptide cholecystokinin to stimulate the gallbladder contraction, then collect the bile-rich duodenal juice, and then observe the liquid under the microscope, if it is found that cholesterol crystals and Or) biliary pigment calcium salt particles are important for the diagnosis of cholelithiasis.
Film degree exam
1. X-ray abdominal plain film, oral gallbladder angiography and venous cholangiography: traditional X-ray plain film, oral cholecystography and intravenous cholangiography have been used less frequently in recent years.
(1) Mixed calcium-containing stones may be developed on X-ray films, while simple cholesterol stones and biliary pigments cannot be developed on X-ray films; 10% to 20% of gallstones are calcium-positive stones. On the flat film of the abdomen, 80% to 90% of the stones are negative stones, which cannot be seen on the plain film.
(2) The gallbladder development rate of oral gallbladder angiography is very high, up to 80%, so it can be found in the gallbladder or even in the extrahepatic bile duct. However, since the development is affected by many factors, the diagnosis of gallstones is diagnosed. The accuracy rate is only 50% to 60%.
(3) Intravenous cholangiography can understand the hepatobiliary duct, the presence or absence of stones and obstruction in the common bile duct, and the presence or absence of dilatation of bile ducts. Because the venous cholangiography is affected by many factors, the accuracy of diagnosis is not very high. Up to 50%.
2. Endoscopic retrograde cholangiography (ERCP): endoscopic retrograde cholangiography is a method of intubating the duodenal papilla with a fiber duodenoscope, injecting a contrast agent, showing the biliary system and pancreatic duct, and treating the gallstone The diagnosis of the disease is extremely valuable. After the angiography, the entire bile duct system and gallbladder can be clearly displayed. Therefore, whether there are stones in the bile duct and gallbladder, whether there is dilatation or stenosis in the bile duct, and the positive rate of ERCP in the diagnosis of common bile duct stones can reach 95. About %, if the bile duct is narrow and the obstruction factor can only show the image of the bile duct below the obstruction, and the presence or absence of stones in the bile duct above the obstruction is often not displayed. In this case, other examination methods such as PTC should be combined to further confirm the diagnosis.
3. Percutaneous transhepatic cholangiography (PTC): Percutaneous transhepatic cholangiography is suitable for obstructive jaundice of unknown cause, diagnosis of biliary stones, stenosis and differentiation with other bile duct diseases, under the guidance of X-ray TV or B-ultrasound, The success rate of percutaneous puncture can reach 80%100%. PTC can clearly show the whole biliary system inside and outside the liver. It can provide the correct anatomical relationship, lesion location, extent and nature of the biliary tract. The diagnosis and differential diagnosis of this disease are Larger help, PTC diagnosis of common bile duct stones rate of about 90%, due to PTC is a damage test, there are certain complications, such as bleeding, bile leakage, infection or cholangitis.
4. CT or MRI examination: When the lesion is not detected by B-mode ultrasound, CT or MRI can be further examined. CT is highly sensitive to calcium-containing stones. It can often show small stones with a diameter of 2 mm. CT diagnosis of gallstones The accuracy rate can reach 80%90%. The flat blood can show the intrahepatic bile duct, the total hepatic duct, the common bile duct and the gallstone containing high calcium. After oral or intravenous contrast agent, CT can show bile. Pigmented stones and mixed stones can also show sediment-like stones in the gallbladder. CT is sometimes easy to miss diagnosis of simple cholesterol stones. In recent years, MRI diagnostic techniques have been gradually applied in clinical practice, and the diagnostic accuracy rate of gallstones is also very high. High, because CT or MRI examinations are more expensive, they are generally not the preferred method of inspection.
5. Intraoperative cholangiography: This method is an excellent supplement for patients who have not been diagnosed with preoperative biliary tract disease. The method is simple and safe. Intraoperative cystic cannulation or direct puncture of the common bile duct, the concentration is 15%. 20% of the contrast agent is about 30ml, you can get a clearer image of the biliary system. Combined with the findings, you can fully understand the condition of the liver and gallbladder, which is conducive to diagnosis and treatment, and can reduce the residual stone rate of the biliary tract. This check.
6.B-type ultrasound examination: Ultrasound examination has the advantages of convenient examination, non-invasiveness, repeated multiple times, high diagnostic accuracy, etc. It has become the first choice for the diagnosis of cholelithiasis, whether it is gallstone, extrahepatic bile duct stone or intrahepatic Biliary stones, on the B-ultrasound image, the stones appear as echo-enhanced light clusters or spots, often accompanied by sound and shadow, the typical manifestations of gallstones are as follows:
(1) One or more strong echogenic light groups in the gallbladder.
(2) The echo light cluster can move as the patient's body position changes.
(3) There is clear sound and shadow behind the strong echo light group.
The stones located at the lower end of the common bile duct are often difficult to display when interfered with by the gas of the gastrointestinal tract. Therefore, the diagnostic accuracy of B-ultrasound to the lower end of the common bile duct is low, and false positive or false negative can also occur due to gallstone structure. Different composition and location, there may be some atypical manifestations, such as gallstones filled with stones, due to lack of bile, the sonogram can be inconspicuous and only sound shadow, loose stones can not appear typical acoustic shadow, gallbladder atrophy and stones It can cause substantial echo and the sound shadow is not clear. It is generally believed that the correct rate of diagnosis of gallstones by B-ultrasound can reach 95%-97%, and the correct rate of diagnosis of common bile duct stones is 53%-84%. Intrahepatic bile duct stones The correct rate is 80% to 90%, especially for permeable X-ray stones and when the gallbladder angiography is not developed, B-ultrasound can make a correct diagnosis.
Diagnosis
Diagnosis and diagnosis of cholelithiasis
Can be diagnosed based on clinical performance and laboratory tests.
Differential diagnosis
1. Diseases differentiated from biliary colic
(1) biliary ascariasis: simple biliary ascariasis is more common in adolescents, often manifested as a sudden onset of xiphoid colic or drill-like pain, a small number of patients with knee-thoracic position can reduce pain, often pain Paroxysmal seizures, remission period can be asymptomatic as normal people, most patients with vomiting, even vomiting bile, there are vomiting mites, although the symptoms of pain are very heavy, but the abdomen often lacks signs, this is The characteristics of biliary ascariasis, such as B-ultrasound examination, sometimes can be found in the bile duct image. In general, according to the characteristics of pain and B-ultrasound examination, the diagnosis rate of this disease can reach more than 90%.
(2) acute pancreatitis: pain is often induced after overeating, the pain is persistent persistent upper abdominal pain, sometimes with knife-like pain, often to the left lumbar radiation, banded traction pain, patient blood, urine Amylase is often significantly elevated; B-mode ultrasound can be seen diffuse or localized enlargement of the pancreas; CT or MRI examination can also find pancreatic enlargement and other important value for diagnosis, such as shock, abdominal puncture, hemorrhagic ascites In which the amylase content is significantly increased, it can be diagnosed as acute hemorrhagic necrotizing pancreatitis. It must be pointed out that sometimes common bile duct stones can induce acute pancreatitis (called biliary pancreatitis), at which time the symptoms of both can occur. Confused, so be wary.
(3) peptic ulcer perforation: severe pain in the upper abdomen and quickly spread throughout the abdomen, physical examination found abdominal muscle plate tonic, full abdominal tenderness and rebound tenderness, liver dullness shrinks or disappears, X-ray or flat film can be found It is not difficult to determine the free gas under the armpit, combined with the history of ulcer history.
(4) angina pectoris or acute myocardial infarction: a small number of patients with angina or acute myocardial infarction may present severe pain in the upper abdomen, and the pain may be radiated to the left upper abdomen and the right upper abdomen. In severe cases, there is often irritability, cold sweat, and fear. Or sudden death, ECG examination can find deep and wide Q wave, ST segment elevation and T wave inversion changes, serum creatine phosphokinase (CPK), aspartate aminotransferase (AST), lactate dehydrogenase (LDH) and Troponin, elevated myoglobin, etc. are extremely helpful for diagnosis.
(5) Other diseases: cholelithiasis also needs to be differentiated from acute intestinal obstruction, acute intestinal torsion, intestinal perforation, acute appendicitis with perforation, mesenteric vascular embolization or thrombosis, and female ectopic pregnancy and ovarian cyst torsion.
2. Diseases differentiated from jaundice
(1) Acute viral hepatitis: There are many prodromal symptoms such as loss of appetite, fatigue and hypothermia. The jaundice appears rapidly and gradually deepens, reaching a peak in 1 to 2 weeks, accompanied by hepatomegaly and tenderness. B-ultrasound can rule out obstructive jaundice. The sonogram shows only a slight increase in the liver, enhanced echo of the liver parenchyma, and intensive general signs. Serum enzymology often has ALT, AST is significantly elevated, and most patients can detect hepatitis virus markers.
(2) pancreatic head cancer: pancreatic head cancer is more common in men, the age of onset is generally larger, jaundice is often progressive deepening, upper abdominal pain is more related to body position, pain in the supine position is aggravated, and the body can be painful when leaning forward. Alleviation or alleviation, duodenal angiography can be found in duodenal curvature, displacement and gastrointestinal compression, B-ultrasound, cholangiopancreatography (ERCP) and CT or MRI examination can be found in the head of the pancreas The lumps of the department.
(3) lack of ampullary carcinoma: jaundice is often the first symptom, more progressive deepening, gastrointestinal barium meal low-tension angiography, gastroscopy or duodenoscopy, B-ultrasound, CT or MRI examination can find ampulla The lump is very helpful for diagnosis, and endoscopic combined with biopsy can make a pathological diagnosis.
(4) Other diseases: cholelithiasis needs to be differentiated from common cholangiocarcinoma, and the primary liver cancer is transferred to the hilar lymph nodes (the swollen lymph nodes can compress the common bile duct and cause jaundice).
