Pathology of hepatitis bile
The liver is usually enlarged in both lobes or dominant in the left liver, which can cause cholestasis. In addition, there may be biliary cirrhosis or cholestatic cirrhosis, chronic cholecystitis.
This is a fairly common condition, ranked second after Amebic liver abscess. Gallstones and biliary tract worms are the two most common causes and predisposing factors.
Mechanism of pathogenesis
Under normal conditions, the Oddi sphincter works well, in the biliary tract, there are no germs or very little quantity not enough to cause disease. In the case of gallstones, it causes obstruction, stagnation, and increased bile pressure, creating favorable conditions for bacteria to go upstream. In bile duct worms, in addition to mechanical mechanisms such as worm stones, also directly carry bacteria from the intestinal tract and possibly parasites into the tract. There are also other diseases such as cholangiocarcinoma, pancreatic head tumor, sphincter of Oddi disease. Sclerosing of the sphincteric sphincter of Oddi or rarer conditions such as peptic ulcer with perforation of the biliary tract, colon cancer, gastric cancer or endoscopic procedures, retrograde cholangiography can cause inflammation. honey. Therefore, the majority of infections are caused by E. coli, and the biliary and anaerobic Gram-negative Bacteroide and Clostridium species.
The liver is often bilateral or predominant in the left liver, which can cause cholestasis. In addition, there may be biliary cirrhosis or cholestatic cirrhosis, chronic cholecystitis.
Focals of necrotizing inflammation with the presence of neutrophils, degenerative phagocytosis, cholestasis, infectious biliary obstruction. The bile ducts are dilated, there may be carcasses and eggs in the abscess and in the biliary tract or cholestatic cirrhosis.
Complete blood count:
WBC increased up to 20000 polymorphonuclear neutrophils. The most increased blood bilirubin is direct bilirubin, alkaline phosphatase increases. (GT and enzymes ALAT, ASAT may be increased.
Endoscopic ultrasound showed good results at the end of the common bile duct, ampulla of Vater, sphincter of Oddi).
It should be placed in patients with a history of stones, biliary tract worms. Clinical signs of severe cholestasis, large liver pain in many places, very painful liver fibrillation poor or unresponsive to treatment. Definitive diagnosis should be based on ultrasound, density computed tomography.
Complications and prognosis
Sepsis and Gram-negative septic shock. Renal syndrome.
Pleural and pericardial effusion.
Acute pancreatitis, possibly as comorbidity. Cholestatic cirrhosis.
The abscess ruptured into the abdomen causing peritonitis.
Bile infiltration into the peritoneum causes biliary peritonitis. Bleeding of the biliary tract
This is a serious condition, in addition to infection, with toxicity and surgical complications, so it should be placed in the context of medical and surgical treatment and emergency resuscitation.
Internally medical treatment
General measures: Provide adequate nutrition, energy, and water and electrolyte balance.
Antibiotics: Need to target anaerobic intestinal Gr (-) bacteria, because this is a condition often associated with biliary obstruction, broad-spectrum antibiotics with high concentrations in the biliary tract should be used, usually by injection and weekdays > 2 weeks. Preferably based on microbiology, antibiogram, and antibiotic combination. The commonly used antibiotics are:
Penicillin 4-6 million units/day.
Third generation Cephalosporins: Céfotaxime (Claforan) 3 g/day, Ceftriaxone (Rocéphin) 2 g/day.
Derivatives: Carbenicilline is usually sensitive to blue pus bacilli and proteus (dose 200 mg/kg/day), Ureidopenicilline such as Azlociline, Piperacilline dose 3g/day. Works well with green pus bacillus, Proteus hemophilus, Enterocoque.
Moxalactam, Carbapenem, Monobactam.
Aminoglycoside group: usually Gentamycine dose 3-5 mg/kg body weight/day, or other antibiotics: Amikacin dose 15 mg/kg/day; Netilmicine dose 5-7 mg/kg/day.
Note: Aminoglycosides can cause inner ear and kidney toxicity.
Quinolone group: Ofloxacine (Oflocet) 400 mg/day; Ciprofloxacine dose 15-20 mg/kg/day.
Metronidazole group: Especially by infusion, usually used in case of anaerobic infections Bacteroide dose 1.5 g/day.
Analgesia and antispasmodic biliary tract used in case of biliary spasm with Spasmaverine 40 mg x 3 tablets/day. Buscopan tube 10 mg x 2-3 ampoules/day; Spasfon (Phloroglucinol) tube 80 mg x 2 -3 ampoules/day; or pain reliever of the Noramidopyrine group: Visceralgin 500 mg x 1-2 ampoules/day. May cause granulocytopenia. Visceralgine forte: a combination of Noramdopyrine (500 mg) + Tinémonium (25 mg) is an antispasmodic drug, given by deep intramuscular or slow intravenous injection to avoid hypotension.
Anti-shock due to Gram-negative infection if present. In addition to active antibiotics, it is necessary to give adequate fluids and use vasopressors such as Dopamine, Dobutamine (Dobutrex). Infusion by the electric pump at a dose of 5-10 μg/kg/min.
It is difficult to perform because pain patients in severe infections may have shocked, moreover there are many small abscesses that can be located deep and difficult to detect or remove. Surgery is also intended to remove mechanical obstructions such as worms or stones.
Endoscopic procedure: Endoscopy and retrograde cholangiography help confirm the diagnosis. In addition, it is also used to remove worms, stones, and sphincters to help relieve mechanical blockages.