Cholera syndrome

2021-01-26 12:00 AM

Bacteria can penetrate into the blood to cause septicemia, this is a very severe stage of biliary obstruction, high risk of death, and long-term obstruction leads to fibrosis of the portal space

Bile obstruction is a blockage in the way of excreting bile inside or outside the liver, causing bile to be absorbed into the bloodstream, causing jaundice and mucosa. When there is a blockage of the bile, bacteria will grow in the bile ducts, causing a biliary tract infection. Bacteria can penetrate into the blood and cause septicemia, this is a very severe stage of biliary obstruction, with a high risk of death. The long-term blockage leads to fibrosis of the portal, causing biliary cirrhosis.

Common causes

Gallstones.

Pancreatic tumour.

U of the Vaster shadow area.

Cancer of the biliary tract (commonly seen with umbilical cord tumours, also known as Kalstein tumours).

Some other causes: Bile duct worms, complications that cause narrowing or obstruction of the bile ducts after cholecystectomy, after gastric bypass ...

Certain anatomical and physiological features

Molasses consists of 2 parts:

The main biliary tract consists of the inner and outer bile.

The extra biliary tract includes the neck of the gallbladder and the gallbladder.

The hepatocytes from the Remark raft excreted bile into the bile ducts, then into the bile in the portal space of the hepatic lobule, which converges into larger tubes forming the bile ducts of the sub-segment. Liver lobe, then hepatic lobe and right and left hepatic duct, then fused in the umbilical tendon to form a common hepatic duct. The common liver tube is about 3 cm long, renamed to the common bile duct (OMC) from the filling site of the gallbladder neck. The lower part of the OMC running behind the head of the pancreas flows into the II part of the duodenum, the smooth muscle here thickens to form Vaster papillae. Before pouring into the duodenum OMC and Wirsum tube have a common segment called the bile-pancreas tube about 0.5 to 1 cm long.

Bile (excreted by liver cells) is a transparent yellow liquid with a pH of 7 - 7.7, consisting of bile salts (lipid emulsifying effect, activating lipase and stimulating bile secretion)., bile pigmentation (bilirubin - the excreted form of Hb) and a number of other substances such as electrolytes, cholesterol, alkaline phosphatase ... In the gallbladder, 50% of the bile is excreted by the liver after being concentrated by absorbing water and Minerals are stored here when there is the stimulation of bile secretion of food, bile is expelled to the duodenum to participate in the digestive process.

Normal biliary pressure varies from 12 - 20 cmH 2 O, when an increase of more than 25 cmH 2 O causes the risk of retrograde infection from the biliary tract into the blood and lymph vessels. When increased over 30 cmH 2 O will stop liver cells from excreting bile.

Clinical symptoms

Stomachache

Painful sites usually appear in the liver, with a little pain in the epigastric region or the right back. The degree of pain depends on the cause of the biliary obstruction:

Can be very severe in cases of acute biliary obstruction caused by moving gallstones or trapping of the lower part of OMC.

Pain in the liver with a very severe degree spread to the shoulder or back (the pain of liver), sometimes causing the patient to bend over and lie down in the bile duct worms ...

Sometimes dull pain or a feeling of pressure in the lower right rib or the area above the navel, such as in biliary tract cancer, balloon Vaster. 

Signs of bloating, indigestion after eating a lot of fat, can have fat or loose diarrhoea.

Fever

Appears simultaneously or after a few hours of pain, high fever 38 - 39 0 C accompanied by chills, each episode occurs in biliary obstruction due to stones. Late-stage with severe cholangitis and cholangiocarcinoma may be continuous. Biliary obstruction caused by cancer is often an end-stage fever. 

Jaundice

Jaundice comes in many forms and is associated with other signs. Jaundice may occur in 1 or 2 weeks, then go away and reappear after a time in blockage due to stones. Or maybe the jaundice gradually increases in biliary obstruction due to tumour. The degree of jaundice can be obvious or discreet

The sequence of jaundice and signs of abdominal pain and fever may indicate the cause of the blockage. For example:

Gallbladder obstruction: The first sign is a pain in the liver, followed by a sign of malaria with trembling and a few days later yellow eyes appear yellow. After treatment, these signs disappear in the same order. Then after a while again like that, called the Charcot trilogy.

Tumour obstruction: Jaundice increases, with little pain and no fever in the early stages. 

Dark urine

Usually occurs when the skin is jaundiced, can be dark red like water or tea.

Discoloured stools: can be as white as stools incomplete obstruction, common in tumour obstruction, and biliary obstruction due to gallstones has less of this sign.

Itching

Due to a gall salt allergy.

Systemic symptoms

Jaundice (when bilirubin> 20 mg / l):

Examination under natural light, the examination location can be the sclera of the eye, palms in cases of discreet jaundice. Clear cases are easy to spot.

Evaluate the degree of jaundice, yellow in colour: light yellow, dark yellow, orange-yellow, yellow-green ...

Intermittent recurrent jaundice (biliary obstruction due to cholelithiasis) or gradual, progressive increase (usually biliary obstruction).

Infection syndrome:

Fever 38 - 39 0 C, sometimes very high fever, dirty tongue, dry lips, bad breath in combination infections.

The condition is usually less likely to change in the early stage of gallbladder obstruction, whereas in tumour obstruction, there are often signs of rapid weight loss, loss of appetite, fatigue ...

Slow circuit:

In the cases of biliary obstruction without biliary tract infection, there is usually a slow pulse. But if there is acute cholangitis or complications of cholangitis, the vessel is fast, sometimes there is shock due to infection of the biliary tract.

Haemorrhage under the skin, sclera due to reduced liver function, low ability to synthesize Prothrombin blood because vitamin K is not absorbed from the intestine or due to severe infections that cause blood clotting disorders 

Entity

Examination: patient lying on his back, physician sitting on the right side of the patient, examining for signs:

Enlarged liver:

Look to see if the ribs are raised due to enlarged liver.

Liver palpation: Normally not palpable. When the liver is enlarged, the lower edge of the liver will be felt. Need to determine the properties of the liver sharp or obtuse.

Determine the upper edge of the liver by typing: The normal limit is an arc following the nipple curve in the intercostal space 5, the axillary line between the intercostal space 7, the axillary line behind the 9 right intercostal space. The larger liver will have sex on this line.

Signs of interstitial pressure or liver fibrillation: The physician's left-hand fingers are placed in the end intercostal cavities of the liver, using the right bank of the hand to tap on the left fingers. Positive sign when a patient has a throbbing pain. This is often seen in liver abscesses.

Large gallbladder:

When the gallbladder is large, a mass can be seen under the right rib, moving according to the breathing rhythm of the patient. Palpation sees a mass, round or fruit-shaped, moving to the rhythm of poetry, tender or painful.

Look for pain spots:

Gallbladder point: The intersection of the right flank and the right-angle bisector from the right navel.

Murphy test: When the gallbladder is not large. How to proceed: the physician's right hand will touch the gallbladder area, in the event of an inflamed gallbladder, the patient is in pain and holds his breath, it is called a Murphy test positive.

Other signs:

Big spleen: Choking for a long time leads to cirrhosis of portal hypertension - blood to the spleen and stagnation of the portal system, the spleen will be enlarged depending on the degree.

Determine splenomegaly: Examination of the left rib network, the patient lies on his right side, the spleen will pour out in the middle. Feeling jagged edges. 

Ascites: Due to decreased liver function, low blood protein synthesis, portal hypertension and increased peritoneal permeability. The fluid will enter the abdomen called ascites or groin. When examining, the patient's abdomen is swollen evenly, the belly button is protruding, there are signs of waves flapping and knocking turbidity in the low area.

Collateral circulation or auxiliary circulation due to increased portal venous pressure: The veins floating under the skin in the hypotonic region, under the ribs 2 or around the navel.

Subclinical

Blood tests

Blockage status:

Normal blood bilirubin: 10 mg / l or 17 mmol / l. When there is an obstruction of bilirubin in the blood, it permeates the adipose tissue, the skin, causes jaundice and increases the direct bilirubin in biliary obstruction.

Alkaline phosphatase is an enzyme that is excreted in bile when it is blocked, this enzyme increases early and has special value to diagnose biliary obstruction. Normally about 10 King-Armstrong units.

Evaluation of liver function:

The rate of blood prothrombin decreased due to deficiency of vitamin K is not absorbed from the intestine due to bile obstruction, encountered an incomplete and prolonged biliary obstruction, rarely in gallstones (found in the severe form).

Bleeding time, blood clotting lasts.

The liver enzymes are normal or slightly increased (GOT, GPT), if increased many times, the cause of combined hepatitis must be considered.

Blood protein may below.

Infections: the number of leukocytes increases, mainly polymorphonuclear leukocytes.

High blood sedimentation rate. 

Image analyzation

X-ray:

Distal liver scan in cases of biliary obstruction will have some signs such as:

Enlarged liver balloon (normal diaphragm line - top from 9 to 12 cm, the diaphragm of spine 14 - 16.5 cm).

Diaphragmatic angle due to pleural reaction.

Gallbladder balloon can be seen under the liver, in a few cases, gallbladder stones with contrast are represented by concentric rings.

Oral or intravenous cholangiography: The drugs that are eliminated through the bile such as Orabilli, billispek ... however, it is difficult to assess the status of the bile, but only look and evaluate the contractile function of the gallbladder by experiment Boyden method, so this method is currently less applicable.

Transcutaneous cholangiography: First done by Huard and Do Xuan Hop in the world in 1937, through the liver through the skin into the bile ducts, injecting contrast agent and then taking film. The results showed that images of the biliary tract inside and outside the liver were very clear, the biliary tract status, the cause and the location of the obstruction. This method of exploration can cause dangerous complications such as abdominal bleeding, biliary peritonitis ... should only be done at the surgical establishment with strict indications. The procedure can be performed concurrently with the diagnostic technique.

ERCP: Endoscopic retrograde cholangiopancreatography: is a new method that has been introduced in recent years. Allows determining the status of the biliary tract and pancreas, the location of damage and causing bile obstruction. The therapeutic procedure can be performed concurrently with the diagnostic technique.

Duodenal frame: Give the patient a contrast medicine, when the drug goes down the duodenum to take the film at this stage, you can see the enlarged duodenum frame (pancreatic head tumor, pancreatic follicle ...) or Vaster tumour Duodenum invades the duodenum ... causing bile obstruction.

Hepatobiliary ultrasound:

Non-traumatic morphological means, with high sensitivity and specificity in the exploration and diagnosis of morphological lesions of the liver and bile ducts, determine the condition of the liver parenchyma such as tumours, cysts, ... dilated internal and external bile ducts that cause biliary obstruction such as gallstones, pancreatic head tumours, bile duct worms, pancreatic tumours... The downside is limited examination when gas entanglement.

CT scanner:

As a diagnostic tool with higher sensitivity and specificity than ultrasound, it is not dependent on the state of intra-abdominal gas, but the price is higher.

Magnetic resonance imaging:

The method is considered to be the best morphological exploration method currently in the diagnosis of biliary obstruction of unknown cause. The downside is that the price is still high.

Duodenum:

Little is done nowadays.

Laparoscopy:

Less applicable.

Common causes

Gallstones

Functional: Severe, severe liver pain. Fever usually appears simultaneously or after a few hours of pain, accompanied by chills. Jaundice appears after these 2 symptoms are obvious or discreet. The above signs appear and disappear in a certain sequence, recurring times called the Charcot trilogy.

Body as a whole: Symptoms of biliary obstruction such as skin, yellow mucosa and septic syndrome, in the early stages, the systemic status is relatively good, with changes in severe morphology such as biliary tract infection shock, hepatobiliary apex honey.

Entity: Common signs of hepatomegaly, about 60% of cases have an enlarged gallbladder.

There may be complications of biliary obstruction such as peritoneal biliary permeability, biliary peritonitis, biliary tract staining or acute pancreatitis ...

Blood tests: Direct hyperbilirubinemia.

Ultrasound: It is bold with conical obstruction of the stones and images of the bile ducts on the obstruction.

CT scanner: Only applicable in case of a difficult diagnosis.

Biliary obstruction due to pancreatic head tumour or balloon Vaster tumour

The clinical signs are very similar:

Mechanical: Abdominal pain is often dull, vague, or a feeling of pressure above the navel. The last stage of cancer is severe and prolonged abdominal pain.

Fever: Appears late or without fever. Often there are signs of weight loss, fatigue, loss of appetite.

Gradual jaundice, discoloured stools: This is a particularly valuable sign to diagnose the disease

Visiting quite saw a large liver, gallbladder: You can see tumours in the lower right rib or the area above the navel, ascites.

Tests:

Expression of biliary obstruction: direct hyperbilirubinemia, increased alkaline phosphatase.

Tumour markers such as CEA, and CA 19 - 9 are elevated.

Means of diagnostic imaging:

Ultrasound: Enlarged liver, enlarged gallbladder, dilated inner and outer bile. Wirsum tube dilated (Vater's tumour) can be seen, enlarged lymph nodes, tumours causing biliary obstruction and liver metastasis ...

Vater cancers can be colonoscopy for definitive diagnosis and biopsy.

Computer tomography or nuclear magnetic resonance imaging has high value in definitive diagnosis and evaluation of surgery ability. However, the price is high.

Biliary tract cancer

Common in patients with progressive jaundice, little pain and fever in the early stages, dark yellow skin.

On examination, the liver is large and dense. The gallbladder can become enlarged if it becomes blocked under the cervical canal.

Tests for biliary obstruction: Increased bilirubin and alkaline phosphatase. Tumor markers such as CEA and CA 19-9 increase.

Image analyzation:

Ultrasound: Enlarged liver, often seen with impaired and homogenous lesions in the bile ducts, rarely having negative mixed mass, thickened and narrow bile ducts, and dilated upper bile ducts. Negative structure resembles liver parenchyma, so it is easy to miss.

ERCP scan: Less pressure used due to risk of upstream infection.

Magnetic resonance imaging or CT Scanner: Gives valuable information in definitive diagnosis, diagnosing the stage of the tumour and diagnosing surgical possibilities.

Bile duct worms     

The disease is quite common in our country, seen in both adults and children.

Functional function: Expressed by severe abdominal pain in the sternum area, often rolling, folded posture, prostrate.

Systemic: Fever appears a few days late due to cholangitis. Jaundice is uncommon because of often incomplete biliary obstruction.

Entity: Enlarged liver and gallbladder can be seen. You can see signs of the worm-induced hepatobiliary apex.

Ultrasound: Pictures of dilated bile ducts, worms inside are dark parallel lines without gloss.