Acute biliary tract infection mainly includes acute cholecystitis and acute cholangitis. “Guidelines for the Diagnosis and Treatment of Acute Biliary Tract Infections (2021 Edition)” is an update based on the 2011 edition of the guideline. It mainly describes the risk factors, diagnosis and severity of acute biliary tract infections. grading standards, and clarified the treatment of acute biliary tract infection.
Overview of the main recommendations of the guideline
Acute cholecystitis
Recommendation 1: when serum creatinine>176.8 μmol/L, prothrombin time-international normalized ratio>1.5 and platelet count<100 When ×109/L, it is necessary to combine the patient’s medical history and exclude renal insufficiency, liver cirrhosis, coagulation dysfunction and other diseases before the correct classification. When patients with acute cholecystitis are complicated with chronic renal insufficiency, liver cirrhosis, and coagulation disorders, multidisciplinary cooperation and careful treatment are recommended.
Recommendation 2: Assess the severity of cholecystitis At the same time, the general condition and comorbidities of the patients also need to be assessed, which can be assessed by the American Society of Anesthesiologists (ASA) patient constitution grading criteria combined with the age-adjusted Charlson comorbidity index (Table 1).
Table 1 Age-adjusted Charlson comorbidity index
Recommendation 3: When antimicrobials and systemic support Gallbladder drainage (puncture, fistula) should be performed in time, and bile culture should be performed at the same time. After 1 to 3 months, the patient’s systemic state and gallbladder inflammation were reassessed, and cholecystectomy was performed in time for those who met the surgical conditions.
Recommendation 4: If the patient’s general condition is unstable, intraoperative dissection is difficult, or the risk of bile duct injury is high, it is necessary to decisively convert to laparotomy.
Recommendation 5: For gallbladder atrophy, gallbladder For patients with irregular wall thickening and suspicious space-occupying lesions in the gallbladder mucosa, intraoperative rapid frozen pathology should be sent to avoid missed diagnosis of gallbladder cancer.
Acute Cholangitis
Recommendation 6 : Abdominal CT examination can diagnose positive bile duct stones, with high sensitivity, can clearly show bile duct dilatation, and help to determine the cause of bile duct stricture. It is recommended as the first choice for acute cholangitis. school inspection.
Recommendation 7: Magnetic Resonance Cholangiopancreatography (MRCP) can clearly show bile duct dilatation, and can clearly image biliary obstruction caused by malignant tumor or bile duct stones. It can be used as an alternative to abdominal ultrasonography or CT when the diagnosis is difficult.
Recommendation 8: Patients with acute cholangitis should First assess the severity. The timing of biliary drainage depends on the severity of the disease, to determine whether biliary drainage is required, and at the same time, active antimicrobial therapy and systemic supportive therapy are performed.
Recommendation 9: Endoscopic Biliary Drainage Including endoscopic biliary stent drainage (ERBD) and endoscopic nasobiliary drainage (ENBD), can be used as the preferred method of biliary drainage for most acute cholangitis. Indwelling nasobiliary duct or stent placement can be selected for endoscopic biliary drainage, and endoscopic sphincterotomy (EST) should be carefully selected.
Recommendation 10: Percutaneous transhepatic puncture Biliary drainage (PTCD) can be used as an alternative for acute cholangitis when endoscopic biliary drainage cannot be performed.
Recommendation 11: Surgical biliary drainage can As the choice for unconditional endoscopic biliary drainage and PTCD, the importance of shortening the operation time and removing the obstruction as soon as possible is emphasized.
Antibacterial therapy for acute biliary tract infections
Recommendation 12: Blood culture or bile culture should be done as far as possible before antibiotics are used, otherwise false-negative culture results may result.
Recommendation 13: Select for the treatment of acute When using antibacterial drugs for biliary tract infection, the factors affecting the efficacy of the drug should be considered as far as possible in combination with the actual situation of the patient.
The above content is excerpted from: Biliary Surgery Group, Surgery Branch of Chinese Medical Association. Acute Biliary System Guidelines for the diagnosis and treatment of infection (2021 edition)[J]. Chinese Journal of Surgery, 2021, 59(6) : 422-429.
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