It is commonly said: “To stand by each other like the liver and gallbladder”. This tells us that the liver and biliary system are very closely related. In the viewpoint of traditional Chinese medicine, the criteria of pathogenesis of biliary tract infection are mainly: attack of pestilential evils, emotional instability, loss of smoothing and regulating ability of liver, loss of power of purgation and catharsis, qi stagnation of liver and gallbladder, enwrapping of wetness-heat or improper diet and internal generation of wetness-heat. The above conditions may cause stasis of blood and energy and over abundance of heat and toxic substances, producing abdominal distention, hypochondrial (肋脅) pain, aversion to oil, nausea, vomiting, belching, acid regurgitation symptoms. In severe cases, there may be abdominal cramps, chilliness and fever, jaundice of skin, reddish yellow urine, thirst of mouth and throat and constipation. This is a real picture of stagnation of wetness-heat of the liver and gallbladder and infection of the hepatic and biliary tract.
Hepatophilic virus disease often involves the liver and biliary duct system. It is proved now that type B hepatitis virus can be duplicated inside and release from the epithelial cells of bile ducts, so that these biliary tract diseases may better be named “virus cholecystitis” or “virus cholangitis”. The direct or indirect long term effect of hepatophilic virus on the biliary tract or the auto immune response of hepatitis patients are important causes of biliary tract inflammatory complications of virus hepatitis.
In addition, due to long term virus infection of the biliary tract system, it may result in venous congestion of the gallbladder and portal hypertension causing prolonged retention time and secretory disturbance of bile. Because of the abnormal composition of bile, cholelithiasis (膽石) often results. At present, our computer data has shown that in 2455 patients with abnormal over dulness, 61 cases (amounting 1.84%) were operated because of cholecystitis (膽囊炎) and cholelithiasis and in these patients, female 39, male, 22.
When the hepatophilic viruses cause infection of the liver and biliary tract, it may result in inflammation and stone formation of the biliary tract and may further cause formation of tumors and secondary infection. Aggravation of liver disease may cause blood coagulative disturbances and hemorrhage from bile duct venous varicosities and these may further produce hemorrhage of the biliary tract. Therefore some authors suggested that hepatophilic virus disease complicated with biliary tract disorder should be tracted according to virus hepatitis and usually no management is needed for the bladder illness. So early TCM systemic treatment for acute or chronic hepatitis is certainly an important measure in the prevention of the hepatogenic biliary tract diseases. In addition, patients with hepatic disease presenting repeated biliary tract infection, cholelthiasis or upper digestive tract hemorrhage, should be thoroughly treated with systemic hepatic TCM therapy and this may prevent the production of symptoms from relapse of biliary tract disease due to progressive development of the hepatic illness.
Acute cholecystitis is only second to acute appendicitis in commonly seen acute abdomen cases. In fact, biliary tract infection is one of the common complications in virus hepatitis. According to the present clinical observation, upper digestive tract hemorrhage caused by acute or chronic cholecystitis, cholelithiasis and biliary tract hemorrhage should all be considered as having a common pathological basis in the chronic cholecystic infected mucosa injured by the hepatophilic virus. Therefore, in the early stage, it usually occurs in the form of non-bacterial inflammation but if not managed in time at the stage of chronic hepatitis, and when cholelithiasis has formed, obstruction of the bile duct (90% due to bladder stone) may lead to cholecystic ischemia (局部缺血), injury, decrease of resistance and eventually, intervention of secondary bacterial infection (chiefly B coli (大腸桿菌)). Clinically, there would be rapid exacerbation of the disease. We found in clinical practice, not few hepatophilic virus disease patients had chronic cholecystitis, cholelithiasis or received biliary tract operation; but although cholecystectomy (膽囊切除術) had been performed and stones removed, the gastrointestinal symptoms of virus hepatitis were often difficult to be eliminated.
Cases study
Case 1
Tong (code number 2417), female, age 48 years. She first came to the clinic on March 2001, complaining that since 8 years of age, she had hepatitis and anemia. Gastroscopy revealed chronic gastritis and bile regurgitation back to stomache could be seen. Sigmoidoscopy (胃腸鏡檢) showed vesicles of the sigmoid. She also suffered from extreme fatigue, gastric distention, hypochondrial pain radiating to right shoulder and frequent paroxysmal palpitation and short breath. She often felt left abdominal pain before defecation and stools showed wetness-heat. She had long term loin pain after delivery of a girl 20 years ago and this caused difficulty of bending down after getting up in the morning and the pain persisted to the afternoon. Amenorrhea (停經) occurred for more that one year.
She felt tired recently and also dryness of mouth and throat, restlessness, repeated abdominal distention and pain, aversion to oil, nausea on the smelling of cooking oil, labial desquamation and pain, fissure of angulus oris and pain of tongue. Physical examination: swelling of labial mucosa, labial lines deep with fissures and desquamation, abdomen soft and distended, liver enlarged to costal margin with apparent percussion tenderness, pain caused by pressure over gallbladder region on deep breathing. The lower extremities showed patches of telangiestasis and had also (+) edema.
The liver was normal after 3 parcels of TCM drugs. Thirst and flatulence was still present. Another 3 parcels of TCM drugs produced mild diarrhea of two times a day, the stools large in amount. There was loin pain, but the edema decreased in the lower extremities. After a week of TCM treatment, the loin pain decreased but sorethroat and swelling of gingivae was present. Wetness-heat was present in defecation and urination. The liver was still normal and right upper abdominal tenderness disappeared. After three weeks of treatment, she occasionally felt tiredness, sleepiness but ostalgia (骨痛) and palpitation did not occur. Loin tenderness decreased so that she could bend down. This was a case of chronic liver disease complicated by biliary tract infection and weakness of liver and kidney. Marked effectiveness was obtained during the course of treatment and systemic treatment was still going on.
主任醫師 黃國雄
2001年5月8日