至少 90% 的患者有胆结石。[3]Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002 Sep 21;325(7365):639-43.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124163
http://www.ncbi.nlm.nih.gov/pubmed/12242178?tool=bestpractice.com
[2]Kimura Y, Takada T, Strasberg SM, et al. TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):8-23.
http://link.springer.com/content/pdf/10.1007%2Fs00534-012-0564-0.pdf
http://www.ncbi.nlm.nih.gov/pubmed/23307004?tool=bestpractice.com
[11]Ko CW, Lee SP. Gastrointestinal disorders of the critically ill. Biliary sludge and cholecystitis. Best Pract Res Clin Gastroenterol. 2003 Jun;17(3):383-96.
http://www.ncbi.nlm.nih.gov/pubmed/12763503?tool=bestpractice.com
偶尔会出现无胆结石的急性胆囊炎。[3]Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002 Sep 21;325(7365):639-43.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124163
http://www.ncbi.nlm.nih.gov/pubmed/12242178?tool=bestpractice.com
饥饿、全胃肠外营养、麻醉性镇痛药和活动受限的是急性非结石性胆囊炎易感因素。急性非结石性胆囊炎亦被描述为急性 EB 病毒(Epstein-Barr virus, EBV)感染过程中较为罕见的现象,属于原发性 EBV 感染的非典型临床表现。[12]Kim A, Yang HR, Moon JS, et al. Epstein-Barr virus infection with acute acalculous cholecystitis. Pediatr Gastroenterol Hepatol Nutr. 2014 Mar;17(1):57-60.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990785
http://www.ncbi.nlm.nih.gov/pubmed/24749090?tool=bestpractice.com
大多数急性非结石性胆囊炎病例会出现继发性革兰阴性菌感染。
蠕虫感染是亚洲、非洲南部和拉丁美洲胆道疾病的主要原因之一,但不包括美国。[13]Shah OJ, Zargar SA, Robbani I. Biliary ascariasis: a review: World J Surg. 2006 Aug;30(8):1500-6.
http://www.ncbi.nlm.nih.gov/pubmed/16874446?tool=bestpractice.com
沙门菌微生物感染已经被描述为继发于伤寒的胆囊炎的主要事件。艾滋病相关的胆囊炎和胆管病变可能继发于巨细胞病毒和隐孢子虫感染。各种微生物可在疾病发作早期鉴别。这些微生物包括大肠杆菌、克雷伯杆菌、肠球菌、假单胞菌和脆弱拟杆菌。[14]Claesson B, Holmlund D, Mätzsch T. Biliary microflora in acute cholecystitis and the clinical implications. Acta Chir Scand. 1984;150(3):229-37.
http://www.ncbi.nlm.nih.gov/pubmed/6380177?tool=bestpractice.com
有人认为,细菌侵入不是导致损伤的主要病因,因为在 40% 以上患者的手术标本中没有发现细菌生长。[3]Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002 Sep 21;325(7365):639-43.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124163
http://www.ncbi.nlm.nih.gov/pubmed/12242178?tool=bestpractice.com
[8]Freidman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol. 1989;42(2):127-36.
http://www.ncbi.nlm.nih.gov/pubmed/2918322?tool=bestpractice.com
[15]Kanafani ZA, Khalifé N, Kanj SS, et al. Antibiotic use in acute cholecystitis: practice patterns in the absence of evidence-based guidelines. J Infect. 2005 Aug;51(2):128-34.
http://www.ncbi.nlm.nih.gov/pubmed/16038763?tool=bestpractice.com
[16]Csendes A, Burdiles P, Maluenda F, et al. Simultaneous bacteriologic assessment of bile from gallbladder and common bile duct in control subjects and patients with gallstones and common duct stones. Arch Surg. 1996 Apr;131(4):389-94.
http://www.ncbi.nlm.nih.gov/pubmed/8615724?tool=bestpractice.com
一般来说,细菌感染为次要特征,不是初始事件。
胆囊颈或胆囊管内固定梗阻或有胆结石通过,引起胆囊壁急性炎症。嵌塞的胆石引起胆囊内胆汁瘀滞,引起胆囊发炎和压力增大。胆结石引起的外伤刺激合成前列腺素 (PGI2、PGE2),继而介导炎症反应。这可导致继发性细菌感染,引起坏死和胆囊穿孔。[3]Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002 Sep 21;325(7365):639-43.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124163
http://www.ncbi.nlm.nih.gov/pubmed/12242178?tool=bestpractice.com
对非结石性胆囊炎的病理生理学机制了解甚少,但很可能与多种因素有关。通常存在功能型胆囊管梗阻,并与脱水或胆汁瘀滞(由于外伤或系统性疾病)引起的胆泥或胆汁浓缩有关。外源性压迫有时可能对胆汁的淤滞起促进作用。一些脓毒症患者可能出现直接胆囊壁炎症,和局部或全身组织缺血,但无梗阻。
黄疸在高达 10% 的患者中出现,由相邻胆管的炎症引起(Mirizzi 综合征)。[1]Ziessman HA. Acute cholecystitis, biliary obstruction and biliary leakage. Semin Nucl Med. 2003 Oct;33(4):279-96.
http://www.ncbi.nlm.nih.gov/pubmed/14625840?tool=bestpractice.com
急性胆囊炎可能在症状发作后的 5 至 7 日内自发消退。嵌顿结石脱落,并重新恢复胆管通畅。如果未重新恢复胆管通畅性,可能会发展为炎症和压迫性坏死,导致囊壁和粘膜出血性坏死。急性胆囊炎不经治疗可导致化脓性、坏疽性和气肿性胆囊炎。