Expert consensus on diagnosis and treatment of acute biliary tract infection in the elderly (2025 edition)

doi:10.3877/cma.j.issn.2095-3232.2025.04.001

Abstract

Abstract:

The "Expert consensus on diagnosis and treatment of acute biliary tract infection in the elderly (2025 edition)" was compiled and organized by the Hepatobiliary Pancreatic Surgery Committee of Chinese Aging Well Association. Acute biliary tract infections in the elderly are common among the acute abdominal diseases in the elderly, with atypical clinical manifestations, rapid progression and high fatality rate. The consensus puts forward targeted recommendations around multiple aspects such as the diagnosis, severity assessment, imaging examination, systemic assessment, rational application of antibiotics, intensive care treatment, nutritional support, surgical treatment and endoscopic treatment of acute biliary tract infections in the elderly. The consensus emphasizes that the diagnosis of elderly patients should be combined with comprehensive assessment of clinical manifestations, laboratory tests and imaging examinations, and that treatment should be individualized, and attach importance to multidisciplinary collaboration during the perioperative period. The consensus provides important references for the standardized diagnosis and treatment of acute biliary tract infections in the elderly.

Key words: Elderly, Biliary tract diseases, Practice guideline, Acute biliary tract infections, Diagnosis, Treatment

Hepatobiliary Pancreatic Surgery Committee of Chinese Aging Well Association, Beijing Hospital, National Center for Gerontology, Institute of Geriatric Medicine of Chinese Academy of Medical Sciences. Expert consensus on diagnosis and treatment of acute biliary tract infection in the elderly (2025 edition)[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(04): 491-507.

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References 110

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临床问题	推荐意见内容	证据级别	推荐强度
1.老年急性胆囊炎诊断标准	推荐意见1：诊断老年急性胆道感染时需同时考虑临床表现、实验室检查及影像结果。此外,同时需结合老年患者临床表现不典型、就诊较晚等发病特点,减少漏诊	低	强推荐
2.老年急性胆管炎诊断标准		低	强推荐
3.老年急性胆囊炎严重程度评估	推荐意见2：在对老年急性胆道感染严重程度进行分级时,需同时对多器官功能进行评价。其中,重度感染的判定并非依据局部表现,而是基于多器官功能不全的诊断	高	强推荐
4.老年急性胆管炎严重程度评估		高	强推荐
5.影像学诊断	推荐意见3：对于急性胆囊炎患者,推荐腹部超声作为首选检查方法;对于怀疑胆总管结石患者,推荐腹部平扫CT作为首选检查。若超声与CT均无法提供明确诊断,建议行MRI/MRCP检查	低	强推荐
6.综合评估及器官功能评估	推荐意见4：对于合并多器官基础病的老年胆道感染患者,推荐结合病史进行个体化器官功能评估,制定功能维持标准,必要时请专科会诊。同时注意急诊状态下评估的必要性和有效性的平衡,避免延误病情	高	强推荐
7.多学科讨论的应用	推荐意见5：对于需急诊手术的或合并严重基础疾病的老年胆道感染患者,可以采用多科会诊或多科共同管理模式,为尽快手术创造条件,同时降低发生不良结局的风险	中	强推荐
8.抗生素应用	推荐意见6：对于老年急性胆道感染患者,应及时启动广谱抗生素进行经验性治疗,并完善血细菌培养和(或)胆汁细菌培养及药敏试验,以指导用药。经验性治疗推荐使用β内酰胺酶抑制剂复合制剂或碳青霉烯类抗生素	中	强推荐
9.重症监护治疗	推荐意见7：对于老年重度急性胆道感染休克患者,应及时启动目标导向性的重症监护治疗	中	强推荐
10.营养支持	推荐意见8：老年急性胆道感染患者需结合血流动力学情况、疾病严重程度、营养筛查及评估结果,制定个体化营养诊疗计划	低	强推荐
11.损伤控制性外科理念及预康复的应用	推荐意见9：对药物治疗失败或合并严重疾病等不适合手术的老年患者,可采用损伤控制外科理念,将重度患者转化为更适合手术的较低风险患者	低	弱推荐
11.损伤控制性外科理念及预康复的应用	推荐意见10：对于择期手术或行分期治疗的老年急性胆道感染患者,可实施包括营养支持、运动干预和心理干预的术前预康复干预	低	弱推荐
12.术前抗凝抗聚药物的管理	推荐意见11：对于正在接受AT的老年急性胆道感染需急诊外科处理的患者,需结合患者用药类型及手术紧急性评价手术出血及围手术期血栓风险。对于需紧急手术患者,必要时可给予拮抗治疗,并预防和控制因凝血功能障碍可能出现的术中和术后出血	中	强推荐
13.手术治疗时机及方式	推荐意见12：对于低风险急性胆囊炎患者,建议早期行胆囊切除术,首选腹腔镜手术。对于高危及重症患者,在积极抗感染治疗的同时,早期行经皮经肝胆囊穿刺引流术以建立有效的引流。老年急性胆管炎患者应尽早解除梗阻,外科手术仍作为无内镜和穿刺引流条件下的治疗措施。对于术后留置T管患者需根据患者营养状况、结石残留等情况决定拔除时机(证据级别：高;推荐意见：强推荐)	高	强推荐
14.内镜治疗	推荐意见13：老年急性胆管炎患者如果条件允许,推荐首选内镜下治疗,建议首选鼻胆管外引流。是否一期取石,需考虑胆管炎严重程度。(证据级别：中等,推荐意见：强推荐)	中	强推荐
15.介入治疗	推荐意见14：不能耐受手术且保守治疗无效的老年急性胆囊炎患者,应积极进行胆囊穿刺引流。老年急性胆管炎患者在抗感染和全身支持治疗基础上尽早行胆管引流。建议结合患者实际情况和单位设备进行治疗选择	中	强推荐

临床问题	推荐意见内容	证据级别	推荐强度
1.老年急性胆囊炎诊断标准	推荐意见1：诊断老年急性胆道感染时需同时考虑临床表现、实验室检查及影像结果。此外,同时需结合老年患者临床表现不典型、就诊较晚等发病特点,减少漏诊	低	强推荐
2.老年急性胆管炎诊断标准		低	强推荐
3.老年急性胆囊炎严重程度评估	推荐意见2：在对老年急性胆道感染严重程度进行分级时,需同时对多器官功能进行评价。其中,重度感染的判定并非依据局部表现,而是基于多器官功能不全的诊断	高	强推荐
4.老年急性胆管炎严重程度评估		高	强推荐
5.影像学诊断	推荐意见3：对于急性胆囊炎患者,推荐腹部超声作为首选检查方法;对于怀疑胆总管结石患者,推荐腹部平扫CT作为首选检查。若超声与CT均无法提供明确诊断,建议行MRI/MRCP检查	低	强推荐
6.综合评估及器官功能评估	推荐意见4：对于合并多器官基础病的老年胆道感染患者,推荐结合病史进行个体化器官功能评估,制定功能维持标准,必要时请专科会诊。同时注意急诊状态下评估的必要性和有效性的平衡,避免延误病情	高	强推荐
7.多学科讨论的应用	推荐意见5：对于需急诊手术的或合并严重基础疾病的老年胆道感染患者,可以采用多科会诊或多科共同管理模式,为尽快手术创造条件,同时降低发生不良结局的风险	中	强推荐
8.抗生素应用	推荐意见6：对于老年急性胆道感染患者,应及时启动广谱抗生素进行经验性治疗,并完善血细菌培养和(或)胆汁细菌培养及药敏试验,以指导用药。经验性治疗推荐使用β内酰胺酶抑制剂复合制剂或碳青霉烯类抗生素	中	强推荐
9.重症监护治疗	推荐意见7：对于老年重度急性胆道感染休克患者,应及时启动目标导向性的重症监护治疗	中	强推荐
10.营养支持	推荐意见8：老年急性胆道感染患者需结合血流动力学情况、疾病严重程度、营养筛查及评估结果,制定个体化营养诊疗计划	低	强推荐
11.损伤控制性外科理念及预康复的应用	推荐意见9：对药物治疗失败或合并严重疾病等不适合手术的老年患者,可采用损伤控制外科理念,将重度患者转化为更适合手术的较低风险患者	低	弱推荐
11.损伤控制性外科理念及预康复的应用	推荐意见10：对于择期手术或行分期治疗的老年急性胆道感染患者,可实施包括营养支持、运动干预和心理干预的术前预康复干预	低	弱推荐
12.术前抗凝抗聚药物的管理	推荐意见11：对于正在接受AT的老年急性胆道感染需急诊外科处理的患者,需结合患者用药类型及手术紧急性评价手术出血及围手术期血栓风险。对于需紧急手术患者,必要时可给予拮抗治疗,并预防和控制因凝血功能障碍可能出现的术中和术后出血	中	强推荐
13.手术治疗时机及方式	推荐意见12：对于低风险急性胆囊炎患者,建议早期行胆囊切除术,首选腹腔镜手术。对于高危及重症患者,在积极抗感染治疗的同时,早期行经皮经肝胆囊穿刺引流术以建立有效的引流。老年急性胆管炎患者应尽早解除梗阻,外科手术仍作为无内镜和穿刺引流条件下的治疗措施。对于术后留置T管患者需根据患者营养状况、结石残留等情况决定拔除时机(证据级别：高;推荐意见：强推荐)	高	强推荐
14.内镜治疗	推荐意见13：老年急性胆管炎患者如果条件允许,推荐首选内镜下治疗,建议首选鼻胆管外引流。是否一期取石,需考虑胆管炎严重程度。(证据级别：中等,推荐意见：强推荐)	中	强推荐
15.介入治疗	推荐意见14：不能耐受手术且保守治疗无效的老年急性胆囊炎患者,应积极进行胆囊穿刺引流。老年急性胆管炎患者在抗感染和全身支持治疗基础上尽早行胆管引流。建议结合患者实际情况和单位设备进行治疗选择	中	强推荐

分级	内容
重度(急性胆囊炎合并以下≥1个器官功能不全可诊断)：
心血管功能障碍	肺毛细血管楔压增高≥13 mmHg;低血压需要多巴胺或使用去甲肾上腺素
外周循环	平均动脉压≤60 mmHg
神经系统功能障碍	明显反应迟钝;有定向障碍;GCS≤12分
呼吸功能障碍	氧合指数≤300 mmHg
肾功能不全	肌酐≥176.8 μmol/L
肝功能不全	PT-INR>1.5;TB≥35 μmol/L;ALT升高或酶胆分离
造血功能障碍	Plt<100×10⁹/L
中度(急性胆囊炎合并以下中的2项可诊断)：
WBC>8×10⁹/L
右上腹触及压痛的肿块
明显的局部炎症	坏疽性胆囊炎、胆囊周围脓肿、肝脓肿、胆汁性腹膜炎、气肿性胆囊炎
轻度：
急性胆囊炎不伴随中度和重度的局部或全身炎症表现，无器官功能不全

分级	内容
重度(急性胆囊炎合并以下≥1个器官功能不全可诊断)：
心血管功能障碍	肺毛细血管楔压增高≥13 mmHg;低血压需要多巴胺或使用去甲肾上腺素
外周循环	平均动脉压≤60 mmHg
神经系统功能障碍	明显反应迟钝;有定向障碍;GCS≤12分
呼吸功能障碍	氧合指数≤300 mmHg
肾功能不全	肌酐≥176.8 μmol/L
肝功能不全	PT-INR>1.5;TB≥35 μmol/L;ALT升高或酶胆分离
造血功能障碍	Plt<100×10⁹/L
中度(急性胆囊炎合并以下中的2项可诊断)：
WBC>8×10⁹/L
右上腹触及压痛的肿块
明显的局部炎症	坏疽性胆囊炎、胆囊周围脓肿、肝脓肿、胆汁性腹膜炎、气肿性胆囊炎
轻度：
急性胆囊炎不伴随中度和重度的局部或全身炎症表现，无器官功能不全

分级	内容
重度(急性胆管炎合并以下≥1个器官功能不全)：
心血管功能障碍	肺毛细血管楔压增高≥13 mmHg；低血压需要多巴胺或使用去甲肾上腺素
外周循环	平均动脉压≤60 mmHg
神经系统功能障碍	明显反应迟钝；有定向障碍；GCS≤12分
呼吸功能障碍	氧合指数≤300 mmHg
肾功能不全	肌酐≥176.8 μmol/L
肝功能不全	PT-INR>1.5；TB≥35 μmol/L；ALT升高或酶胆分离
造血功能障碍	Plt<100×10⁹/L
中度(急性胆管炎合并以下的2项可诊断)：
WBC>12×10⁹/L或< 4×10⁹/L
体温≥39℃
年龄≥75岁
TB≥85.5 μmol/L
ALB<0.7×正常值上限
轻度：
急性胆管炎不伴随中度和重度局部或全身炎症表现，无器官功能不全

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