home All hormones Acute cholecystitis - symptoms and treatment. Symptoms, diagnosis and treatment of acute cholecystitis

Acute cholecystitis - symptoms and treatment. Symptoms, diagnosis and treatment of acute cholecystitis

Cholecystitis is an inflammatory process in the gallbladder, which can be chronic and acute course. Among the pathologies of internal organs, cholecystitis is particularly dangerous, because it not only leads to the development of severe pain, but also to inflammation and the formation of stones. When stones advance, the patient needs urgent surgical care, untimely provision of which can cause death.

Acute and chronic cholecystitis is closely related to cholelithiasis, and in 95% of cases, the diagnosis of these pathologies occurs simultaneously, and it is very difficult to determine which of them is primary. Every year, the number of registered cases of these pathologies increases by 15%, and the formation of stones in the adult population increases by 20% per year. It is also noted that in men the susceptibility to cholecystitis is significantly lower than in women after 50 years.

Clinical picture and causes of cholecystitis

Cholecystitis is divided into gangrenous, perforated, phlegmonous, purulent, catarrhal.

Acute cholecystitis and its causes

The greatest danger is the acute form of cholecystitis, in which stones form not only in the gallbladder itself, but also in its ducts. It is the formation of stones that poses the greatest danger in the disease, which is also called calculous cholecystitis. Initially, the accumulation of calcium salts, cholesterol and bilirubin on the walls of the bladder turns into calcifications, but with the accumulation of these deposits, they increase, which can lead to the formation of inflammatory processes in the gallbladder. Quite often, stones penetrate the bile ducts and create a serious obstacle to the outflow of bile from the gallbladder. This development of events can cause peritonitis if the pathology is not treated in time.

Causes of chronic cholecystitis

Chronic cholecystitis characterized by a longer course of pathology. It is characterized by periods of exacerbation and remission. The pathology is based on damage to the walls of the gallbladder due to a disruption in the process of bile evacuation (pathology of the sphincter of Oddi, hyper- or hypomotor dyskinesia). These factors are joined by a secondary bacterial infection, which not only supports the inflammation process, but also turns it purulent.

Chronic cholecystitis is divided into non-calculous and calculous. In calculous gallbladder, it is stones and sand that cause trauma to the mucous membrane of the gallbladder, clog the neck of the gallbladder or its ducts and prevent the excretion of bile.

Stoneless forms develop against the background of anomalies in the development of the ducts and bladder, their ischemia (in diabetes mellitus) and kinks, strictures and tumors of the bladder and common cystic duct, sludge of bile in those receiving parenteral nutrition, quickly lost weight, pregnant, duct obstruction by worms, irritation by pancreatic enzymes.

The most common microorganisms that cause inflammation are staphylococci and streptococci, as well as Proteus, Pseudomonas aeruginosa, Enterococci, Escheria. Emphysematous forms of the disease are associated with exposure to clostridia. In more rare cases, chronic cholecystitis can occur against the background of viral lesions of the biliary system, protosis infection, or salmonellosis. All types of infections can penetrate into the bladder by hematogenous, lymphogenous or contact (intestinal) route.

At various options helminthic infestations - fascioliasis, strongyloidiasis, opisthorchiasis, giardiasis, roundworms, partial obstruction of the bile ducts may be observed (in the presence of ascariasis), the development of symptoms of cholangitis (with fascioliasis), persistent dysfunction is observed in giardiasis biliary tract.

Common causes of chronic cholecystitis:

violation of the diet, an abundance of spicy and fatty foods in the diet, obesity, alcoholism;

the presence of helminthic infestation - opistrochiasis, strongyloidiasis, giardiasis, ascariasis;

cholelithiasis;

biliary dyskinesia;

organ prolapse abdominal cavity, pregnancy, congenital anomalies in the development of the gallbladder.

In the presence of any type of cholecystitis, the inflammatory process in the walls of the gallbladder leads to obstruction of the lumen of the ducts, its narrowing, stagnation of bile, which gradually begins to thicken. Formed vicious circle, which ultimately leads to allergic or autoimmune inflammation.

The formulation of the diagnosis of acute chronic cholecystitis contains the following data:

stage (remission, subsiding exacerbation, exacerbation);

degree of severity (severe, moderate, mild);

nature of the course (often recurrent, monotonous);

state of gallbladder functions (non-functioning bladder, functionality preserved);

the nature of biliary dyskinesia;

complications.

Symptoms of acute cholecystitis

A provoking factor leading to the development acute attack cholecystitis is alcohol abuse, overeating fatty, spicy foods, and severe stress. In this case, the patient experiences the following symptoms:

the appearance of yellowness of the skin;

belching air;

vomiting that does not bring relief, constant nausea, in some cases vomiting bile;

the presence of an intense bitter taste in the mouth;

slight increase in body temperature to subfebrile levels;

severe weakness, increased fatigue;

acute attacks of pain in the right hypochondrium, upper abdomen, which can radiate to the right shoulder blade; much less often, the pain radiates to the left hypochondrium.

The duration of acute cholecystitis depends on the severity of the pathology and can vary from 10 days to 1 month. In moderate and mild cases, when the purulent process does not develop and there are no stones, the patient recovers very quickly. However, with reduced immunity, the presence secondary pathologies, in case of perforation of the bladder wall, not only severe complications may occur, but also a high probability of death.

Symptoms of chronic cholecystitis

Chronic cholecystitis does not have a sudden onset; on the contrary, it develops systematically, over a long period of time, after exacerbations. During therapy in combination with diet, periods of remission of the pathology occur, the duration of which depends on adherence to the diet and the use of maintenance medications.

The main symptom of chronic cholecystitis is Blunt pain in the area of the right hypochondrium, which is present for several weeks and can radiate to the lumbar region, right shoulder, and become aching. Painful sensations intensify after drinking alcohol, carbonated drinks, spicy or fatty foods, during stress and hypothermia; in women, the period of exacerbation may depend on premenstrual syndrome(PMS).

The main symptoms of chronic cholecystitis:

yellowing of the skin;

low-grade fever;

heaviness in the right hypochondrium;

belching with bitterness, bitterness in the mouth;

dull pain in the right hypochondrium, which radiates to the shoulder blade and back;

lack of appetite, nausea, vomiting, digestive disorders;

quite rare, however, atypical symptoms may be present, which manifest themselves in the form of constipation, bloating, swallowing disorders, and heart pain.

To diagnose the presence of both chronic and acute cholecystitis, the most informative methods are:

cholegraphy;

cholecystography;

scintigraphy;

Ultrasound of the abdominal organs;

duodenal intubation;

biochemical blood test, which in case of illness shows high levels of liver enzymes - AlT, AST, alkaline phosphatase, GGTP;

the most accessible and modern diagnostic methods are bacteriological examination and laparoscopy.

Of course, any pathology is much easier to prevent than to cure, so timely diagnosis can detect the presence of disorders in the early stages and deviations in chemical composition bile. By following an appropriate diet, the period of remission of chronic cholecystitis can be extended to the maximum and the development of serious complications can be prevented.

Treatment of chronic cholecystitis

Treatment chronic process, which passes without the formation of stones, is always performed conservative methods, the main one of which is following a diet (dietary table No. 5 - small, frequent meals with the consumption of a sufficient amount of liquid, mineral water). If there are stones in the gall bladder, limit bumpy driving, physical overload, and hard work.

The following medications are used:

antibiotics - in most cases wide range actions, cephalosporins;

enzyme preparations – “Creon”, “Mezim”, “Pancreatin”;

detoxification - intravenous infusion of glucose solution, sodium chloride;

non-steroidal anti-inflammatory drugs - to relieve pain and inflammation.

Choleretic drugs are divided into:

Choleretics are drugs that stimulate the process of bile formation. Such products contain bile acids and bile: “Decholin” ( sodium salt dehydrocholic acid), "Hologon" (dihydrocholic acid), "Cholenzim", "Vigeratin", "Liobil", "Allohol". Herbal preparations, which enhance the secretion of bile: “Convaflavin”, “Berberine”, corn silk, “Flacumin”. Synthetic drugs: “Gimecromon” (“Cholestil”, “Holonerton”, “Odeston”), “Cyqualon”, “Hydroxymethylnicotinamide” (nicotine), “Osalmid” (oxaphenamide).

Cholekinetics are divided into: cholespasmalytics, which reduce the tone of the sphincter of Oddi and biliary tract: “Mebeverine” (“Duspatalin”), “Eufillin”, “Platifillin”, “Atropine”, “Olymethine”, “No-shpa”, “Drotaverine hydrochloride” ; increasing the tone of the gallbladder and promoting the secretion of bile (cholikinetics) - “Xylitol”, “Mannitol”, “Sorbitol”, “Cholecystokinin”, “Choleretin”, “Pituitrin”, magnesium sulfate.

During periods of exacerbation, herbal medicine is especially widely used, provided there is no allergy - decoctions of calendula, valerian, peppermint, dandelion, chamomile. During periods of remission may be prescribed homeopathic remedies or herbal medicine using other herbs - buckthorn, tansy, marshmallow, yarrow.

It is extremely important to follow a strict diet throughout treatment, both during periods of exacerbation and during periods of remission of the pathology. In addition to diet, for cholecystitis and gallstones, it is necessary to periodically carry out tubages with magnesium or mineral water Physiotherapy with xylitol also has a positive effect - SMT therapy, reflexology, electrophoresis.

In case of calculous chronic cholecystitis, when the symptoms of the pathology are pronounced, it is recommended to perform resection of the gallbladder as a source of proliferation of stones, which, if advanced, can pose a threat to the patient’s life. The advantage of chronic cholecystitis with the presence of stones, compared to acute calculous cholecystitis, is a planned operation, for which you need to carefully prepare. When performing surgical intervention, the cholecystectomy method from a mini-access and laparoscopic surgery are used.

If there are contraindications for surgical intervention, for chronic cholecystitis, in some cases, treatment can be carried out using the method shock wave lithotripsy(crushing stones), with this extracorporeal procedure the stones are not removed, but simply destroyed, so relapses of the pathology occur quite often. There is also a technique for destroying stones by exposure to salts of chenodeoxycholic and ursodeoxycholic acid, but such treatment not only does not provide a complete cure, but is also very long-lasting. The process of destroying stones using this method can continue for up to 2 years.

Treatment of acute cholecystitis

In the case when acute cholecystitis is detected for the first time, there are no stones in the bladder, and severe clinical picture with purulent complications is not registered - conservative treatment is sufficient drug therapy, which includes: choleretic agents, enzyme and detoxification therapy, NSAIDs, antispasmodics, antibiotics.

In the presence of severe forms of destructive cholecystitis, removal of the gallbladder (cholecystectomy) must be performed without fail. Most often, resection of the gallbladder is performed through a mini-access. If the patient refuses to undergo surgery, an attack of acute cholecystitis can be relieved with the help of medications, however, you need to be aware that large stones will cause relapses and lead to the transition of the pathology to chronic form, treatment of which quite often ends with surgery for complications.

Today at medical practice Three main methods of surgical intervention are used to treat cholecystitis - laparoscopic cholecystectomy, open cholecystectomy, and for weakened patients - percutaneous cholecystectomy.

All patients with acute cholecystitis, without exception, must follow a strict diet, which allows only tea for the first two days, after which a transition to dietary table No. 5A occurs. It is characterized by the fact that all products are prepared by boiling or steaming, a minimum of fat is used, alcohol-containing and carbonated drinks, seasonings, smoked and fried foods are excluded.

What is acute cholecystitis? We will discuss the causes, diagnosis and treatment methods in the article by Dr. E. V. Razmakhnin, a surgeon with 22 years of experience.

Definition of disease. Causes of the disease

Acute cholecystitis is a rapidly progressing inflammatory process in the gallbladder. Stones located in this organ are the most common reason of this pathology.

About 20% of patients admitted to the emergency surgical hospital are patients with complicated forms, which include acute cholecystitis. In elderly patients, this disease occurs much more often and is more severe due to the large number of existing somatic diseases. In addition, with age, the incidence of gangrenous forms of acute cholecystitis increases. Acalculous acute cholecystitis is uncommon and is a consequence infectious diseases, vascular pathology (vesical artery thrombosis) or sepsis.

The disease is usually provoked errors in diet - intake of fatty and spicy foods, which leads to intense bile formation, spasm of sphincters in the biliary tract and biliary hypertension.

Contributing factors are stomach diseases , and in particular gastritis with low acidity. They lead to a weakening of protective mechanisms and the penetration of microflora into the biliary tract.

At cystic artery thrombosis against the background of pathology of the blood coagulation system and atherosclerosis, the development of a primary gangrenous form of acute cholecystitis is possible.

Provoking factors if present cholelithiasis Physical activity, “shaky” riding, which leads to the displacement of the stone, blockage of the cystic duct and subsequent activation of the microflora in the lumen of the bladder, can also serve.

Existing cholelithiasis does not always lead to the development of acute cholecystitis; it is quite difficult to predict this. Throughout life, stones in the lumen of the bladder may not manifest themselves, or at the most inopportune moment they can lead to a serious complication that is life-threatening.

Symptoms of acute cholecystitis

The clinical picture of the disease includes pain, dyspeptic and intoxication syndromes.

Typically, the onset of the disease is manifested by hepatic colic: intense pain in the right hypochondrium, radiating to the lumbar, supraclavicular region and epigastrium. Sometimes, in the presence of symptoms of pancreatitis, pain can become girdling. The epicenter of pain is usually localized at the so-called Kehr's point, located at the intersection of the outer edge of the right rectus abdominis muscle and the edge of the costal arch. At this point the gallbladder comes into contact with the anterior abdominal wall.

The appearance of hepatic colic is explained by sharply increasing biliary (biliary) hypertension against the background of a reflex spasm of the sphincters located in the biliary tract. Increased pressure in the biliary system leads to enlargement of the liver and stretching of the Glissonian capsule that covers the liver. And since the capsule contains a huge number of pain receptors (i.e. noceroreceptors), this leads to the occurrence of pain.

The structure of Glisson's capsule

The development of the so-called cholecystocardial Botkin syndrome is possible. In this case, with acute cholecystitis, pain occurs in the heart area, and even changes in the ECG may appear in the form of ischemia. Such a situation can mislead the doctor, and as a result of overdiagnosis (erroneous medical report) coronary disease he risks not recognizing acute cholecystitis. In this regard, it is necessary to carefully understand the symptoms of the disease and evaluate the clinical picture as a whole, taking into account the anamnesis and paraclinical data. The occurrence of Botkin's syndrome is associated with the presence of a reflex parasympathetic connection between the gallbladder and the heart.

After relief of hepatic colic, the pain does not completely go away, as with chronic calculous cholecystitis. It becomes somewhat dull, takes on a constant bursting character and is localized in the right hypochondrium.

In the presence of complicated forms of acute cholecystitis, the pain syndrome changes. With the occurrence of perforation of the gallbladder and the development of peritonitis, the pain becomes diffuse throughout the abdomen.

Intoxication syndrome is manifested by increased temperature, tachycardia (increased heart rate), dry skin (or, conversely, sweating), lack of appetite, headache, muscle pain and weakness.

The degree of temperature rise depends on the severity of the ongoing inflammation in the gallbladder:

in the case of catarrhal forms, the temperature can be subfebrile - from 37°C to 38°C;
for destructive forms of cholecystitis - above 38°C;
when an empyema (ulcer) of the gallbladder or a perivesical abscess occurs, hectic temperature is possible with sharp rises and falls during the day and heavy sweat.

Dyspeptic syndrome is expressed in the form of nausea and vomiting. Vomiting can be either single or repeated with concomitant damage to the pancreas, which does not bring relief.

Pathogenesis of acute cholecystitis

Previously it was believed that the main factor leading to the development of acute cholecystitis was bacterial. In accordance with this, treatment was prescribed aimed at eliminating the inflammatory process. Currently, ideas about the pathogenesis of the disease have changed and treatment tactics have changed accordingly.

The development of acute cholecystitis is associated with a block of the gallbladder, which triggers all subsequent pathological reactions. The block is most often formed as a result of a stone wedging into the cystic duct. This is aggravated by a reflex spasm of the sphincters in the biliary tract, as well as increasing edema.

As a result of biliary hypertension, the microflora located in the biliary tract is activated and develops acute inflammation. Moreover, the severity of biliary hypertension directly depends on the degree of destructive changes in the wall of the gallbladder.

Increased pressure in the biliary tract is a trigger for the development of many acute diseases of the hepatoduodenal zone (cholecystitis, cholangitis, pancreatitis). Activation of intravesical microflora leads to even greater edema and disruption of microcirculation, which, in turn, significantly increases the pressure in the biliary tract - a vicious circle closes.

Classification and stages of development of acute cholecystitis

Based on morphological changes in the wall of the gallbladder, four forms of acute cholecystitis are distinguished:

catarrhal;
phlegmonous;
gangrenous;
gangrenous-perforative.

Different severity of inflammation suggests a different clinical picture.

With catarrhal form the inflammatory process affects the mucous membrane of the gallbladder. Clinically, this is manifested by pain of moderate intensity, intoxication syndrome is not expressed, and nausea occurs.

With phlegmonous form inflammation affects all layers of the gallbladder wall. A more intense pain syndrome, fever up to febrile levels, vomiting and flatulence occurs. An enlarged, painful gallbladder may be palpable. Symptoms are revealed:

With. Murphy - interruption of inhalation when palpating the gallbladder;
With. Mussi - Georgievsky, otherwise called phrenicus symptom - more painful palpation on the right between the legs of the sternocleidomastoid muscle (the exit point of the phrenic nerve);
With. Ortner - pain when tapping on the right costal arch.

In gangrenous form intoxication syndrome comes to the fore: tachycardia, heat, dehydration (dehydration), symptoms of peritoneal irritation appear.

With perforation of the gallbladder(gangrenous-perforated form) the clinical picture of peritonitis prevails: tension of the muscles of the anterior abdominal wall, positive symptoms irritation of the peritoneum (Mendel village, Voskresensky village, Razdolsky village, Shchetkina-Blumberg village), bloating and severe intoxication syndrome.

Forms of cholecystitis without appropriate treatment can flow from one to another (from catarrhal to gangrenous), and the initial development of destructive changes in the wall of the bladder is also possible.

Stages of acute cholecystitis

Complications of acute cholecystitis

Complications can arise with a long course of untreated destructive forms of acute cholecystitis.

If inflammation is limited, it occurs perivesical infiltrate. Its obligatory component is the gallbladder, located in the center of the infiltrate. The composition most often includes the omentum, the transverse colon may be included, antrum stomach and duodenum. It usually occurs after 3-4 days of the disease. At the same time, pain and intoxication may decrease somewhat, and dyspeptic syndrome may be relieved. With correctly chosen conservative treatment, the infiltrate can resolve within 3-6 months; if unfavorable, it can abscess with development perivesical abscess(characterized by severe intoxication syndrome and increased pain). Diagnosis of infiltrate and abscess is based on anamnesis of the disease, objective examination data and is confirmed using ultrasound.

Peritonitis- the most dangerous complication of acute destructive cholecystitis. It occurs when the wall of the gallbladder is perforated and bile leaks into the free abdominal cavity. As a result of this, a sharp increase in pain occurs, the pain becomes diffused throughout the abdomen. The intoxication syndrome becomes more severe: the patient is initially excited, groans in pain, but as peritonitis progresses, he becomes apathetic. Peritonitis is also characterized by severe intestinal paresis, bloating and weakened peristalsis. Upon examination, defence (tension) of the anterior abdominal wall and positive symptoms of peritoneal irritation are determined. Ultrasound examination reveals the presence of free fluid in the abdominal cavity. At x-ray examination signs of intestinal paresis are noticeable. Emergency surgical treatment is required after short-term preoperative preparation.

Another serious complication of acute cholecystitis is cholangitis- inflammation spreads to the biliary tree. In essence, this process is a manifestation of abdominal sepsis. The condition of the patients is severe, intoxication syndrome is pronounced, high hectic fever occurs with large daily temperature fluctuations, heavy sweats and chills. The liver increases in size, jaundice and cytolytic syndrome occur.

Ultrasound reveals dilation of the intra- and extrahepatic ducts. Blood tests show hyperleukocytosis, increased bilirubin levels due to both fractions, increased activity of aminotransferases and alkaline phosphatase. Without appropriate treatment, such patients quickly die from liver failure.

Diagnosis of acute cholecystitis

Diagnosis is based on a combination of medical history, objective data, laboratory and instrumental studies. In this case, the principle must be respected from simple to complex, from less invasive to more invasive.

When collecting anamnesis(during the survey) patients may indicate the presence of cholelithiasis, previous hepatic colic, diet violations in the form of consumption of fatty, fried or spicy foods.

Clinical data assessed by the manifestations of pain, dyspeptic and intoxication syndromes. In the presence of complications, concomitant choledocholithiasis and pancreatitis, cholestasis syndrome and moderate cytolytic syndrome are possible.

From instrumental methods diagnostics the most informative and least invasive is ultrasonography. At the same time, the size of the gallbladder, its contents, the condition of the wall, surrounding tissues, intra- and extrahepatic bile ducts, and the presence of free fluid in the abdominal cavity are assessed.

In the case of an acute inflammatory process in the gallbladder, ultrasound reveals an increase in its size (sometimes significant). Wrinkling of the bladder indicates the presence of chronic cholecystitis.

When assessing the contents, pay attention to the presence of stones (number, size and location) or flakes, which may indicate the presence of stagnation of bile (sludge) or pus in the lumen of the bladder. In acute cholecystitis, the wall of the gallbladder thickens (more than 3 mm), can reach 1 cm, and sometimes becomes layered (in destructive forms of cholecystitis).

With anaerobic inflammation, gas bubbles can be seen in the wall of the bladder. The presence of free fluid in the peri-vesical space and in the free abdominal cavity indicates the development of peritonitis. In the presence of biliary hypertension against the background of choledocholithiasis or pancreatitis, dilation of the intra- and extrahepatic bile ducts is observed.

Evaluation of ultrasound data makes it possible to decide on treatment tactics even at the admission stage: patient management conservatively, emergency, urgent or delayed surgery.

X-ray methods studies are carried out if a block of the biliary tract is suspected. Plain radiography is not very informative, since stones in the lumen of the gallbladder are usually non-contrast (about 80%) - they contain a small amount of calcium, and they can rarely be visualized.

With the development of such a complication of acute cholecystitis as peritonitis, signs of paresis of the gastrointestinal tract can be identified. To clarify the nature of the biliary tract block, contrast research methods are used:

endoscopic retrograde cholangiopancreatography - the biliary tract is contrasted retrogradely through the papilla of Vater during duodenoscopy;
percutaneous transhepatic cholecystocholangiography - antegrade contrast enhancement by percutaneous puncture of the intrahepatic duct.

If diagnosing and differential diagnosis difficult, carried out CT scan belly. With its help, you can evaluate in detail the nature of changes in the gallbladder, surrounding tissues and bile ducts.

If necessary, differential diagnosis from another acute pathology abdominal organs can be performed diagnostic laparoscopy and visually assess existing changes in the gallbladder. This study can be performed either under local anesthesia or under endotracheal anesthesia (the latter is preferable). If necessary, the issue of switching to therapeutic laparoscopy, that is, performing cholecystectomy - removal of the gallbladder, is decided right on the operating table.

Laboratory diagnostics consists of performing general analysis blood, where leukocytosis is detected, a shift in the leukocyte formula to the left and increase in ESR. The severity of these changes will depend on the severity of inflammatory changes in the gallbladder.

IN biochemical analysis blood May be slight increase bilirubin level and aminotransferase activity due to reactive hepatitis in the adjacent liver tissue. More pronounced changes in biochemical parameters occur with the development of complications and intercurrent diseases.

Treatment of acute cholecystitis

Patients with acute cholecystitis are subject to emergency hospitalization in surgery department hospital. After carrying out the necessary diagnostic measures further treatment tactics are determined. In the presence of severe complications - perivesical abscess, destructive cholecystitis with peritonitis - patients are subject to emergency surgery after short preoperative preparation.

Preparation consists of restoring the volume of circulating blood, detoxification therapy by infusion of crystalloid solutions in a volume of 2-3 liters. If necessary, correction of cardiac and respiratory failure. Perioperative antibiotic prophylaxis is performed (before, during and after surgical intervention).

The surgical approach is selected depending on the technical capabilities of the clinic, the individual characteristics of the patient and the qualifications of the surgeon. The most commonly used is laparoscopic access, which is the least traumatic and allows for full inspection and sanitation.

The mini-access is not inferior to the laparoscopic approach in terms of morbidity and has the advantage of eliminating the need to apply pneumoperitoneum (to limit the mobility of the diaphragm). If technical difficulties arise, expressed adhesive process in the abdominal cavity and diffuse peritonitis, it is more advisable to use laparotomic access: upper-median laparotomy, Kocher, Fedorov, Rio Branca access. In this case, the upper midline laparotomy is less traumatic, since in this case the muscles are not intersected, however, with oblique subcostal approaches, the subhepatic space is more adequately opened for surgical intervention.

The operation consists of performing a cholecystectomy. It should be noted that the presence of perivesical infiltrate implies certain technical difficulties in mobilizing the neck of the gallbladder. This leads to increased risk damage to the elements of the hepatoduodenal ligament. In this regard, we should not forget about the possibility of performing cholecystectomy from the fundus, which makes it possible to more clearly identify the elements of the cervix.

There is also the “Pribrama” operation, which consists of removing the anterior (lower) wall of the gallbladder, suturing the cystic duct in the neck area and mucoclasia (removal of the mucous membrane) by electrocoagulation of the posterior (upper) wall. Performing this operation with a pronounced infiltrate in the area of the bladder neck will avoid the risk of iatrogenic damage. It is applicable for both laparotomic and laparoscopic approaches.

If there are no severe complications of acute cholecystitis, then upon admission of the patient to the hospital, conservative therapy aimed at unblocking the gallbladder. Antispasmodics, anticholinergics, infusion therapy are used to relieve intoxication, and antibiotics are prescribed.

An effective method is to block the round ligament of the liver with a solution of novocaine. The blockade can be performed either blindly using a special technique, or under the control of a laparoscope when performing diagnostic laparoscopy and under ultrasound guidance.

If ineffective conservative therapy within 24 hours, the question of carrying out a radical operation is raised - cholecystectomy.

Of no small importance for determining therapeutic tactics has the time elapsed since the onset of the disease. If the interval is up to five days, then cholecystectomy is feasible; if it is more than five days, then it is better to adhere to the most conservative tactics in the absence of indications for emergency surgery. The fact is that in the early stages the perivesical infiltrate is still quite loose, it can be divided during surgery. Later, the infiltrate becomes dense, and attempts to separate it may result in complications. Of course, a period of five days is quite arbitrary.

In the absence of effect from conservative treatment and the presence of contraindications for radical surgery - severe pathology of the cardiovascular and respiratory systems, five days have passed since the onset of the disease - it is better to resort to decompression of the gallbladder by cholecystostomy.

Cholecystoma can be applied in three ways: from a mini-access, under laparoscopic control and under ultrasound control. The most minimally traumatic procedure is to perform this operation under ultrasound guidance and local anesthesia. Single and double punctures of the gallbladder with sanitation of its lumen under ultrasound guidance are also effective. Prerequisite- passage of the puncture channel through the liver tissue to prevent bile leakage.

After stopping the acute inflammatory process, radical surgery is performed in a cold period after three months. Usually this time is enough for the perivesical infiltrate to resolve.

Forecast. Prevention

The prognosis with timely and adequate treatment is usually favorable. After radical surgery, it is necessary for a certain period of time (at least three months) to adhere to diet No. 5 with the exception of fatty, fried and spicy foods. Food intake should be fractional - in small portions 5-6 times a day. It is necessary to take pancreatic enzymes and herbal choleretic agents (they are contraindicated before surgery).

Prevention consists of timely sanitation of stone carriers, that is, performing cholecystectomy as planned for patients with chronic calculous cholecystitis. The founder of biliary surgery, Hans Kehr, said that “carrying a stone in the gall bladder is not the same as wearing an earring in the ear.” In the presence of cholecystolithiasis, factors leading to the development of acute cholecystitis should be avoided - do not break the diet.

Bibliography

Clinical cases

Laparoscopic version of the Pribram operation for acute cholecystitis

Author of the clinical case:

Introduction

Patient M., 65 years old, was transported by an ambulance team to City Hospital No. 1 in Chita with acute pain in the right hypochondrium.

Complaints

Upon admission, the patient complained of pain that radiated to the epigastrium and right shoulder girdle, an increase in body temperature to 38°C, nausea and vomiting twice.

The pain decreased somewhat after taking antispasmodics and analgesics for several hours.

Anamnesis

She became acutely ill three days ago after errors in her diet (using buuz), she independently took the drug "No-shpa" with minor effect. The temperature first rose to 38°C on the eve of hospitalization. Cholelithiasis has been present for several years; the patient has repeatedly suffered from hepatic colic, which was relieved by the administration of antispasmodics, and refused surgical treatment.

There is no allergic history. As a child, she suffered from Botkin's disease (hepatitis A). Suffering hypertension, in connection with this, he is observed by a therapist and receives antihypertensive therapy. There were no injuries or operations.

Survey

The condition is of moderate severity, the situation is active. Patient increased nutrition, BMI - 35. Skin color is normal, humidity is high. Breathing is vesicular, respiratory rate is 18 per minute. Heart sounds are sonorous, rhythmic, heart rate - 88 per minute, blood pressure - 150/80 mm Hg. The tongue is dry, covered with a gray coating. The abdomen is enlarged due to subcutaneous fat, takes part in the act of breathing, during palpation it is moderately tense and sharply painful in the right hypochondrium. An enlarged, painful gallbladder can also be felt there. Symptoms of Ortner, Kehr, Murphy, Mussi - Georgievsky are positive. There are no symptoms of peritoneal irritation. There is no free fluid in the abdominal cavity.

X-ray of organs chest: diffuse pneumosclerosis.
ECG: sinus rhythm, left ventricular hypertrophy, heart rate - 88 per minute.
CBC: leukocytosis up to 14.6x109/l, total bilirubin - 18 µmol/l.
Ultrasound: the gallbladder is significantly enlarged in size, the wall is layered, thickened to 8 mm, there are many echo-positive signals in the lumen with an acoustic shadow from 3 to 18 mm. Common bile duct - 5 mm. No free fluid was found in the abdominal cavity.

Diagnosis

Cholelithiasis. Acute calculous cholecystitis.

Treatment

After additional examination, the patient was prescribed infusion therapy in a volume of 2.0 liters, antispasmodics and antibacterial therapy. Given the lack of effect, a block of the round ligament of the liver was performed with a short-term effect in the form of pain reduction. 12 hours after the start of treatment, the patient continues to have pain in the right hypochondrium, temperature up to 37.8°C. Given the persistent pain and intoxication syndromes, she was transferred to the operating room.
Under endotracheal anesthesia, laparocentesis (puncture of the abdominal wall) was performed, and pneumoperitoneum was applied. Four trocars are installed through standard points. An infiltrate consisting of the gallbladder, a loop of the transverse colon, the greater omentum and the bulb was detected in the right hypochondrium duodenum. This infiltrate was partially divided with technical difficulties; the transverse colon, omentum, and duodenal bulb were separated. The gallbladder is tense, hyperemic, its size is significantly increased, the wall is thickened, and about 60 ml of thick pus is evacuated during puncture. Differentiation of the elements of the bladder neck is impossible due to the rocky density of the infiltrate. It was decided to perform the Pribram operation. The gallbladder is opened, stones of various sizes are evacuated, the walls of the gallbladder are partially excised, leaving small fragments adjacent to the liver and neck. Coagulation (union) of the bladder bed and the remaining fragments of the wall was performed for the purpose of biliary and hemostasis. The neck of the gallbladder is stitched and bandaged. The abdominal cavity was sanitized and drained with a PVC tube to the gall bladder bed.

The postoperative period was satisfactory. During the first two days, the drainage released about 200 ml of serous discharge mixed with bile, which gradually stopped. The drainage was removed on the fourth day after surgery.

On the sixth day after surgery, the patient was discharged in satisfactory condition. She was examined on an outpatient basis two weeks later, had no complaints, the skin and mucous membranes were of normal color, the abdomen was soft, painless, and the stool was colored.

Conclusion

Considering the long period that has passed since the onset of acute cholecystitis, such patients are always expected to have a fairly dense perivesical infiltrate. Of course, in similar cases It is advisable to carry out conservative therapy aimed at unblocking the gallbladder, stopping the inflammatory process and subsequent surgery in a cold period after three months. However, if conservative therapy is ineffective, one must resort to either cholecystostomy or radical surgery. If the infiltrate in the area of the bladder neck is sufficiently dense and inseparable, then you can resort to Pribram’s operation, including the laparoscopic version, which will reduce the invasiveness of the intervention and avoid damage to the tubular structures of the porta hepatis.

State budgetary educational institution of higher professional education

"Tyumen State Medical AcademyMinistry of Health of the Russian Federation"

DEPARTMENT OF FACULTY SURGERY WITH A COURSE OF UROLOGY

ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS

Module 2. Diseases of the bile ducts and pancreas

Methodological guide for preparing for the exam in faculty surgery and the Final State Certification of students of the Faculty of Medicine and Pediatrics

Compiled by: DMN, prof. N. A. Borodin

Tyumen - 2013

ACUTE CHOLECYSTITIS

Questions that a student should know about the topic:

Acute cholecystitis. Etiology, classification, diagnosis, clinical picture. Choice of treatment method. Methods of surgical and conservative treatment.

Acute obstructive cholecystitis, definition of the concept. Clinic, diagnosis, treatment.

Hepatic colic and acute cholecystitis, differential diagnosis, clinical picture, methods of laboratory and instrumental studies. Treatment.

Acute cholecystopancreatitis. Causes of occurrence, clinical picture, methods of laboratory and instrumental studies. Treatment.

Choledocholithiasis and its complications. Purulent cholangitis. Clinical picture, diagnosis and treatment.

Surgical complications of opisthorchiasis of the liver and gall bladder. Pathogenesis, clinical picture, treatment.

Acute cholecystitis This is an inflammation of the gallbladder from catarrhal to phlegmonous and gangrenous-perforated.

In emergency surgery, the concept of “chronic cholecystitis” or “exacerbation of chronic cholecystitis” is usually not used, even if this was not the patient’s first attack. This is due to the fact that in surgery any acute attack of cholecystitis is considered as a phase of a destructive process that can result in purulent peritonitis. The term “chronic calculous cholecystitis” is used almost only in one case, when the patient is admitted for planned surgical treatment in the “cold” period of the disease.

Acute cholecystitis is most often a complication of cholelithiasis (acute calculous cholecystitis). Often the trigger for the development of cholecystitis is a violation of the outflow of bile from the bladder under the influence of stones, then an infection occurs. A stone can completely block the neck of the gallbladder and completely “turn off” the gallbladder; this cholecystitis is called “obstructive”.

Much less often, acute cholecystitis can develop without gallstones - in this case it is called acute acalculous cholecystitis. Most often, such cholecystitis develops against the background of impaired blood supply to the gallbladder (atherosclerosis or thrombosis a.cistici) in elderly people; the cause may also be reflux of pancreatic juice into the gallbladder - enzymatic cholecystitis.

Classification of acute cholecystitis.

Uncomplicated cholecystitis

1. Acute catarrhal cholecystitis

2. Acute phlegmonous cholecystitis

3. Acute gangrenous cholecystitis

Complicated cholecystitis

1. Peritonitis with perforation of the gallbladder.

2. Peritonitis without gallbladder perforation (sweaty biliary peritonitis).

3. Acute obstructive cholecystitis (cholecystitis against the background of obstruction of the neck of the gallbladder in the area of its neck, i.e. against the background of a “switched off” gallbladder. The usual reason stone wedged into the area of the bladder neck. With catarrhal inflammation this takes on the character hydrocele of the gallbladder, with a purulent process occurs gallbladder empyema, i.e. accumulation of pus in the disabled gallbladder.

4. Acute cholecysto-pancreatitis

5. Acute cholecystitis with obstructive jaundice (choledocholithiasis, strictures of the major duodenal papilla).

6. Purulent cholangitis (spreading purulent process from the gallbladder to the extrahepatic and intrahepatic bile ducts)

7. Acute cholecystitis against the background of internal fistulas (fistulas between the gallbladder and intestines).

Clinical picture.

The disease begins acutely as an attack of hepatic colic (hepatic colic is described in the manual on cholelithiasis), when an infection occurs, a clinical picture of the inflammatory process and intoxication develops, and the progressive disease leads to local and diffuse peritonitis.

The pain occurs suddenly, patients become restless and do not find rest. The pain itself is constant and increases as the disease progresses. Localization of pain is the right hypochondrium and epigastric region, the most severe pain is in the projection of the gallbladder (Ker's point). Irradiation of pain is typical: in the lower back, under the angle of the right shoulder blade, in the supraclavicular region on the right, in the right shoulder. Often a painful attack is accompanied by nausea and repeated vomiting, which does not bring relief. A subfibrile temperature appears, sometimes accompanied by chills. The last sign may indicate the addition of cholestasis and the spread of the inflammatory process to the bile ducts.

On examination: the tongue is coated and dry, the abdomen is painful in the right hypochondrium. The appearance of tension in the muscles of the anterior abdominal wall in the right hypochondrium (village Kerte) and symptoms of peritoneal irritation (Shchetkina-Blumberga village) speaks of the destructive nature of inflammation.

In some cases (with obstructive cholecystitis), you can feel an enlarged, tense and painful gallbladder.

Symptoms of acute cholecystitis

Ortner-Grekov symptom– pain when tapping the edge of the palm on the right costal arch.

Zakharyin's symptom– pain when tapping the edge of the palm in the right hypochondrium.

Murphy's sign– when pressing on the area of the gallbladder with the fingers, the patient is asked to take a deep breath. In this case, the diaphragm moves down and the stomach rises, the bottom of the gallbladder collides with the examiner’s fingers, severe pain occurs and breathing is interrupted.

In modern conditions, Murphy's symptom can be checked during an ultrasound examination of the bladder; an ultrasound sensor is used instead of a hand. You need to press the sensor on the anterior abdominal wall and force the patient to take a breath; the device screen shows how the bubble approaches the sensor. When the device approaches the bladder, severe pain occurs and the patient interrupts his breath.

Mussi-Georgievsky's sign(phrenicus symptom) - the occurrence of painful sensations when pressing in the area of the sternocleidomastoid muscle, between its legs.

Ker's symptom- pain when pressing with a finger into the angle formed by the edge of the right rectus abdominis muscle and the costal arch.

Pain on palpation of the right hypochondrium is called Obraztsov's symptom, but since it resembles other symptoms, sometimes this sign is called the Kera-Obraztsev-Murphy symptom.

Pain when pressing on the xiphoid process is called the xiphoid process phenomenon or Likhovitsky's symptom.

Laboratory research. Acute cholecystitis is characterized by an inflammatory reaction of the blood, primarily leukocytosis. With the development of peritonitis, leukocytosis becomes pronounced - 15-20 10 9 /l, the band shift of the formula increases to 10-15%. Severe and advanced forms of peritonitis, as well as purulent cholangitis, are accompanied by a shift of the formula “to the left” with the appearance of young forms and myelocytes.

Other blood counts change when complications occur (see below).

Instrumental research methods.

There are several methods for instrumental diagnosis of bile duct diseases, mainly ultrasound and radiological methods (ERCP, intraoperative cholangiography and postoperative fistulocholangiography). Computed tomography is rarely used to examine the bile ducts. This is written in detail in the Guidelines on cholelithiasis and methods for studying the bile ducts. It should be noted that for the diagnosis of cholelithiasis and diseases associated with impaired bile outflow, both ultrasound and x-rays are usually used. methods, but to diagnose inflammatory changes in the gallbladder and surrounding tissues - only ultrasound.

At acute cholecystitis, the ultrasound picture is as follows. Most often, acute cholecystitis occurs against the background of cholelithiasis, so in most cases indirect sign cholecystitis is the presence of stones in the gall bladder, or bile sludge or pus, which are determined in the form of suspended small particles without an acoustic shadow.

Often acute cholecystitis occurs against the background of obstruction of the neck of the gallbladder; this cholecystitis is called Obstructive; on ultrasound it is visible as an increase in the longitudinal (more than 90-100 mm) and transverse direction (up to 30 mm or more). Finally straight Ultrasound signs of destructive cholecystitis is: thickening of the bladder wall (normally 3 mm) to 5 mm or more, stratification (doubling) of the wall, the presence of a strip of liquid (effusion) next to the gallbladder under the liver, signs of inflammatory infiltration of surrounding tissues.

Tactics and treatment:

When a patient with acute cholecystitis is admitted to an emergency surgical hospital, treatment of cholecystitis comes down to 3 principles:

1. Emergency surgery is performed on patients with signs of diffuse or diffuse peritonitis, as well as purulent cholangitis. At obvious signs peritonitis, emergency surgery is indicated. Purulent cholangitis is also an indication for surgery, but it takes some time to make this diagnosis, while purulent cholangitis itself is rare. As a result, the main indication for emergency surgery is cholecystitis complicated by diffuse purulent peritonitis.

2. All other patients are treated conservatively, but only for 24 hours. Antispasmodics, analgesics, antibiotics, IV infusion of solutions in a volume of 1.5 liters are prescribed. If during this period the clinical picture of cholecystitis is not relieved, or the symptoms of the disease increase, the patient is indicated for surgery.

3. If the clinical picture of cholecystitis has resolved, the patient continues to be treated conservatively, and the issue of planned surgical treatment must be resolved. The presence of stones in the gall bladder + a previous attack of hepatic colic or acute cholecystitis (especially multiple attacks) are an absolute indication for performing planned cholecystectomy. Such an operation can be performed without discharging the patient from the hospital, or the patient must be put on a waiting list.

Operation:

The most optimal surgical treatment option (operation of choice) is cholecystectomy. Performing this operation radically solves all issues. Firstly, the source of inflammation and intoxication is removed - the phlegmonous or gangrenous gallbladder. Secondly, all stones are removed and subsequently new stones cannot form, since in most cases they form only in the gallbladder. All newly formed bile, as it is produced in the liver, continuously moves through the bile ducts into the duodenum. If cholecystectomy is performed within a reasonable time from the onset of cholelithiasis, i.e. until the moment when gross morphological changes (fibrosis, strictures, cysts) occur in the bile ducts and pancreas, then such a patient feels himself to be a healthy person in the future and his dietary restrictions are minimal.

There are two types of cholecystectomy – from the cervix and from the fundus. It is most correct to perform the operation “from the neck”.

There are also different accesses when performing an operation. Despite the fact that the purpose of the operation and its scope remain unchanged - cholecystectomy, reducing the invasiveness of the intervention itself significantly facilitates the course of the postoperative period and reduces rehabilitation time. There are 3 main accesses.

1. Traditional laparotomy, wide dissection of the tissues of the anterior abdominal wall - 15-18 cm, along the midline of the abdomen, or through an oblique approach (according to Kocher, according to Fedorov) in the right hypochondrium.

2. Mini-access using a special tool - “mini-assistant”. Access 4-5 cm, through the rectus abdominis muscle, in the projection of the gallbladder.

3. Video laparoscopic cholecystectomy using a video camera, laparoscope, television monitor and special power tools. The operation is performed through 3 punctures on the anterior abdominal wall.

Another option is surgery - Cholecystostomy. This is a palliative, low-traumatic operation. It is performed in elderly, weakened patients, in the presence of severe concomitant diseases, when a long and traumatic operation poses a significant risk for the patient. In other words, it relieves the patient from a specific attack of acute cholecystitis, but does not relieve him from similar attacks in the future.

The essence of the operation is as follows: in the area of the bottom of the gallbladder, a small incision is made on the skin - 3-5 cm. Through the incision, the bottom of the gallbladder is isolated and a puncture is made in it with a scalpel. Pus, bile, bile sludge and stones are sucked out through the puncture, then a drainage tube is installed into the lumen of the gallbladder. The tube is fixed to the wall of the bladder with two purse-string sutures, the bottom of the gallbladder itself is sutured to the edges of the wound, and the wound is sutured around the tube. In the postoperative period, pus, bile, and small stones drain through the tube. Usually this is enough to cure the patient even from destructive forms of cholecystitis. The method also helps if the patient has obstructive jaundice and purulent cholangitis, provided the cystic duct is patent. The only exceptions are gangrenous forms of cholecystitis with signs of deep necrotic decay of the gallbladder walls.

A similar amount of intervention can also be performed by puncture, under ultrasound control, or laparoscopically.

COMPLICATIONS OF ACUTE CHOLECYSTITIS

Gangrenous cholecystitis with the development of peritonitis in most cases, it is a consequence of the progression of the phlegmonous stage of inflammation of the bladder into the gangrenous stage with the development of necrosis and perforation of its wall. In addition, “Primary gangrenous cholecystitis” occurs against the background of atherosclerosis and thrombosis of the cystic artery in elderly and senile people.

With the development of peritonitis, the symptoms of intoxication come first with signs of local or widespread muscle tension in the anterior abdominal wall and symptoms of peritoneal irritation (Shchetkin-Blumberg).

When the bladder is perforated, symptoms of diffuse peritonitis quickly develop. The condition of the patients is serious. Body temperature is increased. Tachycardia up to 120 beats per minute or more. Breathing is shallow and rapid. The tongue is dry. The abdomen is swollen due to intestinal paresis; its right parts do not participate in the act of breathing. Intestinal motility is reduced or absent. Symptoms of peritoneal irritation are positive. In the tests: high leukocytosis with a shift of the formula to the left, an increase in ESR, disturbances in the electrolyte composition of the blood and the acid-base state, proteinuria and cylindruria. In elderly and senile people, the symptoms of the disease are not clearly expressed, which can complicate diagnosis.

Peritonitis without gallbladder perforation or "sweating" peritonitis is a special form of development of peritonitis that occurs in some patients with acute cholecystitis. One of the reasons for its occurrence is the reflux of pancreatic juice through the common ampulla of the major duodenal papilla into the bile ducts and bladder with the development of enzymatic cholecystitis. Another reason is the morphological features of the structure of the gallbladder: its thin-walled nature, the absence of a submucosal (the strongest) layer.

The clinical picture of acute cholecystitis in this case is transformed into the clinical picture of local and diffuse bile peritonitis. During the operation, a large amount of cloudy yellow effusion is found in the abdominal cavity, and the intestines and other abdominal organs are colored bright yellow. On examination, the gallbladder is inflamed, but there are no obvious signs of necrosis of the bladder wall. In this case, it is clear that cloudy bile is secreted (sweats) from the surface of the gallbladder into the abdominal cavity, which is the cause of biliary peritonitis.

Treatment consists of emergency cholecystectomy and treatment of peritonitis in accordance with generally accepted standards: sanitation, drainage of the abdominal cavity. This is written in detail in the Peritonitis Guidelines.

Acute obstructive cholecystitis is cholecystitis occurring against the background obstruction of the gallbladder neck stone and inflammation products. Sometimes students call obstruction of the bile ducts (choledochus) the cause of obstructive cholecystitis, but this is not correct, since in this case another complication arises - obstructive jaundice. Obstructive cholecystitis occurs without obstructive jaundice, its essence is different - inflammation occurs in a confined space, namely in the “disconnected” gallbladder.

If the inflammation in the “disabled” bladder is catarrhal in nature, then the patient develops “dropsy of the gallbladder.” New bile does not enter the bladder, and the existing bile pigments are gradually absorbed, the bladder is filled with serous effusion. As a result, when a puncture of the gallbladder is performed during the operation, a light whitish liquid is evacuated from the swollen bladder, resembling whey in appearance, the so-called “white bile”.

If the inflammation in the “disconnected” bladder is purulent in nature, “gallbladder empyema” is formed and the bladder is filled with pus. When puncturing from such a bladder into large quantities pus is pumped out, sometimes with a foul odor.

Clinically, the disease begins acutely; when the stone migrates from the neck of the gallbladder back into the lumen of the bladder, the attack may end. If this does not happen, inflammatory changes progress. Clinically, this is similar to the clinical picture of ordinary cholecystitis, but there are some peculiarities. The main distinguishing feature of obstructive cholecystitis is a significant increase in the size of the bladder; as a result, it can be easily palpated through the anterior abdominal wall in the form of a large pear-shaped, tense and painful formation. An enlarged gallbladder (more than 10-11 cm in length) can be seen on an ultrasound; an ultrasound can also detect a stone “impacted” into the neck of the bladder.

Other clinical signs correspond to ordinary acute cholecystitis.

The tactics and methods of treatment are approximately the same as for ordinary cholecystitis. Namely: obstructive cholecystitis in itself is not an indication for emergency surgery; emergency intervention is performed only in the presence of peritonitis. If there is no peritonitis, then the patient is treated conservatively. But if, against the background of analgesics, antispasmodics, antibiotics, infusion therapy, the patient within 24 hours it didn't get better and the gallbladder has not contracted - urgent surgery is performed.

Cholecystopancreatitis. One of the variants of the course of acute cholecystitis is its combination with the phenomena of acute pancreatitis. This course of the disease is due to the presence common ampulla of the major duodenal papilla, where the common bile duct and the main (Wirsung) pancreatic duct merge. The presence of stones in the bile ducts and strictures of the major duodenal papilla can lead to the simultaneous development of both acute cholecystitis and acute pancreatitis. The disease begins as acute cholecystitis, but a violation of the outflow of pancreatic juice, or reflux of bile into the pancreas leads to the development of signs of pancreatitis.

As pancreatitis develops, the clinical picture changes, new signs appear, pain from the right hypochondrium spreads to the epigastric region, the left hypochondrium and becomes encircling in nature. The pain radiates to the lower back. Vomiting intensifies, signs of intoxication increase.

Objectively, pain is noted in the projection of the pancreas (Kerte p.), bloating of the upper half of the abdomen (Sentry Loop p.), pain in the left costovertebral angle (Mayo-Robson p.), the appearance of spots of cyanosis on the lateral walls of the abdomen, near the umbilical region and face.

Subicteric skin, darkening of urine and discoloration of feces may be noted due to swelling of the head of the gland and the occurrence of cholestasis against this background.

Laboratory testing confirms the presence of pancreatitis by an increase in amylase in the blood and diastase in the urine.

Ultrasound examination shows an increase in the transverse dimensions of the pancreas up to 4-5 cm, an increase in the distance between back wall stomach and anterior surface of the pancreas over 3 mm and reaching 10 - 20 mm, which characterizes swelling of the parapancreatic tissue.

In the absence of signs of pancreatic necrosis, treatment of cholecystopancreatitis is the same as for acute cholecystitis and depends on changes in the bladder wall (see above for treatment of cholecystitis). Additionally, the prescription of drugs that reduce pancreatic secretion is required: sandostatin, octreotide; detoxification infusion therapy, prescription of antibiotics, analgesics and antispasmodics.

Purulent cholangitis – This is the spread of a purulent inflammatory process to the extrahepatic bile ducts: the common bile duct, the common hepatic duct, to the lobar ducts, and then to the intrahepatic ducts. If left untreated, single or multiple liver abscesses form. Purulent cholangitis, as a complication of acute cholecystitis, is rare, but when it develops, the patient’s condition becomes severe and can result in death.

The peculiarity of this complication is that it is practically never develops in the backgroundunchanged bile ducts. Those. In order for purulent cholangitis to develop, there must be stones in the common bile duct, or stricture of the biliary tract or major duodenal papilla. Against this background, bile stasis occurs in the ducts, then infection occurs.

Purulent cholangitis is characterized by increasing jaundice, increased body temperature to 39-40 0 C and higher, pain in the right hypochondrium. All these signs are called Charcot's triad. A very characteristic sign of cholangitis is amazing chills, with temperature rises of 40 0 and above, followed by a feeling of heat and heavy sweats.

The patient's condition is serious, they are lethargic and lethargic, the pulse is frequent, blood pressure is reduced. On palpation of the abdomen, along with symptoms of acute cholecystitis and pain in the right hypochondrium, an enlarged liver and spleen are determined (by palpation, percussion and ultrasound).

Progression of the disease leads to the development of liver abscesses and hepatic-renal failure. Signs of sepsis and bacterial toxic shock appear: high hyperthermia gives way to hypothermia, increasing jaundice, drop in blood pressure, sharp tachycardia, tachypnea, oliguria, confusion.

In the blood, pronounced leukocytosis, a shift of the L-formula to the left, a sharp increase in ESR, high bilirubinemia due to direct and indirect bilirubin, high activity of transaminases (AST, ALT) and alkaline phosphatase. Nitrogenous wastes in the blood (residual nitrogen, urea, creatinine) increase.

Purulent cholangitis is an indication for emergency surgery .

If cholangitis develops against the background of acute cholecystitis, the patient undergoes cholecystectomy, but treatment of purulent cholangitis itself requires external drainage of the bile ducts (see Fig.). A plastic drainage is installed through the cystic duct stump or choledochotomy opening into the lumen of the common bile duct. Pus and bile flow through the drainage, which leads to the disappearance of jaundice and relief of jaundice symptoms. The drainage itself can be T-shaped (Keur drainage), or it can be a regular plastic tube with an additional side hole at the end (Vishnevsky drainage).

Another method of treating purulent cholangitis is endoscopic nasobiliary drainage of the common bile duct . Using an endoscopic device - a fiber duodenoscope, the patient is examined at the duodenum, where the large duodenal papilla is found. If there is a stricture of the papilla, the latter is dissected, stones are removed from the common bile duct, and a thin tubular drainage is installed into the lumen of the common bile duct from the side of the duodenum. After removing the endoscope, the drainage remains in the bile ducts and is discharged through the duodenum-stomach-esophagus-nose, therefore this type of drainage is called nasobiliary. This method is especially indicated for those patients who do not have a gallbladder (cholecystectomy was performed earlier).

Mechanical jaundice. A complicated course of acute calculous cholecystitis can manifest itself as a clinical manifestation of obstructive jaundice, which occurs when the bile ducts are obstructed by stones (choledocholithiasis) and the presence of a stricture of the major duodenal papilla. Often these bile duct stones and stricture occur together.

When cholecystitis and obstructive jaundice are combined, signs of inflammation of the bladder and peritonitis occur against the background of cholestasis, which aggravates the patient’s condition. Intense yellow staining of the sclera and skin appears one day or more after the onset of an acute attack of pain in the right hypochondrium, the appearance of dark colored urine and discolored feces, skin itching, high levels of bilirubin (200-300 µmol/l) in mainly due to direct (conjugated) bilirubin. These signs are described in detail in the manual of the department “Obstructive jaundice”.

Meanwhile, this combination of pathology significantly complicates the choice of tactics and methods of treating the patient. On the one hand, the patient must be freed from the source of inflammation - the gallbladder, and on the other hand, biliary hypertension must be eliminated in one way or another. The decision must be made quickly, since the presence of infection and cholestasis creates all the conditions for the development of another very severe complication– purulent cholangitis.

In acute cases, the body tries to remove destroyed cells and pathogens. This disease indicates the body's immune response. Indicates infection of the gallbladder and the presence of stones in this organ.

Symptoms of cholecystitis

Symptoms of cholecystitis may resemble, or. Men and children rarely get sick. The disease often affects middle-aged women. Acute stage The disease is characterized by a strong and sharp attack of pain in the hypochondrium area with right side. Discomfort may be felt in the collarbone or shoulder blade.

Other manifestations of the disease include:

belching, bloating, nausea and frequent vomiting;
increased, chills;
the patient has no appetite;
a light coating appears on the tongue, the mucous membranes of the mouth are dry;
blood pressure is high, pulse is rapid.

Important! Vomit is a bitter, colorless or dark green substance with a large amount of bile.

Causes of the disease

The main cause of the development of acute cholecystitis is bacterial infections. The bloodstream can transfer pathogens from any internal organ to the gallbladder. Which will provoke severe inflammation.

Disturbances in the drainage system of the organ lead to stagnation of bile. Destructive processes begin, pockets of inflammation appear in the walls of the gallbladder.

Excessive consumption junk food and alcohol, a lack of fiber in the diet - all this can provoke stagnation of bile and acute cholecystitis.

Female causes of the disease:

sudden changes in body weight - dieting, constant desire to lose weight, excess weight;
pregnancy - any woman who has been in interesting position at least once, falls into a risk group;
oral contraceptives and long-term estrogen therapy.

Diabetics and people with gastrointestinal problems are susceptible to biliary dyskinesia. Therefore, they should regularly undergo diagnostics to identify stones in the bile ducts.

They call it calculous special form cholecystitis, which is characterized by the presence of stones in the bladder and bile ducts. Acute culculous cholecystitis is one of the most common ailments of the abdominal organs. Often accompanied by complications and associated ailments.

The disease occurs due to infection and disruption of the process of bile outflow. The disease can also be caused by atherosclerosis, changes in the vessels of the gallbladder, and damage to the mucous membrane.

The acute form is characterized by sharp pain, which increases with physical activity.
Vomiting is reflexive, repeated, constant nausea.
IN acute form the illness lasts several weeks. Then it goes into the chronic stage.

Acute phlegmonous

The phlegmonous form is a logical continuation of catarrhal cholecystitis. The inflammatory process begins in all layers of the bladder, pus is formed.

The pain is intense, constant, intensifies during breathing and changing body position.
All signs of intoxication are clearly expressed.

Important! With this type of disease, urgent surgical intervention is necessary.

Sharp stoneless

A characteristic feature is the absence of stones in the biliary tract. The disease only carries infectious nature. It differs in the nature of pain. The pain is constant, nagging, poorly expressed. Accompanied by a burning sensation in the right hypochondrium.

Sometimes the pain syndrome manifests itself differently. The attacks of pain are short-lived and very intense.

Important! Any form of cholecystitis is accompanied by leukocytosis and increased ESR. Required clinical analysis blood.

The acute form can cause the following concomitant diseases:

strong inflammatory processes– pus accumulates in large quantities in the cavity of the bladder, the patient constantly has a fever, the pain is severe and constant;
organ perforation – often accompanies acute calculous cholecystitis. Necrosis of the bladder walls begins, adhesions form;
– suppuration occurs in the gall bladder and surrounding tissues;
purulent peritonitis - pus breaks into the abdominal cavity;
pancreatitis – inflammation from the bladder spreads to the pancreas;
jaundice - appears due to blockage of the bile ducts and stagnation of bile. Bilirubin increases in the blood, the skin and mucous membranes become jaundiced, and severe itching appears.

The extreme, but extremely rare stage of cholecystitis is gangrene.

Acute cholecystitis in children

The causative agents of cholecystitis in children are pathogenic microorganisms - cocci, coli, proteas. The disease develops against the background of giardiasis of the biliary tract and helminthic infestation. Previously suffered tonsillitis, appendicitis, scarlet fever can provoke the appearance of acute cholecystitis.

Non-compliance with diet, addiction to carbohydrate and fatty foods, a deficiency of vegetables has a negative impact on a child’s health. Which can also lead to cholecystitis.

When the disease occurs, children complain of bitterness in the mouth, their appetite decreases, and their stool becomes unstable. But the main symptom is pain under the ribs on the right side, nausea and vomiting.

Antibiotics are used for treatment (penicillin, chloramphenicol, erythromycin).

In pregnant women

Acute cholecystitis is diagnosed in every third pregnant woman. The uterus, increasing in size, puts pressure on internal organs. Bile stagnation begins and stones form. Another cause is a bacterial infection in the bile ducts.

Cholecystitis can appear in any trimester of pregnancy. Circumstances provoking the onset of the disease:

poor appetite, overeating;
lack of physical activity;
weak ;
foci of infection (dysbiosis,);
stress and depression.

A pregnant woman suffering from cholecystitis must adhere to a strict diet. The doctor also prescribes choleretic drugs (xylitol, sorbitol). These medications also help prevent constipation.

Important! During pregnancy, cholecystitis may not have a very pronounced pain syndrome. Therefore, if you experience the slightest discomfort on the right side, you should consult a doctor.

How to provide first aid for acute cholecystitis?

Provide the patient with rest.
Eliminate food intake completely.
Apply cold to the area of the right hypochondrium.
Call a doctor.

Treatment at home

In addition to following a diet and taking medications at home, you can do tubage.

To do this, you need to slightly warm a glass of mineral water without gas, add 15 g of xylitol (sorbitol, magnesia). Lie on a warm heating pad with your right side. The duration of the procedure is 1.5-2 hours. Tubage should be done in the morning on an empty stomach, once every 3 days. The course consists of 10 procedures.

When pain approaches, you can take a non-hot pine bath. You should stay in the water for no more than a quarter of an hour.

Important! Don't forget to move more - this helps the normal flow of bile. Jogging, bending, exercises on the horizontal bar are indicated for cholecystitis.

Drug treatment

Drug treatment necessarily includes taking antibiotics. Antibiotics are prescribed from the group of cephalosporins (cefixime, ceftibuten) and fluoroquinologists (moxifloxacin).

Important! Antibiotics cannot be stopped destructive process in the walls of the gallbladder. Because in the acute form of cholecystitis, the blood supply to the organ is disrupted. Therefore, the disease should be diagnosed in time.

Other groups of medicinal drugs:

antispasmodics – no-shpa, papaverine (preferably in the form of suppositories);
to stimulate the flow of bile - hofitol, holagol;
normalizing peristalsis - cerucal;
enzymes – mezim, festal.

What folk remedies can be used for treatment?

Reception natural preparations helps prevent stagnation of bile in the bladder.

Salt with lemon juice

Take 1 lemon and squeeze the juice.
Add 15 g of coarse salt.
Mix ingredients with 1 liter of warm water.

The drink should be drunk before breakfast.

For calculous cholecystitis, you need to drink 110 ml of brine sauerkraut before every meal. Duration of treatment – 2 months.

Honey and lemon

Take:

natural honey – 1 l;
olive oil – 200 ml;
lemon – 4 pcs.

Grind the peeled lemons using a blender. Mix all ingredients. Take 40 ml of medication three times a day half an hour before meals.

Herbs

Herbal medicine ranks first among traditional medicine.

Most effective herb is - it is used in many medicinal drugs. To prepare the decoction, you need to pour 15 g of herb into 210 ml of boiling water. The medicinal drug must be taken per day in 3 doses.

In a similar way, you can prepare medicine from agrimony.

Treatment fee:

dill seeds – 15 g;
mint leaves – 15 g;
hawthorn berries – 10 g;
– 5 g.

Mix all ingredients and add 270 ml of water. Keep the broth in a water bath for half an hour. Drink 65 ml twice a day.

Diet for illness

During an exacerbation, the patient is advised to fast and drink warm or medicinal mineral water. In the future, it is necessary to adhere to fractional meals, arrange fasting days(milk, fruit, rice). Drink rosehip decoction before breakfast.

What you can eat:

dried bread;
light soups;
lean meat and fish - it is better to boil them or bake them in one piece;
vegetable fats;
omelette egg yolks(raw or soft-boiled);
products with a high content of magnesium salts – buckwheat, vegetables.

What is not allowed - smoked and fatty foods, very cold food, sour berries, vegetables and fruits, beans, offal. Avoid alcohol completely.

It’s not in vain that doctors spend so much time proper nutrition. Healthy eating helps you avoid health problems and surgery. Good habits are much cheaper than any treatment.

One of the complications of cholelithiasis (hereinafter referred to as cholelithiasis) can be acute cholecystitis. Its treatment in adults is carried out only surgical methods, so timely diagnosis plays a significant role in this matter.

Of course, it is important to see a doctor when symptoms first appear. A “protracted” disease can negatively affect the patient’s general health. And also his immunity. This will affect further daily well-being and expose the body to a number of infectious diseases.

What is acute cholecystitis?

Acute cholecystitis (from the Greek Cholecystitis - gall bladder) is an inflammation of the gallbladder associated with a violation of the outflow of bile. Most often it occurs due to:

foreign formations inside it;

When it enters the cystic duct, calculous cholecystitis occurs. This process is accompanied by swelling of the walls of the gallbladder.

The disease can also occur for other reasons, the so-called acalculous cholecystitis. It appears as a result of infection of bile by bacteria.

Acute cholecystitis is coded according to the World Clinical Database (hereinafter referred to as ICD 10), as a disease whose manifestation may be due to a number of factors and may differ. Due to this, its characteristics are divided into acute and chronic. There are many forms of it. The general classification does not depend on the reason for which the disease arose or its course.
Photo: classification Also, the division into types depends on the patient’s well-being, the level of symptoms, and other things.

Distinguish different shapes diseases. They depend on the stage and level of development of the disease at the stage of examination and treatment:

Catarrhal.
Phlegmonous.
Gangrenous.

Each of these stages of acute cholecystitis is a continuation of the previous one and is accompanied by worsening general condition. Also, as the disease progresses, the complexity of its treatment increases. And if at the very beginning the disease can still be cured without surgical intervention, then if it worsens, it cannot be avoided.

This is precisely the main advice to see a doctor as soon as possible if the patient notices the first symptoms of the disease:

In the first stages, pharmacological intervention can be used.
In the second and third stages, only the surgery department will help. And since such intervention is a potential threat to human life, even with the most standard operations, every doctor tries to identify the disease at the first, easy stage its development.

The disease is considered chronic when frequent repetition inflammation, even after successful treatment. Remissions lead to deterioration in well-being and the need for constant pharmacological intervention in the functioning of the human body.

Chronic manifestation can be either stoneless or accompanied by the presence of stones in the gastric bladder. Chronic cholecystitis can lead to yellowing of the skin over time, in which case the patient needs to receive emergency care. In any case, it will require surgical intervention by doctors.

Why is acute cholecystitis dangerous?

IN advanced stages acute cholecystitis can develop into:

inflammation of the pancreas;
perforation of the gallbladder;
formation of vesico-intestinal fistula;
peritonitis.

These diseases may require urgent surgical intervention and put the patient at great risk.

Less dangerous occurrence and development bacterial infections, which appear inside the gallbladder and also require timely treatment. However, such therapy takes place on easy level, requiring only a course special tablets, which can be purchased without difficulty at any pharmacy according to your doctor's prescription.

Symptoms and signs of acute cholecystitis

The main symptom is biliary colic - sharp pain in the right hypochondrium. It is accompanied by nausea, vomiting and fever.

The patient may complain of:

bitterness in the mouth;
decreased appetite.

More severe stages of the disease are accompanied by yellowing of the skin and whites of the eyes, similar to symptoms of jaundice. This may indicate the development of peritonitis.

Diagnosis of acute cholecystitis

When initial symptoms the patient should be hospitalized in the clinic. For an accurate diagnosis, differential diagnostic methods are used. Doctor:

Conducts an examination of the patient.
Prescribe tests:

blood;
urine;
Ultrasound of the abdominal cavity.

If, based on the test results, the patient is diagnosed with acute cholecystitis, the doctor analyzes the medical history and extreme cases insists on the use of surgery.

Photo: Ultrasound of the gallbladder

Treatment of the disease

On early stages Help for acute cholecystitis is carried out by prescribing a course of medications. These include:

Amoxiclav.
Atropine.
Cefotaxime.
Diclofenac.

The patient is prescribed a special diet to prevent the worsening of the stage of acute cholecystitis. Antibiotics are also used in treatment to fight bacteria and viruses. This helps to avoid serious complications in mild forms of the disease.

In more advanced stages, surgery may be required - cholecystectomy. It comes in several different forms, but the main purpose of this operation is to remove the gallbladder.

Surgeries for acute cholecystitis are prescribed by doctors, and their choice depends on:

conditions of the disease;
contraindications.

Most often, surgery is resorted to when stones are discovered. But even after removal of the gallbladder, you can usual image life, following a mandatory diet.

Diet for acute cholecystitis

Regardless of the method of treatment, the patient is prescribed diet No. 5. In case of acute cholecystitis, it is important to exclude harmful foods from the diet, such as:

flour;
fat;
fried;
smoked.

The structure of the gallbladder In the first two days, it is better to abstain from food completely and drink only water. This diet allows.