Sharp holangit - it is a nonspecific inflammation of intra hepatic or extra hepatic bile-excreting channels. It is characterized by a triad of symptoms – bystry temperature increase to febrilny figures, severe pains under the right podreberye, jaundice. For the purpose of diagnostics of a sharp holangit carry out ultrasonography of a liver and a gall bladder, a computer tomography of biliary tract, biochemical tests of a liver. Also the diagnosis is specified by means of ERPHG, a chreskozhny chrespechenochny holangiografiya. Treatment is conservative, only in hard cases resort to surgical intervention for the purpose of a decompression of bilious ways.
Sharp holangit - it is a disease of generally infectious nature which is followed by an inflammation in bilious channels, stagnation of bile, frequent obstruction of biliary tract. People of age group from 40 to 60 years, women are ill in most cases more often than men. In risk group there are patients with cholelithiasis, congenital cysts of intra hepatic channels, a chronic skleroziruyushchy holangit, cancer of a gall bladder. The quantity of the registered cases of a sharp holangit grows therefore the problem becomes more and more urgent. According to many researchers in the field of gastroenterology, in recent years incidence of a sharp holangit increased approximately for 40%. Gastroenterologists are engaged in diagnosis and treatment of pathology. Only patients with the heavy and complicated forms demanding surgery are subject to hospitalization in office of surgery.
Reasons of a sharp holangit
Two conditions are necessary for emergence of a sharp holangit: stagnation of bile in bile-excreting channels and existence of an infection. Obstruction of biliary tract most often results in stagnation of bile. The main reasons for an obturation – , congenital striktura of a holedokh and smaller channels, cysts, malignant tumors, helminthic invasions. Also stagnation of bile can arise at long dyskinesia of biliary tract, violation of activity of sphincters. Owing to all these reasons bile changes the physical and chemical properties, and favorable conditions for development of an infection are created. Sharp holangit can arise after operations, endoscopic low-invasive manipulations.
Activators at a sharp holangit get to system of bilious channels in three ways: from intestines, through a lymph and through blood. If hit of microorganisms from intestines is the reason of infection, process has the ascending character, the inflammation extends from a holedokh to intra hepatic canals, can is followed by symptoms of sharp cholecystitis, an empiyema of a gall bladder. At hit of an infection through blood and a lymph small intra hepatic channels can initially be surprised.
Generally sharp holangit various bacteria, representatives of intestinal flora cause: enterobakteriya (colibacillus, klebsiyella, proteas), grampolozhitelny microorganisms (staphylococcus, , pneumococcus), anaerobe bacterias (klostridiya, pseudo-monad). Also the disease can arise at helminthic invasions, such as , , , , . The aseptic inflammation of channels owing to a pankreatobiliarny reflux and throwing of pancreatic enzymes becomes the reason of a sharp holangit sometimes. Such state creates favorable conditions for further infection.
Classification of a sharp holangit
On an etiology sharp holangit divide on bacterial, virus, gelmintozny, toksiko-allergic, autoimmune. It is necessary to notice what autoimmune holangit more often gets a subsharp or chronic current, with periodic aggravations owing to accession of an infection.
On features of development sharp holangit classify on primary (virus, bacterial, gelmintozny, autoimmune); secondary (directly connected with cholelithiasis, hems, striktura, dyskinesia, cysts, postoperative complications, insufficiency of a sphincter of Oddi etc.). As an inflammation sharp holangit can be catarrhal, purulent, obstructive, destructive not purulent.
Symptoms of a sharp holangit
Manifestations of a sharp holangit keep within a so-called triad of Sharko: temperature increase, pain under the right podreberye of different intensity, yellowness a skler, skin and mucous. The disease practically always suddenly and rather violently begins. At first body temperature to 39-40 degrees increases, the fever, plentiful perspiration appears. Fever can be constant or alternating, with fluctuations within a day (insignificant decrease in the morning and sharp increase in the evening). Almost along with temperature pain with irradiation to the area of a neck, the right shoulder, a hand and a right shoulder-blade develops. A little later at patients with a sharp holangit symptoms of stagnation of bile are shown: subikterichnost skler and mucous, yellowing of skin. The liver is increased, a smooth edge, at a palpation painful.
The subsequent development of a sharp holangit is characterized by emergence of signs of infectious and toxic shock. Nausea, sometimes vomiting, euphoria or confusion of consciousness joins above-mentioned symptoms. In blood the level of hepatic enzymes increases, thrombocytopenia develops. Such simptomokompleks carries the name of a pentade of Reynolds, is observed most often at primary sharp holangit. The subsequent development of process leads to emergence of symptoms of a renal failure, increase in blood of level of urea and creatinine, to decrease in rates of a diuresis. At the patient the gepatorenalny syndrome develops. Also warm activity is broken, tachycardia, dullness of tones of heart at an auskultation develops, arrhythmia, arterial hypotonia, on the ECG it is possible to see signs of dystrophic changes in a cardiac muscle (myocardium). Recidivous sharp holangit can proceed less brightly, sometimes without hyperthermia, with the minimum displays of dyspepsia and the alternating jaundice.
In many respects manifestations of a sharp holangit depend on its etiology, a type of the activator and extent of obstruction of biliary tract. For example, sharp holangit, caused by a pneumococcus, proceeds very hard and can lead to formation of abscess of a liver. The symptomatology often decreases; if impassability of a holedokh or smaller channels is eliminated - jaundice disappears, temperature decreases, the pain syndrome is stopped.
Complications of a sharp holangit develop quite often. Process can extend to a liver parenchyma that leads to development of hepatitis, liver failure, abscesses (single or multiple). Quite often sharp holangit is complicated by sepsis or peritonitis. After the postponed disease or its recurrence there is biliarny cirrhosis.
Diagnostics of a sharp holangit
For establishment of the diagnosis of a sharp holangit first of all conduct laboratory researches. Biochemical tests of a liver reveal increase in levels of bilirubin, alkaline phosphatase, triglycerides, ALT and nuclear heating plant. The total of protein of blood at the expense of albumine decreases and γ-globulins raise.......... Often at a sharp holangit increase in level of amylase, a lipase, and also trypsin and its specific inhibitors is observed that demonstrates involvement in process of a pancreas. With development of symptoms of a renal failure the level of creatinine and urea increases. In the general blood test it is possible to see significant increase in number of leukocytes with shift of a formula to the left, increase in SOE. In blood often reveal bacteremia.
At duodenal sounding in bile a significant amount of epitelialny cages, increase in level of lipids, sialovy acids, different types , fibrin is found. At crops the huge number of bacteria, often not one, but two or even three different activators comes to light. On ultrasonography of a liver and gall bladder it is possible to see expanded intra hepatic and extra hepatic channels, increase in a gall bladder, liver, structural changes in its parenchyma. If the picture is insufficiently informative, KT of biliary tract, a magnetic and resonant tomography of a liver and biliary tract is in addition carried out.
From tool methods for diagnostics use an endoscopic retrograde pankreatokholangiografiya and a chreskozhny chrespechenochny holangiografiya. The first technique has also medical value, helps to eliminate obstruction in a holedokha if it is caused by a stone of the small and average size. These researches give the chance to well visualize bilious channels, to define the place of obstruction.
Treatment of a sharp holangit
Therapy of a sharp holangit is directed to elimination of obstruction of bilious ways and fight against an infection. From the very beginning to the patient appoint antibiotics. The choice of medicine depends on sensitivity of flora. If it is not possible to make the sensitivity test, use the antibiotics operating on intestinal and anaerobic flora. It is synthetic penicillin, aminoglycosides, tsefalosporina (mainly III and IV generations), ftorkhinolona. Reserve antibiotics – karbapenema. At the choice of medicines it is desirable to give preference to those which are removed through a liver together with bile, for example, to a tseftriakson or a tsefoperazon. If medicine was chosen correctly, then improvement of a condition of the patient occurs in 12-24 hours. The course of antibiotic treatment makes 14-21 days.
Except antibiotics to the patient surely appoint dezintoksikatsionny therapy. At displays of a heavy liver failure steroid hormones can be used. Also carry out correction of activity of kidneys and heart. At the sharp holangit caused by a helminthic invasion appoint protivogelmintny drugs. If sharp holangit is followed by obstruction of biliary tract, carry out their decompression by method of endoscopic RPHG. Go for open surgery seldom and only after stabilization of a condition of the patient.
Forecast and prevention of a sharp holangit
The forecast at a sharp holangit in many respects depends on its stage and extent of obstruction of biliary tract. If obstruction insignificant and it was succeeded to eliminate in time, a current of a holangit favorable. At a long holangit, late diagnostics, after development of infectious and toxic shock the forecast considerably worsens. The prospects of treatment are also influenced by a type of the activator. The sharp holangita caused by a pneumococcus and multiresistant flora will badly respond to treatment. The forecast at oncological patients worsens, 50 years are more senior than patients.
Prevention of a sharp holangit is a treatment of the main disease (cholelithiasis, dyskinesia of bilious ways etc.). Gastroenterologists advise patients who are in risk group properly to eat, watch body weight, in time to have planned medical examinations.