Obstruction of bilious channels
Obstruction of bilious channels – a mechanical obstacle in a way of advance of bile from a liver and a gall bladder in a duodenum. Develops against the background of cholelithiasis, tumoral and inflammatory diseases of biliary tract, and hems of the general bilious channel. As symptoms of obstruction of bilious channels serve pains in the right podreberye, jaundice, akholichny kcal and dark urine, substantial increase of level of bilirubin in blood. The diagnosis is made on the basis of researches of biochemical tests of blood, RHPG, ultrasonography, MPT and KT of abdominal organs. Treatment usually surgical – is possible performing endoscopic, laparoscopic or expanded surgery.
Obstruction of bilious channels
Obstruction of bilious channels - a dangerous complication of various diseases of a gastrointestinal tract which leads to development of mechanical jaundice. The cholelithiasis affecting up to 20% of people is the most frequent reason of obstruction of bilious channels. Women suffer from ZhKB three times more often than men. Difficulty of outflow of bile from a liver and a gall bladder is followed by gradual development of a clinical picture of subhepatic (mechanical) jaundice. Sharp obstruction of bilious ways can develop right after an attack of bilious colic, however it practically is always preceded by symptoms of an inflammation of bilious ways. Untimely assistance to the patient with obstruction of bilious channels can lead to development of a liver failure and even the death of the patient.
Reasons of obstruction of bilious channels
Can cause obstruction of bilious ways both their obstruction from within, and a sdavleniye from the outside. The mechanical obstacle to outflow of bile can be full or partial, brightness of clinical manifestations depends on extent of obstruction.
There is a number of diseases which can promote violation of passing of bile from a liver in a duodenum. Obstruction of bilious channels is possible in the presence at the patient: concrements and cysts of bilious ways; holangit or cholecystitis; hems and channels; tumors of a pancreas, gepatobiliarny system; pancreatitis, hepatitis and cirrhosis; increases in lymph nodes of gate of a liver; parasitic invasions; injuries and surgeries on the bilious ways.
The pathogenesis of obstruction of bilious channels multicomponent, the beginning usually serves inflammatory process in bilious ways. The inflammation leads to a thickening mucous, to narrowing of a gleam of channels. If the concrement gets to this moment to canals, he cannot independently leave and causes full or partial overlapping of its gleam. Bile begins to accumulate in bilious ways, causing their expansion. From a liver bile can get at first into a gall bladder, considerably stretching it and causing an aggravation of symptoms of cholecystitis. If in a gall bladder there are concrements, they can get to the puzyrny canal and block its gleam. In the absence of outflow of bile on a puzyrny channel the empiyema or dropsy of a gall bladder can develop. An adverse predictive sign at obstruction of bilious ways is secretion of mucous whitish slime of a holedokh (white bile) – it speaks about the beginning of irreversible changes in bilious channels.
The bile delay in intra hepatic canals leads to destruction of hepatocytes, hit of bilious acids and bilirubin in a blood-groove. The active direct bilirubin which is not connected with proteins of blood because of what it causes considerable damage of cages and body tissues gets to blood. The bilious acids which are contained in bile facilitate absorption and exchange of fats in an organism. If bile does not get into intestines, absorption of fat-soluble vitamins A, D, E, K is broken. Because of it at the patient the gipoprotrombinemiya, violation of coagulability of blood, other symptoms of hypovitaminosis develops. Further stagnation of bile in intra hepatic ways leads to considerable damage of a parenchyma of a liver, development of a liver failure.
Risk factors of development of obstruction of bilious channels are obesity or, on the contrary, bystry loss of weight; injuries of the right half of an abdominal cavity; recent surgeries on the bilious ways; infections of gepatobiliarny system and a pancreas against the background of considerable easing of immunity.
Symptoms of obstruction of bilious channels
Symptoms of obstruction of bilious channels usually appear gradually, the sharp beginning meets rather seldom. Usually development of clinic of bilious obstruction is preceded by an infection of biliary tract. The patient shows complaints to temperature increase, loss of weight, skhvatkoobrazny pains in the right podreberye. Skin gets an icteric shade, the patient is disturbed by an itch of integuments. Lack of bilious acids in intestines is led to decolouration by a calla, and the increased removal of direct bilirubin kidneys - to emergence of urine of dark color. At partial obstruction of bilious channels alternation of the decoloured portions a calla with painted is possible.
Against the background of destruction of hepatocytes all functions of a liver are broken, the acute liver failure develops. First of all dezintoksikatsionny activity of a liver suffers that is shown by weakness, increased fatigue, gradual violation of functioning of other bodies and systems (lungs, heart, kidneys, a brain). If the patient with obstruction of bilious channels is not given help before this stage of a disease, the forecast extremely adverse.
Diagnostics of obstruction of bilious channels
Initial manifestations of obstruction of bilious channels remind symptoms of cholecystitis or bilious colic with which the patient can be hospitalized in office of gastroenterology. Preliminary diagnostics is performed by means of such simple and safe method as an ultrasonografiya of a pancreas and bilious ways. If concrements of bilious ways, expansion of a holedokh and intra hepatic bilious channels are found, for specification of the diagnosis MR-pankreatokholangiografiya's carrying out, a computer tomography of biliary tract can be required. For specification of the reason of mechanical jaundice, an arrangement of a concrement, extent of obstruction of bilious ways the chreskozhny chrespechenochny holangiografiya, a dynamic stsintigrafiya of gepatobiliarny system is carried out. They allow to find violation of dynamics of bile, its outflow from a liver and a gall bladder.
The most informative method of diagnostics of obstruction of bilious channels is the retrograde holangiopankreatografiya. This technique includes a simultaneous endoscopic and radiological research of biliary tract. At detection of stones in a channel gleam during this procedure extraction of concrements from a holedokh can be made. In the presence of the tumor squeezing a bilious channel the biopsy undertakes.
In biochemical tests of a liver increase in level of direct bilirubin, alkaline phosphatase, , amylases and lipases of blood is noted. Protrombinovy time is extended. In the general blood test decrease in level of erythrocytes and platelets can be revealed with shift of a leykoformula to the left. In a koprogramma a significant amount of fat is found, bilious acids are absent.
Treatment of obstruction of bilious channels
All patients with obstruction of bilious channels need consultation of the gastroenterologist and surgeon. After carrying out all inspections, clarification of localization and extent of obstruction, tactics of expeditious treatment is defined. If the condition of the patient heavy, can be required its transfer to intensive care unit for performing antibacterial, infusional and dezintoksikatsionny therapy. Before stabilization of a condition of the patient carrying out expanded operation can be dangerous therefore use noninvasive techniques of simplification of outflow of bile. Refer extraction of concrements of bilious channels and nazobiliarny drainage at RPHG to them (via the probe entered above the place of narrowing of bilious channels), a chrezkozhny puncture of a gall bladder, a holetsistostomiya and a holedokhostomiya. If the condition of the patient does not improve, more difficult intervention can be required: chreskozhny transhepatic drainage of bilious channels.
After the condition of the patient is normalized, recommend use of endoscopic techniques of treatment. During endoscopy carry out expansion (an endoscopic buzhirovaniye) of bilious ways at their cicatricial stenosis and tumoral striktura, introduction to bilious ways of a special plastic or mesh tube for preservation of their gleam (endoscopic stenting of a holedokh). At an obturation a concrement of the cicatricial narrowed nipple of a duodenum endoscopic balloon dilatation of a sphincter of Oddi can be required.
If to remove concrements and other obstacles for bile outflow in the endoscopic way it is impossible, carrying out expanded operation is required. During such surgery opening of a holedokh (holedokhotomiya) therefore further it is necessary to prevent infiltration of bile through seams of a bilious channel in an abdominal cavity is made. External drainage of bilious ways according to Kerr (A T-shaped tube), and after a holetsistektomiya - external drainage of bilious channels on Holsteda (the polyvinylchloride catheter entered into a stump of a puzyrny channel) is for this purpose made.
If not to carry out timely surgical treatment of obstruction of bilious channels, at the patient sepsis, bilirubinovy encephalopathy, cirrhosis, a liver failure (can develop at full obstruction of bilious channels – sharp, and at partial – chronic).
Forecast and prevention of obstruction of bilious channels
The forecast at timely assistance to the patient with obstruction of bilious channels favorable. Considerably worsens the course of a disease and results of treatment cancer obstruction of a holedokh. Prevention of obstruction of bilious channels consists in treatment of chronic inflammatory diseases of gepatobiliarny system, cholelithiasis. Observance of a healthy lifestyle, healthy nutrition with an exception of greasy, fried and extractive food is recommended.