Striktura of bilious channels
Striktura of bilious channels - narrowing and an obliterayotion of a gleam of bilious ways of traumatic or cicatricial and inflammatory genesis. Striktura of bilious channels lead to development of a holestaz, emergence of pains in a podreberye, jaundices, intoxications, fevers. Diagnostics bilious channels is based on the laboratory indicators given to ultrasonography, RHPG, a stsintigrafiya, a chreskozhny chrespechenochny holangiografiya, MRT. Treatment bilious channels is carried out by an endoscopic buzhirovaniye or dilatation, stenting, surgical correction (a holedokhoyeyuyonostomiya, a gepatikoyeyunostomiya).
Striktura of bilious channels
Striktura of bilious channels are one of urgent and complex problems in operational gastroenterology. Increase in frequency of development of this pathology is caused by the increased surgical activity at cholelithiasis in recent years. Striktura of bilious channels are in most cases formed as a result of intraoperative injury of biliary tract during interventions on a gall bladder (an open holetsistektomiya, a holetsistektomiya of mini-access, a laparoscopic holetsistektomiya).
In the place of emergence distinguish striktura of share bilious channels, the general bilious and general hepatic channel. On degree of passability of bilious channels of a striktura can be partial or full.
Reasons bilious channels
Allocate three main groups of the reasons of formation bilious channels: traumatic, inflammatory and tumoral. Traumatic striktura of bilious channels, as a rule, develop as a result of intraoperative damages of bilious ways at a holetsistektomiya, endoscopic manipulations, a resection of a stomach, transplantation and a resection of a liver. Refer cicatricial narrowings of the biliodigestivny anastomoz imposed concerning impassability of bilious channels, abdominal injuries to the same group.
Intraoperative damages of bilious channels, as a rule, happen under difficult conditions of surgical intervention: serious condition of the patient, operation urgency, bleeding in an abdominal cavity, presence of severe hypostasis and pus at a zone of operational intervention, existence of obesity etc. In these cases wrong assessment by the surgeon of an anatomic stroyoeniye of bilious channels, their proshivaniye or crossing, a poyovrezhdeniye by the laser or an electrocoagulator and so forth is not excluded.
In case of full bandaging or crossing of a holedokh of a striktur of a bilious channel develops in the next postoperative period; at partial bandaging or wound – in terms from 2 to 6 month; the obliteration of a biliodigestivny anastomoz is usually formed during 1 year from the moment of its imposing. Inflammatory bilious channels lead cicatricial changes of walls of channels at a skleroziruyushchy holangit, chronic pancreatitis, low ulcers of a 12-perstny gut, parasitic zaboyolevayoniya of a liver (echinococcosis, an opistorkhoza), decubituses from the concrements fixed in a puzyrny channel etc. to emergence.
Tumoral striktura of bilious channels meet at cancer of extra hepatic bilious ways, cancer of a gall bladder, metastatic defeats of gate of a liver and gepatoduodenalny sheaf. In rare instances striktura of bilious channels are caused by congenital anatomic anomalies of bilious ways, performing radiation therapy.
Existence of a striktura causes expansion and a thickening of walls of the bilious channels located above the place of narrowing. Bile in the corked channels stands, becomes vyazyoky, is easily infected that creates conditions for formation of gallstones. Long violation of outflow of bile from a liver at not recognizable and not eliminated obstruction promotes development of secondary biliarny cirrhosis and portal hypertensia.
Symptoms bilious channels
Manifestations depend on a look and a damage rate of bilious channels. In case of full crossing of a holedokh clinical signs of a striktura develop for 3-7 postoperative days: there is pain in the right departments of a stomach, fever, jaundice, the bile expiration demonstrating formation of an external bilious fistula. The dispepsichesky phenomena - nausea, vomiting, anorexia, a meteorizm are noted; in certain cases intestinal impassability develops. At release of bile through the damaged bilious channel bilious peritonitis develops in an abdominal cavity, formation of subhepatic abscess is possible.
During the bandaging or a perezhatiya of a holedokh there are phenomena of the accruing holestatichesky zhelyotukha and a holangit with fever, oznoba, pains in an epigastriya, decolouration a calla and urine darkening, a skin itch. At a partial striktura of a bilious channel signs of a holangit and jaundice develop within several months, have easier current reminding a SARS.
Striktura of bilious channels at untimely elimination of obstruction cause formation of abscesses of an abdominal cavity, sepsis, biliarny cirrhosis, portal hypertensia, gastrointestinal bleedings, a liver failure.
Diagnostics bilious channels
In most cases bilious channels points connection of clinical manifestations with surgery to development. Biochemical tests of a liver are characterized by increase in level of bilirubin, , aktivyonost of alkaline phosphatase.
As primary method of visualization bilious channels serves ultrasonography by means of which expressiveness and level of obstruction comes to light. For detection of an isteyocheniye of bile the stsintigrafiya of gepatobiliarny system is used. By means of MRT of biliary tract definition of the reasons, localizations, degrees, striktura extents, development of vtorichyony complications is possible.
At striktura of bilious channels carrying out a chreskozhny chrespechenochny holangiografiya, relaxation duodenografiya, retrograde holangiopankreatografiya, pankreatokholangiografiya MRT has high informational content. With the diagnostic and medical purpose the laparoscopy allowing to examine an abdominal cavity, to remove the bile remains, to establish drainages can be applied.
Treatment bilious channels
Danger of serious consequences of long obstruction of bilious ways demands obligatory elimination bilious channels in the endoscopic or open surgical way. In the preoperative period for removal of intoxication infusional therapy, antimicrobic therapy taking into account data of crops of bile and blood is carried out.
Chreskozhny or endoscopic balloon dilatation, endoscopic buzhirovaniye , endoscopic stenting of a holedokh belong to low-invasive methods of treatment bilious channels. Limitation of application of these methods consists in a possibility of their use only at incomplete and not extended striktura, and also in the high frequency of development of a restenoz of bilious channels.
At impossibility of low-invasive elimination bilious channels resort to excision of a striktura and carrying out reconstructive operations. In surgical practice operations of imposing of anastomoz between the proximal end of a holedokh and a loop of a lean gut (holedokhoyeyuyonoanastomoz) or a hepatic channel and a lean gut (gepatikoyeyunoanastomoz) are most often performed. In certain cases for permission of mechanical jaundice the first stage carries out a decompression of a biliarny path by external drainage of bilious channels, chreskozhny transhepatic drainage, nazobiliarny drainage at RPHG, and then, in the cold period, reconstructive and recovery interventions are carried out.
If elimination of a striktura of a bilious channel does not lead to reduction of portal hypertensia, performing portokavalny shunting in addition is required.
Forecast and prevention bilious channels
Timely elimination of obstruction of bilious ways allows to avoid development of complications. Nevertheless, all patients from a strikturama of bilious ways in the anamnesis, demand observation of the gastroenterologist and the hepatologist for an exception of repeated development of a stenosis.
Prevention yatrogenny bilious channels consists in the qualified and technically competent carrying out operations on a GIT. The prevention inflammatory bilious channels is promoted by timely therapy of a holangit, pancreatitis, hepatitis, a holedokholitiaz, etc. diseases.