Kalkulezny cholecystitis — the inflammation of a wall of a gall bladder which arose against the background of a holelitiaz. It is shown by bilious colic or dull aches in the right podreberye, dyspepsia, intoxication, jaundice. It is diagnosed by means of ultrasonography, a dynamic stsintigrafiya of gepatobiliarny system, a survey X-ray analysis and MSKT of an abdominal cavity, a retrograde holangiopankreatografiya. For treatment use miotropny spazmolitik, NPVS, narcotic analgetics, antibiotics, infusional therapy, antiemetic and fermental medicines. Out of an aggravation carry out a holetsistektomiya.
Kalkulezny cholecystitis — one of cholelithiasis forms therefore its prevalence correlates with ZhKB frequency in population. About 10-20% of the population of the different countries suffer from Holelitiaz, the sharp option of cholecystitis develops at a third of patients, chronic — at 60-96%. Pathology is usually diagnosed after 40 years, women get sick 3-5 times more often than men. The patients with the burdened heredity, excess weight, a hypodynamia, errors in food having diabetes, cirrhosis, a disease Krone enter into risk group it is long the medicines using estrogen-gestagennye, analogs of a somatostatin, some antibiotics.
Development of kalkulezny cholecystitis is closely connected with progressing of cholelithiasis, is provoked by the same etiologichesky factors, as processes of a kamneobrazovaniye. According to experts in the sphere of gastroenterology and hepatology, are the main reasons for inflammatory defeat of covers of a gall bladder at a holelitiaza:
- Irritation mucous concrements. Initially microlitas and small concrements are as a part of bile in suspension and are evacuated from a bubble at a zhelchevydeleniye. Against the background of the raised bile litogennost stones increase in sizes, begin to put the mechanical pressure upon walls of body, provoking local inflammatory, atrophic, necrotic processes. The greatest danger is constituted by large dense formations of a many-sided or awl-shaped form.
- Stagnation of bile. At a holestaza crystallization and growth of concrements accelerates, the risk of obstruction of bilious channels and mechanical damage of mucous increases, conditions for bystry reproduction of microflora are created. The inflammation against the background of kalkulezny process arises at dyskinesia of a gall bladder and biliary tract, Faterov's obstruction of a nipple pancreatic tumors, sdavleniya of the bilious courses volume educations (neoplaziya, ekhinokokkovy cysts) more often.
- Infection of a gall bladder. At 50-75% of patients with a kalkulezny inflammation from bile pathogenic and opportunistic microorganisms are sown. Activators usually get to body hematogenic, limfogenny, more rare in the ascending way from a duodenum gleam. The inflammation is often caused by colibacillus, bakteroida, develops in the presence of the infection centers in other bodies or decrease in immunity during pregnancy, against the background of diabetes, reception of immunosupressor.
The mechanism of development of pathological processes differs at sharp and chronic forms of kalkulezny cholecystitis. At an obturation the concrement of a puzyrny channel breaks bile outflow that leads to stretching of walls of body, damage mucous, to strengthening of an ekssudation, release of prostaglandins, phospholipases And, other mediators. Squeezing of vessels, violation of their tone under the influence of biologically active agents is followed by disorder of microcirculation, distribution of an inflammation on all layers of a zhelchepuzyrny wall, in hard cases — sharp ischemia, a necrosis. Owing to a bacterial invasion the situation is aggravated with infectious process.
Sometimes the chronic inflammation arises after sharp kalkulezny though usually it develops gradually as a result of the constant pressure of stagnant bile and mechanical irritation of epiteliotsit concrements. More often mucous atrophies, the giperplaziya with papillomatozy and polipozy is less often noted. Perhaps divertikuloobrazny introduction mucous between gladkomyshechny fibers on the course of vessels (Rokitansky-Ashoffa's sine). All covers of body infiltrirutsya by lymphoid cages and macrophages, in muscular and subserous layers slizeobrazuyushchy ferruterous educations are formed (), there are dot necroses. Fibrosis, cicatricial deformation, a petrifikation of body becomes an outcome of a chronic inflammation.
At systematization of clinical forms of kalkulezny cholecystitis consider dynamics of emergence and the course of pathology. Taking into account the prime cause distinguish the sharp process provoked by an obturation of a gall bladder a concrement and gradually progressing chronic inflammation. Allocate three forms of the chronic cholecystitis which complicated :
- Primary and chronic inflammation. Differs in gradually accruing dispepsichesky frustration and poorly expressed pain syndrome. Demands careful diagnostics as often masks under other gastroenterologichesky diseases.
- Chronic recidivous process. The main option of a disease with characteristic alternation of aggravations and remissions, an intensive pain syndrome. Because of similarity to sharp cholecystitis dynamic observation and treatment in stationary conditions is required.
- Chronic residual cholecystitis. Is the result of sharp process. It is connected with unreasonable conservative maintaining the patient, is followed by synchronization of an inflammation, development of complications with preservation of pain after normalization of temperature.
Taking into account intensity of symptomatology distinguish a painful pristupoobrazny form of a disease and a torpedo inflammation with prevalence of dull aches, developing of gripes of times in several years. Depending on the frequency of attacks and the accompanying symptomatology the course of disease happens easy (not more often than 1-3 bilious gripes a year), moderated (1-2 attacks a month), heavy (from 3 and more recurrence a month).
Symptoms of kalkulezny cholecystitis
In a clinical picture the pain syndrome dominates. At sharp process, an aggravation of a chronic inflammation after food errors or emotional experiences there is bilious colic — an attack of intolerable pains in an epigastriya and a projection of a bubble which can irradiate in a shovel, a back, prekardialny area. Distinctive feature of colic at cholecystitis — high intensity of pain, duration till several o'clock, a combination to febrilny fever, perspiration, a fever, the pallor of integuments expressed by nausea, vomiting with bile impurity.
Pains at chronic cholecystitis stupid or aching, develop periodically, are localized on the right in a podreberye. Sometimes patients complain not of pain, and of weight in the right subcostal area. Also dispepsichesky frustration are observed: bitterness in a mouth, nausea and vomiting, violations of a chair with alternation of locks and diarrheas, an abdominal distension. Symptoms usually amplify after reception of big portions of greasy food, at women – before periods. At the long course of a disease patients become irritable, emotionally labile, complain of bystry fatigue, sleeplessness.
As a result of penetration of bacterial flora against the background of chronic stagnation of bile at kalkulezny cholecystitis the empiyema of a gall bladder can be formed, perikholetsistit. 15% of patients have a perforation of a wall of body to development of bilious peritonitis. Heavy bacterial inflammations are complicated by sepsis. At it is long the current disease quite often puzyrno-intestinal fistulas are formed that is caused by ischemia and a necrosis of a wall in the field of pressure upon it of a big concrement. In 1% of cases active reproduction of gas-forming bacteria leads to development of emphysematous cholecystitis.
Obturation of biliary tract provokes developing of mechanical jaundice with intoxication of an organism and defeat of cells of a brain. The most dangerous complication of a kalkulezny inflammation — calcification of walls with reduction of a cavity of body (a so-called "porcelain" gall bladder). This state demands immediate treatment as it in 5-7% of cases becomes the reason of formation of a malignant tumor. When involving in process of the next bodies it is observed papillit, biliarny pancreatitis, hepatitis, other inflammatory diseases and dystrophic processes.
The gastroenterologist, the hepatologist, the abdominal surgeon participate in diagnosis. Possible development of kalkulezny cholecystitis is demonstrated by a typical clinical picture, existence of positive puzyrny symptoms (Murphy, Ortner, Kerr). For confirmation of the diagnosis conduct comprehensive examination with application of the methods allowing to visualize concrements of biliarny system. The most informative are:
- Ultrasonography of a gall bladder. Sonografiya — the main method of diagnostics of a kalkulezny inflammation which allows to find concrements more than 2 mm in the diameter. Also at ultrasonography the thickening of a zhelchepuzyrny wall, availability of liquid in okolopuzyrny space comes to light.
- X-ray analysis of an abdominal cavity. The survey roentgenogram is used for diagnostics of complications: free gas in a gleam of body testifies to emphysematous cholecystitis, the diffusion kaltsifikation of a wall indicates development of a "porcelain" gall bladder.
- MSKT of abdominal organs. The computer tomography is recommended in difficult diagnostic cases and at insufficient informational content of other methods. During the research determine thickness of walls of body, reveal hypostasis, inflammatory infiltration, rejection of a mucous membrane.
- Dynamic stsintigrafiya of gepatobiliarny system. On a series of x-ray pictures after introduction of radiopharmaceutical it is possible to estimate motor function of biliarny system. Informational content of a method in confirmation of the diagnosis of kalkulezny option of cholecystitis reaches 95-100%.
- Retrograde holangiopankreatografiya. The X-ray analysis added with endoscopy is applied to assessment of a condition of bile-excreting channels, by identifications of small stones which were not visualized at a sonografiya. The method is used in the medical purposes for extraction of concrements from the general bilious channel.
Laboratory techniques play a supporting role in diagnostics of a kalkulezny form of a disease. In the general blood test in the period of an aggravation increase in SOE is observed with shift to the left. In biochemical blood test increase in the general cholesterol and alkaline phosphatase is defined. For an exception of stomach diseases and a 12-perstny gut the gastroduodenoskopiya can be carried out. Differential diagnostics is carried out with pathologies of a gall bladder (sharp and chronic beskamenny cholecystitis, holesterozy), diseases of other bodies of a gastrointestinal tract (pancreatitis, hepatitis, gastroduodenity), right-hand renal colic, defeats of cardiovascular system (a myocardial infarction, unstable stenocardia).
Treatment of kalkulezny cholecystitis
The choice of tactics depends on a form of a holelitiaz, surgical removal of a gall bladder is recommended to most of patients. Patients with an acute inflammation are hospitalized in a surgical hospital where after an additional examination and short preparation carry out a laparoscopic holetsistektomiya. Carrying out operation within three days after emergence of symptoms allows to reduce a lethality and to reduce the frequency of complications in comparison with the planned interventions executed in 6-8 weeks of conservative therapy. At the heavy, complicated course of sharp cholecystitis, advanced age of patients operation of the choice is the chreskozhny holetsistektomiya added with antibiotic treatment.
At chronic option of a kalkulezny inflammation conservative treatment before knocking over of signs of an aggravation is recommended. In the first days of a recurrence food is limited to the use of liquids, in the subsequent in a diet reduce amount of refractory fats, extractive substances, products with cholesterol. The scheme of medicamentous therapy includes:
- The anesthetizing medicines. Apply miotropny spazmolitik which due to impact on a muscular cover of a bubble and bilious channels eliminate . At the expressed pain syndrome (bilious colic) nonsteroid resolvents are shown, is more rare – narcotic analgetics.
- Antibacterial means. Usually use medicines to which opportunistic intestinal microflora is sensitive (colibacillus, klebsiyella, pseudo-monads). Aminoglycosides in a combination about linkozamidam, imidazoles in combination with tsefalosporina of the 3rd generation, a karbapenema are most effective.
At the expressed intoxication dezintoksikatsionny therapy is required. Antiemetic and enzymatic medicines are symptomatic appointed. After stabilization of a state in a planned order it is made open, laparoscopic, SILS or removal of a bubble through mini-access. Crushing of concrements is carried out to cavities of body seldom in the presence of contraindications to other interventions.
Forecast and prevention
It is possible to achieve permanent improvement of a state from most of patients. Forecast of uncomplicated kalkulezny cholecystitis rather favorable. In case of heavy purulent complications the lethality can reach 50-60%. Prevention is directed to prevention of a kamneobrazovaniye, includes normalization of a diet (observance of the balanced diet, restriction of the use of high-calorific fat dishes, meal of 4-5 times a day), feasible physical activities, refusal of purpose of the medicines stimulating formation of concrements.