Cholecystitis – various on an etiology, a current and clinical manifestations of a form of inflammatory damage of a gall bladder. Are followed by the pain in the right podreberye giving to the right hand and a clavicle, nausea, vomiting, diarrhea, a meteorizm. Symptoms arise against the background of an emotional stress, errors in food, abuses of alcohol. Diagnostics is based on data of fizikalny survey, ultrasound examination of a gall bladder, a holetsistokholangiografiya, duodenal sounding, biochemical and general blood test. Treatment includes a dietotherapy, physical therapy, purpose of analgetics, spazmolitik, bile-expelling means. According to indications carry out a holetsistektomiya.
Cholecystitis — an inflammatory disease of a gall bladder which is combined with motor and tonic dysfunction of bile-excreting system. At 60-95% of patients the disease is accompanied by existence of bilious concrements. Cholecystitis is the most widespread pathology of abdominal organs, makes 10-12% of total of diseases of this group. The inflammation of body comes to light at people of all age, patients of middle age (40-60 years) suffer more often. The disease 3-5 times more often affects female persons. The beskamenny form of pathology whereas among adult population kalkulezny cholecystitis prevails is characteristic of children and teenagers. Especially often the disease is diagnosed in civilized countries that is caused by features of food behavior and a way of life.
In development of pathology stagnation of bile and an infection in a gall bladder has major importance. Pathogenic microorganisms can get into body gematogenno and limfogenno from other centers of a chronic infection (periodontosis, otitis, etc.) or a contact way from intestines. Pathogenic microflora is more often presented by bacteria (stafilokokka, colibacillus, streptococci), is more rare viruses (hepatotrophic viruses C, B), elementary (lyambliya), parasites (ascarids). Violation of utilization of bile from a gall bladder arises at the following states:
- Cholelithiasis. Cholecystitis against the background of ZhKB meets in 85-90% of cases. Concrements in a gall bladder become the reason of a staz of bile. They cork a gleam of an exhaust outlet, injure a mucous membrane, cause ulcerations and solderings, supporting process of an inflammation.
- Dyskinesia of biliary tract. Development of pathology is promoted by functional violation of motility and a tone of biliarny system. Motor and tonic dysfunction leads to insufficient depletion of body, a kamneobrazovaniye, emergence of an inflammation in a gall bladder and channels, provokes .
- Congenital anomalies. The risk of cholecystitis increases at congenital curvatures, hems and banners of body, doubling or narrowing of a bubble and channels. Above-mentioned states provoke violation of drainage function of a gall bladder, stagnation of bile.
- Other diseases of bile-excreting system. Tumors, cysts of a gall bladder and bilious channels, dysfunction of valvate system of a biliarny path (Oddi's sphincters, Lyutkens), a syndrome of Mirizzi exert impact on developing of cholecystitis. These states can cause deformation of a bubble, a sdavleniye of channels and formation of a staz of bile.
Besides the major etiologichesky factors there is a number of states which existence increases probability of emergence of symptoms of cholecystitis, influencing both bile utilization, and change of its qualitative structure. It is possible to carry a diskholiya (violation of normal structure and a consistence of puzyrny bile), hormonal reorganization during pregnancy to such states, menopauses. Development of enzymatic cholecystitis is promoted by regular throwing of enzymes of a pancreas in a bubble cavity (a pankreatobiliarny reflux). Cholecystitis often arises against the background of improper feeding, abuse of alcohol, tobacco smoking, an adinamiya, sedentary work, a hereditary dislipidemiya.
The main pathogenetic link of cholecystitis it is considered to be puzyrny bile. Owing to dyskinesia of biliarny ways, an obturation of a bile-excreting channel barrier function of an epithelium mucous a bubble, resistance of its wall to influence of pathogenic flora decreases. Stagnant bile becomes the favorable environment for reproduction of microbes which form toxins and migrations in the center of an inflammation of gistaminopodobny substances promote. At catarrhal cholecystitis in a mucous layer there is hypostasis, a thickening of a wall of body due to infiltration by her macrophages and leukocytes.
Progressing of pathological process leads to distribution of an inflammation on submucous and muscular layers. Sokratitelny ability of body up to paresis decreases, its drainage function worsens even more. In the infected bile impurity of pus, fibrin, slime appears. Transition of inflammatory process to the next fabrics promotes formation of perivezikalny abscess, and formation of purulent exudate leads to development of flegmonozny cholecystitis. Owing to violation of blood circulation there are hemorrhage centers in a wall of body, sites of ischemia, and then and a necrosis appear. These changes are peculiar to gangrenous cholecystitis.
In gastroenterology there are several classifications of a disease, each of which is of great importance, gives to experts the chance to refer these or those clinical manifestations to a certain type of a disease and to choose rational tactics of treatment. Taking into account an etiology distinguish two types of cholecystitis:
- Kalkulezny. In a cavity of body concrements are found. About 90% of all cases of a disease fall to the share of kalkulezny cholecystitis. Can be followed by intensive symptomatology with attacks of bilious colic or long time to proceed asymptomatically.
- Nekalkulezny (beskamenny). Makes 10% of all cholecystitises. It is characterized by lack of concrements in a gleam of body, the favorable current and rare aggravations which are usually connected with alimentary errors.
Depending on expressiveness of symptoms and type of inflammatory and destructive changes cholecystitis can be:
- Sharp. Is followed by the expressed inflammation signs with the rough beginning, bright symptomatology and the phenomena of intoxication. Pain, as a rule, intensive, has wavy character.
- Chronic. It is shown by a gradual slow current without the expressed symptoms. The pain syndrome can be absent or have the aching, slabointensivny character.
On severity of clinical manifestations allocate the following forms of a disease:
- Easy. It is characterized by a slabointensivny pain syndrome lasting 10-20 min. which is stopped independently. Violations of digestion come to light seldom. The aggravation arises 1-2 times a year, no more than 2 weeks proceed. Function of other bodies (a liver, a pancreas) is not changed.
- Average weight. Painful feelings resistant with the expressed dispepsichesky violations. Aggravations develop more often than 3 times a year, more than 3-4 weeks last. Changes in work of a liver (increase in ALT, nuclear heating plant, bilirubin) are noted.
- Heavy. Is followed sharply expressed painful and dispepsichesky by syndromes. Aggravations frequent (is more often than 1 time a month), long (more than 4 weeks). Conservative treatment does not provide significant improvement of health. Function of the next bodies is broken (hepatitis, pancreatitis).
On character of a course of inflammatory and destructive process distinguish:
- Recidivous current. It is shown by the periods of an aggravation and full remission during which displays of cholecystitis are absent.
- Monotonous current. A typical sign is lack of remissions. Patients complain of constant painful feelings, discomfort in the right departments of a stomach, frustration of a chair, nausea.
- The alternating current. Against the background of continuous ill-defined displays of cholecystitis periodically there is sharpening of various degrees of severity with the phenomena of intoxication and bilious colic.
Clinical manifestations depend on character of an inflammation, existence or lack of concrements. Chronic cholecystitis meets more often sharp and usually has a wavy current. In the period of an aggravation at a beskamenny and kalkulezny form pristupoobrazny pain of different intensity in the right part of a stomach, irradiirushchy in the right shoulder, a shovel, a clavicle develops. Painful feelings result from improper feeding, heavy physical activities, a severe stress. The pain syndrome often is followed by vegeto-vascular disorders: weakness, perspiration, sleeplessness, nevrozopodobny states. Besides pains nausea, vomiting with impurity of bile, violation of a chair, an abdominal distension is observed.
Patients note temperature increase of a body to febrilny values, a fever, feeling of bitterness in a mouth or an eructation bitter. In hard cases intoxication symptoms are found: tachycardia, short wind, hypotonia. At a kalkulezny form against the background of a resistant holestaz yellowness of skin and a skler, a skin itch is observed. In a remission phase symptoms are absent, the discomfort and weight around the right podreberye, frustration of a chair and nausea is sometimes noted. There can periodically be a holetsistokardialny syndrome which is characterized by pains behind a breast, tachycardia, violation of a rhythm.
Sharp beskamenny cholecystitis is diagnosed rather seldom, shown by incidental nagging pains in a podreberye after an overeating, the uses of alcoholic beverages on the right. This form of a disease proceeds without violation of digestion and complications more often. At a sharp kalkulezny form symptoms of a holestaz (pain, a skin itch, yellowness, bitterish smack in a mouth) prevail.
At a long current transition of an inflammation to nearby bodies and fabrics with development of a holangit, pleurisy, pancreatitis, pneumonia can be observed. Lack of treatment or late diagnostics at a flegmonozny form of a disease lead to an empiyema of a gall bladder. Transition of pyoinflammatory process to nearby fabrics is followed by formation of okolopuzyrny abscess. At perforation of a wall of body a concrement or purulent fusion of fabrics happens izlity bile in an abdominal cavity to development of the poured peritonitis which in the absence of the emergency actions can end with a lethal outcome. At hit of bacteria in a blood-groove there is sepsis.
The main difficulty of verification of the diagnosis it is considered to be definition of type and the nature of a disease. The first stage of diagnostics is consultation of the gastroenterologist. The expert on the basis of complaints, studying of the anamnesis of a disease, carrying out fizikalny inspection can establish the preliminary diagnosis. At survey Murphy, Kerr's positive symptoms, Myussi, Ortnera-Grekova come to light. For definition of a look and severity of a disease the following examinations are conducted:
- Ultrasonography of a gall bladder. Is the main diagnostic method, allows to establish the size and a form of body, thickness of its wall, sokratitelny function, existence of concrements. At patients with chronic cholecystitis reinforced sklerozirovanny walls of the deformed gall bladder are visualized.
- Fractional duodenal sounding. During the procedure take three portions of bile (And, In, C) for a microscopic research. By means of this method it is possible to estimate motility, color and a consistence of bile. For the purpose of detection of the activator which caused a bacterial inflammation define sensitivity of flora to antibiotics.
- Holetsistokholangiografiya. Allows to obtain information on work of a gall bladder, a biliarny path in dynamics. By means of a X-ray contrast method find violation of motive function of bile-excreting system, concrements and deformation of body.
- Laboratory blood test. During the sharp period in OAK acceleration of SOE comes to light neytrofilny . In biochemical blood test increase in the ALT, nuclear Heating Plant level, a holesterinemiya, a bilirubinemiya, etc. is noted.
In doubtful cases for studying of work of a biliarny path in addition carry out a gepatobilistsintigrafiya, FGDS, MSKT of a gall bladder, a diagnostic laparoscopy. Differential diagnosis of cholecystitis is carried out with the sharp diseases which are followed by a pain syndrome (sharp pancreatitis, appendicitis, perforative stomach ulcer and a 12-perstny gut). The clinic of cholecystitis should be distinguished from an attack of renal colic, sharp pyelonephritis, right-hand pneumonia.
Treatment of cholecystitis
The basis of treatment of sharp and chronic nekalkulezny cholecystitis is made complex medicamentous also by a dietotherapy. At often recidivous kalkulezny form of a disease or at threat of development of complications resort to surgery on a gall bladder. As the main directions in treatment of cholecystitis are recognized:
- Dietotherapy. The diet is shown at all stages of a disease. Fractional food of 5-6 times a day in the boiled, stewed and baked look is recommended. It is necessary to avoid big breaks between meals (more than 4-6 hours). Patients are recommended to exclude alcohol, bean, mushrooms, fat meat, mayonnaise, cakes.
- Medicamentous therapy. At sharp cholecystitis appoint anesthetics, spazmolitichesky medicines. At identification of pathogenic bacteria in bile apply antibacterial means, proceeding from a type of the activator. During remission use the bile-expelling medicines stimulating a bile production (holeretik) and improving outflow of bile from body (holekinetika).
- Physical therapy. It is recommended at all stages of a disease for the purpose of anesthesia, reduction of signs of an inflammation, restoration of a tone of a gall bladder. At cholecystitis appoint an induktotermiya, UVCh, an electrophoresis.
Removal of a gall bladder is carried out at the started cholecystitises, inefficiency of conservative methods of treatment, a kalkulezny form of a disease. Broad application was found by two technicians of removal of body: open and laparoscopic holetsistektomiya. Open operation is carried out at the complicated forms, existence of mechanical jaundice and obesity. The video laparoscopic holetsistektomiya is a modern low-traumatic technique which use allows to reduce risk of postoperative complications, to reduce the rehabilitation period. In the presence of concrements perhaps not surgical crushing of stones by means of an extracorporal shock and wave lithotripsy.
Forecast and prevention
The forecast of a disease depends on severity of cholecystitis, timely diagnostics and competent treatment. At regular reception of medicines, observance of a diet and control of aggravations the forecast favorable. Development of complications (phlegmon, holangit) considerably worsens the forecast of a disease, can cause serious consequences (peritonitis, sepsis). For prevention of aggravations it is necessary to adhere to bases of a balanced diet, to exclude alcoholic beverages, to lead active lifestyle, to carry out sanitation of the centers of an inflammation (antritis, tonsillitis). Sick chronic cholecystitis it is recommended to undergo ultrasonography of gepatobiliarny system annually.