Holedokholitiaz – existence in bilious channels of the concrements causing violation of a zhelcheottok. Symptoms of a holedokholitiaz are defined by extent of overlapping of a channel a stone and include pain, jaundice, sometimes temperature increase of a body. At initial stages the disease can pass asymptomatically. For statement of the exact diagnosis carry out ultrasonography of a liver and a gall bladder, a holedokhoskopiya, an endoscopic retrograde holangiopankreatografiya, a chreskozhny chrespechenochny holangiografiya, MR-holangiopankreatografiya, estimate biochemical tests of a liver. Delete stones in the surgical way or by an endoscopic method.
Holedokholitiaz is one of forms of cholelithiasis at which stones are formed in a holedokha or get from a gall bladder there. Concrements in a gall bladder – the phenomenon very widespread. They occur approximately at a third of women and at a quarter of men in the territory of Europe and North America. Among patients with cholelithiasis about 5-15% suffer holedokholitiazy. After removal of a gall bladder the risk of a holedokholitiaz increases, but it proceeds in such cases generally asymptomatically. Importance of this problem is also connected with frequent complications which demand emergency aid and create risk for the patient's life. Diagnostics and treatment of a holedokholitiaz are carried out in offices of gastroenterology and abdominal surgery.
Reasons of a holedokholitiaz
The main reason for a holedokholitiaz – migration of stones of the small size from a gall bladder to canals. Statistically, this phenomenon provokes about 85% of all cases. Movement of concrements is carried out due to increase in pressure in a gall bladder, strengthenings of sokratitelny function of its walls. The stone size is of great importance: the concrement is less, the it is more than chances that it migrates to canals.
Directly in a holedokha stones are formed approximately at 10-15% of patients. They are formed because of an inflammation of channels, their mechanical damages during operation or at invasive endoscopic inspection. Also the reason can become primary skleroziruyushchiya holangit, cysts in bilious channels, the striktura formed after inflammatory diseases and manipulations, helminthic invasions (helminthoses).
Increase in pressure in bilious channels is the cornerstone of pathogenesis of a holedokholitiaz. As a result the stone moves from one department to another, causing irritation of walls, hypostasis and further overlapping of a gleam of a holedokh. If the stone small, and in a holedokha and in the field of a faterov of a nipple is not present , it can independently leave in a duodenum gleam. Otherwise there will be a full or partial obstruction of a bilious channel. Bile evacuation is as a result broken, above the place of obstruction extends, there is an inflammation, the favorable environment for growth of bacteria is formed.
Symptoms of a holedokholitiaz
About 15% of all cases of a holedokholitiaz proceed asymptomatically. Such current is observed at patients with a remote gall bladder and when stones of the small size are quickly evacuated from a holedokh in a duodenum, without causing obstruction with which the main displays of a disease are connected.
One of the first symptoms of a holedokholitiaz is pain. She has deep visceral character, partially reminds pain at sharp cholecystitis; can be stupid, aching or rather sharp, with little changes of intensity. Pain is localized in an epigastriya or in the right podreberye, often gives to a back. When the stone falls to the area of a faterov of a nipple, the pain syndrome can gain the surrounding character, as at sharp pancreatitis. If in this department the stone is not blocked, it leaves in a duodenum gleam, and all symptoms independently disappear to the following attack.
The second symptom of a holedokholitiaz – jaundice. It develops approximately in 12 hours after emergence of pain, process can sometimes be dragged out for days. At the same time the pain syndrome decreases or disappears completely. Feature of jaundice at a holedokholitiaza – its alternating character. Intensity of yellowness of skin and mucous amplifies, weakens. It allows to differentiate a disease with pancreas head cancer, acute viral hepatitises, leptospirosis which can proceed sometimes with the expressed pain syndrome too. At a long current of a holedokholitiaz with considerable obstruction of a channel at patients the kcal becomes colourless, up to an acholia, urine darkens.
Becomes complicated holangity, pancreatitis, at a long current – secondary biliarny cirrhosis. At accession of a holangit (an inflammation of bilious ways), except the main symptoms, at the patient temperature increase, symptoms of intoxication (nausea, vomiting, strong general weakness) is observed. Sometimes patients complain of intensive back pain. Pancreatitis is shown by severe pains on the left side or pains of the surrounding character, continuous vomiting, decrease in a vermicular movement or full paresis of intestines. In blood the level of enzymes of a pancreas increases. Cirrhosis develops long, after the frequent recurrence of a holedokholitiaz which was becoming complicated holangity.
Diagnostics of a holedokholitiaz
For specification of the diagnosis of a holedokholitiaz conduct a number of researches. Begin with ultrasonography of a liver and a gall bladder, biochemical tests of a liver. In blood test often determine the increased level of bilirubin, alkaline phosphatase. ALT, nuclear heating plant in most cases remain within norm. Changes in biochemical composition of blood can be insignificant, quickly return to normal when the stone is evacuated from a gleam of a holedokh. At an asymptomatic current do screening researches of biochemistry of blood at which it is possible to find periodic moderate rises in level of bilirubin and alkaline phosphatase.
Laboratory data can not always help with diagnosis or define degree of an obturation of channels. Therefore for specification of existence of a holedokholitiaz it is expedient to conduct other researches. Ultrasonography of a liver and a gall bladder allows to find expansion of channels, signs of stagnation of bile, concrements in a gleam of a holedokh or a gall bladder. If this research did not give a full picture, carry in addition out ERHPG. Advantage of this technique is that it is possible to carry out at the same time operation on removal of a stone from a channel.
One of methods of specification of the diagnosis of a holedokholitiaz is the chreskozhny chrespechenochny holangiografiya. In difficult cases will see off MR-holedokhopankreatografiya. The Computer Tomography (CT) of biliary tract is used seldom as it is insufficiently informative in this case.
Treatment of a holedokholitiaz
Most often at a holedokholitiaza extraction of concrements of bilious channels at RHPG is carried out. During endoscopy through Oddi's sphincter enter a special balloon catheter which broadens a channel and gives the chance easily to remove a stone. If a stone big, carry out a holedokhotomiya or a sfinkterotomiya. The technique of ERHPG allows to remove a stone in 85% of cases. Concrements more than 18 mm in size subject previously to crushing. Do it by means of a mechanical litotriptor, method of a laser or magnetic and wave lithotripsy. After crushing efficiency of extraction of concrements of bilious channels at RHPG increases to 90%.
When it is impossible to remove a stone with an endoscopic method, resort to surgical intervention. Operation is carried out by a classical method or in the way of a laparoscopy. During operation carry out a holedokhotomiya or full removal of a gall bladder (holetsistektomiya). Recommend to delete a gall bladder in all cases of repeated emergence of a holedokholitiaz. Conservative treatment of a holedokholitiaz is carried out seldom, only in those cases if surgery is impossible.
The forecast at a holedokholitiaza
Because often gives complications, the forecast at this disease quite serious. Without timely treatment seldom it is possible to avoid obstruction, mechanical jaundice, a holangit, in the started cases - pancreatitis and cirrhosis. Postoperative complications (especially after classical open intervention) make about 15% therefore now try to apply endoscopic and laparoscopic techniques to treatment of a holedokholitiaz more often.
After removal of a stone a recurrence for five years develops approximately at a quarter of all patients. At a repeated attack of a holedokholitiaz recommend to delete a gall bladder. For prevention appoint ursodezoksikholevy acid. It is necessary to accept it not less, than six months in a year, otherwise efficiency of treatment will be doubtful.