Chronic kalkulezny cholecystitis
Chronic kalkulezny cholecystitis – the persistiruyushchy inflammation of a mucous membrane of a gall bladder interfaced to existence of concrements in it. Gastroenterologists consider that this pathology is connected with secondary infection of bile. Chronic kalkulezny cholecystitis clinically proves pains in the right side, nausea, mood swings. Diagnostics includes hepatic tests, ultrasonography of gepatobiliarny system, a survey X-ray analysis of OBP, RHPG, MRT and KT of a liver and biliary tract, a holestsintigrafiya. Treatment conservative (a diet, analgetics, spazmolitik, antibiotics) or combined (it is supplemented with surgery).
Chronic kalkulezny cholecystitis
Chronic kalkulezny cholecystitis is very widespread pathology: not less than 20 percent of women and 10 percent of men of reproductive age have this illness. High incidence among women is connected with a large amount of estrogen in their organism as these hormones lead to strengthening of secretion of cholesterol in bilious ways and to formation of concrements. Concrements in biliary tract including in a gall bladder, are found in 30% of all pathoanatomical sections. It is noticed that with age the frequency of identification of the bilious concrements which are followed by inflammatory process increases. For this reason this pathology is an urgent problem of gastroenterology.
Reasons of chronic kalkulezny cholecystitis
The main causal factor leading to development of chronic kalkulezny cholecystitis – the concrement located in a gall bladder and an obturiruyushchy puzyrny channel. The concrement located in a gleam of a gall bladder a long time can exist asymptomatically. Sooner or later there comes the moment when the concrement is displaced and blocks an exit from a gall bladder that results in stagnation of bile in it. Developments of stagnation cause the increased development of pro-inflammatory mediators and injury of a mucous membrane which begins to produce a large amount of slime and inflammatory exudate. Cholecystitis develops. Restretching of a gall bladder exudate comes to an end with even more massive development of pro-inflammatory mediators - the pathological circle becomes isolated.
Inflammatory infiltration of a wall of a gall bladder starts its cicatricial wrinkling which gradually leads to a thickening and calcination of a puzyrny wall. Inflammatory process (cholecystitis) is supported constantly with the periods of remissions and aggravations. It is long the current chronic kalkulezny cholecystitis contributes to development of cancer of gall bladder.
Carry belonging to a female, obesity or sharp weight loss, use of a hormonal method of contraception, reception of some medicines, pregnancy to other risk factors of development of chronic kalkulezny cholecystitis. Gastroenterologists also note incidence growth with age.
Symptoms of chronic kalkulezny cholecystitis
The most characteristic symptom of chronic kalkulezny cholecystitis is pain in the right podreberye. Most often it arises in several hours after meal (especially fat, fried), has the stupid aching character. Irradiation in the right shoulder, a neck, a shovel is inherent in a pain syndrome. Pain can sometimes accept acuity, reminding at the same time bilious colic. Pain is followed by nausea, sleeplessness. Character changes are inherent in this pathology: irritability, suspiciousness, the increased concern.
Cases when chronic kalkulezny cholecystitis is not shown throughout a long time in any way are frequent. Jaundice is not characteristic of this disease. Chronic kalkulezny cholecystitis can be complicated by such states as an empiyema of a gall bladder, an anaerobic infection, puzyrno-intestinal fistula (it is formed as a result of formation of decubitus in the location of a concrement), perforation of a gall bladder, pancreatitis and sepsis.
Diagnosis of chronic kalkulezny cholecystitis
Main goal of consultation of the gastroenterologist is earlier establishment of the diagnosis, timely identification of complications of chronic kalkulezny cholecystitis, definition of indications to expeditious treatment. At survey and a palpation of a stomach it is possible to reveal a number of the symptoms indicating inflammatory process in a gall bladder: Murphy's symptom (when pressing on area of the right podreberye the patient holds the breath), Ortner's symptom (pain at percussion on the right costal arch), Kerr's symptom (pain at breath height at simultaneous pressing in the field of the right podreberye), a frenikus-symptom (pain when pressing between two legs - a clavicular and mastoidal muscle).
Laboratory analyses and biochemical tests of a liver have no crucial importance, but can point by a concrement increase in levels of the general bilirubin, ShchF, ALT and nuclear heating plant to a full obturation of bilious channels. Ultrasonography of a liver and a gall bladder is very specific and sensitive method of diagnosis of chronic kalkulezny cholecystitis. The most informatively this research if it is conducted after eight hours of starvation.
On a survey X-ray analysis of abdominal organs bilious concrements are visualized only at every tenth patient. On an anaerobic etiology of cholecystitis specifies gas in a gleam or in the thickness of a wall of a gall bladder. Also on the roentgenogram the partial or total kaltsifikation of walls of a gall bladder can be visible. When carrying out MPT and KT of biliary tract in favor of chronic kalkulezny cholecystitis the thickening of a puzyrny wall, availability of liquid in okolopuzyrny cellulose, rejection of a mucous membrane, gas in a gleam testifies or bubble walls are thicker.
Holestsintigrafiya possesses nearly 100% sensitivity at diagnosis of chronic kalkulezny cholecystitis. For improvement of filling of a gall bladder before a research morphine is appointed – thanks to introduction of this medicine a bile exit through Oddi's sphincter in a 12-perstny gut is slowed down.
Consultation of the endoscopist and retrograde holangiopankreatografiya is appointed to those patients at whom existence of concrements in the general bilious channel is suspected. RHPG is not only the diagnostic, but also medical procedure during which concrements can be removed. It is necessary to remember risk of development of pancreatitis after RHPG (about 5% of patients).
Treatment of chronic kalkulezny cholecystitis
Patients with chronic kalkulezny cholecystitis in an aggravation stage, and also with the heavy course of a disease demand hospitalization in office of gastroenterology. The others can receive treatment on an outpatient basis. Therapy is long, out of the aggravation period usually conservative. Main directions of treatment: infection eradikation, elimination of a pain syndrome, bile outflow improvement. Therapy of chronic kalkulezny cholecystitis in many respects coincides with treatment of cholelithiasis.
Conservative treatment includes a dietotherapy, purpose of the antibacterial and anesthetizing medicines, spazmolitik. At an exacerbation of chronic kalkulezny cholecystitis in the first two days observance of a water pause is required, then the diet No. 5a with gradual transition to a table No. 5 is appointed.
The antibacterial medicines appointed at chronic kalkulezny cholecystitis include the protected penicillin, aminoglycosides, tsefalosporina of the 3rd generation, a linkozamida, a karbapenema. Appointing analgetics, it is necessary to remember that morphine breaks outflow of bile through Oddi's sphincter. From narcotic analgetics preference is given to a promedol, from not narcotic – to paracetamol, analginum. As a spazmolitik usually use a papaverine.
Considering the fact that as the major causal factor of formation of chronic kalkulezny cholecystitis concrements in biliary tract act, full treatment from this disease requires removal of stones. The gold standard in this area the laparoscopic holetsistektomiya is considered, however also the open holetsistektomiya is widely used. Holetsitektomiya from mini-access is applied much less often. During remission sanatorium treatment is recommended to patients.
Forecast and prevention of chronic kalkulezny cholecystitis
The uncomplicated course of chronic kalkulezny cholecystitis usually has the favorable forecast. At the complicated disease option, and also at the patients having serious associated diseases, the forecast worsens – the lethality can make 50-60%. Bystry development of an empiyema and gangrene of a gall bladder, the svishchevy courses, abscesses of a liver, peritonitis is characteristic of the complicated chronic cholecystitis.
Prevention of chronic kalkulezny cholecystitis includes the prevention of formation of stones and timely treatment of sharp cholecystitis. Primary prevention of formation of concrements consists in weight reduction at obesity, refusal of the hormonal medicines containing estrogen.
If the patient has concrements in a gall bladder, for the prevention of chronic cholecystitis it is required to meet a number of conditions: to adhere to a diet with restriction fat and sweet, to maintain sufficient physical activity, not to allow the long periods of starvation, to accept enough liquid. After removal of concrements from a gall bladder it is recommended to carry out ultrasonography of gepatobiliarny system at least two times a year for timely identification of a recurrence of a holelitiaz.