Chronic holangit – the inflammatory disease of bilious ways (as inside - and extra hepatic channels) which is characterized by a long recidivous current and leading to a holestaz. The main clinical signs – a pain combination in a liver, high fever, a fever and jaundice. The diagnosis is established on the basis of an ultrasonografiya of a pancreas and bilious ways, a retrograde holangiopankreatografiya, a computer tomography of biliary tract, biochemical and general blood test. The treatment combined: conservative antibacterial therapy, anesthesia, desintoxication, surgical decompression of bilious ways.
Chronic holangit meets much more less than other inflammatory diseases of gepatobiliarny system. This pathology develops generally at adult population (middle age about 50 years), at the same time there are no essential distinctions in incidence among men and women. Most often chronic holangit arises against the background of other diseases of a liver and gall bladder, in 37% of cases is formed after a holetsistektomiya. There is a special form of this disease - primary skleroziruyushchiya holangit which develops against the background of relative health, slowly progresses and within about ten years leads to irreversible damage of a liver. True figures of incidence of a skleroziruyushchy holangit are unknown as its diagnostics is complicated. Among patients young men prevail (the disease demonstrates at the age of 20-25 years). In recent years the tendency of growth of cases of a skleroziruyushchy holangit is noted that it is connected, first of all, with improvement of its diagnostics. Depending on terms of identification and a course of disease, mortality at a chronic holangit can vary within 15-90%.
Reasons of a chronic holangit
Chronic holangit the bacterial nature can call practically all activators which are present at intestines: enterokokk, klebsiyella, proteas, colibacillus and other. Practically always at a chronic holangit infection with several activators at the same time is noted, extremely seldom at crops of bile only one bacterial agent comes to light. Most often the chronic holangit is accompanied by identification of bacteria in blood (positive crops of blood on sterility).
Can promote penetration of intestinal flora into biliary tract: violation of work of a duodenal nipple, hematogenic and limfogenny dissemination of bacterial agents. This mechanism of infection is observed at anomalies of development of bilious ways (congenital cysts, etc.); stenoses and deformations after surgical interventions, endoscopic procedures; tumors of a pancreas and ZhVP; to a holestaza against the background of cholelithiasis; invasions of parasites. Formation of a chronic holangit usually requires a combination of a translocation of intestinal flora in bilious ways, a holelitiaza and increases in intra pro-current pressure. Chronic holangit it can be formed as logical continuation of a sharp holangit, but also its primary and chronic current is possible.
Thus, risk factors of a chronic holangit are any medical and diagnostic and surgical interventions on the bilious ways which are carried out against the background of congenital anomalies of development and infectious process.
Symptoms of a chronic holangit
Identification of a triad of Sharko is characteristic of a clinical picture of a chronic holangit – it is shown by a combination of moderate pain in the right podreberye, a fever and temperature increase to subfebrilny figures, jaundice. Pains usually stupid, aching, low-intensive. After a while after bilious colic the patient notes the moderate fever which is followed by not expressed fever. The clinic of a chronic holangit which is usually erased, recuring therefore patients not always attach significance to the first displays of a disease. At later stages of a disease the ikterichnost of skin, mucous can be shown. Gradually the general weakness, increased fatigue which is especially expressed at advanced age develops. After 60 years diagnostics of a chronic holangit is usually complicated as the clinical picture does not correspond to weight of inflammatory process, symptoms erased therefore the diagnosis is established late.
Chronic purulent holangit can lead to penetration of an infection into a system blood-groove and development of biliarny septic shock which in 30% of cases comes to an end with a lethal outcome. Not less terrible complications are liver abscess, porto-kavalny thrombosis and other septic manifestations. Skleroziruyushchy chronic holangit often is complicated by cirrhosis, a gepatotsellyulyarny carcinoma.
Diagnostics of a chronic holangit
Consultation of the gastroenterologist is required to all patients with suspicion of pathology of biliary tract. A basis for statement of the right diagnosis is definition at the patient of a triad Sharko. Further inspection is begun with laboratory tests. In the general blood test at a chronic holangit reveal high , neytrofilny shift of a leykotsitarny formula, the increased SOE. Biochemical screening finds increase in level of bilirubin, activity of ShchF and G-GTP, is rare - activities and alpha amylases. Microbiological researches practically at 100% of patients indicate existence of intestinal flora in bile, at a half of patients – in blood.
Broad application at a chronic holangit was found also by tool methods of diagnostics. So, the ultrasonografiya of a pancreas and bilious ways indicates expansion and a thickening of walls of bilious channels. KT of biliary tract not only will confirm the data obtained when performing ultrasonography but also will help to reveal complications of a purulent holangit (liver abscesses, pileflebit).
Consultation of the endoscopist is necessary for carrying out a retrograde holangiopankreatografiya which will help to visualize concrements in bilious ways and will indicate their expansion. The magnetic and resonant pankreatokholangiografiya succeeds in recent years ERHPG as is the noninvasive technique allowing not only to reveal signs of a chronic holangit, but also to define the reasons of its development. If diagnostic search is carried out before surgery, the chreskozhny chrespechenochny holangiografiya can be used – through the needle entered into bilious ways not only their contrasting, but also drainage is carried out.
To differentiate chronic holangit follows with viral hepatitises, obstruction of bilious channels at cholelithiasis, sharp and kalkulezny cholecystitis, tumors (a liver, a pancreas, bilious channels), strikturam of bilious channels of other etiology.
Treatment of a chronic holangit
Treatment of a chronic holangit is usually carried out in out-patient conditions, only at the heavy course of a disease, a malignant holestaz, at senile age hospitalization in office of gastroenterology is recommended.
Medicamentous therapy at bilious hypertensia is considered as a stage of preparation for expeditious unloading of bilious ways. In office desintoxication is carried out, the anesthetizing and antibacterial therapy is appointed. Before receiving bacterial crops antibiotics of a broad spectrum of activity – the tsefalosporina, penicillin (getting into bile), aminoglycosides are appointed. At verification of a parasitic infection etiotropny antiparasitic treatment is appointed.
The surgery purposes at a chronic holangit are removal of concrements from bilious ways and bile outflow improvement (drainage of ZhVP). External drainage of bilious channels (according to Kerr, on Holsteda), chreskozhny transhepatic drainage of bilious channels, nazobiliarny drainage is for this purpose carried out at RPHG, extraction of concrements from a holedokh, extraction of concrements of bilious channels at RPHG, endoscopic stenting of a holedokh, endoscopic balloon dilatation of a sphincter of Oddi.
In the postoperative period it is recommended to continue antibacterial and bile-expelling therapy, to keep to a diet, to include in a food allowance food, vitamin-rich and vegetable oils.
Forecast and prevention of a chronic holangit
Chronic holangit - it is the serious pathology having rather high lethality and frequency of complications. Worsen the forecast at a chronic holangit senile age, a female, a long hyperthermia (more than two weeks), disorders of consciousness, anemia, signs of insufficiency of functions of a liver and kidneys. Prevention of a chronic holangit is secondary and directed to timely diagnosis and treatment of the diseases leading to this state.