Chronic cholecystitis (1)

Chronic cholecystitis

1. Chronic cholecystitis

2. Definition of Chronic cholecystitis Chronic cholecystitis is a chronic recurring disease of the gallbladder, characterized by a violation of its motor evacuation function, a change in the physicochemical properties of bile and a fairly frequent formation of intravesical calculi, which is clinically most often manifested by biliary colic.

3. Epidemiology With diseases of the biliary system, 294 people per 10,000 population are registered, they make up more than 25% (up to 50%) of patients with pathology of the digestive system. Chronic cholecystitis is central to diseases of the biliary system. Women get sick more often than men 3-4 times.

4. Etiology The causative agents of cholecystitis, as a rule, are representatives of the intestinal microflora, which are more often found in associations. These include: - Microorganisms of the enterobacteriaceae family, among which the leading role is played by E.coli (50-60 %), are less commonly found Klebsiella spp. (8-20%), Serratia spp., Proteus spp., Enterobacter spp., Acinetobacter spp. (2-5%). - Gram-positive microorganisms (Streptococcus, Enterococcus, detected, according to various authors, in 2-30% of cases). - Non-spore-forming anaerobes ( Bacteroides spp.), Clostridium spp., Fusobacteria, peptococcus (up to 20% of cases). - Pseudomonas spp. (2-4%).

5. Predisposing factors: 1 . Stagnation of bile, which is facilitated by: - violation of diet (rhythm, quantity and quality); - psychoemotional factors; - physical inactivity; - disorders of innervation of various origins; - constipation; - pregnancy; - metabolic disorders, leading to a change in the chemical properties of bile (obesity, atherosclerosis, diabetes, etc.); - organic disorders of the outflow of bile.

6. Predisposing factors: 2. Sensitization of the body to various bacteria. 3. Damage to the walls of the gallbladder: - irritation of the mucous membrane of the gallbladder with bile with altered physico -chemical qualities; - trauma with calculi; - irritation by pancreatic enzymes flowing into the common bile duct.

7. Pathogenesis Two anatomical and physiological conditions predispose to the development of chronic cholecystitis: bile stasis and the possibility of developing a “microbial attack ”. Stagnant bile is subject to thickening, sludge and is easily infected most often by ascending route from the intestine . (about reasons of stasis of bile were said above).

8. Pathogenesis Violation of the passage of bile into the small intestine is often observed in diseases of the duodenum, pancreas, polyps and cysts of the common bile duct . Distal resection of the stomach with the part of the stomach and duodenum turned off from the digestive act causes secretory and motor-evacuation disorders due to a decrease in the production of hormones, including cholecystokinin- pancreosimine , motilin.

9. Pathogenesis The development of ascending cholecystitis predisposes pathological reflux of the contents of the small intestine into the biliary tract, which can be observed with increased pressure in the duodenum and insolvency of the sphincter of Oddi , after papillophageal sphincterotomy . However, pathological reflux does not play a decisive role if the outflow of bile occurs normally.

10. Pathogenesis With the combination of two factors (bile congestion + pathological reflux), an inflammatory process develops that contributes to a change in the physicochemical properties of bile, and the acid-base balance in the gall bladder shifts to the acid side. In this regard, the lipoprotein complex protecting the bilirubin micelle is destroyed, and bilirubin in the form of a crystal precipitates. The phenomenon of crystallization of bilirubin in an unsaturated solution of cystic bile during inflammation of the gallbladder was recorded as the Galkin – Chechulin effect.

11. Pathogenesis The development of bacterial inflammation is facilitated by damage to the walls of the gallbladder caused by irritation of the mucous membrane by bile with altered physicochemical properties, pancreatic enzymes that enter the common bile duct, and trauma to calculi.

12. Pathogenesis It must be remembered that the risk factors for the development of the inflammatory process in the gallbladder are numerous foci of chronic inflammation (both in the digestive system and focal septic foci - chronic tonsillitis, periodontal disease, pyelonephritis), leading to sensitization of the body. As a result, the chronic course of cholecystitis is maintained and the conditions for its recurrence are created.

13. Classification (A.M. Nogaller , 1979) 1. By form: 1.1. Stoneless . 1.2. With Stone. 2. By severity: 2- .1. Mild form (exacerbations 1-2 times a year, short - 2-3 weeks). 2.2. Moderately severe (exacerbations 5-6 times a year of a protracted nature). 2.3. Severe form (exacerbations 1-2 times a month with prolonged biliary colic). 3. By stages of the disease: 3.1. Exacerbations. 3.2. Subside exacerbation. 3.3. Remission (persistent, unstable).

14. Classification (A.M. Nogaller , 1979) 4. By the presence of complications: 4.1. Uncomplicated 4.2. Complicated: 4.2.1. Pericholecystitis . 4.2.2. Cholangitis. 4.2.3. Perforation of the gallbladder. 4.2.4. Dropsy. 4.2.5. Empyema of the gallbladder. 4.2.6. Formation of stones. 5. By the nature of the developing: 5.1. Recurrent. 5.2. Monotone. 5.3. Intermittent.

15. Classification (A.M. Nogaller , 1979) 6. The functional state of the gallbladder and biliary tract: 6.1. Dyskinesia of the biliary tract of the hypertonic-hyperkinetic type. 6.2. Hypotonic-hypokinetic dyskinesia of the biliary tract ... 6.3. No biliary dyskinesia. 6.4. Disconnected gallbladder.

16. Clinical picture of chronic cholecystitis

17. Complains : pain. 1. The central symptom of chronic cholecystitis is the biliary type of pain. The main reason for the occurrence of abdominal pain in biliary pathology is most often a smooth muscle spasm , less commonly, overgrowth of the gallbladder wall and bile ducts as a result of the development of biliary hypertension or mechanical irritation of the duct system with biliary sludge or calculus. In this regard, the nature of the pain can vary significantly.

18. Complains : pain. In case of stoneless cholecystitis, patients complain of dull pain in the right hypochondrium , arising 40–90 minutes after eating, especially plentiful and rich in fats, as well as after shaking and prolonged weight bearing. Often, pain occurs or intensifies with prolonged sitting. The pain radiates upward to the right shoulder and neck, right shoulder blade. In 85% of patients, pain is monotonic, only 10-15% have rare, relatively low-intensity attacks of biliary colic

19. Complains : pain. With hypermotor dyskinesia of the gallbladder in the right hypochondrium , there are paroxysmal pains radiating to the back, right shoulder, under the right shoulder blade, intensifying with a deep breath. Sometimes pain radiates to the left half of the abdomen (when the pancreas duct system is involved in the process). The pain lasts 20 minutes or more, usually occur after an error in the diet, when taking cold and carbonated drinks, physical exertion, stressful situations, rarely at night.

20. С ommon symptoms Of the common symptoms, weight loss, irritability, fatigue, sweating, headaches, tachycardia can be noted . Fever with an increase in body temperature not higher than 38 ° C, is neuro-reflex in nature, normalizes after an attack, accompanied by chills, cold, clammy sweat. Keeping the temperature above 38 ° C indicates the development of complications . Vomiting A lot, not relieving, first with food, then with an admixture of bile, accompanied by nausea.

21. Jaundice may be notted Icteric sclera, short-term discoloration of feces, dark urine. Due to impaired patency of the common gall duct: calculus, papillitis , stenosis of the large duodenal papilla, compression of the enlarged edematous head of the pancreas.

22. With hypomotor dysfunction With hypomotor dysfunction of the biliary tract, prolonged, often constant dull pain in the right hypochondrium , sensations of pressure, bursting are noted. The pain can increase with the bending the torso and with an increase in intra-abdominal pressure, which changes the pressure gradient for the flow of bile. Common symptoms are nausea, bitterness in the mouth, bloating, constipation, and excess body weight.

23. Additional syndroms Chronic cholecystitis is characterized by signs of dyspeptic syndrome - heartburn, a feeling of bitterness in the mouth in the morning, nausea, vomiting that does not bring relief, belching with air and food, flatulence, constipation.

24. 1/3 of patients have atypical forms: 1 . The cardialgic form ( cholecystocardial syndrome) is characterized by prolonged dull pain in the region of the heart, as well as tachycardia, arrhythmias (more often such as extrasystoles ) that occur after a hearty meal, often in the supine position. On the ECG, there is a change in the final section of the ventricular complex - flattening, and sometimes inversion of the T wave.

25. A typical forms: Esophagalgic forms are characterized by persistent heartburn, combined with dull pain behind the sternum. After a hearty meal, sometimes there is a sensation of a “stake” behind the sternum. The pain is long. Sometimes there are slight difficulties when passing food through the esophagus (mild intermittent dysphagia).

26. Atypical forms: Intestinal forms occur with bloating, low-intensity, clearly not localized pain throughout the abdomen, a tendency to constipation.

27. Syndromes 1. Pain (was said above). 2. Dyspeptic syndrome: nausea, vomiting, belching, a feeling of bitterness in the mouth in the morning, a change in appetite, poor tolerance of certain types of food (fats, alcohol, vinegar in foods, etc.). Vomiting does not bring relief. 3 . Inflammatory syndrome (with exacerbation): fever, all laboratory signs of inflammation. 4 . Violation of bowel function: there may be bloating, constipation (more often). 5 . Cholestatic syndrome occurs when the bile ducts are blocked, obstructive jaundice develops. 6 . Cholecyst-cardial syndrome: pain in the heart, palpitations 7 . Astheno -neurotic syndrome.

28. Diagnostics 1 . History taking. Identification of predisposing factors, past diseases of the liver and biliary tract, etc. 2 . Inspection. With blockage of the bile ducts, yellowness of the skin, mucous membranes can be observed. 3 . Palpation. Superficial palpation of the abdomen allows you to determine the degree of tension of the abdominal muscles walls and the area of ​​greatest pain. The gallbladder point is the intersection point of the right costal arch and the outer edge of the right rectus abdominis muscle. In chronic cholecystitis, the following symptoms can be identified, which are divided into 3 groups.

29. Group 1 - symptoms associated with involvement in the pathological process of segmental nerves (segmental reflex symptoms): - Mackenzie symptom - pain when pressed at the point of intersection of the right costal arch with the outer edge of the rectus abdominis muscle (Mackenzie point ); - Aliev’s symptom - pain when pressed at the Mackenzie point, extending inward towards the gallbladder ( antidromic spread of pain ); - Boas symptom - pain in the region of the end of the XI-XII ribs on the right. The presence of symptoms of the first group indicates an exacerbation of cholecystitis and, as a rule, coincides with the corresponding subjective symptoms.

30. Group 2 - symptoms detected by direct or indirect palpation of the gallbladder: - Kerr symptom - soreness with deep palpation in the projection of the gallbladder on inspiration; - Murphy symptom - with deep palpation in the projection of the gallbladder on inspiration, the patient interrupts the inspiration; - symptom of Gausman — Vasilenko — Lepene — soreness when striking under the costal arch in the projection of the gallbladder with the protruded position of the abdomen on inspiration; - Ortner-Grekov symptom - soreness in the projection of the gallbladder when striking edge of the palm along the costal arch on the right. Symptoms of the second group are positive with exacerbation of cholecystitis and the presence of symptoms of the first group. But checking them in this case is considered unethical, because it will certainly cause a pain sensation. The diagnostic significance of the symptoms of the second group is great in the presence of chronic cholecystitis in the anamnesis and the absence of exacerbation symptoms at the time of examination.

31. Group 3 - symptoms associated with involvement of the autonomic nervous system in the pathological process on the right (the so-called right-sided reactive autonomic syndrome): - a symptom of Mussey-Georgievsky ( phrenicus -symptom) - pain when pressing between the legs of the sternocleidomastoid muscle on the right; - Bergman's orbital point - pain at the exit point of one of the branches of the trigeminal nerve on the right in the deepening of the orbit; - the occipital point Jonasha is the intersection point of the paravertebral line on the right with a perpendicular to it, drawn from the angle of the right lower jaw; - Kharitonov's thoracic point - located 2 cm to the right of the spinous process of the IV thoracic vertebra .

32. Group 3 - symptoms associated with involvement of the autonomic nervous system in the pathological process on the right The presence of symptoms of the third group indicates the duration of the process, because for the development of autonomic nervous system dysfunction with cholecystitis, a rather long period from the onset of the disease is necessary,

33. Laboratory research:  a general blood test is usually without features, but with an exacerbation, leukocytosis with neutrophilia, a shift of the leukoformula to the left, a slight increase in ESR are observed;  urinalysis is most often normal; a positive reaction to bilirubin (with complication of chronic cholecystitis obstructive jaundice);  biochemical parameters - hyperbilirubinemia, mainly due to the conjugated fraction, hypercholesterolemia, an increase in other markers of cholestasis. There may be a short-term and slight increase in blood transaminases; enzyme immunoassay for the detection of helminths: opisthorchiasis , giardiasis, toxacarosis , ascariasis; feces on eggs worm three times ; coprological research.

34. Instrumental research: Ultrasound is the main method of instrumental research in gallbladder disease, affordable and very informative. It reveals a thickening of the gallbladder wall (with an exacerbation of the process - more than 3 mm), an increase in its volume, in the lumen of the gallbladder — a thick secret, calculi. Sometimes a wrinkled, reduced gall bladder is found, filled with calculi and practically containing no bile;

35. Instrumental research: endoscopic retrograde cholangiography is used to assess the condition of the bile ducts and the presence of calculi in them. The study is performed when small stones are found in the gallbladder in combination with an expansion of the diameter of the common bile duct and an increase in the bilirubin content in the blood. At the presence of stones in the common bile duct can be performed endoscopic papillosphincterotomy and stone removal;

36. Instrumental research: Duodenal sounding: dyskinetic changes in multi-stage duodenal sounding in combination with changes in the biochemical properties of bile ( dyscholy ) and the release of pathogenic and conditionally pathogenic flora during bacteriological examination of bile.

37. Instrumental research: computed tomography (CT) and magnetic resonance imaging (MRI) - very informative, but quite expensive methods research. They allow you to identify the expansion of the bile ducts, an increase in retroperitoneal lymph nodes, head disease pancreas and liver;

38. Instrumental research: X-ray contrast research methods of the gallbladder: oral cholecystography, intravenous cholecystocholangiography . Defects are detected in the images. filling in the gallbladder due to the presence of stones in it. With obstruction of the cystic duct, a "negative cholecystogram "(the bile duct is determined, and the gall bladder does not contrast), the so-called "Disconnected gall bladder ";

39. Instrumental research: Survey radiography of the right hypochondrium as a diagnostic method for cholelithiasis does not currently have independent significance. It allows you to identify only x-ray positive calculi (most often calcareous).

40. Differential diagnosis: Chronic right-sided pyelonephritis - pain usually localized in the lumbar region or in the midline of the abdomen in paraumbilical area. Most often, the pain radiates to the groin area or on the front of the thigh. Pain syndrome is often accompanied by an increase in temperature and dysuric phenomena. IN clinical analysis of urine - manifestations of urinary syndrome in the form proteinuria, leukocyturia , bacteriuria, hematuria in various combination.

41. Differential diagnosis: Right-sided lower lobe pleuropneumonia is characterized by an acute onset, hypothermia. Among the clinical manifestations, along with pulmonary symptoms (pain in the chest and right hypochondrium , shortness of breath, cough) there are also signs of intoxication: an increase in temperature up to 38-40 degrees, chills, sweating, tachycardia). Patients take up a forced position - lie on the affected side, facial features are pointed, cheek flushing on to the side of the lesion, shallow gentle breathing, the nostrils are distended when breathing, diffuse cyanosis, dry cough. Right chest half cells lag behind when breathing, with lung percussion - dullness on the side lesions, on auscultation - various breathing sounds, depending on stages of the disease (crepitus, wet wheezing, pleural friction noise). IN X-ray examination can help differential plan organs of the chest, in which the infiltration of the pulmonary tissues within the lobe of the lung, signs of pleurisy

42. Differential diagnosis: Acute intestinal obstruction. Symptoms: dyspeptic phenomena (vomiting, stool and gas retention), cramping pains, temperature the body is normal at the beginning, with complication of peritonitis 38-40C. Symptom of irritation of the peritoneum is weak, positive symptom Valya (fixed and balloon-stretched bowel loop), Kivulya (tympanic sound with a metallic tinge), Mondora (rigidity abdominal wall), a symptom of " Obukhovskaya hospital", "Grave silence". Symptoms of irritation of the peritoneum after 12 hours, with the development of peritonitis. X-ray signs: Separate bowel loops are detected filled with liquid and gas, Kloyber bowls, arched or vertically located loops of the small intestine swollen with gas (symptom "Organ pipes")

43. Treatment goals:  elimination of pain and dyspeptic disorders;  elimination of inflammatory changes in the gallbladder, allowing in some cases to prevent the occurrence of complications;  therapy of complications requiring surgical treatment (carrying out required operation);  prevention of complications and rehabilitation of patients;  improving the quality of life.

44. Non-drug treatment: Diet N 5 according to Pevzner . The general principle of diet therapy is frequent fractional food intake (up to 5-6 times a day), at the same hours, taking into account the individual tolerance of foods. Table N 5 has energy value 2500-2900 kcal with optimal content proteins, fats, carbohydrates and vitamins. The decrease in dietary proportion of animal fats and an increase in vegetable. Among products containing animal protein, preference should be given lean meats (beef, poultry, rabbit, fish).

45. Therapy by diet Into the stage exacerbation of the disease, meat dishes are prepared in boiled and steam form . To prevent bile stagnation and improve passage chyme through the intestines are enriched with dietary fiber in the form wheat bran, buckwheat and millet porridge, milk tea, kefir, fresh and baked apples, rosehip decoction, dried fruit compote, wheat bread and rusks. All patients are advised to drink plenty of fluids (up to 2 liters per day).

46. Exclude in diet Spicy and cold dishes are excluded from the diet of patients, spices, alcoholic beverages, fried, fatty, smoked food, products from dough , especially butter, meat and fish broths, carbonated and cold drinks, nuts, creams. Foods containing large the amount of cholesterol (liver, brains, egg yolks, lamb and beef fats , etc.).

47. Drug treatment: Antibacterial drugs for chronic non-calculous cholecystitis is prescribed in case of bacterial etiology:  ampicillin 4-6 g / day  cefazolin 2-4 g / day  gentamicin 3-5 mg / kg / day  clindamycin 1.8-2.7 g / day.  cefotaxime  clarithromycin 500 mg 2 times a day  erythromycin 0.25 g 4-6 times a day  ciprofloxacin 500-750 mg 2 times a day Treatment with antibacterial agents is carried out on average for at least 8-10 days.

48. Treatment for for giardiasis  Metronidazole 500 mg x 2-3 times a day  Ornidazole 500mg: for giardiasis, 1.5g of the drug is usually prescribed once a day ( Ornidazole is preferably taken in the evening). The duration of the course of treatment is 1-2 days.

49. Mycotrophic antispasmodics: 1 . Anticholinergics:  atropine 0.1% - 1 ml;  platifillin 0.2% - 2 ml;  metacin 0.1% - 1 ml .

50. 2. Antispasmodics:  drotaverine 2% 2-4 ml intramuscularly or intravenously;  papaverine 2% - 2 ml under the skin;  mebeverine hydrochloride 200 mg 2 times a day for 2-4 weeks;  gimecromone 200-400 mg 3 times a day before meals for 15-20 min .;  hyascin butyl bromide 2% - 2 ml intramuscularly, intravenously drip, then in pills, 10 mg × 3 times a day.

51. Suppression of vomiting and nausea in chronic cholecystitis  Metoclopramide 2 ml × 2 times intramuscularly or intravenously;  Domperidone 10 mg 1 tablet 2-3 times a day, 7-14 days.

52. Anti-inflammatory drugs They are prescribed for pronounced signs of an inflammatory process (fever, accelerated ESR, leukocytosis, etc.) for 7-10 days. Anti-inflammatory drugs are prescribed, including as analgesics: - indomethacin 0.25 g 3 times a day after meals; - Brufen 0.2 g 3 times a day after meals; - butadion 0.15 g 4 times a day after meals.

53. Choleretic drugs (cholecystitis without stone!) 1 . Choleretics (stimulate the formation of bile): 1.1 . True (increase the secretion of bile and bile acids): 1.1.1 . Containing bile acids: - cholenzyme ; - holagol ; - holosas ; - deholil . 1.1.2. Synthetic: - tsikvalon ; - oxaphenamide . 1.2 . Vegetable origin: - peppermint; - tansy; - rosehip; - parsley . 1.3. Hydrocholeretics (increase the water component of bile): - Valerian; - sodium salicylate; - mineral water

54. Cholekinetic Cholekinetic (increase the tone of the gallbladder and reduce the tone of the biliary tract): - magnesium sulfate; - sorbitol; - xylitol; - barberry; - cholecystokinin; - sea buckthorn and olive oils; - M-anticholinergics; - nitrosorbide ; - aminophylline.

55. Nota bene! Choleretics are contraindicated in severe inflammation in the gallbladder and ducts, in hepatitis. Cholekinetics are contraindicated in duodenal and biliary hypertension. Choleretics are best used in the remission phase and in combination with enzyme preparations, and in hypokinetic dyskinesia it is better to use with cholekinetics .

56. Oral cholelitholytic drugs Oral cholelitholytic drugs - in some cases effective with X-ray negative (cholesterol) stones : Ursodeoxycholic acid at 8-15 mg / kg / day in 2-3 doses orally for a long time ( up to 2 years old).

57. Physiotherapy 3. Apply physiotherapy (heating pads, inductothermy , paraffin on the right hypochondrium , warm peat), which has a thermal, antispasmodic, soothing effect.

58. Surgical treatment (indications): - long-term ineffective conservative treatment; - "disconnection" of the gallbladder or its sharp deformation ; - the addition of difficult to treat pancreatitis, cholangitis.

59. Treatment in remission phase 1 . Diet regimen (table number 5). 2 . Preventive treatment courses: choleretic plus antispasmodics or cerucal during the first 10 days of the month for 2-3 months in the spring-autumn period. 3 . Treatment courses with mineral waters 4 weeks, 2 times a year.

60. Forecast Satisfactory in patients with acalculous cholecystitis with adequate treatment of exacerbations and dispensary observation. The need for surgical treatment under these conditions is relatively rare. On the contrary, in patients with calculous cholecystitis, a favorable outcome of the disease depends on radical treatment (cholecystectomy, lithotripsy) before the development of complications and concomitant diseases (pancreatitis, sclerosing odditis , etc.).

61. Preventive actions: (Prophylactic) Primary prevention focuses on early recognition and treatment of diseases of the biliary system. Secondary - to prevent exacerbations and the development of complications.