- Causes and mechanisms of development
- Symptoms of biliary dyskinesia
- Treatment of biliary dyskinesia
Dyskinesia of the biliary tract (synonyms - biliary dysfunction, functional disorders of the biliary tract) - a group of functional diseases, the occurrence of which is caused by motor disorders of the biliary tract (biliary tract).
The bile formed in the liver in a healthy person falls into the hepatic ducts (left and right), then into the main hepatic duct, at the end of which there is a sphincter Mirrizzi (it separates the main hepatic duct from choledocha). Bile accumulates and concentrates in the bladder during the inter-digestive period. When you eat any food under the influence of hormonal and nerve signals, the bubble contracts, and the accumulated bile enters through the opened sphincter of Lutkens into the cystic duct, and then into the holedoch (common bile duct), and from it through the sphincter of Oddi already into the duodenum.
Possible motor disorders include changes in the contractility of the gallbladder (filling it with bile or emptying) and the valvular (sphincter) apparatus of the bile duct. The biliary sphincters are the valves of Lutkens, Mirrizzi and Oddi. Of all these, dyskinesia is more often detected in the work of the sphincter of Oddi (fibro-muscular valve of the hepatic-pancreatic ampulla), which regulates the ingress of bile and pancreatic juice into the lumen of the duodenum.
Prolonged dyskinetic disorders of the biliary tract can cause a cholelithiasis, pancreatitis , cholecystitis.
Causes and mechanisms of development
The following mechanisms are the basis for the formation of violations of the motor coordination of the biliary tract:
- disorders of autonomic or central nervous regulation;
- pathological reflexes from other parts of the digestive tract (for example, in inflammatory processes);
- hormonal shifts (imbalance of the production of sex hormones, gastrin, cholecystokinin, enkephalins, angiotensin, glucagon, etc.).
Their development can lead to:
- anomalies of intrauterine development of the biliary tract;
- psychoemotional stress;
- inaccuracies in the diet (unhealthy diet, excess fatty, etc.);
- parasitic diseases ( opisthorchiasis , giardiasis, etc.);
- diseases of the biliary tract (cholecystitis, cholelithiasis, cholangitis);
- postoperative disorders (postcholecystectomy syndrome, conditions after vagotomy, gastric resection, etc.);
- hepatic diseases (cirrhosis, hepatitis of different origin, etc.);
- peptic ulcer;
- premenstrual syndrome;
- hypothyroidism ;
- celiac disease;
- hormone-active tumors;
- treatment with somatostatin;
- use of hormonal contraceptives;
- excessive physical exertion;
- running or brisk walking;
- food allergy.
Practitioners use different classifications of biliary dysfunctions. At their location they are divided into:
- dysfunction of the sphincter of Oddi (3 types: pancreatic, biliary, combined);
- dysfunction of the gallbladder.
Depending on their origin, primary (without organic disorders of extrahepatic components of the biliary system) and secondary dysfunctions are distinguished.
On functional disorders, the following forms of biliary dysfunction are determined:
- hypertonic hyperkinetic;
Symptoms of biliary dyskinesia
Despite the functional nature, biliary dysfunction is very painful for patients, which can seriously worsen the quality of their everyday life. Its most characteristic manifestations are:
- pain syndrome;
- dyspeptic syndrome;
- neurotic syndrome.
Painful sensations can vary depending on the type of dyskinesia. So, when hypotonic-hypokinetic variant they are in the zone of the right hypochondrium, they have a pulling, dull character, they are quite long, they decrease after eating, cholagogue preparations or plant collections, duodenal sounding. The hypertonic-hyperkinetic type is manifested by cramping (sometimes quite intense), short-term pains, which are often provoked by food, but calmed down in the warmth or after consumption of antispasmodics. With dysfunctions of the sphincter of Oddi, recurrent (for at least three months) pain attacks are very similar to biliary colic (biliary type) or pancreatic pain (pancreatic type). They can occur after eating or at night.
Dyspeptic symptoms inherent in biliary dysfunctions include nausea with vomiting (more often accompany a painful attack), bitter aftertaste, stool disorders, belching, loss of appetite, bloating.
In addition, such patients are often prone to sudden mood swings (it is reduced in the morning), they are unnecessarily worrisome, fixed in their condition, touchy, quick-tempered, irritable, sleep disturbed.
When examining patients, the doctor may assume the presence of biliary dyskinesia, if palpation and tapping of the abdomen reveals soreness and the zone of the right hypochondrium and positive biliary symptoms (Kera, Mussi-Georgievsky, Ortner, Vasilenko, Murphy, etc.).
However, some of these data are not enough to understand the true clinical situation. All patients should be examined. The volume of diagnostic diagnostics is determined by the doctor. Their complex may include:
- biochemical tests (the levels of transaminases, pancreatic enzymes, bile pigments are estimated, with Oddi's sphincter dysfunction, there may be a twofold increase in alkaline phosphatase, ALT, AST during pain);
- provocative tests (morphine-choleretic, morphine-stigmine, with cholecystokinin, with egg yolks, etc., which stimulate the contractile activity of the gallbladder or sphincter and provoke a pain attack);
- Ultrasound (estimates the size of the gallbladder, the thickness of its walls, the nature of the contents, excludes the presence of stones, polyps, neoplasms, the diameter of the biliary tract, sometimes combined with provocative tests);
- hepatocholecystography (radioisotope study with technetium demonstrates the rate and degree of capture of the radioisotope introduced by the liver from the blood, its excretion into the bile, sequential admission of the gallbladder, extrahepatic bile ducts, then into the duodenum, allows to identify and determine the form of biliary dyskinesia);
- Fibroesophagogastroduodenoscopy (an indirect indicator of biliary dysfunction is the absence of bile in the duodenal cavity, endoscopic examination excludes organic changes in the zone of the large duodenal nipple - scars, tumors, etc.);
- duodenal sounding (now rarely used, allows verifying dyskinesia and determining its shape, detect changes in colloid balance of bile);
- X-ray studies (cholecystography, cholangiography allow to evaluate the structure, concentration function and contractility of the biliary tract and gallbladder);
- MRI-cholangiopancreatography (a non-contrast method with high informativeness, assesses the status and functions of both intra- and extrahepatic bile ducts, the gallbladder);
- endoscopic manometry of the sphincter of Oddi (in case of dysfunction, an episodic or stable increase in basal pressure above 40 mm Hg is recorded);
- ERCP (endoscopic procedure - retrograde cholangiopancreatography is a highly informative, but complex procedure, therefore it is performed rarely and only according to indications).
Treatment of biliary dyskinesia
After establishing the primary biliary dysfunction and clarifying its type, the doctor will be able to develop the necessary treatment strategy. It is based on the following blocks:
- diet therapy;
- physiotherapeutic procedures;
- surgical techniques.
In most cases, for complex treatment, patients do not need to be hospitalized.
With the secondary origin of dyskinesias, all medical efforts should first be directed to the treatment of the underlying disease.
Changing the diet is one of the key tasks of non-surgical treatment of patients with biliary dysfunction. And the correction of the usual composition of foods and products requires understanding and a certain patience from the patients themselves. After all, this is not a momentary measure, but a long-term conscious change in the way of life. Only then will the diet have a beneficial effect.
Therapeutic diet recommended for patients with biliary tract disease must comply with the following principles:
- the breakdown of meals (regular ingestion of food in the digestive tract counteracts the stagnation of bile, so optimal nutrition is considered every 4 hours);
- Food should be consumed in small portions, since overeating can exacerbate the hyponeus and provoke pain;
- refusal of excessively cold drinks and dishes (otherwise the spasm of Oddi may arise or intensify);
- balanced ratio and content of basic nutrients (carbohydrates, proteins, fats), corresponding to the energy costs of a particular patient and his age norms;
- with severe congestion of bile for three weeks sometimes prescribed a diet with increased quota of vegetable fats;
- allowed dishes are boiled and / or steam-produced, with tolerance, they are extinguished and baked;
- half of the protein of the diet should be of animal origin (fish, seafood, eggs, meat, dairy products provide an increase in bile cholates along with a simultaneous lowering of cholesterol, therefore, interfere with stone formation);
- restriction of animals of refractory fats (lamb, beef, duck, pig, goose, sturgeon, etc.), fried foods;
- active use of vegetable oils: cotton, olive, soybean, sunflower, etc. (they increase both bile formation and bile secretion, the polyene fatty acids contained therein have a beneficial effect on cholesterol metabolism and stimulate the motility of the smooth muscles of the gallbladder), they are added to ready-made dishes;
- a sufficient amount of indigestible fiber, which is abundant in cereals, berries, bran, vegetables, fruits (it reduces pressure in the duodenum, improving the outflow of bile along the ducts into the intestine);
- inclusion of vegetable juices (cucumber, carrot, carrots, etc.), significantly enhancing the production of bile;
- Exclusion of products with a high content of essential oils (garlic, radish, etc.), smoked products, spicy seasonings (mustard, horseradish, etc.), pickles, marinades;
- refusal of alcohol-containing beverages;
- in the hypotonic-hypokinetic type of dyskinesia, a diet with an increased amount of vegetable oils and fiber is shown, and in the case of a hypertonic hyperkinetic variant, food is prescribed with restriction of the cholekinetic products (egg yolks, etc.) and the inclusion of magnesium-containing products (millet, buckwheat, vegetables, wheat bran).
In addition, patients are recommended therapeutic mineral waters. They increase the production of bile, promote its liquefaction, reduce the existing stagnant phenomena, affect the tone of the gallbladder. The choice of certain mineral waters is determined by the form of dyskinesia.
In the case of the hypotonic-hypokinetic variant, the patients are assigned mineral waters with an average mineralization (Arzni, Batalinskaya, Borzhomi, Truskavets, Essentuki No. 17, Jermuk, Naftusya, etc.). They are drunk in a cool form, the allowable volume reaches up to half a liter per day (it is divided into three different methods). Mineral water can not only be drunk, but also up to 1 liter injected during duodenal sounding (with severe hypotension).
Hypertonic-hyperkinetic form is the reason for taking warm, slightly mineralized waters (Narzan, Slavyanovskaya, Essentuki No. 20, etc.).
The choice of effective medications is based on the form of established dyskinesia. So, if a hypotonic-hypokinetic form is diagnosed in the patient, then he will be shown:
- prokinetics, which have a positive effect on motor activity (taperpride, metoclopramide, domperidone);
- tonic (eleutherococcus, tinctures of ginseng, magnolia vine, aralia, etc.);
- choleretics - stimulants of liver bile production (allochol, lobil, chologon, tsikvalon, oxaphenamid, holonerton, holosas, flamin, hofitol, holaflux, cholenzym, nikodin, hepabene, etc.);
- cholekinetics - stimulators of bile secretion (berberine, xylitol, magnesium sulfate, sorbitol, etc.).
It should be remembered that in this case, the patient must necessarily avoid antispasmodics. These funds will further exacerbate hypotension and aggravate pain.
Cholekinetics are often used during tjubazhi - "blind probing" (an additional method for treating hypotonic-hypokinetic biliary dysfunction).
Hypertonic-hyperkinetic variant should be an indication for the following medications:
- analgesics - analgesics (baralgin, tempalgin, pentalginum, trigan D, etc.);
- antispasmodics (mebeverin, drotaverin, otilonium citrate, bentsiklan, papaverine hydrochloride, pinaverium bromide, etc.);
- choleretic: cholespasmolytics or cholelithics - drugs, relaxing bile ducts (claston, olimethine, euphyllin, etc.);
- nitrates (nitrosorbide, sustac, nitroglycerin, etc.);
- M-holinolitiki (buscopan, metacin, chlorosyl, atropine, etc.);
- benzothiazepines (diltiazem);
- calcium channel blockers (nifedipine, halopamide, verapamil, etc.).
Regardless of the form of biliary dysfunction, many patients are recommended:
- vegetative stabilizing agents (motherwort, belladonna preparations, benzohexonium, etc.);
- psychotropic medications (amitriptyline, melipramine, attarax, elenium, sulpiride, tazepam, grandaxin, rudothel, etc.).
Arsenal of physiotherapy techniques can greatly facilitate the lives of patients with biliary dyskinesia. Competently chosen procedures:
- reduce pain;
- eliminate spasm of smooth muscles;
- normalize the tone of the biliary sphincters and gallbladder;
- stimulate the contractility of the gallbladder.
In the case of a hypertonic hyperkinetic form of dyskinesia, patients are recommended inductothermy (electrode-disk placed above the right hypochondrium), UHF, microwave therapy, high intensity ultrasound, novocain electrophoresis, ozocerite or paraffin applications, galvanic mud, coniferous, radon and hydrogen sulphide baths.
In the hypotonic-hypokinetic variant, diadynamic currents, faradization, sinusoidal modulated currents, low-impulse currents, low-intensity ultrasound, pearl and carbonic baths are more effective.
Acupuncture can normalize the tone of the biliary tract in any form of biliary dysfunction.
Many plants are able to activate the bile formative capacity of the liver, regulate the motor function of the sphincter apparatus and bile ducts. They are used in the form of infusions, decoctions, extracts or syrups.
To such natural natural cholagogic include the medicine fume, milk thistle, turmeric root, immortelle, parsley, corn stigmas, caraway, tansy, leaves of the three-leafed watch, root with dandelion leaves, yarrow, chicory, peppermint, dogrose, celandine, barberry, rouge, thistle and etc.
Hollespazmolytic effect can have the roots of valerian and licorice, chamomile, dill, herbage motherwort, steppe sage, melissa officinalis, St. John's Wort.
In the absence of long-awaited relief after adequate and complex conservative therapy, doctors use surgical techniques. They may be:
- minimally invasive (often with the use of endoscopic equipment);
In the case of the revealed sphincter dysfunction, Oddi conducts:
- injections directly into this sphincter of botulinum toxin (it significantly reduces spasm and pressure, but the effect is temporary);
- balloon dilatation of this sphincter;
- staging a special stent catheter in the bile duct;
- endoscopic sphincterotomy (its excision together with duodenal nipple) followed by (if necessary) surgical sphincteroplasty.
The extreme measure of the fight against a severe hypotonic-hypokinetic variant of biliary dysfunction is cholecystectomy (complete removal of the atonic gallbladder). It is performed laparoscopically (instead of a cut on the abdominal wall, several punctures are made for apparatus and instruments) or laparotomic (with a traditional incision) pathway. But the effectiveness of this serious surgical intervention is not always felt by patients. Often after this, the resumption of complaints is associated with the development of postcholecystectomy syndrome. Conduct rarely.
To prevent biliary dysfunction, patients are usually advised to:
- regular meals that meet the above requirements;
- avoid psycho-emotional overload;
- normalization of the labor regime;
- refrain from smoking;
timely treatment of all other chronic ailments, as possible reflex influence from the affected organs on the motility of the bile excretory system.