Cholecystitis: symptoms, treatment
- Causes of cholecystitis
- Classification of cholecystitis
- Symptoms of cholecystitis
- Complications of cholecystitis
- Diagnosis of cholecystitis
- Treatment of cholecystitis
- Conservative treatment
- Surgical treatment of cholecystitis
With this disease, surgeons (with an acute form of cholecystitis), and therapists (with chronic cholecystitis) often face. In recent decades, medical statistics have noted a persistent tendency to increase the incidence of this disease.
Causes of cholecystitis
Inflammation in the gallbladder can occur for a variety of reasons. The main ones are:
- the formation of stones that permanently damage the mucous membrane and can interfere with normal cholic flow;
- dietary (abuse of fatty, high-calorie and fried foods, hot drinks, messy meals);
- psycho-emotional overstrain;
- burdened heredity;
- abnormal (often congenital) form of the gallbladder (different constrictions, bends, septums predispose to violations of the choleretic);
- hormonal imbalance and hormonal agents (including the intake of hormonal contraceptives, preparations used during IVF);
- allergy (eg, food);
- immune disorders;
- drugs (ciclosporin, clofibrate, octreotide);
- sharp weight loss;
- infectious agents (bacteria, parasites, viruses) that can penetrate into the gallbladder from the already existing in the body foci of dormant chronic infection.
Infectious factors enter the gallbladder and ducts along with lymph (lymphogenous pathway), blood (the hematogenous pathway) and from the duodenum (ascending way).
The inflammation in the gallbladder can not affect the functions of this organ, but it can also disrupt both the concentration and motor functions (up to a completely non-functioning or "disconnected" bladder).
Classification of cholecystitis
In the course of the course, cholecystitis is divided into:
Both acute and chronic cholecystitis can be:
- calculous (that is, associated with the formation of a stone in the bladder, its share reaches 80%);
- without stones (up to 20%).
In young patients, as a rule, there is acalculous cholecystitis, but since the age of 30 the frequency of verification of calculous cholecystitis is rapidly increasing.
Symptoms of cholecystitis
At a small part of patients the cholecystitis can be asymptomatic (its chronic variant), they have no clear complaints, therefore the diagnosis is often verified randomly during the examination.
But nevertheless in most cases the disease has bright clinical manifestations. Often they manifest after some dietary error (feast, consumption of fried foods, alcohol), psycho-emotional overstrain, shaking or excessive physical exertion.
All signs of cholecystitis can be combined into the following syndromes:
- painful (dull or sharp pain, localized, as a rule, in the right hypochondrium, but sometimes it arises in the epigastric region, and in the left hypochondrium, can give to the right shoulder, neck, under the shoulder blades);
- dyspeptic (bloating, bitter taste in the mouth, nausea with vomiting, various disorders of the stool, a feeling of heaviness in the upper right side of the abdomen, fat intolerance);
- intoxication (weakness, fever, loss of appetite, muscle aches, etc.);
- syndrome of vegetative disorders (headaches, sweating, premenstrual tension, etc.).
In patients, not all of the listed symptoms can be observed. Their severity varies from barely perceptible (with a slow chronic course) to almost intolerable (for example, in the case of biliary colic-a sudden attack of intense pain).
Complications of cholecystitis
The presence of any cholecystitis is always fraught with the possible development of complications. Some of them are very dangerous and require urgent operational intervention. Thus, as a result of cholecystitis, patients may experience:
- empyema of the gallbladder (its purulent inflammation);
- necrosis of the wall (necrosis) of the gallbladder due to inflammation and pressure on it with stones (stone);
- perforation of the wall (the formation of a hole in it) as a result of necrosis, as a result of which its contents appear in the abdominal cavity of the patient and lead to inflammation of the peritoneum (peritonitis);
- the formation of fistulas between the bladder and bowel, bladder and renal pelvis, bladder and stomach (the result of necrotic changes in the gallbladder wall;
- "Disabled" (inoperative) gallbladder;
- pericholecystitis (passage of inflammation to nearby tissues and organs located nearby);
- Cholangitis (spread of inflammation to the intra- and extrahepatic bile ducts of different calibrations);
- blockage of the bile ducts;
- "Porcelain" gallbladder (the result of the deposition in the wall of the bubble of calcium salts);
- secondary biliary cirrhosis (consequence of prolonged calculous cholecystitis);
- cancer of the gallbladder.
Diagnosis of cholecystitis
After listening to the patient's complaints described above, any doctor must necessarily examine him, paying attention to the color of the skin, sclera, frenulum of the tongue (they may turn out to be icteric). When the abdomen is probed for possible cholecystitis, the soreness found in the right hypochondrium and in particular gallbladder points and the local muscular tension above this zone indicate the cholecystitis. Such patients often have pain with accurate tapping on the right costal arch and the right hypochondrium region.
To determine the exact diagnosis further, the patient is usually sent to be examined. The following diagnostic methods help to detect cholecystitis:
- hemogram (with the activity of the disease, signs of inflammation: leukocytosis, thrombocytosis, acceleration of ESR);
- biochemical blood tests (with exacerbation, markers of cholestasis can be detected - elevation of alkaline phosphatase, bilirubin, gamma-glutamyltranspeptidase, acute phase inflammatory proteins - SRB, haptoglobin, etc.);
- urine analysis (after an attack, bile pigments may be present);
- ultrasonography (the study assesses the size of the gallbladder, the presence of deformations, stones, tumors, the uniformity of bile, the condition of its walls and tissues around it, in case of acute cholecystitis the walls are stratified, their "double contour" appears, and when chronic it thickens, sometimes to clarify functional disorders, this study is supplemented by a breakdown with a choleretic breakfast);
- MRI / CT (the diagnostic capabilities of the non-contrast observational studies are similar to ultrasonography, MRT-cholangiography is more informative, which analyzes the condition and patency of the ducts, excluding some of the complications of cholecystitis);
- endoscopic ultrasonography (the method combines fibrogastroduodenoscopy and ultrasonography, since the diagnostic sensor is placed on an endoscope, it better visualizes the state of the bile ducts);
- duodenal sounding (the results of the method indirectly indicate cholecystitis if in a vesicle portion the collected bile is turbid with flakes, there are parasites);
- sowing of bile (reveals pathogenic microorganisms, specifies their appearance and sensitivity to different antibacterial drugs);
- An overview radiograph of the abdomen (a simple study can confirm the perforation of an inflamed gallbladder, its calcification, detect some stones);
- cholecystography is an X-ray contrast method, during which contrast is injected directly into the veins or through the mouth (it detects stones, the "disconnected" bladder, functional disorders, but after widespread introduction of routine ultrasonography, it is rarely used);
- retrograde cholangiopancreatography (allows to establish a complication - blockage of the duct system and even extract some stones);
- cholescintigraphy with technetium (radioisotope technique is indicated for the verification of acute cholecystitis and exclusion of the "disconnected" bladder);
- hepatocholecystcystography (radioisotope diagnostic procedure for clarifying the type of functional disorders);
- microscopy of feces to detect eggs or fragments of worms, cysts of lamblia;
- immunological (ELISA) and molecular genetic analysis (PCR) for the detection of parasites.
Treatment of cholecystitis
Medical tactics are determined by the form of cholecystitis, its stage and severity. Acute forms of illness are treated exclusively in the hospital. In chronic cases without hospitalization, patients with mild and uncomplicated forms without intensive pain syndrome can get by.
In general, it is used in the case of chronic ailments. Possible non-surgical methods include:
- drug therapy;
- extracorporeal lithotripsy (shock wave).
Nutrition of patients in the acute phase of the process must certainly be gentle and fractional. In especially serious cases, sometimes even resort to a couple of "hungry" days, during which only the use of liquids (mild warm tea, broth of wild rose, diluted berry or fruit juice, etc.) is allowed. Next, all the products are cooked or cooked with a steamer, and then wiped. Extinguishing and baking before the onset of remission is prohibited. All fatty foods and foods (dairy, pork, goose, lamb, duck, red fish, lard, confectionery creams, etc.), smoking, canned food, spicy seasonings, sweets, cocoa and caffeinated drinks, chocolate, egg yolks , baking. Mucous soups, mashed porridge, vegetable, fish, meat or cereal souffle, puddings, knels, steam cutlets, kissels, mousses, albumen omelettes are welcomed. Cream (as a source of the protector of the mucous membranes - vitamin A) and vegetable oils (soybean, corn, vegetable, cotton, olive, etc.) are allowed. All drinks and dishes should be served warm to the patient, since cold can cause a painful pain attack.
After the onset of the long-awaited remission, baking and quenching are allowed, the products stop rubbing, the diet includes fresh berries, greens, vegetables, fruits. To improve the composition of bile and reduce its ability to form stone shows dietary fiber. She is rich in grains (buckwheat, oats, barley, etc.), kelp, bran, vegetables, algae, fruits.
Drug treatment of cholecystitis
During an exacerbation of any cholecystitis patients are recommended:
- antibiotics penetrating into the bile in sufficient concentrations to kill infection (doxycycline, ciprofloxacin, erythromycin, oxacillin, rifampicin, zinnate, lincomycin, etc.);
- antibacterial agents (biseptol, neviramone, furazolidone, nitroxoline, etc.);
- antiparasitic drugs (depending on the nature of the parasite appoint - makmiror, metronidazole, tiberal, nemozol, biltricidum, vermox, etc.);
- detoxifying agents (Ringer's solutions, glucose, reamberin, etc .;
- non-narcotic analgesics (baralgin, spazgan, trigan D, took, etc.);
- antispasmodics (papaverine, halidor, mebeverin, no-shpa, buscopan, etc.).
- paranephric neocaine blockade (with unbearable pain, if they are not removed with other medicines);
- means for stabilizing the autonomic nervous system (elenium, motherwort, eglonyl, melipramine, benzohexonium, etc.);
- antiemetic drugs (domperidone, metoclopramide, etc.);
- immunomodulators (imunofan, polyoxidonium, sodium nucleate, lycopide, thymopter, etc.).
After the relief of inflammation in the case of calculous cholecystitis, some patients try to dissolve stones with the help of medications. For this purpose doctors write out to them means with ursodeoxycholic or chenodeoxycholic acid (ursofalk, henofalk, urdoksa, ursosan, etc.). It is better not to take these drugs yourself, as they can only be effective in 20% of patients. To receive them there are certain clear indications, which can only be determined by a qualified specialist. For each patient, optimal doses of drugs are set individually. They should be taken long enough (about a year) and regularly. Treatment is carried out under medical and laboratory control (periodically it is necessary to determine biochemical parameters of blood, perform ultrasound). Self-medication is fraught with the development of pancreatitis (inflammation of the pancreas), blockage of the biliary tract, intense pain, severe diarrhea.
In the phase of remission of stone-free cholecystitis, patients can start a course of cholagogue preparations. But for this purpose it is advisable to have information about the type of functional disorders. The arsenal of modern choleretic is extremely rich. The patients are recommended hofitol, zestoston, oxaphenamid, tykveol, cholenzim, nikodin, hepatofalk, milk thistle, tansy, fumigant, barberry, immortelle, galsten, holagogum, magnesium salts, xylitol, etc. In the presence of confirmed stones in any fragment of the biliary system (bile ducts or gallbladder) choleretic are dangerous.
Extracorporeal lithotripsy (shock wave)
Stones are destroyed by shock waves generated from special installations. The technique is possible only with the cholesterol composition of the stones and the preserved contractile capacity of the bladder. Often, it is combined with a medicinal litholytic (preparations of heno-and ursodeoxycholic acid) therapy, which is needed to remove fragments of stones formed as a result of extracorporeal lithotripsy. In the Russian Federation, this technique is used rarely.
Surgical treatment of cholecystitis
If these conservative methods are ineffective, a non-functioning bladder, a serious acute disease, permanent exacerbations, frequent biliary colic, complications, treatment can only be operative. Surgeons perform removal of the inflammation of the gallbladder (cholecystectomy). Depending on the access and the way the cholecystectomy is done:
- traditional with a cut of the abdominal wall and wide open access (preferable in complicated flow, but more traumatic, after it patients recover longer, more postoperative problems compared to the following two species);
- laparoscopic (it is considered an advantageous option, access to the bladder is provided by several punctures, the necessary instrumentation and a video camera are inserted through them, it is easier to transfer, patients are better rehabilitated and are discharged from the clinic earlier);
minicholecystectomy (characterized by a mini-access, whose length is not more than 5 centimeters, is an intermediate method, since there are elements of "open" technology).
- Acute and chronic calculous cholecystitis
- Stones in the gallbladder: symptoms, treatment without surgery
- Chronic cholecystitis
- Acute cholecystitis
- Biliary dyskinesia