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Acute and chronic calculous cholecystitis


Acute or chronic inflammatory process, characterized by a progressive course and accompanied by the formation of stones in the cavity of the gallbladder, is one of the complications of gallstone disease, called calculous cholecystitis. This is a fairly common pathology that occurs in 10-15% of the adult population of the planet (women are 2-3 times more than men). The most dangerous is the condition in which the stones move to the neck of the bladder and common bile duct and cause an attack of biliary colic and the development of obstructive jaundice.

Causes of calculous cholecystitis

Calculous cholecystitis

  • Metabolic disease;
  • Stagnation of bile (dyscholium);
  • Infectious and inflammatory processes;
  • Motor tonic disorders of biliary excretion (dyskinesia).

The main role in the development of stone formation plays a violation of the metabolism of bilirubin and cholesterol. These are poorly soluble in water components of bile, kept in solution due to the emulsifying action of bile acids. In the case of increasing the concentration of cholesterol and bilirubin in the bile there is a risk of stone formation. This condition is observed in atherosclerosis, obesity, gout, diabetes, hyperlipoproteinemia.

However, an important role in the development of calculous cholecystitis is played by poor nutrition (excessive consumption of refined carbohydrates, fatty foods containing a high percentage of food cholesterol, flour and coarse meals), which leads to a shift in the pH of the bile and reduce the solubility of cholesterol.

Risk factors contributing to the development of stone formation

  • Vitamin A deficiency;
  • violation of the neurohumoral regulation of the contractile function of the gallbladder and bile ducts;
  • adhesions, scars, excesses of the bile ducts;
  • pancreatic pathology;
  • persistent constipation;
  • omission of internal organs;
  • hypodynamia;
  • genetic predisposition;
  • irregular meals (overeating, fasting, rare meals);
  • impaired immune status;
  • pregnancy;
  • hormonal contraceptive use.

Types of gallstones

Homogeneous (homogeneous) stones. This group includes cholesterol stones, which are formed due to metabolic disorders. These X-ray active structures that do not cause inflammatory changes in the gallbladder are most often found in obese patients. Bilirubin (pigment) stones, arising as a result of enhanced erythrocyte decay, are characteristic of patients suffering from congenital hemolytic anemia, thalassemia, and sickle anemia. They are also formed in an aseptic environment. Calcareous stones (very rare formations) occur as a result of complications of acute inflammatory processes in the biliary tract.

Mixed stones (this group is 80% of the total number of gallstones). The core of such a stone is represented as organic matter, around which cholesterol, bilirubin and calcium salts are located in layers.

Difficult concretions (10% of the total). They are a combination of both forms. The core consists of cholesterol, and the shell consists of a mixture of bilirubin, cholesterol and calcium. As a rule, complex stones are observed with inflammation in the gallbladder and biliary tract.

Classification of calculous cholecystitis

In clinical practice, calculous cholecystitis , depending on the nature of the course of the disease, is divided into acute and chronic. In turn, each form of the disease in severity is smooth and complicated.

Acute calculous cholecystitis

The acute form of calculous cholecystitis is a rather rare pathology that develops on the background of a long asymptomatic cholelithiasis. This condition is characterized by blockage by calculus of the common bile duct, leading to the development of the inflammatory process in the walls of the gallbladder. The infection most often provokes inflammation that penetrates into the cavity of the gallbladder from nearby organs due to a violation of the aseptic properties of bile. This can lead to thickening and destruction (destruction) of the walls, accumulation of pus inside the organ and the development of biliary peritonitis.

Chronic calculous cholecystitis

The chronic form of calculous cholecystitis is characterized by slow development, with periods of exacerbations and remissions. In this situation, causes of inflammation is a violation of the composition, thickening and stagnation of bile, leading to irritation of the walls of the gallbladder. Most often chronic calculous cholecystitis develops due to errors in nutrition, with frequent infectious diseases, endocrine pathologies and metabolic disorders.

Predisposing factors include hepatic pathologies, chronic gastritis , duodenitis , biliary dyskinesia.

Symptoms of calculous cholecystitis

The development of acute calculous cholecystitis is accompanied by an attack of biliary colic. Patients complain of severe pain in the right side, extending to the shoulder or shoulder blade. Most often, an exacerbation of the inflammatory process is observed after suffering stress, consumption of alcoholic beverages, fatty, fried, spicy or smoked food. In this situation, there is a weakness, accompanied by copious cold sticky sweat, nausea, not bringing relief of vomiting, with an admixture of bile in the vomit. Often the body temperature rises (especially with the development of purulent inflammation) and blood pressure decreases. Also recorded is the darkening of urine and short-term discoloration of feces, possibly yellowing of the skin, ikterichnost sclera.

Chronic calculous cholecystitis is characterized by constant dull aching pains in the right hypochondrium. Attacks of acute pain may occur 2-3 hours after the consumption of fatty, fried and salty foods. After some time, the pain gradually passes. In this situation, temperature indicators and blood pressure remain within the normal range. Patients often complain of bitter taste in the mouth, nausea, and belching bitter. When violations of the diet may be attacks of vomiting with admixture of bile. Often the development of an attack is preceded by dyspeptic symptoms (belching with food or air, bitter and dry mouth, flatulence, heartburn, unstable stool, a tendency to constipation or diarrhea, loss of appetite).

Diagnosis of calculous cholecystitis

  1. The main non-invasive method for the diagnosis of calculous cholecystitis is ultrasound. This is a fairly informative study, in 98% of cases allowing to detect gallstones.
  2. ERPHG (endoscopic retrograde cholangiopancreatography). This is a highly accurate method of direct contrasting of the gallbladder and bile ducts, with the help of which stones are found in the bile ducts, biliary hypertension and narrowing of the terminal part of the organ.
  3. Computed tomography (CT). Allows you to identify lesions of the liver and pancreas.
  4. Dynamic hepatobiliscintigraphy. Provides for the introduction of radiopharmaceuticals. By the speed of its movement from the gallbladder to 12p. the intestine checks the patency of the bile ducts and the functioning of the bile-producing organ.
  5. Endoscopic ultrasonography. Using this technique, small stones are found in the terminal part of the common bile duct.
  6. Laboratory methods for testing blood, feces and urine.

Differential diagnostics

Calculous cholecystitis should be differentiated from the following pathologies:

  • biliary dyskinesia;
  • adenomyomatosis;
  • stoneless cholecystitis;
  • cholesterosis of the gallbladder;
  • right renal colic;
  • chronic hepatitis;
  • gastroesophageal reflux;
  • chronic pancreatitis ;
  • chronic gastritis;
  • chronic colitis;
  • irritable bowel syndrome;
  • stomach ulcer and 12p. guts.

Complications of calculous cholecystitis

  • Obstructive jaundice;
  • Dropsy of the gallbladder;
  • Perforation of the gallbladder;
  • Secondary inflammation of the pancreas;
  • Abscesses, necrosis of the gallbladder, peritonitis;
  • Cancer of the gallbladder.

Treatment of calculous cholecystitis

Conservative treatment

In the period of exacerbation of the pathological process, the patient is assigned a starvation diet (1-3 days), then a strict diet (table No. 5, 5A), relief of biliary colic attacks, relief of pain and dyspepsia, litholytic therapy.

For relief of seizure and pain relief, intramuscular administration of 1% solution of Atropine sulfate, Platyphylline, Drotaverin (No-spa) is indicated. With a prolonged seizure, Buscopan and Papaverine are introduced. After relief of pain - Drotaverine, Duspatalin and Papaverine tablets. With a strong pain syndrome, antispasmodic drugs should be used together with analgesics.

In the event that the patient's condition does not improve within five hours from the start of pharmacotherapy, he is sent to the surgical hospital.

In the treatment of chronic calculous cholecystitis, the main group of drugs are antispasmodics. They are recommended to be used both in the period of exacerbations, and during the time between attacks (in the presence of pain). By means of antispasmodic agents, pain syndrome is stopped, dyspeptic disorders are eliminated, the patency of the cystic duct is restored and a normal flow of bile is provided in 12n. the gut.

Surgical treatment of calculous cholecystitis

Today, the only effective method for the surgical treatment of calculous cholecystitis is cholicytectomy, (removal of the gallbladder). This technique prevents the development of serious, sometimes deadly complications that require emergency medical care. Experts recommend surgical treatment in a planned manner. This is due to the fact that the planned operation, which is performed after appropriate preparation, is much easier tolerated by patients and much safer than emergency surgery.

In the 90s of the last century, laparoscopic techniques began to be used in surgical practice when performing a holicystectomy, which allows performing operations without wide classical incisions on the anterior abdominal wall. Currently, this technique is the "gold standard" for the surgical treatment of gallstone disease. Now abdominal “full-scale” operations are performed only in case of complicated course of the disease (peritonitis or perforation of the gallbladder).

Laparoscopic cholecystectomy involves performing 3-4 trocar punctures (5-10 mm). Through them, surgical microtools and video cameras with a wide dynamic range and high resolution are introduced into the abdominal cavity. This is a low-impact technique that does not require a long rehabilitation period. After surgery, postoperative pain is almost completely absent. Laparoscopic cholecystectomy does not require strict bed rest (after a few hours the patient is allowed to rise, and after 5-6 days he can start work).

If it is impossible to perform a cholystectomy from laparoscopic access (due to the presence of an inflammatory or adhesions process, anatomical anomalies of the biliary tract or the development of intraoperative complications), a surgical procedure involves a transition to minimally invasive or traditional abdominal surgery.

Laparoscopic single-puncture surgery and mini-laparoscopy is a more benign version of the surgical treatment of an uncomplicated form of calculous cholecystitis. In the first case, ultrathin surgical instruments are inserted into the abdominal cavity through a single puncture in the navel. After surgery, the body does not remain stitches and scars. Minilaparoscopy is performed using the same technology as traditional laparoscopy, however, when it is performed, instruments not exceeding 3 mm in diameter are used. Such punctures do not require suturing, after surgery there is an excellent cosmetic effect and the traumatic effect decreases even more. With strict adherence to the recommended diet and exercise regime within 30-40 days after removal of the gallbladder, the patient's body fully adapts to the functional changes that have occurred.

Postoperative diet

In the first month after surgery, easily digestible fast carbohydrates (confectionery, high-grade wheat flour products, sugar, honey, some fruits, mayonnaise, chocolate, soft drinks), spicy, fatty, fried and spicy foods are completely excluded from the patient’s diet. as well as alcohol. Meals should be fractional and regular (4-6 times a day). New foods in the diet are introduced gradually, with the permission of the doctor. Removal of dietary restrictions is possible after 30-40 days, on the recommendation of a gastroenterologist.

| 3 June 2015 | | 1 446 | Surgery
Leave your feedback

Being Beautiful: Can surgery be done during acute cholecystitits due to gallstone stuck at neck? Our doctor advised to wait for 4 to 5 weeks after 5 days of antibiotics?

Jwala jj: Thank you very much. A very informative and inspiring vedio. It makes learning easier and interesting. I have a similiar method of learning with diagrams.your work is just awesome

Nancy Jacobs: This is the best video I have ever seen showing the details of the actual laparoscopic procedure. Unfortunately you stopped right where my problem began. The explain as briefly as I can the clip on the duct came off almost directly after the procedure. It was not detected for seven days nor was it dealt with in hospital for close to two weeks. Bile was basically pouring into my body all this time. What effect did this have on my body? Doctors don’t want to talk about it with me

Raphaëlle Lalonde-Fortin: Armando, you're the man! Thank you for what you do, you give my medical studies another dimension. (From Montreal, Canada) :)

Rahul Kore: Amazing! Liked the details in surgery part. Sir please keep making beautiful videos and do describe treatment in detail as always. Thank you

Ryan Schott: I just wanted to say how much I appreciate the time you take to upload all these medically-specific videos. They're incredibly informative and helpful! Keep it up!