Cholecystitis

Cholecystitis

Classification of cholecystites:

  1. An acute cholecystitis: an acute calculous cholecystitis and an acute acalculous cholecystitis
    1. Acute catarral cholecystitis
    2. Phlegmonous cholecystitis
    3. Gangrenous cholecystitis
  2. A chronic cholecystitis:
    1. Chronic acalculous cholecystitis
    2. Chronic calculous cholecystitis

Acute calculous cholecystitis

Aetiology: the acute cholecystitis develops in 90-95 % of cases at obstruction a stone of a neck of a gallbladder or a vesical duct. The immediate prelum a mucosa concrement leads to an ischemia, a necrosis of a mucosa and disturbance of venous outflow. There is the infiltration by neutrophils caused by a small amount of bacteria, initially containing in a gallbladder later. Also the bacteriemic infection can result in an inflammation.

Classification:

  1. Acute catarral cholecystitis. The inflammation is limited by mucous and submucosal covers
  2. Phlegmonous cholecystitis - a purulent inflammation with infiltration of all layers of a gallbladder. The ulceration of a mucosa with the subsequent exudation of an inflammatory liquid in paravesical space is possible.
  3. Gangrenous cholecystitis - a partial or total necrosis of a wall of a gallbladder. At punching of a wall of a bubble bile expires in an abdominal cavity (gangrenous - ruptured cholecystitis). A gallbladder empyema - a purulent inflammation of a gallbladder.

Clinical picture

  1. Complaints:
    • On the colic pains which have arisen suddenly or which have developed after long, gradually enlarged pains in the right epigastri? area. Localisation of pains: under the right costal arch, in an anticardium or in the right top quadrant of a stomach. Pains can be surrounding and is spent to a back; in process of development of pathological process of a pain become more excruciating and constant
    • Nausea and unitary vomiting
    • Rise in temperature to 38-39 degrees
  2. The anamnesis:
    • Hepatic gripes
    • Occurrence of pains after diet disturbance - the use of fat pork, mayonnaise, fried dishes, cold drinks, sometimes a painful syndrome arises after excitements and a nervous shock. Each of these reasons can cause strong reductions of a gallbladder with infringement of a stone in a neck or in a vesical duct and their occlusion
  3. Symptoms:
    • At survey it is possible to tap insignificant yellowness of integuments which can proceed after an attack of a colic till 2 days. The icterus has obturation character, it develops more often because of inflammatory infiltration in Ligamentum hepatoduodenale and in portal fissures. The secondary cholangitis and a choledocholithiasis can be the icterus reason in some cases.
    • At survey of a stomach of the patient spares the right half at breath, at a superficial palpation symptoms of a boring of a peritoneum (are positive more often at a phlegmonous or gangrenous acute cholecystitis)
    • At a stomach palpation following symptoms are defined:
      • Murphy's symptom - a consensual breath holding on an inspiration at pressing on area of the right hypochondrium
      • Kehr's symptom - morbidity at a palpation in right the hypochondrium, sharply amplifying on an inspiration
      • Ortner's symptom - a pain at effleurage by internal edge of a brush on a costal arch.
      • Morbidity at pressing on point Mussy (is between projections to a skin of legs right sternomastoid muscle).
      • Local Blumberg sign.
  4. Data of laboratory research:
    • The leukocytosis, ESR rising become perceptible for 2 days of disease, at a gallbladder empyema the neutrophilic leukocytosis becomes perceptible
    • At patients with an acute cholecystitis the maintenance of a serumal alkaline phosphatase in 23 % of cases, bilirubin - in 45 %, aspartate transaminase - in 40 %, alanine transaminase - in 13 % is raised.
    • At urine there is an urobilinigen, and at an icterus - bilirubin
  5. Data of tool research:
    • Roentgenography a little informative. On a survey x-ray film sometimes it is possible to tap contrast stones. The cholecystography yields negative results as often the cholecystitis is accompanied by an occlusion of a vesical duct.
    • Gallbladder ultrasonic taps presence of stones, allows to define the sizes of an organ and a thickness of its wall, presence of a paravesical infiltrate and a consistence of a contained gallbladder.
    • Radioisotope scanning. Absence of visualisation of a gallbladder at radioisotope scanning assumes obstruction of a vesical duct.
    • The electrocardiogram and thorax roentgenography is spent for differential diagnostics.

Differential diagnostics

The differential diagnosis spend with following diseases:

  1. Ruptured or penetrating stomach ulcer and/silt a duodenum
  2. Myocardial infarction
  3. Pancreatitis
  4. Hernia of an esophageal aperture of a diaphragm
  5. Right-hand pneumonia
  6. Appendicitis
  7. Hepatitis
  8. Infectious diseases

Treatment

Carry out a cholecystectomia. Operations part on performance terms:

  • Urgent operations spend within 72 hours from the disease beginning
  • Delayed operations spend approximately in 6 weeks after conservative treatment of the acute inflammatory phenomena (antibacterial, disintoxication infusional therapy)

Immediate surgery: patients with the acute cholecystitis complicated by a peritonitis are subject to an immediate surgery

(1-2 days of observation and conservative therapy) spend urgent operation by the patient with remaining against conservative therapy by semiology.

Planned operation carry out in case of efficiency of conservative treatment of an attack of an acute cholecystitis.

Conservative treatment - "a cold, hunger and rest".

  1. Confinement to bed
  2. Diet - a tea-water pause
  3. Spasmolyticses
  4. Infusional therapy for putting off of an intoxication and a restore of vodno-electrolytic and power losses
  5. Bilaterial perinephric novocainic blockade on Vishnevsky

Cholecystectomia

Access: begin from a median line below a xiphoid process, conduct some centimetres downwards, and then to the right to in parallel costal arch, on 2-3 centimetres below it. In a medial part of the specified cuts cross a direct muscle of a stomach in which depth dress a. Epigastrica superior. In a lateralis part of a wound consistently cut external, internal and cross-section muscles of a stomach, a cross-section fascia and a peritoneum.

After opening of an abdominal cavity the right share of a liver raise up, and colon transversum and duodenal intestines push aside from top to bottom. A liver keep a special rectangular mirror or immediately arm by means of a gauze napkin. Examine also a palpation of a gallbladder, cholic ways and surrounding organs.

Excision of a gallbladder from a neck. Having delayed a liver up, and a duodenum from top to bottom, pull hepatoduodenal ligament. Along its right edge, from level of a neck of a bubble down to a duodenum, cautiously make cuts a forward peritoneal leaf of ligament; moving apart a fat, bare the general duct and a place of a confluence of it of a vesical duct. Allocate the vesical duct usually forming of some flexures. On the allocated duct impose a silk ligature, and to periphery from it, is closer to a bubble neck, on a duct impose bent Hemostatic Forceps. Not to damage a wall of a cholic duct, the ligature is imposed on distance by of 1.5 sm from a place of merge of ducts; leaving of longer stump is undesirable, as it can lead subsequently to formation ampoule figurative expansion (new "gallbladder") with a lithogenesis. After a deligation and a clamp a vesical duct between them cross, a stump cauterise iodine and cover with a gauze napkin. In the top angle of a wound find referred to the right and a little up a vesical artery; it isolate and carefully dress two silk ligatures and cross; it is necessary to be careful to grasp in a ligature the right branch of a hepatic artery from which vesical artery departs. Then start gallbladder secreting. If it is sharply stretched liquid contents, expediently preliminary to empty its puncture and to close a puncture place pursestring a seam or to impose on it fenestrated forceps Luer. By means of a clamp a bubble neck delay from a liver so that the place of transition of a visceral peritoneum of a bubble on a liver was visible. On this line a peritoneum cautiously dissect along one edge of a bubble. When the cut is made, a finger or a peanut stupidly peel to peel out a wall of a bubble from its bed; The bubble unit is facilitated by hydraulic preparation of 0.25 % by Novocainum solution. Further dissect a peritoneum along other edge. Secreting can be made differently: a cut of a forward leaf of hepatoduodenal communication continue on a wall of a bubble in the form of two semiovals going near to an axis of a gallbladder and converging at its bottom. Each of the turned out flaps of a visceral peritoneum from a bubble surface to its edges. When bubble edges are bared, it is easily enucleated from the bed stupid by. After excision of a bubble peritoneum leaves take in over a hepatic bed of a bubble a continuous or nodal catgut seam, having continued it along a cut of hepatoduodenal ligament; thereby peritonize a bed of a bubble and a duct stump. Isolating napkins delete, to a bed of a gallbladder and to a stump bring 2-3 gauze strias-wads in width of 3 sm everyone; they are lead up to the bottom by wounds deduce through an operational wound. Delete their gradual straining since 9-11 days. The platen clean; For a relaxation of an abdominal wall raise the top part of a trunk a little and start closing of an operational wound. An abdominal wall sew up in layers: a continuous catgut seam - a peritoneum, nodal silk seams - the crossed muscles and walls of a vagina of a direct muscle of a stomach, a skin.

Excision of a gallbladder from a bottom make upside-down: at first allocate a gallbladder, and then carry out receptions of secreting and a ligation of a vesical artery and a duct. For this purpose allocated bubble delay; then the vesical artery which isolate is taped and cross between two ligatures in the way described above. After that allocate, legate and cross a vesical duct. The further course of operation same, as at secreting of a bubble from a neck. Secreting of a bubble from a bottom is less expedient, as thus fine stones from a bubble cavity are easy for tiring out in ducts.

Roentgenography of the general cholic duct through a vesical duct with contrasting (an intraoperative cholangiography) carry out at suspicion on migration of stones in the general cholic duct or disturbance of its passableness of other aetiology.

Cystifellotomy - a choice method at treatment somatically serious patients with diseases of cardiovascular and respiratory systems in a decompensation stage. Carry out at the expressed inflammatory process and presence of a mechanical icterus for decompression of bile-excreting ways. Open a bottom of a gallbladder, delete bile and stones. Into a gallbladder enter a probe for evacuation of the infected bile. At laparoscopic cholecystectomy a gallbladder drain spinal.

Cholecystitis complications

  • Emphysematous cholecystitis develops under the influence of metabolites of gas-forming bacteria (often clostridiums, E.Coli, or streptococcuses). With an emphysematous cholecystitis men is more often are ill, at 20-30 % tap a diabetes. At an emphysematous cholecystitis tap gas in a gallbladder, the report between a gallbladder and GASTROINTESTINAL TRACT is not present. Treatment: a cholecystectomia, an antibioticotherapia.
  • Acute cholecystitis causes a concrement impaction in a mouth of a vesical duct. Allocated phases:
    • Bubble edema - accumulation of serously liquid in its lumen
    • Empyema - a becoming infected with development of an acute purulent inflammation of a gallbladder. The intoxication and high risk of punching are characteristic
  • Gangrenous cholecystitis arises against a clottage of a vesical artery and leads to a gallbladder necrosis. Antibacterial therapy taking into account sensitivity of a microflora of bile is necessary. Operation - a cholecystectomia.
  • Ruptured cholecystitis arises at a necrosis of a wall of a gallbladder:
    • Local punching arises during the period from several days about one week after the beginning of an acute cholecystitis and leads to development of a paravesical abscess.
    • Open punching in an abdominal cavity with the bile efflux in subhepatic space leads to development of a diffuse peritonitis, 25 % are accompanied by a lethality, arises at an early stage of a clinical current of disease.
    • Punching in an interfacing organ - in a duodenal, lean, colonic intestine or a stomach with formation of an internal fistula is possible. Passage to a lumen of an intestine of a stone can cause its obstruction (gallstone impassability).
    • Cholically-stone fistula and gallstone impassability. Internal cholic fistulas arise owing to a decubitus a stone of a wall of the gallbladder soldered to nearby organs (to the general cholic duct, a stomach, duodenal and thick intestines). Gallstones can obturate a lumen of an intestine and cause clinic of intestinal impassability. Most often arise gallbladder-duodenum fistula. The obstruction arises in terminal part of an ileal intestine - the narrowest fate of a small bowel. Gallstones of the sizes less than 2-3 sm usually independently leave through a rectum. Hit of gallstones at punching in a free abdominal cavity leads to an inflammation and adherent process. In this case intestinal impassability arises at any level of an intestinal tube.

Choledocholithiasis

Choledocholithiasis arises at passage of a gallstone from a bubble in the general duct or at a delay of the stone which has been not noticed at a cholangiography or research of the general duct. Stones in the general cholic duct can be single and plural. Them tap at a cholecystectomia in 10-20 % of cases. After gallbladder excision probably lithogenesis in the general duct, especially in the presence of a stasis caused by obstruction of a duct.

Clinical picture:

Complaints:

  1. On colic pains, in right hypochondrium, with radiation of pains to the right and in a back
  2. On the raised temperature, a headache, cold fits
  3. Icterus
  4. Itch
  5. At a latent choledocholithiasis of the patient does not show complaints or only complains of a dull ache under the right costal arch
  6. At the dyspeptic form a choledocholithiasis of the patient complains of an uncharacteristic pressing pain under the right costal arch or in epigastri? area and on a dyspepsia - a nausea, an eructation, gases and intolerance of Adepses
  7. At the cholangitis form the fervescence, often septic character that is accompanied by an icterus is characteristic

At survey:

  1. Yellowness of integuments. At valvular stones the icterus can be time - at reduction of an inflammation, puffiness choledoch the stone leaves also a bile secretion is restored.
  2. At a stomach palpation morbidity in right hypochondrium is defined, at the cholangitis form - liver augmentation, moderate morbidity.
  3. Clinical current of the complicated choledocholithiasis serious as, except a liver lesion, at a secondary stenosis papilla duodeni major the pancreas lesion simultaneously develops.

Diagnostics:

  1. The anamnesis: presence of cholically-stone illness, cholecystitis attacks, etc.
  2. Complaints (see above)
  3. Survey data
  4. Data of laboratory research:
    • Biochemical analysis of blood: augmentation of the maintenance of bilirubin, an alkaline phosphatase
  5. Data of tool research:
    • Ultrasonic: choledoch stones
    • Endermic, transhepatic cholangiography or radioisotope research, CT - visualisation of stones of a choledoch.

Treatment

  • Intraoperative cholangiography
  • Cholecystectomia
  • Choledochotomy (opening of the general cholic duct)
  • Audit of the general cholic duct, removing calculus, the equipment of a time external drainage of the general cholic duct. For preventive maintenance or treatment of infectious complications prescribe antibiotics. Excision of concrements by an endoscopic method is rather effective.

Indications to opening and audit of the general cholic duct.

  • Stone palpation in a lumen of the general cholic duct
  • Augmentation of diameter of the general cholic duct
  • Icterus episodes, cholangitis, pancreatitis in the anamnesis
  • Fine stones in a gallbladder at a wide vesical duct
  • Cholangiographic indications: defects of filling in intra-and extrahepatic cholic ducts; an obstacle to contrast agent entering in a duodenum.

Temporary external the drainage is necessary for pressure decrease in bile-excreting system and preventions of infiltration of bile in an abdominal cavity and peritonitis developments:

  • T-shaped Kerr a drainage
  • G - a figurative drainage Vishnevsky. The internal extremity of a tube is referred towards portal fissures. The additional aperture (for passage of bile towards a duodenum) is located in a place of a flexure of a tube. For the prevention of premature abaissement of a drainage it file catguts to a wall of the general cholic duct.
  • Tubular drainage Holsted-Pikovsky spend to a stump of a vesical duct.

Chronic cholecystitis

Chronic cholecystitis - a condition with relapsing subacute semiology. At patients tap essential differences in degree of inflammatory reaction, a thickening and a fibrosis of a wall of a gallbladder.

Clinical picture:

Complaints:

  1. On moderate changeable pains in right hypochondrium and the epigastric area, irradiating in the right scapular area.
  2. Nausea, vomiting, heartburn, eructation bitterness.
  3. Symptoms arise after reception of the acute, fried, fat nutrition possessing cholagogue effect.

At survey:

  1. At stomach survey, occasionally the patient spares a sick half of stomach
  2. At a palpation the enlarged, painful gallbladder is defined
  3. Symptoms Ortner, Mussy's, Merphy etc. are defined

Laboratory researches:

Laboratory indicators within norm.

Tool indicators: at ultrasonic gallbladder stones, a thickened wall of a gallbladder are taped. Also carry out an excretory cholecystography for visualisation of stones and an estimation of a condition of a wall of a gallbladder.

Treatment

Treatment - surgical-cholecystectomia. Now 80-90 % of operations spend laparoscopy. At 75 % of the operated patients the disease clinic regresses. At 25 % observe residual symptoms of disease.

Conservative treatment: reception of cholic salts or a lithotripsy prescribe the patient with gallstones of the small sizes at conservation of function of a gallbladder. Chenodesoxycholic acid lyses only small (no more than 1 sm) cholesteric stones. The lithotripsy and litholytic therapy are interfaced to danger of an obturation of ducts of stones and high frequency of relapses (the kept gallbladder remains the basic for a new lithogenesis).

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