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RUSSIAN STATE

MEDICAL UNIVERSITY

Department of Hospital Surgery

Head department professor Nesterenko Yu.P.

Teacher Andreytseva O. I.

Topic: "Calculous cholecystitis, complicated by obstructive jaundice."

Completed by a V year student

medical faculty

511а gr. Krat V. B.

Obstructive jaundice is one of the most common complications
calculous cholecystitis. The reasons for the appearance of jaundice at the same time
widespread disease are diverse, but in most
cases it is a consequence of organic lesions
intrahepatic bile ducts. Obstructive jaundice with
calculous cholecystitis is most often caused by gallstones
ducts, cicatricial stenosis of the greater papilla of twelve duodenum
(BSD) and inductive pancreatitis, compressing the distal section
common bile duct. Violating the patency of the bile ducts, these
causes lead to stagnation of bile, biliary hypertension and cholemia.
In addition, with calculous cholecystitis, jaundice may be
a consequence of pericholedocheal lymphadenitis, primary
sclerosing cholangitis, helminthic invasion, hemobilia, and
can occur during the inflammatory process - cholangitis and
hepatitis, often accompanying acute cholecystitis.

Clinic of calculous cholecystitis complicated by mechanical
jaundice.

The clinical picture of complicated calculous cholecystitis
obstructive jaundice is extremely diverse, which is explained
existence various reasonscausing obstruction of biliary
ducts, the severity and duration of jaundice, as well as frequent
a combination of obstructive cholestasis with acute pancreatitis, purulent
cholangitis or acute pancreatitis. But with all the variety
clinical symptoms of calculous cholecystitis, complicated
obstructive jaundice, there are a number of features that
allows you to distinguish the following forms of this disease:
icteric-painful, icteric-pancreatic, icteric-cholecystis,
icteric-painless and icteric-septic.

Jaundice-painful form is the most frequent form clinical
manifestations of non-neoplastic lesions of the bile ducts, complicated
obstructive jaundice. The main clinical symptoms her
are pain, nausea, vomiting, fever, and jaundice.

Pain in this clinical form of the disease occurs suddenly and
is in the nature of biliary colic. The pain is extremely intense
localized in the right hypochondrium and epigastric region,
radiate to the right scapula, shoulder or lumbar region.
An attack of biliary colic lasts several minutes and hours, and
sometimes it is protracted and lasts more than a day. Overly
intense abdominal pain, most characteristic of a blockage
a stone of BSD and preampular bile ducts, authors
explain by spastic contraction of the muscles of the gallbladder,
sudden onset of hypertension and distension of the bile ducts, and
also by BSD injury and severe spasm of his muscular sphincter.

Nausea and vomiting are often observed during an attack of biliary
colic. Vomiting is one or two times and is extremely rare
multiple. It is believed that vomiting with biliary colic is
reflex character.

For the icteric-painful form of the disease, an increase in
body temperature up to 38-39 (C and a sharp chill that occurs during
time of attack. Fever and chills occur in most
sick and stop immediately after the passage of the attack.
The seizure origin is thought to be related to arousal
central heat regulation, or with exacerbation of inflammatory
process in the bile ducts and bacteremia.

Jaundice is the most prominent and persistent symptom of the disease. It
appears 12-24 hours after subsiding pain attack... IN
in most cases, jaundice of the sclera and skin takes persistent and
progressive nature, and most often this is observed with
impacted stones of the distal common bile duct and
infringement of a stone in the BSD. Jaundice resolves quickly if the condition
not complicated by cholangitis.

After the relief of the painful attack, the condition of the patients remains
satisfactory. Heart rate is within normal range or
tends to bradycardia. The abdomen is determined by palpation
soft and painless. In most patients, the gallbladder does not
palpable, and the liver is not enlarged. Classic symptoms
Ortner, Murphy, Georgievsky-Mussey - with this clinical form
usually negative.

The icteric-pancreatic form is most characteristic of the restrained
stone and cicatricial narrowing of the BSD, is rarely observed with
extended stricture of the distal common bile duct
on the basis of indurative pancreatitis. The commonality of two ductal
systems determines the symptoms of the disease, which includes
symptoms of obstructive jaundice and acute pancreatitis.

According to the Opie theory, the development of acute pancreatitis with infringement
stone in the BSD is caused by reflux of bile into the pancreatic duct
glands. But the development of acute pancreatitis may not lead
only reflux of bile, but also a violation of the outflow of secretion from it with
an increase in intraflow pressure, which can occur when
closure of the mouth of the duct with a stone or compression of the interductal
partitions.

There are two options for the manifestation of icteric-pancreatic
calculous cholecystitis complicated by obstructive jaundice. When
the first variant of the phenomenon of acute pancreatitis occurs immediately
after an attack of biliary colic, and in this case in a clinical
the picture of the disease is dominated by symptoms of acute pancreatitis,
masking the clinic of a strangulated stone and BSD stenosis. At the second
variant, acute pancreatitis develops after a second attack
biliary colic and against the background of jaundice that has already arisen. In this case
symptoms of acute pancreatitis appear against the background of symptoms
obstructive jaundice and do not mask them.

The leading symptom of this form of the disease is pain, which
in the first variant of the flow, which in the first variant of the flow
diseases become permanent from the moment of development
attack, and in the second option - after a second attack
biliary colic. Pain is usually localized in the upper half
abdomen or are shingles. They are accompanied by
nausea and repeated vomiting. Icteric staining appears
12-24 hours after the onset of the attack. Jaundice quickly
increases in intensity, which is to some extent associated with
compression of the common bile duct by the head of the pancreas.
The patients have chills, weakness, urine acquires
dark brown, and feces are discolored. Tongue dry and
coated. Palpation is determined by significant pain in
right hypochondrium and epigastric region, and sometimes in the left
hypochondrium. Here local muscle tension is observed, and when
the presence of an effusion in the abdominal cavity reveals a symptom
Shchetkin-Blumberg. As a rule, symptoms of acute
pancreatitis: Voskresensky and Mayo-Robson.

In the diagnosis of this form of calculous cholecystitis, complicated
obstructive jaundice, along with the determination in the blood of the content
bilirubin and the activity of liver enzymes and amylase in the urine.

The basis for the isolation of the icteric-cholecystitis form was
numerous evidences of a combination of acute cholecystitis with
obstructive cholestasis, most often due to
choledocholithiasis and BSD stenosis. It is believed that
the determining factor in its origin is acute
cholecystitis, causing a blockage of the common bile duct with a stone
in connection with inflammatory edema of the bile ducts or reflex
spasm of the sphincter of Oddi. It is also believed that the basis of development
acute cholecystitis and obstructive jaundice is the primary
blockage of the bile duct with a stone, leading to stagnation of bile and
exacerbation of the infectious process in gallbladder.

Persistent symptoms, in addition to jaundice, hyperthermia and tachycardia,
are pain in the right hypochondrium and epigastric region,
muscle tension, positive symptoms of Shchetkin-Blumberg,
Ortner and Georgievsky-Mussey. With moderate muscle tension
abdominal wall manage to palpate tense and sharp
painful gallbladder. In the clinical analysis of blood
revealed leukocytosis and a shift of the leukocyte formula to the left.

A distinctive feature of the icteric-painless form is the absence
a history of indications of a pain attack preceding
the appearance of jaundice. Jaundice appears gradually in the background
satisfactory condition of the patient. Sometimes her appearance
preceded by short-term chills and fever
up to 38-39 (C, which may be associated with an exacerbation of inflammatory
process in the area of \u200b\u200bobstruction of the bile duct. Abdomen in patients
remains soft and painless, the gallbladder is not palpable.
The liver is not palpable at first, but as cholestasis increases
increases.

At the heart of the icteric-septic form of the disease is a violation
outflow of bile into the intestine due to complete or partial
obturation of the bile ducts and the addition of a virulent infection,
which quickly leads to the development of purulent cholangitis, often
complicated by the formation of abscesses in the liver and sepsis. it
one of the most severe forms of the disease, giving the highest
mortality.

The clinical picture of the icteric-septic form of the disease
bright enough. The disease begins acutely with the appearance of strong
pain in the right hypochondrium, radiating to the right scapula,
shoulder or lumbar region. A pain attack is accompanied by
nausea, vomiting, tremendous chills and fever
body up to 38-39 (C. Moreover, chills and rises in temperature are repeated
several times a day; temperature takes hectic
character. Sclera jaundice soon appears, intensity
which is gradually increasing.

The general condition of patients is usually difficult. The sick are apathetic
drowsy, may be confused and disoriented. Pulse
increases to 100-120 per minute. The abdomen is soft on palpation,
painful in the right hypochondrium. The liver often enlarges in
size and the edge becomes painful. Irritation symptoms
the peritoneum is negative. In the study of blood, a high
leukocytosis up to 18-25 (109 / l and above. In the biochemical blood test
hyperbilirubinemia, increased aminotransferase activity,
alkaline phosphatase and aldolases. Diuresis decreases. In clinical
urine analysis reveals protein and casts.

With the progression of the disease, purulent intoxication increases,
may develop septic shock, acute hepatic, renal, and
also heart failure. These patients are shown urgent
surgical intervention with external drainage of biliary
ducts and intensive care, including
targeted and adequate antibacterial therapy.

Establishing an accurate diagnosis is complicated by similar symptoms
of the above forms of calculous cholecystitis, complicated
obstructive jaundice of non-neoplastic genesis, as well as similarity with
clinical picture of obstructive jaundice of tumor origin
and viral hepatitis, which requires clarification of the diagnosis using
special diagnostic methods.

Instrumental research methods.

Of instrumental methods diagnostics of calculous cholecystitis
first of all, it should be noted ultrasound of the abdominal organs,
the diagnostic accuracy of which is in acute
cholecystitis 89%. The use of this diagnostic method allows not
only to establish the presence of acute cholecystitis, complicated
obstructive jaundice, but also to clarify the inflammation of the gallbladder and
the nature of jaundice. The use of the method becomes especially
valuable when acute cholecystitis proceeds under the guise of "acute
stomach "or acute pancreatitis. Having accurate information about
form of acute cholecystitis and the prevalence of inflammatory
process, it seems possible to determine the treatment tactics and
resolve issues about the timing of the operation.

Diagnosis of gallbladder stones with ultrasound is based on three
signs: 1) focal darkening with a path going from the stone,
called acoustic shadow; 2) no shadow of the gallbladder
and the appearance in the zone of its dense echo structure with acoustic
shadow; 3) the presence of a focal echo structure that does not give an acoustic
shadows.

A reliable echographic sign of extrahepatic cholestasis
is the expansion of the bile ducts. Based on only one
of this echographic sign, obstructive
the nature of jaundice, but one cannot speak about its nature and cause.
Correctly diagnose the cause of jaundice
possible in those patients who, when scanning in the bile
ducts, an acoustic shadow is revealed, indicating the presence
stone.

The final stage of the diagnostic examination of patients with
obstructive jaundice is an assessment of the state of the pancreas
glands. Scanning has two goals: diagnosing cancer
as possible reason disease and detection of concomitant
acute pancreatitis and determination of the severity of the process.

Summarizing the above, it should be noted that limited
the diagnostic capabilities of ultrasound determine the need
supplementing it with a radiopaque study of biliary
ducts (ERCP, PCH) to clarify the diagnosis and determine
the possibility of using non-operative methods for resolving jaundice.

Gastroduodenoscopy is of great importance for both
diagnosis of the underlying disease that caused biliary obstruction
ducts, and to assess concomitant changes in the stomach and
duodenum.

Gastroduodenoscopy is especially effective in identifying a restrained
stone and cancer BSD. The diagnosis of a restrained stone is based on
direct and indirect endoscopic signs of the disease. By
direct endoscopic signs, which include imaging
stone directly at the mouth of the papilla, the disease is diagnosed
rarely. Most often, the diagnosis is made by indirect
endoscopic signs: an increase in BSD in size up to 1-1.5
see, bulging it into the lumen duodenum, the emergence
in the mucous membrane of the papilla of hemorrhage, hyperemia, edema, and
also erosion and fibrinous plaque. With a restrained stone, the mouth
BSD gapes or does not differentiate.

Endoscopic diagnosis of BSD cancer usually does not cause
difficulties if a polypoid tumor with a tuberous
or a knotty surface of crimson or crimson color with
areas of ulceration. The tumor is of different sizes, protrudes into
the intestinal lumen and obturates it. When the tumor decays,
contact bleeding. The diagnosis of BSD cancer is confirmed
cytological examination of biopsy material.

Implementation in medical practice endoscopic method
retrograde cholangiopancreatography greatly simplified and
improved the solution of diagnostic problems in organ diseases
hepatoduodenal zone. Since there are absolute contraindications for
there is no ERCP for extrahepatic cholestasis, then
for the timely diagnosis and choice of treatment
it must be done in every patient with suspected
obstructive obstruction of the bile ducts. Application experience
ERCP showed a high efficiency of the method in identifying the causes
obstructive jaundice, the level of obstruction of the bile ducts and
assessment of the anatomical and functional state of biliopancreatic
systems. Early diagnosis of the disease with this
the primary radiopaque method of research gives
the ability to rationally solve the issues of treatment tactics, and, besides
in addition, to reduce the time of examination of the patient.

Cholangiography by percutaneous puncture of the intrahepatic biliary
ducts is a valuable diagnostic method for obstructive
cholestasis. Being a rather complex procedure and having
many complications, the frequency response should be carried out in a well-equipped
operating room by experienced professionals. The frequency response is used in cases where
when the data of clinical laboratory and other research methods
do not differentiate obstructive jaundice from
parenchymal; when the nature and level of obturation is not established
extrahepatic bile ducts, and to clarify the nature of the disease
ERCP method is not possible for a number of reasons;
if patients with prolonged blockage of the bile ducts had
severe cholemic intoxication, to eliminate which
it is advisable to combine a diagnostic study with
intraductal therapeutic measures.

Frequency response, being an accurate method for diagnosing diseases complicated by
obstructive jaundice, according to the range of its diagnostic
capabilities, it is equivalent to intraoperative cholangiography, which
excludes performing cholangiography during surgery.

Computed tomography is the most modern method
research and very simple to perform. Normal on CT
all organs of the hepatoduodenal zone are visualized. CT most
effective in identifying choledocholithiasis, expansion of intra- and
extrahepatic bile ducts as a sign of obstructive
cholestasis, cysts and liver tumors of 0.5 cm and more,
acute pancreatitis, cystic formations of the pancreas and
less informative in the differentiation of chronic pancreatitis and
pancreatic cancer.

Laparoscopy is technically simple and relatively
safe research methods. Application of laparoscopy
contraindicated in extreme severity general condition sick,
severe heart and lung failure, as well as with
suspicion of massive adhesions in the abdominal cavity.

Based on the diagnostic information content of laparoscopy, the use of
it is advisable for the unclear nature of jaundice and the impossibility
differentiate jaundice of a mechanical nature from
parenchymal. Differential diagnosis jaundice based
mainly on visual assessment of liver color: bright red
its color is a reliable sign viral hepatitis, and
green or greenish brown liver with smooth
surface and expansion of the subcapsular bile ducts
indicates obstructive jaundice. Establishment
the etiology of jaundice for endoscopic signs is difficult in
early stages of the disease, since it is known that the distinctive
the liver acquires a color shade in 2-3 weeks from the moment
the appearance of jaundice.

Laparoscopy for acute cholecystitis and pancreatitis in the last
time began to be widely used for medicinal purposes to create
cholecystostomy, which promotes relief inflammatory process
and elimination of biliary hypertension. Laparoscopic drainage
the gallbladder allows you to postpone the operation and perform
it in the cold period or even abandon it in patients with
high operational risk.

If you suspect a pancreatic disease occurs
the need to use radionuclide scanning in patients
with obstructive jaundice of non-neoplastic genesis. Method used
how to assess the degree of pancreatic dysfunction
and to identify focal formations in it.

The main indications for scintigraphy include cases where
suspicious of inductive pancreatitis, and the inability
to exclude cancer of the head of the pancreas. It is also shown
with an unclear nature of obstructive jaundice in patients who
by the severity of the general condition, it is impossible to carry out a radiopaque
study of the bile ducts, and with intolerance to iodine
drugs.

Assessment of the state of the pancreas is carried out according to generally accepted
criteria: location, shape, size and outline of the image
glands, the nature and rate of accumulation of the radionuclide, the presence of zones
with increased or decreased activity. Final conclusion
about the nature of the lesion of the gland according to the results of
scintigraphy should be done only after
multivariate analysis of data obtained in clinical and laboratory
and other research methods.

Therapeutic tactics for calculous cholecystitis, complicated
obstructive jaundice is to eliminate jaundice before
surgical intervention, if the nature of the disease does not require
emergency or urgent surgery. To eliminate jaundice, wide
endoscopic operations - papilosphinkerotomy and
laparoscopic cholecystostomy, as well as transhepatic
drainage of the bile ducts. Application for this contingent
patients with endoscopic and transhepatic interventions are directed
to eliminate jaundice and biliary hypertension and their causes
development, in order to perform an operation in more
favorable conditions for the patient, with less risk for him
and to a lesser extent. Thanks to modern diagnostic
methods to speed up the examination of the patient and clarify
diagnosis, the duration of the operation can be reduced to 3-5 days.
In this relatively short period of time, you can carefully examine
sick and evaluate functional state different systems
organism, as well as fully prepare the patient for surgery.

When obstructive jaundice is combined with acute cholecystitis,
adhere to active tactics, which is determined not only
the presence of cholestasis and cholemia, but also the addition of purulent
intoxication. In these cases, the timing of the operation depends on the severity
inflammatory process in the gallbladder and the severity of peritonitis.
In the surgical treatment of acute cholecystitis at the same time
intervention is performed on the extrahepatic bile ducts,
and after assessing the nature of the pathological process in them. Have
patients with a high operational risk for acute
cholecystitis, laparoscopic cholecystostomy is performed, and for
resolution of jaundice - endoscopic transpapillary intervention,
combined with the phenomenon of purulent cholangitis with nasobilary
drainage. Endoscopic gallbladder surgery and
bile ducts allow you to stop the inflammatory process and
eliminate jaundice.

When preparing patients for surgery and conducting them in
postoperative period first of all you need to keep in mind
violation of protein metabolism with the development of hypoproteinemia and
hypoalbuminemia. To eliminate these consequences, apply
protein preparations, giving preference to non-split
proteins (dry plasma, protein, albumin), half-life
which in the body is 14-30 days, and amino acids,
which are used by the body to synthesize organ proteins. TO
such drugs include casein hydrolyzate, aminosol, alvezin,
vamyn et al. Albumin deficiency should be started to
3-4 days before the operation by transfusion of 10-20% solution of it in the amount
100-150 ml per day and continue for 3-5 days after.

To provide the patient with energy material, as well as for
stimulation of regenerative processes in the liver, increasing its
antitoxic function and resistance of hepatocytes to hypoxia
recommend injecting concentrated glucose solutions in bulk
500-1000 ml per day. To improve metabolic efficiency
intravenously administered glucose, insulin must be added, when
this dose should be slightly higher than the standard, so that
showed its metabolic effect.

Mandatory components of the treatment program for obstructive
jaundice are drugs that improve the functional state
hepatocytes and stimulating the process of their regeneration. To such
include Essentiale, Legalon, Carsil, Sirepar, etc.
they need to be resorted to in the immediate postoperative period and
abstain until cholestasis is eliminated so as not to cause a relapse
adaptation of hepatocytes to the resulting changes in the bile
hypertension and cholemia. Multicomponent therapy for mechanical
jaundice should include vitamin therapy with group vitamins
A, B (B1, B6, B12), C, E.

Fluid therapy should focus on recovery
BCC, KOS correction. Antibiotic therapy should be
is aimed at the prevention of septic complications. Most
an effective regimen of antibiotic therapy is considered
intraoperative administration of antibacterial drugs.

Conducting pathogenetically substantiated infusion-medication
therapy in patients with calculous cholecystitis and mechanical
jaundice allows for a favorable course
postoperative period and prevent the development of acute
hepatic, renal and cardiovascular failure.

Literature:

Korolev B. A., Pikovsky D. L. "Emergency surgery of the biliary tract",
M., Medicine, 1990;

Rodionov V.V., Filimonov M.I., Moguchev V.M. "Calculus
cholecystitis ", M., Medicine, 1991;

Saveliev V.S. "Guidelines for emergency surgery of the abdominal organs
cavities ", M., 1986;

Skripnichenko D.F. " Emergency surgery abdominal cavity ", Kiev,
"Healthy", 1974;

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Obstructive jaundice in patients with acute cholecystitis complicated by obstructive jaundice is caused by obstruction of the main bile ducts with calculi, less often by stenosis of the nipple of Vater, cholangitis, or compression of the terminal part of the common bile duct by the head of the pancreas.

Clinic and diagnostics... Complication of acute cholecystitis with obstructive jaundice leads to the development of a pronounced syndrome of endogenous intoxication. The clinical picture is extremely diverse. This is due to the intensity and duration of jaundice, as well as the combination of cholestasis with destructive cholecystitis or purulent cholangitis. With all the variety of clinical symptoms of acute cholecystitis with obstructive jaundice, a number of features can be traced that are characteristic of most patients.

Jaundice is the most prominent symptom of the disease. It appears most often 12 - 14 hours after the pain attack subsides. In most cases, the yellowness of the skin and sclera becomes persistent and progressive. With severe and prolonged jaundice, patients appear itchy skin, scratching of the skin, weakness, decreased appetite, darkening of urine and discoloration of feces. Blood bilirubin is increased due to the direct fraction.

In diagnostics, preference is given to ultrasound as a non-invasive and screening method.

Treatment in all patients with various forms acute cholecystitis is aimed at eliminating pain syndrome, using disinfecting and anti-inflammatory therapy. An emergency operation (within 2 - 3 hours from the moment of admission) is performed on a patient with signs of peritonitis. An urgent operation (24 - 48 hours) is performed for patients who still have the clinical picture of obstructive cholecystitis, the symptoms of the inflammatory process and endotoxicosis are increasing. For a delayed operation - in the "interval" - they prepare more painfully, in which, thanks to conservative therapy, an attack of acute cholecystitis is stopped (within 24 - 48 hours) and the outflow of bile into the duodenum is restored.

General principles of preparation for surgery: normalization of homeostasis, creation of functional reserves of vital important organs, treatment of existing concomitant diseases, adaptation of the patient's psyche.

In cases of subsiding of an attack of acute cholecystitis, but the persistence of obstructive jaundice, intensive preoperative preparation and topical diagnostics are carried out in the near future, not exceeding 5 days from the date of admission.

Operative treatment... Adequate radical surgical intervention is cholecystectomy with revision of the extrahepatic bile ducts. Each operation for cholecystitis should be accompanied by a revision of the main extrahepatic ducts. Further tactics depends not only on the nature of the pathological process in the biliary tract, but also on the patient's reserve capabilities. Sometimes in a serious condition of the patient ( old age, concomitant diseases) cholecystolithostomy is performed. The most difficult and crucial moment is the operation on the common bile duct. Indications for choledochotomy can be absolute and relative.

Absolute indications for choledochotomy: obstructive jaundice at the time of surgery; stones palpable in hepaticoholedochus; the presence of filling defects along the ducts on the operating radiographs; wedged stone of the large duodenal papilla; lack of evacuation contrast agent into the duodenum on operating radiographs.

Relative indications to choledochotomy: history of jaundice or before surgery; shrunken gallbladder, wide cystic duct (more than 3 mm), small stones in the gallbladder; wide extrahepatic bile ducts (more than 10 mm); narrowing of the terminal portion of the common bile duct with impaired evacuation of contrast agent on radiographs.

The most common methods for external drainage of the bile ducts are: (1) according to Pikovsky: a thin drainage is carried out into the cystic duct; (2) according to Vishnevsky: drainage, approximately equal to the diameter of the common bile duct and having an oval opening, 2-4 cm away from the distal end, is carried out towards the liver hilum; (3) according to Keru (at present, this drainage is recognized as the most successful): the drainage is a T-shaped tube, due to which bile flows naturally into the duodenal lumen, or when the pressure in the common bile duct rises, it additionally flows out.

External choledochostomy is controllable at all stages of the postoperative period, does not introduce new anatomical relationships in the bile ducts. Along with external drainage in biliary tract surgery, internal drainage, most often choledochoduodenostomy is used for this. The main indications for it are extended tubular strictures of the terminal section of the common bile duct, as well as its expansion over 2 cm in diameter.

When restrained stoneduodenal nipple, cicatricial stenosis of the large duodenal nipple, if necessary, revision of the pancreatic duct, patients undergo transduodenal papillosphincterotomy with plastics. Along with transduodenal papillosphincterotomy, endoscopic papillosphincterotomy is also widely used.

25.06.2013

Acute cholecystitis complicated by obstructive jaundice

Obstructive jaundice in patients with acute cholecystitis complicated by obstructive jaundice is caused by obstruction of the main bile ducts with calculi, less often by stenosis of the nipple of Vater, cholangitis, or compression of the terminal part of the common bile duct by the head of the pancreas.

Clinic and diagnostics... Complication of acute cholecystitis with obstructive jaundice leads to the development of a pronounced syndrome of endogenous intoxication. The clinical picture is extremely diverse. This is due to the intensity and duration of jaundice, as well as the combination of cholestasis with destructive cholecystitis or purulent cholangitis. With all the variety of clinical symptoms of acute cholecystitis with obstructive jaundice, a number of features can be traced that are characteristic of most patients.

Jaundice is the most prominent symptom of the disease. It appears most often 12 - 14 hours after the pain attack subsides. In most cases, the yellowness of the skin and sclera becomes persistent and progressive. With severe and prolonged jaundice, patients develop skin itching, scratching on the skin, weakness, decreased appetite, darkening of urine and discoloration of feces. Blood bilirubin is increased due to the direct fraction.

In diagnostics, preference is given to ultrasound as a non-invasive and screening method.

Treatment in all patients with various forms of acute cholecystitis, it is aimed at eliminating the pain syndrome, the use of disinfection and anti-inflammatory therapy. An emergency operation (within 2 - 3 hours from the moment of admission) is performed on a patient with signs of peritonitis. An urgent operation (24 - 48 hours) is performed for patients who still have the clinical picture of obstructive cholecystitis, the symptoms of the inflammatory process and endotoxicosis are increasing. For a delayed operation - in the "interval" - they prepare more painfully, in which, thanks to conservative therapy, an attack of acute cholecystitis is stopped (within 24 - 48 hours) and the outflow of bile into the duodenum is restored.

General principles of preparation for surgery: normalization of homeostasis, creation of functional reserves of vital organs, treatment of existing concomitant diseases, adaptation of the patient's psyche.

In cases of subsiding of an attack of acute cholecystitis, but the persistence of obstructive jaundice, intensive preoperative preparation and topical diagnostics are carried out in the near future, not exceeding 5 days from the date of admission.

Operative treatment... Cholecystectomy with revision of the extrahepatic bile ducts is an adequate radical surgery. Each operation for cholecystitis should be accompanied by a revision of the main extrahepatic ducts. Further tactics depends not only on the nature of the pathological process in the biliary tract, but also on the patient's reserve capabilities. Sometimes in a serious condition of the patient (old age, concomitant diseases), cholecystolitostomy is performed. The most difficult and crucial moment is the operation on the common bile duct. Indications for choledochotomy can be absolute and relative.

Absolute indications for choledochotomy: obstructive jaundice at the time of surgery; stones palpable in hepaticoholedochus; the presence of filling defects along the ducts on the operating radiographs; wedged stone of the large duodenal papilla; lack of evacuation of contrast agent into the duodenum on operating radiographs.

Relative indications for choledochotomy: history of jaundice or before surgery; shrunken gallbladder, wide cystic duct (more than 3 mm), small stones in the gallbladder; wide extrahepatic bile ducts (more than 10 mm); narrowing of the terminal portion of the common bile duct with impaired evacuation of contrast agent on radiographs.

The most common methods for external drainage of the bile ducts are: (1) according to Pikovsky: a thin drainage is carried out into the cystic duct; (2) according to Vishnevsky: drainage, approximately equal to the diameter of the common bile duct and having an oval opening, 2-4 cm away from the distal end, is carried out towards the liver hilum; (3) according to Keru (at present, this drainage is recognized as the most successful): the drainage is a T-shaped tube, due to which bile flows naturally into the duodenal lumen, or when the pressure in the common bile duct rises, it additionally flows out.

External choledochostomy is controllable at all stages of the postoperative period, does not introduce new anatomical relationships in the bile ducts. Along with external drainage in biliary tract surgery, internal drainage, most often choledochoduodenostomy is used for this. The main indications for it are extended tubular strictures of the terminal section of the common bile duct, as well as its expansion over 2 cm in diameter.

When restrained stoneduodenal nipple, cicatricial stenosis of the large duodenal nipple, if necessary, revision of the pancreatic duct, patients undergo transduodenal papillosphincterotomy with plastics. Along with transduodenal papillosphincterotomy, endoscopic papillosphincterotomy is also widely used.

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Obstructive jaundice is clinical syndrome, which develops as a result of a violation of the outflow of bile along the biliary tract into the duodenum and is manifested by icteric staining skin and mucous membranes, pain in the right hypochondrium, dark urine, acholic feces, as well as an increase in the concentration of bilirubin in the blood serum.

The main method of treating obstructive jaundice is surgical intervention, the purpose of which is to restore the outflow of bile into the duodenum.

Most often, obstructive jaundice develops as a complication of cholelithiasis, but can be caused by other organ pathologies digestive tract... If medical care is not provided on time, this condition can provoke the development liver failure and be fatal.

Source: pechenka.online

The causes of obstructive jaundice

The immediate cause of obstructive jaundice is obstruction (blockage) of the biliary tract. It can be partial or complete, which determines the severity clinical manifestations syndrome.

The pathological mechanism for the development of obstructive jaundice is complex. In most cases, it is based on an inflammatory process that affects the biliary tract. Against the background of inflammation, edema and thickening of the mucous membrane of the ducts occurs, which leads to a decrease in their lumen. By itself, this process disrupts the passage of bile. If at this moment even a small calculus enters the duct, the outflow of bile through it may completely stop altogether. Accumulating and stagnating in the bile ducts, bile promotes their expansion, destruction of hepatocytes, and the entry of bilirubin and bile acids into the systemic circulation. Bilirubin, which enters the bloodstream from the bile ducts, is not bound to proteins - this explains its high toxicity for cells and tissues of the body.

Source: pechen1.ru

The patient is recommended to drink at least two liters of fluid per day, this contributes to the early elimination of bilirubin, thereby reducing its negative effect on the central nervous system, kidneys, lungs.

Cessation of the flow of bile acids into the intestine disrupts the absorption of fats and fat-soluble vitamins (K, D, A, E). As a result, the process of blood coagulation is disrupted, hypoprothrombinemia develops.

Prolonged stagnation of bile in the intrahepatic ducts contributes to the pronounced destruction of hepatocytes, gradually leading to the formation of liver failure.

Factors that increase the risk of developing obstructive jaundice are:

• a sharp decrease in weight or, conversely, obesity;
• liver and pancreas infections;
• surgical interventions on the liver and biliary tract;
• injuries to the right upper quadrant of the abdomen.

Acute onset is rare, most often the clinical picture develops gradually. Usually the symptoms of obstructive jaundice are preceded by inflammation of the biliary tract, the signs of which are:

• increased body temperature;
• weakness;
• decreased appetite;

Later, an icteric coloration of the skin and mucous membranes appears, which intensifies over time. As a result, the patient's skin becomes yellowish-greenish. Other signs of obstructive jaundice are dark coloration of urine, discoloration of feces, itching of the skin.

Source: cdn77.org

If the patient is not provided health care, then against the background of mass death of hepatocytes, liver functions are impaired, liver failure develops. Clinically, it manifests itself with the following symptoms:

• increased fatigue;
• drowsiness;
• coagulopathic bleeding.

As the liver failure progresses, the patient's functioning of the brain, kidneys, heart, lungs is disturbed, that is, multiple organ failure develops, which is a prognostically unfavorable sign.

Most often, obstructive jaundice develops as a complication gallstone disease, but may be due to other pathologies of the digestive tract.

Diagnostics

A patient with obstructive jaundice is admitted to the department of gastroenterology or surgery. Within the primary diagnosis perform ultrasonography of the biliary tract and pancreas. When detecting expansion of the intrahepatic bile ducts and common bile duct (bile duct), the presence of calculi may additionally be prescribed cT scan biliary tract and magnetic resonance cholangiopancreatography.

Source: infopechen.ru

Dynamic scintigraphy of the hepatobiliary system and percutaneous transhepatic cholangiography are performed to identify the degree of obstruction of the biliary tract, features of the location of calculus and outflow of bile.

The most informative diagnostic method for obstructive jaundice is retrograde cholangiopancreatography. The method combines X-ray and endoscopic examination biliary tract. If, during the study, calculi located in the lumen of the common bile duct are found, they are removed (extracted), that is, the procedure from diagnostic goes to therapeutic. If a tumor is found that has caused obstructive jaundice, a biopsy is performed, followed by a histological analysis of the biopsy.

Laboratory research for obstructive jaundice includes the following studies:

• coagulogram (lengthening of prothrombin time is detected);
• biochemical blood test (increased activity of transaminases, lipase, amylase, alkaline phosphatase, direct bilirubin level);
• a general blood test (an increase in the number of leukocytes, a shift in the leukocyte formula to the left, an increase in ESR, a decrease in the number of platelets and erythrocytes is possible);
• coprogram (there are no bile acids in the feces, fats are present in a significant amount).

As the liver failure progresses, the patient's functioning of the brain, kidneys, heart, lungs is disrupted, that is, multiple organ failure develops.

Obstructive jaundice treatment

The main method of treating obstructive jaundice is surgical intervention, the purpose of which is to restore the outflow of bile into the duodenum. In order to stabilize the patient's condition, detoxification, infusion and antibacterial therapy is carried out. The following methods are used to temporarily improve the outflow of bile:

• choledochostomy - creating drainage by imposing an external fistula on the bile duct;
• cholecystostomy - the formation of an external fistula of the gallbladder;
• percutaneous puncture of the gallbladder;
• nasobiliary drainage (placing a catheter in the biliary tract during retrograde cholangiopancreatography).

If, despite the undertaken treatment of obstructive jaundice, the patient's condition does not improve, percutaneous transhepatic drainage of the bile ducts is indicated.

After stabilization of the patient's condition, the question of the next stage of treatment of obstructive jaundice is decided. Endoscopy methods are preferred because they are less traumatic. With tumor strictures and cicatricial stenosis, bougienage of the biliary tract is performed, followed by installation of stents into their lumen, i.e., endoscopic stenting of the common bile duct is performed. When the sphincter of Oddi is blocked by a stone, endoscopic balloon dilation is used.

In cases where endoscopic methods it is not possible to remove the obstacle to the outflow of bile, they resort to the traditional open abdominal surgery... In order to prevent leakage of bile into the abdominal cavity through the seams in the postoperative period, external drainage of the bile ducts according to Halstead is performed (installation of a polyvinyl chloride catheter in the cystic duct stump) or external drainage of the biliary tract according to Keru (installation of a special T-shaped tube in them).

Federal Agency for Healthcare and Social Development

State educational institution higher professional education

Saratov State Medical University named after V.I. Razumovsky

(GOU VPO Saratov State Medical University named after V.I.Razumovsky of Roszdrav)

Department of Faculty Surgery, Faculty of General Medicine

Academic medical history

Patient: ____, 73 years old

Main diagnosis: Acute calculous cholecystitis. Obstructive jaundice

Complications: no

Concomitant diseases: ischemic heart disease, angina pectoris 2 f. Cl. Atherosclerosis of the aorta, coronary, cerebral vessels. Arterial hypertension 3 tbsp., Risk 4. Acquired rheumatic heart disease. Mitral stenosis. Severe mitral insufficiency. Aortic insufficiency. Decompensation of blood circulation in the pulmonary circulation. Pulmonary hypertension... Persistent form of atrial fibrillation

Saratov 2011

General information about the patient

FULL NAME. patient: ______

Date of birth (age): 03/06/1938, 73 years old

Gender Female

Education: secondary

Profession: Salesman

Place of residence: Saratov. _______

Received: 22.09.2011

Curation date: 06.10.2011- 08.10.2011

Clinical diagnosis: Acute calculous cholecystitis. Obstructive jaundice.

Complications: no

Concomitant diseases: ischemic heart disease, angina pectoris 2 f. Cl. Atherosclerosis of the aorta, coronary, cerebral vessels. Arterial hypertension 3 tbsp., Risk 4. Acquired rheumatic heart disease. Mitral stenosis. Severe mitral insufficiency. Aortic insufficiency. Decompensation of blood circulation in the pulmonary circulation. Pulmonary hypertension. Persistent form of atrial fibrillation. Superficial gastritis. Duodenogastric reflux.

Complaints on the day of supervision: the patient complains of a feeling of heaviness in the right hypochondrium, spreading to the epigastric region, nausea, dry mouth, weakness, rapid fatigue.

The patient considers herself sick since December 2010, when for the first time intense pains of a bursting character in the upper abdomen began to bother her, arising after ingestion of fatty foods and accompanied by nausea, general malaise, and fever up to subfebrile numbers. Was in the hospital from 22.12.2010 to 29.12.2010, where, after ultrasound, stones in the gallbladder were revealed. The operation was refused for health reasons (persistent atrial fibrillation, Acquired rheumatic heart disease. Mitral stenosis. Severe mitral insufficiency. Aortic insufficiency. Decompensation of blood circulation in the pulmonary circulation. Pulmonary hypertension). After the therapy, she was discharged with recommendations on adherence to a diet with restriction of abundant intake of fatty foods.

The last deterioration of the patient's condition on September 16, 2011, when, after an error in the diet, intense pains appeared in the right hypochondrium, nausea, and vomiting. Similar attacks were noted earlier. Outpatient ultrasound revealed gallbladder calculi. The patient was independently treated with antispasmodics without positive effect... September 22, 2011. noted yellowing of the skin and sclera, darkening of urine. She applied for medical help and was hospitalized at 3 GKB named after Mirotvortseva S. R. SSMU in ECHO, where she arrives at the moment. Thus, the disease:

At first, it is spicy;

Downstream - progressive;

Pathogenesis - exacerbation of chronic.

She was born on 03/06/1938 in the city of Saratov in a working class family. Material and living conditions in which it developed satisfactory. Physical and mental development she did not lag behind her peers. Hygienic conditions and material support is currently satisfactory. She is married, has an adult daughter and grandchildren. Bad habits does not, denies drug use. Diseases transferred in childhood: ARVI, tonsillitis. Diseases transferred throughout life (tuberculosis and contact with it; Botkin's disease; diabetes; venereal - gonorrhea, syphilis, AIDS; malaria) denies in himself and in his relatives. Operations: amputation of the uterus in 1986. Out of the area within last year did not leave. There were no hemotransfusions. Allergic reactions: does not mark.

preasens universalis

The general condition of the patient moderate, clear consciousness, active position, hypersthenic physique, height 164 cm, weight 91 kg. Body temperature 36, 7 ° C.

The skin is icteric, dry, warm to the touch. The conjunctiva of the eyelids and sclera are icteric. Skin turgor is reduced, the hairline is expressed normally, hairiness is female. Nails on hands and feet are not changed.

The subcutaneous fat is overdeveloped and evenly distributed. It is painless on palpation. There are no swelling in the legs.

Lymph nodes are palpable, not enlarged, densely elastic consistency, painless, mobile, not soldered to each other and to the surrounding tissue, the skin above them is not changed. Muscles are developed satisfactorily. Soreness when palpating is not noted. Muscle tone is preserved.

The bones of the skull, chest, spine, pelvis, limbs, deformity, as well as pain when palpating and tapping is not noted.

The joints are of normal configuration. The skin over them is of a normal color. On palpation of the joints, their swelling and deformation, changes in the periarticular tissues, as well as pain are not noted. Movement in full.

The thyroid gland is not visualized or palpable

RESPIRATORY SYSTEM

No complaints.

Palpation

Without features.

Percussion

Topographic percussion:

Lower boundaries of the lungs.

Right lung: parasternalis - 6 rib;. medioclavicularis - 7 rib;. axillaris anterior - 7 rib ;. axillaris media - 8 rib;. axillaris posterior - 8 rib;. scapularis - 9 rib;. paravertebralis - at the level of the spinous process Th 10.

Left lung: parasternalis - 6 rib;. medioclavicularis - 6 rib;. axillaris anterior - 7 rib ;. axillaris media - 8 rib;. axillaris posterior - 9 rib;. scapularis - 10 rib;. paravertebralis - at the level of the spinous process Th 11.

The boundaries of the upper edge of the lungs:

Right lung:

In front, 3.5 cm above the clavicle.

Behind at the level of the spinous process of the 7th cervical vertebra.

Left lung:

In front, 3 cm above the clavicle; Behind at the level of the spinous process of the 7th cervical vertebra.

Comparative percussion.

A clear pulmonary sound is determined percussion above the symmetrical areas of the lungs.

Auscultation

Vesicular breathing throughout the pulmonary fields.

THE CARDIOVASCULAR SYSTEM

No complaints.

Pulsations at the base of the heart, in the apical impulse, the epigastric region are not observed.

Palpation

The apical impulse is determined by the 5th intercostal space 2 cm outward from the midclavicular line. Normal height, moderate strength, non-resistant. The pulse is symmetrical, frequency 75 beats per minute, rhythmic, good filling.

Percussion

Right - in the 4th intercostal space 2 cm outward from the right edge of the sternum

Upper - at the level of the 3rd rib between l. sternalis et l. Parasternalissinistrae

Left - in the 5th intercostal space, 2 cm outward from the left midclavicular line. The vascular bundle extends beyond the sternum in the 2nd intercostal space by 1.5 cm.The diameter of the vascular bundle is 8 cm.

Auscultation

Heart sounds are rhythmic, sonority of tones is muffled. Heart rate - 60 beats. in min.

URINARY SYSTEM

Complaints about darkening of the color of urine.

No visible changes were found in the lumbar region. The kidneys could not be palpated. The symptom of tapping in the lumbar region is weakly positive on the right, and negative on the left. There is no tenderness to palpation of the upper and lower ureteral points. Percussion, the bladder does not protrude above the pubic articulation. There are no dysuric phenomena.

NEUROSYCHOLOGICAL RESEARCH

No complaints.

Consciousness is clear, the mood is calm. Pupil reaction to light live D \u003d S.

DIGESTIVE SYSTEM

Complaints (at the time of supervision)

Complaints of intense, bursting pain in the right hypochondrium, epigastric region, nausea; general weakness... Aholy chair. Dark urine.

Examination of the oral cavity.

On examination of the oral cavity, the lips are dry, without cracks, ulcerations and rashes. The mucous membrane of the oral cavity is icteric, clean, moist. Language without white bloom, wet. Swallowing is free, painless.

On examination, the abdomen is round, soft, painful in the right hypochondrium and epigastric region, does not participate in the act of breathing. There is no visible peristalsis, protrusions and retractions, no enlargement of the veins of the abdominal wall, the skin is icteric.

Examination of the abdomen.

The abdomen is rounded, swollen in the epigastric and paraumbilical regions, asymmetric, collaterals on the anterior surface of the abdomen and its lateral surfaces are not expressed; no pathological peristalsis; the muscles of the abdominal wall are involved in the act of breathing; limited protrusions of the abdominal wall during deep breathing and straining are absent. There are no enlarged veins of the abdominal wall.

Percussion.

With abdominal percussion, tympanitis of varying severity is determined. There is no accumulation of fluid in the abdominal cavity. No splash noise. Ortner's symptom is positive.

Approximate superficial palpation of the abdomen.

The abdomen is soft. Soreness is determined in the right hypochondrium, in the epigastric region. Kera's symptom is positive. Symptom Shchetkin-Blumberg negative. When examining the "weak points" of the anterior abdominal wall (umbilical ring, aponeurosis of the white line of the abdomen, inguinal rings), hernial protrusions are not formed.

With deep palpation of the abdomen using the Obraztsov-Strazhesko method:

By the method of percussion, by the method of steto-muscular palpation, the lower border of the stomach is determined 3 cm above the navel.

The lesser curvature and the pylorus are not palpable; the splash noise to the right of the midline of the abdomen (Vasilenko symptom) is not feathered.

Auscultation.

At auscultation of the abdomen, weakened peristaltic murmurs are heard. Noises of splashing and friction of the peritoneum.

The chair is acholic.

Borders of the liver according to Kurlov:

upper (along the right midclavicular line) - VI rib;

lower on the right midclavicular line - 2 cm below the edge of the costal arch;

lower along the anterior midline - 1 cm below the border of the upper and middle third of the distance from the navel to the xiphoid process;

lower along the left costal arch - 1.5 cm to the left of the left parasternal line.

Liver size according to Kurlov:

on the right midclavicular line - 11 cm;

along the anterior median line - 10 cm;

along the left costal arch - 8 cm.

Survey plan

General analysis blood

General urine analysis

Blood chemistry

Ultrasound of the abdominal organs

Fibrogastroduodenoscopy

Chest X-ray

Endoscopy + endoscopic retrograde cholangiography

Data from laboratory and additional research methods

Blood chemistry

Total protein 51.0 g / l

Albumin 39.0 g / l

Creatinine 76.2 mmol / L

Glucose 7.3 mmol / L

Urea 6.9 mmol / l

Total bilirubin 275.8 mmol / L

Direct bilirubin 117.8 mmol / L

ALT 100.9 U / L 147.2 U / L

Alpha-amylase 34.0 U / L

General urine analysis.

Color dirty yellow

The reaction is acidic

Specific gravity 1009

Clouded transparency

Protein 0.09 g / l

Sugar neg

Acetone neg

Erythrocytes 4-6 in p. Sp. unchanged.

Cylinders neg

Mucus a little

No bacteria

Salt neg

General blood analysis.

09.2011 13.0 * 10 33.86 * 10 613.3 g / dl 33.2%

NEUT 91.9% 5.3% 86.0 1 mm 330.3 1 pg

MCHC 35.2 g / dL T 203 * 10 3 1 mm 3

ESR 13 mm / h

Ultrasound of the abdominal organs. (23.10.2011)

The liver is not enlarged, the contours are even, the parenchyma is homogeneous, there is an expansion of the intrahepatic ducts of the liver lobes. The gallbladder is irregular in shape, dimensions 70 * 30 mm. The wall is 5 mm doubled, sealed. Multiple calculi with a diameter of 0.5 to 1.1 cm. The choledoch is enlarged to 11-13 mm in the lumen, calculi up to 1.0 cm are determined.

Pancreas .: dimensions: head 27 mm, body 11 mm, tail 23 mm; the contours are diffusely inhomogeneous, the echogenicity is increased, the contours are not clear, the Wirsung duct is not visualized.

Spleen: sizes 9.0 × 4.3 cm, the structure is homogeneous, not changed.

Conclusion: signs of acute calculous cholecystitis, chronic pancreatitis; obstructive jaundice, choledocholithiasis.

Fibrogastroduodenoscopy:

Esophagus: Freely passable, mucous membrane is pale pink, no varicose veins, no polyps, no diverticulums

Stomach: peristalsis is normal, gastric contents are normal, folds are normal, mucous membrane is atrophic, no erosions or ulcers, no polyps, no duodenogastric reflux, pylorus normal.

Duodenal bulb: no deformities, normal lumen, normal contents, atrophic mucosa, no erosions or ulcers.

Conclusion: Chronic atrophic gastritis, duodenitis.

ECG: sinus rhythm, heart rate 60 in 1 minute, the electrical axis of the heart is horizontal. Left atrial hypertrophy, left and right ventricular hypertrophy. Signs of rheumatic lesions of the mitral and aortic valves.

Chest X-ray: Conclusion. The pulmonary pattern is not strengthened, the lung tissue is homogeneous, the sinuses are free of fluid; the heart shadow is not enlarged.

Endoscopy + endoscopic retrograde cholangiography

The duodenoscope is inserted into the duodenum, in the lumen bile, mucous membrane and large duodenal papilla are not changed. The mouth of the large duodenal papilla \u003d 0.2 cm contalated - the catheter is passed into the common bile duct. The bile ducts are contrasted, they are enlarged. The choledoch in the upper and middle third is up to 1.5-1.8 cm, in its middle third the stone is 1.5 to 2.0 cm. It adheres tightly to the walls, it is difficult to streamline the contrast, the instrument cannot be held above the stone. The distal part of the common bile duct is up to 0.8 cm, due to which lithoextraction is impossible, and papilotomy is not advisable

Summary of pathological symptoms

Sharp. Prolonged, intense pain in the right hypochondrium and epigastric region, arising from an error in the diet.

General weakness.

Increase in pressure 160/90 mm Hg

Yellowness of the skin and mucous membranes, conjunctiva and sclera.

Sharp soreness at the point of the gallbladder (Kera's symptom)

Soreness when tapping along the right costal arch (Ortner's symptom)

Leukocytosis.

On ultrasound, acute calculous cholecystitis.

Differential diagnosis

This disease can be differentiated from acute heart attack myocardium in both cases, the pain is based in the epigastric region, radiates behind the sternum, accompanied by nausea, vomiting. In laboratory tests, blood sugar N will be N, urine diastasis and bilirubin are not elevated. However, in acute MI, pain is associated with exercise. Can be stopped with NO drugs. Blistering symptoms are not determined. With ultrasound, there are no changes in the liver and biliary tract. Characteristic changes on the ECG. While this patient has a connection between the pain and the consumption of fatty foods, vomiting of bile brings short-term relief. On admission, positive symptoms were noted: Grekov-Ortner, Kera. In the analysis of blood there is leukocytosis, which indicates an inflammatory process. Typical changes according to ultrasound data.

This disease can also be differentiated from acute pancreatitis. In both cases, the pain is sharp, constant (sometimes increasing) in the epigastric region. Characterized by posterior irradiation of pain - to the back, spine, lower back. Soon, repeated profuse vomiting appears, the connection of the disease with alcohol intake, there are no characteristic changes on the ECG.In the blood test, there is leukocytosis. However, for acute pancreatitis, it is characteristic: Gallbladder symptoms are not determined. A sharp increase in urine diastase, and bilirubin is not increased, vomiting does not relieve pain, while in this patient, vomiting of bile brought short-term relief. On admission, there were positive symptoms: Grekov-Ortner, Kera. Diastasis is not increased. Detection of calculi in the gallbladder by ultrasound.

The presence in the clinical picture of a disorder of the general condition, pain syndrome (pain in the parva hypochondrium, radiating to the epigastric region), nausea, ultrasound data - pancreas of a heterogeneous structure, increased echogenicity with areas of reduced echogenicity. On the lateral contour there is a hyperechoic sickle 0.2 cm thick, the tissue of the gland is edematous. They allow us to think of acute pancreatitis as the main disease, but since there is no increase in the level of blood amylase, the pain syndrome is not pronounced sharply, we can think of acute pancreatitis only as a complication of the underlying disease. But the level of amylase in the blood is not elevated, the diagnosis of acute pancreatitis can be refuted.

On the basis of pain (pain in the right hypochondrium and epigastric region, appearance after ingestion of fatty and spicy foods, bursting, encircling nature of pain) and dyspeptic (accompanying pain with nausea, vomiting that does not bring relief, severity in the right hypochondrium) syndromes can be assumed peptic ulcer duodenum in a supervised patient. But, distinctive features pain syndrome in case of duodenal ulcer are: connection with food intake, its quality and quantity, seasonality, increasing character, decrease after eating, application of heat, anticholinergic agents. While in this patient, pain attacks are deprived of a daily rhythm, occur after eating fatty foods, accompanied by nausea, bitterness in the mouth, vomiting that does not bring relief, decrease after taking antispasmodics and analgesics. Soreness on palpation at the point of the gallbladder, positive symptoms of Ortner, Murphy, Mussi-Georgievsky, which is absent in patients with duodenal ulcer, are determined. The FGDS data also confirm the absence of duodenal ulcers in the patient: the lumen of the duodenal bulb is normal, the contents are normal, the mucous membrane is atrophic, there are no ulcers or erosions.

Based on the patient's complaints of a feeling of heaviness and bursting pain in the right hypochondrium, nausea, it is possible to make a diagnostic assumption about the presence chronic hepatitis... However, in chronic hepatitis, even with its benign course, an objective examination reveals a slight increase in the liver, and on palpation a moderately dense, slightly painful edge. In our patient, the edge of the liver is at the level of the lower edge of the costal arch, soft, rounded, moderately painful. With hepatitis of any form, a slight enlargement of the spleen is also detected, and with chronic active hepatitis, the spleen reaches a significant size. In this patient, the spleen is not palpable. Its size is normal. When taking an anamnesis for chronic hepatitis, either a past infectious disease (brucellosis, syphilis, Botkin's disease) or toxic poisoning (industrial, household, medicines). When collecting anamnesis, the patient contact with the above infectious diseases denied. Based on the nature of the disease (chronic hepatitis), one can expect the appearance in the patient's clinical picture of periods of exacerbation, during which he is worried about weakness, fever, pruritus, and yellowness of the skin. But in the supervised patient, pain appears after eating fatty foods. Also, in the clinical picture of this patient, the greatest pain is observed at the Kera point, and in chronic hepatitis, the most painful point does not exist, the entire area of \u200b\u200bthe right hypochondrium hurts. Also, the yellowness of the skin is not associated with chronic hepatitis, since endoscopic retrograde cholangiography revealed a stone from 1.5 to 2.0 cm in the middle third of the common bile duct, which is tightly attached to the wall. Also, a biochemical analysis of blood revealed an increase in the level of total bilirubin (275.8 mmol / L) and the fraction of direct bilirubin (117.8 mmol / L). As a result of obstructive jaundice, the patient has acholic feces and dark urine, which is not typical for the clinic of chronic hepatitis. Due to the lack of a characteristic clinical picture, the absence in the history of contact with infectious diseases and poisoning with toxic substances, as well as periods of exacerbation, the assumption that the supervised patient has chronic hepatitis can be refuted.

Final diagnosis

Main - Chronic calculous cholecystitis, exacerbation phase.

Complications - no.

Concomitant diseases - ischemic heart disease, angina pectoris 2 f. Cl. Atherosclerosis of the aorta, coronary, cerebral vessels. Arterial hypertension 3 tbsp., Risk 4. Acquired rheumatic heart disease. Mitral stenosis. Severe mitral insufficiency. Aortic insufficiency. Decompensation of blood circulation in the pulmonary circulation. Pulmonary hypertension. Persistent form of atrial fibrillation.

Acute calculous cholecystitis is based on:

patient complaints: pain in the right hypochondrium, nausea, repeated vomiting of bile, bringing short-term relief.

Based on the medical history: intake of fatty foods.

Clinical data: On palpation, the abdomen is soft, moderately painful in the right hypochondrium. Positive symptoms: Grekov-Ortner, Kera.

Data laboratory research: leukocytosis, increased ESR, changes in biochemical parameters (preservation high level bilirubin with a predominance of direct)

Ultrasound data: the size of the gallbladder 70 * 30 mm, irregular shape, wall up to 5 mm. doubled. Concretions ranging in size from 0.5 to 1.0 cm.

Etiology and pathogenesis of cholelithiasis

There are two types gallstones: cholesterol and pigment.

The following factors are believed to contribute to the formation of stones:

female;

age 40 and above;

fat-rich foods;

metabolic diseases;

heredity;

pregnancy;

stagnation of bile;

an infection in the gallbladder cavity.

Cholesterol stones in the gallbladder are formed due to a violation of the relationship of the main bile lipids, which are cholesterol, phospholipids and bile acids. Due to cholesterol, cholesterol stones are formed, and due to bilirubin, pigment stones.

Cholesterol is able to be excreted in bile exclusively in the form of micelles formed by phospholipids and bile acids, therefore, its amount depends on the amount of secreted bile acids, which also increase its absorption in the intestine, thus regulating its level in bile.

It is practically insoluble with cholesterol and forms crystals in the form of monohydrates. If the amount of bile acids and lecithin is insufficient for the formation of micelles, then such bile is considered oversaturated. Such bile is considered a factor predisposing to the formation of stones, as a result of which it is called lithogenic. ° C, they spontaneously form complex micelles formed from the outside by bile acids located so that cylinder-like structures appear, from the ends of which the hydrophilic groups of lecithin (phospholipid) are directed to the aqueous medium. Cholesterol molecules are located inside the micelle, which are isolated from the aqueous environment on all sides. In an aqueous medium at a temperature of 37 ° Molecules of all three main lipids are amphiphilic and, being in an aqueous medium at a temperature of 37

Theoretically, you can imagine following reasons the occurrence of bile oversaturation with cholesterol:

) its excessive secretion into bile;

) decreased secretion of bile acids and phospholipids into bile;

) a combination of these reasons.

Lack of phospholipids is practically not found. Their synthesis is always sufficient. Therefore, the first two reasons determine the frequency of occurrence of lithogenic bile. Moreover, most cholesterol stones have a pigment center, although the pigment is not the center of initiation, since it penetrates into the stone again through cracks and pores.

Pigment stones can form when the liver is damaged, when it secretes pigments that are abnormal in structure, which immediately precipitate in the bile, or under the influence of pathological processes in the biliary tract, which convert normal pigments into insoluble compounds. More often this happens under the influence of microflora. Fatty acids that enter the stone are products of lecithin breakdown under the influence of lecithinases of microorganisms.

The main reasons for the development of an inflammatory process in the wall of the gallbladder are the presence of microflora in the cavity of the bladder and a violation of the outflow of bile.

Infection is of prime importance. Pathogenic microorganisms can enter the bladder in three ways: hematogenous, lymphogenous, enterogenic. More often the following organisms are found in the gallbladder: E. coli, Staphilococcus, Streptococcus.

The second reason for the development of the inflammatory process in the gallbladder is a violation of the outflow of bile and its stagnation. In this case, mechanical factors play a role - stones in the gallbladder or its ducts, bends of an elongated and convoluted cystic duct, its narrowing. Against the background of cholelithiasis, according to statistics, up to 85-90% of cases of acute cholecystitis occur. If sclerosis or atrophy develops in the wall of the bladder, then contractile and drainage functions the gallbladder, which leads to a more severe course of cholecystitis with deep morphological disorders.

Vascular changes in the bladder wall play an absolute role in the development of cholecystitis. The rate of development of inflammation, as well as morphological disorders in the wall, depend on the degree of circulatory disturbance.

In this patient, it is possible to assume that the leading factors in the development of acute cholecystitis are the presence of stones in the cavity of the gallbladder, which clog the lumen of the duct. Thus, the patient has reasons for the development of gallstone disease. female; age over 40 years old food rich in fat; a sedentary lifestyle leading to an increase in cholesterol levels.

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