Acute cholangitis mcb 10. What is cholangitis and how should it be treated? Antibiotics and other medications

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Cholangitis is an inflammatory process in the bile ducts (cholangiolitis is a lesion of small bile ducts; cholangitis or angiocholitis is a lesion of the larger intra- and extrahepatic bile ducts; choledochitis is a lesion of the common bile duct; papillitis is a lesion of the Vater's nipple region). As a rule, it occurs against the background of violations of the patency of the biliary tract. Bile infection can provoke inflammation. Often, pathology occurs together with cysts of the common bile duct, as well as cancer of the bile duct. The disease occurs against the background of the entry of pathogens of bacterial infection into the bile ducts.

ICD-10 code

This disease belongs to the cycle - other diseases of the biliary tract (K83). True, in this case, conditions that relate to the gallbladder (K81-K82), cystic duct (K81-K82), postcholecystectomy syndrome (K91.5) are excluded.

K83.0 Cholangitis Cholangitis: ascending, primary, recurrent, sclerosing, secondary, stenosing and purulent. Completely excluded: cholangitis liver abscess (K75.0) cholangitis with choledocholithiasis (K80.3-K80.4) chronic non-suppurative destructive cholangitis (K74.3).

K83.1 Blockage of bile duct Occlusion, bile duct stenosis without stones, narrowing. Completely excluded: with cholelithiasis (K80).

K83.2 Perforation of bile duct Rupture of the bile duct. K83.3 Fistula of bile duct Choledochoduodenal fistula. K83.4 Spasm of sphincter of Oddi K83.5 Biliary cyst K83.8 Other specified diseases of biliary tract Adhesions, atrophy, bile duct hypertrophy, ulcer. K83.9 Disease of biliary tract, not subtle

ICD-10 code

K83.0 Cholangitis

K80.3 Calculus of bile duct with cholangitis

A common cause is the presence of benign structures of the pancreas, Caroli disease, sphincter dyskinesia. Throwing the contents of the small intestine into the biliary tract, as well as complications arising from reconstructive operations on the bile ducts, can lead to the disease. There are several ways in which infection travels to the bile ducts. Often everything happens by hematogenous, or lymphogenous. The causative agents can be microorganisms of the intestinal microflora, which are found in associations. Most often, the disease is bacterial in nature. It can be provoked by representatives of the enterobacteriaceae family, gram-positive microorganisms, non-spore-forming anaerobes.

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Pathogenesis

The main causal disease is its combination with a violation of the outflow of bile. In its pure form, it is not so common, it is mainly combined with cholecystitis or hepatitis. Mostly the problem is caused by a bacterial infection. It can penetrate into the bile ducts through the intestines or together with the blood stream. The most common causative agent is Escherichia coli. It is extremely rare that this is enterococcus, staphylococcus and anaerobic infection.

The mechanism of development lies in the stagnation of bile. This is observed when the passages are blocked with a stone. A cyst of the bile duct, an ulcer, endoscopic manipulations on the common bile duct are capable of provoking the phenomenon. In general, any problems associated with the outflow of bile. Therefore, timely eliminated problems can reduce the risk of developing the disease. By the nature of inflammation, the disease is divided into several types. So, cholangitis can be catarrhal, purulent and diphtheria.

Cholangitis symptoms

The acute form of the disease can occur against the background of complications with total obstruction of the gallbladder. It is extremely rare that everything happens as a complication of common bile duct. The clinical picture of manifestation includes malaise, jaundice, pain in the scapula, forearm. All this can flow into fever, nausea, vomiting. A person is pestered by confusion, arterial hypotension is observed. Patients have thrombocytopenia. It is a manifestation of intravascular coagulopathy.

The acute form of the disease has slightly different symptoms. More precisely, it has a more acute course. In most cases, a person is pestered by dyspeptic disorders that occur without fever and jaundice. There is no pain syndrome. In the intervals between exacerbations, symptoms can be completely absent. If the liver is also affected, then those that correspond to parenchymal jaundice are added to all the signs.

At times, the illness can start like sepsis. So, a person is pestered by alternating chills and fever. The severe form is accompanied by septic shock and renal failure. The frequency of fever depends on the pathogen that triggered the disease. Pneumococcal cholangitis is extremely difficult. As soon as biliary hypertension subsides, symptoms disappear. During an exacerbation, the liver is able to increase in size.

In a chronic course, everything is accompanied by dull pains, a feeling of pressure, itching, slight yellowness of the mucous membranes. Often manifests itself as an unmotivated subfebrile condition. The elderly have a pronounced asthenic syndrome. It is characterized by fever and pain.

First signs

Much depends on what form of the disease is present in a person. So, chronic cholangitis is characterized by an asymptomatic course, which is accompanied by an acute form, but only occasionally. This condition is characterized by the presence of fever, severe cramping pain in the abdomen and chest... Weakness, nausea, vomiting and a sharp decrease are especially pronounced blood pressure... From these symptoms, it is possible to make a diagnosis.

Chronic cholangitis does not have the first symptoms, since it is practically asymptomatic. This is the main danger. The disease can lead to kidney coma. Therefore, if any discomfort appears or there are problems accompanying the development of cholangitis, you should seek help from medical institution... The chronic form is characterized by the appearance of pain syndrome of varying intensity. A person feels tired, itchy, and fever. Redness of the palms is often observed. The terminal phalanges of the fingers are able to thicken.

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Charcot triad with cholangitis

For the acute form of the disease, the presence of the Charcot triad is characteristic. It consists in the presence of three main symptoms. Typically, this is pain in the right upper quadrant of the abdomen, fever, and jaundice. It is very easy to determine the presence of the last two signs. To do this, it is enough to examine the liver, it is clearly enlarged and this is noticeable on palpation.

There is also Murphy's symptom. It is characterized by the presence of point sensitivity in the gallbladder region. It is easy to determine this by palpation. There is sensitivity in the right hypochondrium. It usually spreads across the entire width of the liver. Liver edema can vary in severity. Therefore, it is easy to determine the presence of this symptom. If the clinical manifestations are correctly evaluated, then the treatment will be not only correct, but also effective.

Therefore, patients with cholecystitis or biliary colic are referred for ultrasound. This will allow you to confirm or deny that there is a problem. With an untimely determination of pathology, it is able to actively progress. This adds a couple more symptoms, namely confusion and septic shock... These signs, together with the Charcot triad, can be fatal. The decision on hospitalization and treatment must be made in an hour.

Sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a condition characterized by the production of antibodies against the bile ducts. All this is accompanied by a violation of the outflow of bile. The causes of this form of the disease are unknown. It is believed that the problem is associated with the presence of an infectious agent, which is a provoking factor in people with a genetic predisposition.

Men are affected by this phenomenon much more often than women. Pathology develops at the age of 25-45 years. In some cases, this happens in children. early age... Almost 70% of cholangitis is accompanied by ulcerative colitis. It can be combined with diabetes mellitusas well as thyroiditis.

The disease does not manifest itself clearly. The symptomatology is simple, it consists in a change biochemical parameters... Most often accompanied by the absence of signs. At the beginning of the disease, a person begins to lose weight dramatically, he has itching, pain in the right hypochondrium, as well as jaundice. If the symptoms began to manifest themselves, then the process has a difficult course. Fever is not specific.

Diagnosis of the disease consists in the study of blood serum. The condition is characterized by an increase alkaline phosphatase, as well as bilirubin, the level of γ-globulins, IgM. During ultrasound, thickening of the walls of the bile ducts is observed. The disease is characterized by the development of liver damage, which is accompanied by cirrhosis and hepatocellular failure.

Acute cholangitis

The acute course of the disease is characterized by chills and fever. Profuse sweat, bitterness in the mouth, and vomiting are not excluded. Pain in the right hypochondrium is not uncommon. Sometimes the pain syndrome is too intense. The liver can grow in size, be accompanied by jaundice and itchy skin.

Sometimes there is a fever, aching pain in the right hypochondrium. There is weakness, fatigue. A person quickly gets tired, he shivers. The liver and spleen are of considerable size. The disease can carry complications. They are characterized by the presence of suppuration, necrosis.

The disease often leads to hardening of the bile ducts. All this over time spills over to the development of hepatitis. The outcome of the situation is liver cirrhosis. Diagnosis is by symptomatology. On palpation, the liver is significantly enlarged. A number of X-ray and laboratory tests are performed to confirm the diagnosis. History of gallbladder disease.

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Chronic cholangitis

This disease is characterized by chills, which are accompanied or alternating with fever. A person is bothered by profuse sweating, bitterness in the mouth, as well as vomiting and pain in the right hypochondrium. The liver may enlarge significantly. Jaundice often occurs, as well as itchy skin. In the blood is observed elevated level leukocytes.

The chronic form of the disease occurs against the background of a previously existing acute period. The clinical picture is similar. A person is pestered by an increased low-grade fever, as well as yellowness of the sclera. There are aching pains in the right hypochondrium. The victim quickly gets tired, he has weakness, sharp weight loss. The liver and spleen are rather enlarged.

The chronic form can lead to a number of complications. Suppuration, hepatitis and even cirrhosis of the liver may occur. Therefore, it is impossible to admit this disease, especially its progression. On palpation, a sharp increase in the liver is felt. It is important to diagnose the disease in time and start treating it.

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Bacterial cholangitis

Most often, the classical form manifests itself, namely the Charcot Triad. The person is pestered by pain, accompanied by all jaundice and fever. Pain sensations are localized mainly in the epigastric region. Most often, patients complain of intense or colicky pain. In rare cases, discomfort is felt.

This pathology is characterized by an increase in temperature, up to 39 degrees. Sometimes it is much higher. In addition, there is headachechills. During the examination, the doctor notices an enlarged liver as well as pain in the right side. In almost all cases, leukocytosis is observed.

Diagnostics is carried out by passing laboratory tests. Instrumental research is being actively carried out. Usually, donating blood is sufficient. Additionally, you can take a coprogram and urinalysis, but after the approval of the doctor. Ultrasound, ECG and CT are performed. It is important to diagnose the problem on time and start treatment.

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Giardous cholangitis

This disease is caused by common lamblia. Pathology occurs in both adults and children. It is transmitted mainly through unwashed hands, by entering the mouth. Bacteria live in the duodenum, as well as the upper intestines. Sometimes found in gallbladder.

It is not so easy to determine the presence of a problem, because it is closely related to other diseases of the intestine, as well as the biliary tract. It is possible to diagnose pathology only when the simplest lamblia is detected. Despite this, the symptoms are still observed. So, a person is pestered by pain in the right hypochondrium, nausea, dizziness, as well as problems with the gastrointestinal tract. Heartburn, diarrhea, or constipation may occur. Sometimes there is an increase in temperature, as well as pain syndromes in the liver. The problem can be eliminated exclusively by observing a special diet. Observation by a gastroenterologist is mandatory.

Purulent cholangitis

This pathology is clinically manifested in the form of fever and jaundice. A person may have confusion, as well as arterial hypotension. May develop over time renal failure, as a consequence of this - thrombocytopenia. The condition must be corrected by medical intervention.

You can diagnose everything with the help of laboratory tests. Usually, a person is sent for a blood culture, the number of leukocytes. Consider indicators of kidney function. An ultrasound scan is performed. Even if the results are negative, endoscopic cholangiography is recommended.

Treatment is with broad spectrum antibiotics. Detailed information on this type of medication will be provided below. It is not so difficult to fix the problem, but the work is painstaking. Therefore, it is advisable to seek help from a doctor when the first symptoms appear. Comprehensive elimination of the problem will help remove the disease once and for all.

Cholangitis after removal of the gallbladder

From the liver, bile must flow into the gallbladder. Here it accumulates and reaches a certain concentration. As soon as food enters the body, concentrated bile is sent to duodenum and then participates in the digestion and assimilation of fats.

When surgery is performed to remove the gallbladder, bile begins to flow directly into the duodenum. It comes directly from the liver. But bile is less concentrated, it is simply unable to fulfill its main function. In the process of digestion, it does not participate, or rather does not give the desired result.

In order to avoid complications, a person must follow a special diet. Otherwise, there will be stagnation of bile in the liver. Development hazard inflammatory process is at a high level. Cholangitis may appear first. The patient should eat a little and often, 6-7 times. In this case, there will be no complications.

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Calculous cholangitis

This pathology does not arise just like that. For its development, a special impetus must occur. As a rule, it consists in the presence of an infectious focus in the body. In order to defeat the immune system, the infection must be very severe and the body's functions significantly weakened. Only, in this way, the development of the disease is possible.

Often everything occurs against the background of the presence of cholecystitis. The fact is that the focus of infection is located too close to the liver and ducts. Therefore, its penetration into the biliary tract is quite likely. Plus, there is stagnation of bile, which significantly aggravates the situation. Stagnation always leads to the development of a severe infection.

Inflammation can lead to swelling and redness. They are the satellites of inflammation. It is important to pay attention to the main symptoms in time and start treatment. For a person suffering from cholangitis at this stage, the presence of high temperature, jaundice and dull pain in the liver.

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Autoimmune cholangitis

The disease resembles primary biliary cirrhosis in its histological features. However, it is characterized by the presence of antimyochondrial antibodies, as well as antinuclear antibodies and / or antibodies to smooth muscles. Thus, the disease is considered idiopathic, with a mixed pattern of hepatitis and cholestasis.

The main symptoms are immune cholangitis. However, the definition of the disease is ambiguous. After all, it is not clear for what reasons it developed. More precisely, how the disease intersects with the syndrome of primary biliary cirrhosis, as well as hepatitis. Cholangitis of this type can take the form of an independent disease. Seeing this fine line is not easy. The problem does not occur so often, but only in 5-10% of cases.

It is important to start diagnosing the disease on time. Moreover, it is necessary to correctly determine in what form the pathology is. Correct diagnosis and treatment will help to cope with the problem.

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Biliary cholangitis

The disease is an idiopathic liver disorder. The problem mainly affects only adults. Mostly middle-aged women suffer from it. Young men are also subject to it. The disease is characterized by diffuse inflammatory and fibrotic changes in the entire biliary tree.

The root cause of the problem has not yet been identified. There are several main signs that indicate the presence of a disease. So, cholangitis is often associated with other autoimmune diseases. The presence of antibodies circulating in the blood often provokes the development of pathology. During it, the bile ducts are affected. A family predisposition can provoke the disease.

Finding a problem is not easy. It usually goes in conjunction with another problem. It is necessary to take blood tests and examine the liver. This will help track your white blood cell count, as well as other basic indicators. Then quality treatment is prescribed.

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Stenosing cholangitis

The onset of the disease is asymptomatic. Everything develops gradually, so for a long time nothing bothers a person. The first manifestation is an increase in the activity of g-glutamyl transpeptidase (GGTP) and serum alkaline phosphatase (ALP). I mean, there are no visual manifestations. The only way to identify the problem is by donating blood.

The asymptomatic course is especially dangerous, because it can lead to the development of cirrhosis of the liver, as well as portal hypertension. But there are no signs of cholestasis. Most often diagnosed directly "cryptogenic cirrhosis".

It is much better when the disease begins to manifest itself. This will avoid possible complications and save the person. Everything manifests itself in the form of fever, fatigue, constant pain. Changes in body weight are possible, as well as skin itching. Jaundice develops at a progressive stage. Gradually, hepatic cell failure appears, as a consequence of this, biliary cirrhosis is formed.

It is possible to diagnose pathology only thanks to laboratory research... The disease is manifested by slight hyperbilirubinemia and an increase in IgM levels, an increase in the CEC level (70% of cases).

Recurrent cholangitis

If the outflow of bile is constantly disturbed, then the disease progresses and becomes chronic. Repeated repetition of this process leads to the fact that pathology is constantly present and pesters a person everywhere. Naturally, everything alternates with periods of calm and serious manifestations of the disease.

The period of exacerbation is characterized by the presence acute pain in the right hypochondrium. All this is accompanied by fever, jaundice and itching of the skin. The outflow of bile is able to spontaneously recover. But this happens during the so-called periods of calm. Then the pain gradually subsides, the person's condition improves, signs of jaundice are not observed. The person feels much better. But this state is not for long. Over time, the phase of active manifestation of pathology will begin. The symptomatology is constantly repeated. It is important to maintain a person's condition. Otherwise, the condition will worsen significantly. Constantly recurring relapses predict the development of a chronic form.

Hematogenous cholangitis

It is characterized by hematogenous spread of the pathogen. The disease can proceed in different ways. So, its forms can be varied. The developmental option depends on the reason why cholangitis appeared.

All forms of development are based on bacteria or protozoan microorganisms that enter the body. Most often these are opportunistic microflora, lamblia, helminths. Inflammation of the gallbladder, the presence of stones in it, as well as helminthic invasion can serve as a background for the development of the disease. Stagnation of bile provokes the development of cholangitis.

Pathology is characterized by an acute onset. Usually, a sharp rise in temperature is recorded, up to 40 degrees. In parallel with this, a person feels pain in the right side. Moreover, the pain syndrome can be of varying intensity. Sometimes it just looks like colic. The entire right half, side, shoulder, neck and scapula area can pull. In these places there are bundles of nerve endings. With progression, itching, nausea, vomiting, and impaired appetite appear.

Cholangitis in children

The acute form of the disease in children is extremely rare. Basically, it has a secondary form. Initially, the baby can undergo streptococcal etiology, and then this pathology will already arise. Sometimes it has dire consequences. So, pleurisy, lung abscess, sepsis and pancreatitis are not excluded. If the treatment method is chosen incorrectly, the development of toxic liver dystrophy is possible.

Primary pathology has acute symptoms. If it is chronic, then there are no signs. Only occasionally does the baby feel pain in the right hypochondrium, he is pestered by weakness, chills and fever. Usually this manifestation is characteristic of the acute phase. With secondary development, biliary cirrhosis is not excluded. It is very difficult to diagnose, and the disease itself has a complex course.

It is better to treat this form surgically... Because the further condition of the child depends on this. You should not allow a chronic form. There can be many consequences. It is important to observe proper nutrition.

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Cholangitis classification

By etiology:

1. Bacterial.
2. Helminthic.
3. Toxic and toxic-allergic.
4. Viral.
5. Autoimmune.

With the flow:

1. Acute.
2. Chronic.

By pathogenesis:

Most often, cholangitis is of a bacterial nature and the pathogens are most often Escherichia coli, enterococci, Friedlander's bacillus, pneumococci, streptococci.

Effects

If timely treatment is not available, then the inflammatory process may become more serious. Gradually, it spreads to the peritoneum, because of this, the development of peritonitis is possible. Pathology is capable of "spreading" to the surrounding tissues. As a result, subphrenic and intrahepatic abscesses begin to form. Sepsis and toxic shock are common. The last complication develops against the background of the bacterial form of cholangitis.

The patients' condition becomes extremely difficult. Sometimes it is impossible to do without resuscitation measures. The inflammatory process for a long time can lead to sclerotic changes. As a result, the disease takes on a chronic form and leads to the development of biliary cirrhosis.

Self-medication and attempts to eliminate pathology with folk remedies, on the contrary, will aggravate the situation. On the whole, such interference is unacceptable. After all, time may be lost, and the pathology will take on a more serious character. In the later stages, the prognosis is far from the most favorable.

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Complications

If a person is not prescribed timely treatment, complications can be aggravating. Most often, it all ends with liver cirrhosis. In order to prevent such a development of events, it is enough to start treatment on time. Cholangitis often leads to peritonitis. The peritoneum becomes inflamed, and the surrounding tissues are also affected. As a consequence of this, the development of toxic shock is possible. The patient has a hard time tolerating all the symptoms, he needs help in the form of resuscitation measures.

A prolonged inflammatory process leads to the appearance of a chronic form of the disease. This can lead to changes in liver tissue. Ultimately, biliary cirrhosis of the liver takes its development.

To deal with self-elimination of the problem in this case is stupid. While the person tries to remove all the signs, the disease will begin to progress and it is not always possible to save the victim. This should be taken seriously.

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Cholangitis diagnostics

To suspect the existence of a problem simply by the Charcot triad. So, diagnostics is carried out against the background of laboratory and instrumental research... Biochemical tests can indicate cholestasis. In the presence of cholangitis, an increase in the level of bilirubin, as well as a-amylase and alkaline phosphatase, is noted.

There are imaging methods for assessing the condition. As a rule, this is an ultrasound of the abdominal cavity and liver. It will allow you to determine the presence of an inflammatory process, an increase in organs. Computed tomography is rarely done. This will allow you to see an accurate image of the bile ducts and their expansion, as well as the presence of focal changes.

Instrumental diagnostics is also widely used. She occupies a leading position in the definition of pathology. So, it is endoscopic retrograde cholangiopancreatography, as well as magnetic resonance cholangiopancreatography. On the images obtained, you can see the biliary tract and the cause of their obstruction.

Differential diagnosis is necessary only if there is viral hepatitis, right-sided pneumonia, as well as primary biliary cirrhosis.

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Cholangitis tests

An experienced specialist is able to diagnose only one examination. After all, it is worth listening to the patient and palpating so that the picture becomes more or less clear. But, nevertheless, analyzes are necessary in order to clarify in what phase the disease is. This will make it possible to identify the accompanying processes and assess the situation as a whole. After all, an important place in this matter is given to the functionality of the liver and other organs.

First of all, the patient is offered a blood test. Thanks to him, the level of leukocytes is determined. Their significant increase indicates an inflammatory process in the gallbladder. A urine test is also taken. This pathology is characterized by a positive reaction to bilirubin.

A biochemical blood test is performed. It shows the level of bilirubin, as well as gamma globulins, amylase, alkaline phosphase and alpha-2 globulins. It is recommended to take a blood test for sterility. This will rule out or confirm the presence of bacteria. This analysis is carried out exclusively in specialized institutions, because it requires compliance with certain rules. Duodenal intubation is also prescribed. This procedure will allow you to take bile and study it.

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Instrumental diagnostics

This research methodology includes several main areas. So, the first of them is ultrasound, in other words, usually ultrasound. Thanks to it, you can identify an increase in the size of the liver and notice the expansion of the bile ducts.

Second option instrumental diagnostics consists in retrograde cholangipancreatography (ERCP). This is the main method. He is x-ray examination bile ducts by introducing a special contrast agent using an endoscope. The technique allows you to study changes in the biliary tract. In primary cholangitis, changes in the person are visible.

Magnetic resonance cholangiography is also widely used. A special place is given to computed tomography. Duodenal intubation is also used. It allows you to examine bile and see any changes in it. All techniques can be used both independently and in combination. Much depends on the condition of the patient himself.

Ultrasound diagnostics

You can notice changes in the liver and abdominal cavity using ultrasound examination... Focuses of infections, changes in size and shape should immediately prompt the specialist to think that the victim has cholangitis. Naturally, everything is combined with laboratory tests and manifest symptoms.

The study clearly shows the uneven width of the lumen of the bile ducts. They increase significantly inside the kidneys or outside, and they are echogenic. The unevenness is clearly visible. The portal arteries are protruding. With complications, changes in the contours of the liver are visible. Echogenic material is observed in the duct lumen.

An ultrasound examination allows for an accurate diagnosis. It can be confirmed by endoscopic retrograde cholangiography. Naturally, everything is supported by biopsy and clinical data. Based on the data obtained, a diagnosis is made and the person is prescribed quality treatment.

Differential Dianostics

This technique includes a blood test. Thanks to it, you can identify the presence of an inflammatory process in the body. This is usually evidenced by an increase in ESR and leukocytes. Not the last role is assigned to biochemical analysis blood. This study shows the level of bilirubin, especially the direct fraction. The level of alkaline phosphase and gama-glutamyl transpeptidase is determined. These indicators are closely related to the outflow of bile. Any changes in them indicate the presence of violations during this process. An increase in transaminase activity indicates toxic liver damage. In principle, it is impossible to do without differential diagnostics. Laboratory analyzes are especially important.

There is also general analysis urine. The appearance of bile pigments can be noticed here. Feces are given for the presence of helminth eggs and other protozoa in it. Differential diagnostics strictly interacts with instrumental diagnostics.

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With conservative elimination, the patient should refuse food for the first three days, and then proceed to a gentle diet. This will suppress the vital activity of pathogens. After all, they have nowhere to receive recharge. Together with special nutrition, broad spectrum antibiotics are used. Metronidazole is commonly used. In order to reduce the pain syndrome, antispasmodics and analgesics are used. It is recommended to pay attention to Drotaverin and Meverin. If a person has severe intoxication, glucose-saline solution is administered to him.

Surgery is a liver transplant. It is commonly used for cirrhosis, recurrent bacterial cholangitis, and persistent jaundice.

Medicines

As mentioned above, drugs are widely used that reduce pain, eliminate infection and contribute to the rapid recovery of the body. The most popular drugs are: Drotaverine, Meverin, Albendazole, Ademeteonin, Hollestiramine, Ursodeoxycholic acid and Rifampicin. Antibiotics are considered separately.

Broad spectrum antibiotics are used to suppress infection. These include Metronidazole, Tetracycline and Levomecitin. You can take them for no more than 2 weeks in an individual dosage.

• Metronidazole. It is an antimicrobial drug. Apply it one tablet 2-3 times a day. In special cases, the dosage is increased to 4-5 tablets. It is not worth making adjustments on your own, the tool has a number of side effects. So, nausea, vomiting, weakness, presence of metallic taste in the mouth, dizziness. If symptoms appear, you should consult a doctor. Contraindications: pregnancy, childhood, hypersensitivity and lactation period.
• Tetracycline. This drug has a bacteriostatic effect. It should be used at 200-250 mg 2-3 times a day. For children, 20-25 mg / kg is enough. The duration of treatment is assigned on an individual basis. Contraindications: hypersensitivity, pregnancy, lactation, impaired liver and kidney function. Side effects: skin pigmentation, inflammation of the mucous membranes, dysbiosis, allergic reactions. The drug is usually well tolerated.
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Alternative treatment

It should be noted right away that in the presence of such a disease, resort to help traditional medicine not worth it. After all, while a person selects the optimal treatment for himself, the pathology will begin to progress. Liver cirrhosis and other complications pose a colossal threat to human life. You need to understand this fact and not try to fix the problem yourself. Yes there are folk methods treatment, but still it is impossible to do without specialized drugs.

• Recipe 1. For its preparation, you need to take 6 tablespoons of dioecious nettle, 3 tablespoons of grass of a turnip and flowers of sandy immortelle. In the amount of 2 tablespoons, corn stigmas and St. John's wort are taken. All this is mixed with each other. For cooking, it is enough to take only 2 spoons of the collection and mix them with honey. Then everything is poured with boiling water in the amount of 500 ml. You need to insist on the remedy for 2 hours. Then apply 3-6 times a day for half a glass.
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Herbal treatment

Herbs can help in many situations and even cope with bile outflow problems. True, they can be used exclusively as supportive therapy. You should not use them on your own.

• Recipe 1. You need to take a tablespoon of St. John's wort and pour a glass of boiling water over it. Then put on fire and boil for about 15 minutes. The resulting product is taken in a quarter of a glass 3 times a day. The broth is able to have a pronounced anti-inflammatory effect, as well as provoke the outflow of bile.
• Recipe 2. Pour a spoonful of oregano herb with a glass of boiling water. The remedy is infused for 2 hours. It is necessary to take it in a quarter of a glass 3 times a day. The remedy is really effective, but pregnant girls should not take it.
• Recipe 3. Take 100 grams of corn stigmas and mix with 75 grams of marigold and yarrow. All this is poured with two glasses of boiling water (collection is enough to take 2 tablespoons). At night, the agent is left alone. In the morning, everything is filtered and used in 100 ml up to 4 times a day.

Homeopathy

Homeopathic remedies have long gained popularity and special distribution. Nevertheless, it is recommended to resort to the help of standard methods of treatment. When it comes to homeopathy, it is effective, but not for everyone. A variety of remedies are used to combat cholangitis.

• Arsenicum Album. It is a poisonous substance. It is prescribed for people who suffer from itchy skin, worsening at night. Often the drug causes allergic reaction, nausea and upset stomach.
• Baptisia tinctoria (wild indigo of the legume family). The drug is widely used in the chronic form of the disease. Especially if it proceeds along with fever, vivid dreams and sensations of heat in the morning.
• Berberis vulgaris (barberry). It is used when there is bitterness in the mouth, aching painsas well as dryness in oral cavity... The development of pain syndrome during movement is possible.
• Briony alba (white step). A remedy is prescribed for very painful palpation and the presence of a pathological process in the liver.
• Cuprum (copper) and zinc (zinc). They are widely used for severe spasms of the gallbladder. They are able to have anti-inflammatory effects.
• Lycopodium clavatum. It is used for cholangitis accompanied by liver disease. Especially when there is a pronounced symptomatology. In this case, we mean bitterness in the mouth, impaired appetite, heartburn.

WITH complete list medications are available from a homeopathic physician. It is he who prescribes this or that remedy depending on the person's condition and symptoms.

Diet for cholangitis

• Diet number 5. You need to eat food 5 times a day, in small portions. It is forbidden to eat before bedtime, in any case, to eat too much. Spicy and spicy dishes are prohibited. You will have to give up garlic, horseradish and radish. Alcoholic drinks are strictly prohibited. Fatty meat and fish should be deposited until better times. A person consumes up to 3500 kilocalories per day. The daily intake is 90-100 grams of protein, 100 grams of lipids and 400 grams of carbohydrates. Buckwheat, lean meat, fish, cottage cheese and oatmeal should be included in the diet. As soon as the condition improves, you can switch to vegetable and milk soups. Lean meat and fish are allowed. You can eat cookies, fresh vegetables (cabbage, carrots and potatoes). Bread is allowed, but slightly dried. Honey, sugar and berry infusions are very useful. You can compose a diet yourself, starting from the list of permitted foods.
• Diet number 5a. You can eat absolutely any cereals, but they need to be very boiled. Meat and fish are eaten steamed. You can't fry anything! Not worth eating raw fruit and vegetables. Is under the ban rye bread... It is advisable to spend mono-diet days on apples or cottage cheese. To eliminate constipation, the diet is diluted with dried fruits, beets and vegetable juices. When the condition improves, you can switch to diet number 5.

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All patients who suffer from a chronic form of pathology should always be under dispensary supervision. It is important to carry out anti-relapse treatment, this is done 1-2 times a year, depending on the person's condition and the progression of the pathology. It is necessary to constantly consume mineral water, choleretic drugs and health food. It is advisable to periodically refer patients to health resorts and dispensaries.

Forecast

The prognosis for the disease completely depends on the person's condition and the form of the flow, as well as the outflow of bile. If the treatment was carried out in a timely manner, then there should be no complications. A quick intervention leads to a positive result. But, it is important to support the body so that a relapse does not occur. The constant repetition of the pattern of pathology leads to a chronic course. In this case, the prognosis can be extremely unfavorable.

If we talk about the later stages of pathology, then everything here depends on the treatment. But still, the probability of an unfavorable forecast is several times higher. It is not always possible to save a person, especially if he has cirrhosis of the liver. Here only organ transplantation is needed. Additional symptoms related to acute liver failure, cirrhosis and liver abscess can worsen the prognosis. Women over the age of 50 are at risk. Therefore, it is important to get tested and respond to any symptoms in a timely manner.

Primary sclerosing cholangitis Is a chronic cholestatic syndrome characterized by areas of inflammation, fibrosis, and narrowing in the intrahepatic and extrahepatic biliary tract.

In about 80% of patients, primary sclerosing cholangitis is associated with ulcerative colitis. The disease leads to obliteration biliary tract with their cirrhosis, liver failure and, sometimes, cholangiocarcinoma.

On early stages diseases include symptoms of ulcerative colitis, and symptoms such as weakness and itching occur late.

Diagnosis of the disease is based on the conduct of ERPCG or MRPCG.

There are no specific treatments. With severe lesions, liver transplantation is indicated.

• Epidemiology of primary sclerosing cholangitis

  The prevalence of primary sclerosing cholangitis in the world is not exactly known. The prevalence of the disease in the United States is about 6.3 cases per 100,000 population. In the Scandinavian countries, the prevalence of this disease is slightly higher.

  In about 80% of patients, primary sclerosing cholangitis is associated with chronic inflammatory bowel disease (primarily ulcerative colitis). However, in Japan, the combination of ulcerative colitis and primary sclerosing cholangitis occurs in only 23% of cases.

  Approximately 70% of patients with primary sclerosing cholangitis are men. The average age of sick men is about 40 years.

Primary sclerosing cholangitis, bacterial cholangitis

Version: MedElement Disease Handbook

Cholangitis (K83.0)

Gastroenterology

general information

Short description

Cholangitis- an inflammatory disease of the extra- and intrahepatic bile ducts, with an acute or chronic recurrent course. Much less common inflammatory diseases gallbladder.

Notes

1. To this subheading included:
1.1 Bacterial cholangitis.
1.2 Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease characterized by inflammation and progressive fibrosis Fibrosis - growth of fibrous connective tissue, which occurs, for example, in the outcome of inflammation.
intra- and extrahepatic bile ducts, which sequentially leads to their narrowing, obliteration, ductopenia Ductopenia is a disappearing bile duct syndrome.
and, as a consequence, to the development of liver cirrhosis and cholangiocellular carcinoma.

2. From this subheading excludeds:
- cholangitis with liver abscess ();
- cholangitis and choledocholithiasis (K80.3 -, K80.4);
- chronic destructive non-purulent cholangitis in primary biliary cirrhosis ().

Progressive cholangitis;

Cholangitis, unspecified;

Primary cholangitis;

Recurrent cholangitis;

Sclerosing cholangitis;
- secondary cholangitis;

Stenosing cholangitis;

Purulent cholangitis.

4. Synonyms:

Bacterial cholangitis;

Bacterial cholangitis;
- primary sclerosing cholangitis.

Classification

A clear, comprehensive classification of cholangitis does not currently exist. The following types of cholangitis are tentatively distinguished. Some forms of cholangitis (cholangitis with gallstones, ischemic cholangitis, and others) are classified in other headings.

I. According to the clinical course:acute and chronic cholangitis (some authors also distinguish recurrent cholangitis).

II. Primary and secondary (as complications of diseases, manipulations).

III. By the nature of the process:

2. Sclerosing:

2.1 Primary sclerosing cholangitis (PSC):
- in combination with ulcerative colitis (NUC);
- without NUC.

2.2 Secondary sclerosing cholangitis:

2.2.1 Toxic damage:
- with the introduction of formaldehyde and absolute alcohol into echinococcal cysts;
- taking thiobendazole.

2.2.2 Ischemic injury:
- with thrombosis of the hepatic artery after liver transplantation;
- in case of a graft rejection reaction;
- with the introduction of 5-fluorouracil into the hepatic artery during tumor chemotherapy;
- during operations on the bile ducts.

2.2.3 Bile duct stones, including choledocholithiasis.

2.2.4 Congenital anomalies bile ducts:
- common bile duct cyst;
- Caroli's disease.

2.2.5 Cytomegalovirus infection or cryptosporidiosis in AIDS.

2.2.6 Histiocytosis.

2.2.7 Cholangiocarcinoma.

Primary sclerosing cholangitis is also classified by stage (severity of damage to the bile ducts and fibrosis):
- Stage 1 (early changes) - damage to the bile ducts and inflammation limited to the area of \u200b\u200bthe portal tract;
- stage 2 - the spread of inflammation and fibrosis outside the portal tract;
- stage 3 - a decrease in the number of bile ducts and bridging fibrosis;
- stage 4 (terminal) - the development of liver cirrhosis.

Etiology and pathogenesis

Bacterial cholangitis

Etiology

The spectrum of pathogens of bacterial infection in cholangitis corresponds to the spectrum of intestinal microflora (Escherichia coli, Proteus vulgaris, Enterococcus). With purulent cholangitis in more than 90% of patients, several pathogens are detected in the bile at the same time and, in addition, positive results of blood culture for sterility are recorded.

Pathogenesis

Microorganisms can enter the bile ducts as a result of dysfunction of the duodenal nipple (condition after endoscopic retrograde cholangiopancreatography, ERCP) or can enter the bile ducts by hematogenous or lymphogenous routes.

(PSH)

The etiopathogenesis of PSC is unknown. Toxins, infectious agents and immune disorders are considered as possible etiological factors.
Excessive copper deposition in liver tissue was found in PSC patients. However, chelation therapy in these patients turned out to be ineffective, which indicates the secondary nature of copper overload (in particular, this is typical for patients with primary biliary cirrhosis).
The epithelium of the intrahepatic bile ducts is infected with cytomegalovirus and reovirus type 3, but the probability of detecting these viruses in all patients with PSC remains hypothetical.
The possibility of a genetic predisposition to the disease is indicated by the high incidence of various autoimmune disorders (including the liver - autoimmune cross syndrome) in PSC patients. The loci HLA-B8 and HLA-DR3, which are often found in patients with autoimmune diseases, are also found in patients with PSC.
With PSC, T-lymphocytes and immune-mediated mechanisms are actively involved in damage to the bile ducts, the action of which is manifested by lymphoplasmacytic infiltration, accumulation of eosinophils and obliterating phlebitis.

Pathogenesis of ductopenia and cholestasis in PSC:

Decreased secretion due to exposure to pro-inflammatory cytokines;

Disruption of the expression and functional activity of carrier molecules;

Blockade of the patency of the bile ducts as a result of chronic inflammation and fibrosis;

Retention of bile acids and activation of apoptosis Apoptosis is a programmed cell death by internal mechanisms.
hepatocytes.

Epidemiology

Cholangitis

The mortality rate varies between 13-88%.

Geography. There is an increase in frequency in Southeast Asia.

Floor. No difference

Age. It mainly occurs in adults, the average age of onset is 50-60 years.

Primary sclerosing cholangitis

The prevalence is estimated at an average of 6.3 cases per 100,000 population.

Gender and age. The disease usually begins at the age of 20-30, although it can also manifest itself in childhood. About 70% of patients with PSC are men. The average age at diagnosis for them is about 40 years.
Patients with PSC but no inflammatory bowel disease are more likely to be older women at the time of diagnosis.

The true frequency of PSC in the population is unknown, but it is increasing every year due to improved diagnostic methods. It is assumed that in some countries the underestimation of the prevalence of the disease is significant figures (underestimated by 3-4 times).

Factors and risk groups

- young men (25-45 years old);
- patients with ulcerative colitis of any age and gender;
- patients with type 1 diabetes mellitus;
- patients with a burdened family history.

Symptoms, course

Bacterial cholangitis

Classic symptoms of cholangitis: pain in the right hypochondrium, chills, fever, Charcot triad (a combination of fever, chills and jaundice).

The pain is usually localized in the epigastric region, is intense and colicky.
Fever, as a rule, is intermittent, but in elderly patients and those in a state of immunosuppression, it can be subfebrile.
In the case when signs of sepsis in the form of arterial hypotension and mental disorders join the described symptoms, this symptom complex is called reynold's pentad.

Primary sclerosing cholangitis

In patients with primary sclerosing cholangitis (PSC), many clinical signs characteristic of primary biliary cirrhosis (PBC) are revealed. The disease usually begins imperceptibly and retrospectively it is difficult to fix the time interval of the disease onset.
Some signs of the disease may appear in 75% of patients with PSC within 1-2 years before diagnosis.

Main complaints associated with increasing general weakness and itchy skin, to which jaundice subsequently joins. This triad of symptoms is typical for 2/3 of patients.
When clinical signs cholangitis (pain in the right hypochondrium, fever and jaundice), it is necessary to exclude the possibility of complications (choledocholithiasis and others). On the stage clinical manifestations in 75% of patients, jaundice is found in combination with hepatosplenomegaly. Melasma and xanthelasma (xanthomas) are less common than in patients with PBC.

Initial symptoms in 29 patients with PSC (after S. Sherlock, J. Dooley, 1999)

Symptom	Number of patients	%
Jaundice	21	72
Itching	20	69
Weight loss	23	79
Pain in the right upper quadrant of the abdomen	21	72
Acute cholangitis	13	45
Bleeding from varicose veins of the esophagus	4	14
Malaise	1	3
Asymptomatic course	2	7
Total	29

PSC is often combined with lesions of other organs and systems. Diseases associated with PSC:

Chronic inflammatory bowel disease (NUC, Crohn's disease);

Pancreatitis;

Diseases of the joints;

Sarcoidosis;

Celiac disease;

Thyroiditis;

Type 1 autoimmune hepatitis.

Always, even in the absence of symptoms of bowel disease, UC (and in rare cases Crohn's disease) should be ruled out with sigmoidoscopy and rectal mucosa biopsy. PSC can be detected earlier or later than colitis. Colitis is usually chronic, diffuse, mild, or medium severity. The activity of cholangitis is inversely proportional to the activity of the colitis. Remissions are usually long-term.

Diagnostics

The basis for the diagnosis of any cholangitis is the study of the clinical symptoms of the disease.

Bacterial cholangitis

1. Ultrasound... In acute cholangitis, the following are often detected: thickening of the walls of the bile ducts, an increase in their echogenicity, the presence of gas bubbles in the bile ducts, sometimes some expansion of the ducts and indistinct visualization of the lumen.
Cholangitis often enough can lead to the development acute cholecystitis or develop in parallel with it. After clinical recovery from cholangitis in the echographic picture of the liver, multiple hyperechoic point and small focal inclusions in the parenchyma can be detected Parenchyma - a set of basic functioning elements internal organ, limited by the connective tissue stroma and capsule.
in the zones of the location of the intrahepatic ducts.
One of frequent reasons cholangitis and cholecystocholangitis in some regions can serve as opisthorchiasis Opisthorchiasis - helminthiasis from the group of trematodes, caused by a feline fluke (Opisthorchis felineus) or a squirrel fluke (Opisthorchis viverrini); manifests itself in the early phase by the phenomena of cholangitis, pancreatitis and allergies; human infection occurs when eating infested fish
.

2. CT scan also allows you to see the expansion of the intra- and extrahepatic bile ducts.

3. If you suspect obstruction of the biliary tract, perform ERCP ERCP - endoscopic retrograde cholangiopancreatography
.

Primary sclerosing cholangitis

1. ERCP - the method of choice, transhepatic cholangiography can also be used with success. The diagnostic criterion is the identification of areas of uneven narrowing and expansion (distinctness) of the intra- and extrahepatic biliary tract.

2. Ultrasoundreveals thickening of the bile duct walls and signs of portal hypertension Portal hypertension is venous hypertension (increased hydrostatic pressure in the veins) in the portal vein system.
.

3. CT scanallows visualization of minimally dilated areas along the bile ducts.

Laboratory diagnostics

Bacterial cholangitis

1. Signs of inflammation:
- leukocytosis with a shift of the formula to the left;
- increased ESR ESR - erythrocyte sedimentation rate (non-specific laboratory blood index, reflecting the ratio of plasma protein fractions)
.
2. Cholestasis: increased activity of alkaline phosphatase, GGT Gamma-glutamyl transpeptidase (GGT) - an enzyme involved in the exchange of amino acids
, concentration of bilirubin.

3. Cytolysis (rare): increased activity of serum transaminases.

Notes:
1. High levels of bilirubin occur mainly in patients with malignant obstruction.
2. A simultaneous increase in amylase indicates a possible obstruction in the area of \u200b\u200bthe Vater's nipple.
3. Blood culture results are positive in almost 50% of patients. Bile culture results are positive in almost all patients.
Several organisms are identified as the most common (approximately 60% of patients): Escherichia coli, Klebsiella, Enterococcus species. Of the anaerobic pathogens, the most frequently isolated culture was Bacteroides fragilis.

Primary sclerosing cholangitis (PSH)

1. Cholestasis:
- increased activity of alkaline phosphatase 3 times higher than normal Attention! ;

The bilirubin level fluctuates significantly and in rare cases exceeds 170 μmol / L;
- in all patients with severe and prolonged cholestasis, the content of ceruloplasmin and copper in the blood serum may increase.

2. Levels of gamma globulins and IgM are increased in 30 and 50% of cases, respectively.

3. Low titers of anti-smooth muscle antibodies (SMA) can be detected in serum, p-ANCA is present in 84% of patients; anticardiolipin (ACL) antibodies - in 66% of cases; antinuclear antibodies (ANA) - in 53% of cases. Antimitochondrial antibodies (AMA) are usually absent.

4. Eosinophilia (rare).

Notes:
1. Some patients with hypothyroidism, hypophosphatemia, magnesium deficiency, or zinc deficiency may have normal alkaline phosphatase levels.
2. Sometimes there is hypoalbuminenmia, which occurs either in the late stages of the disease, or in the presence of an active stage of inflammatory bowel diseases.

Biopsy and morphological examination of liver tissue
Morphological studies of liver tissue are carried out to confirm the diagnosis of PSC (morphological data are especially valuable in the case of lesions of small bile ducts).

Stage 1.The early stage of damage to the bile ducts has no specific signs. Focal atrophy and epithelial deformity are typical. Hyperplasia is not characteristic Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to increased organ function or as a result of pathological tissue neoplasm.
bile epithelium, characteristic of patients with primary biliary cirrhosis. Focal obliteration is possible Obliteration is an infection of the cavity of an internal organ, canal, blood or lymphatic vessel.
and division of the bile ducts. The portal tracts show signs of moderate lymphocytic inflammatory infiltration. Sometimes lymphoid follicles without germinal centers are visible, rarely granulomas.

Stage 2.Characterized by signs of lobular hepatitis, often resembling autoimmune hepatitis or chronic hepatitis C. Proliferation of the bile ducts is typical (usually focal). Moderate fibrosis of the portal tracts is possible. At this stage, signs of hepatitis have a more serious prognostic value than damage to the bile ducts.

Stage 3. Typical (non-pathognomonic Pathognomonic - characteristic of a given disease (about a sign).
) sign of PSC - periductular fibrosis ("symptom onion peelThe presence of ductopenia and fibrous fields in the places of loss of bile ducts is very characteristic.
In the portal tracts, only the branches of the portal vein and the hepatic artery are visible (the bile ducts are obliterated). The parenchyma is dissected by portoportal fibrous septa, the inflammatory infiltrate is less pronounced An infiltrate is a tissue site characterized by an accumulation of cellular elements usually not characteristic of it, an increased volume and increased density.
... In the periportal zones, copper deposits, intralobular cholestasis, and in some cases Mallory's little bodies are detected.

Stage 4.Characterized by widespread fibrosis of the biliary type with signs of biliary cirrhosis. This fact can complicate the differential diagnosis between PSC and primary biliary cirrhosis.

Differential diagnosis

Bacterial cholangitisshould be differentiated with infectious hepatitis, as well as with infectious and non-infectious lesions of other parts of the biliary tract, gallbladder, pancreas.

Primary sclerosing cholangitisdifferentiate with the cholestatic form of sarcoidosis (granulomatous lesions of the bile ducts are uncommon for sarcoidosis).

Primary biliary cirrhosis is another more common cholestatic disease in which the bile ducts are affected by immune inflammation. In diagnostically unclear cases, the determination of antimitochondrial antibodies is shown.

Complications

Bacterial cholangitis
The main complication is "septic" or "acute biliary septic" shock, which is hemodynamic disturbances that develop as a result of the penetration of microorganisms from bile into the systemic circulation. Such shock is diagnosed in 10-30% of patients with biliary tract infection; its development is accompanied by high mortality.
An abscess may develop Abscess - a cavity filled with pus and delimited from the surrounding tissues and organs by a pyogenic membrane
liver, phlebitis Phlebitis - inflammation of the vein wall
portal vein and other purulent-septic complications.

Primary sclerosing cholangitis:
- bacterial cholangitis;
- cholangiocarcinoma (10-30%);
- increased risk of developing colorectal cancer.

Treatment abroad