Postcholecystectomy syndrome: symptoms and treatment by physical factors. Postcholecystectomy syndrome: treatment, symptoms, and diagnosis How the doctor's diagnosis is encrypted bds and ps

Gallstone disease (GSD) is extremely common in civilized countries, including Russia. The incidence is especially high among women aged 35-40 years and older. ZhKB is characterized by the formation gallstones in the biliary system, mainly in the gallbladder, and complications arising from the progression of the pathological process.

The main treatment for this disease is cholecystectomy. In 25% of patients who underwent cholecystectomy, either persist, or after a while, abdominal pain and dyspeptic disorders appear, requiring treatment. Adequate therapy for patients depends on a correct understanding of the pathogenesis of clinical symptoms that develop after cholecystectomy. The peculiarities of their formation are associated, on the one hand, with disturbances in cholesterol metabolism inherent in gallstone disease, and on the other hand, with the fact that the pathological process proceeds in new anatomical and physiological conditions, i.e., in the absence of a gallbladder.

It is known that removal of the gallbladder for calculous cholecystitis does not relieve patients of metabolic disorders, including hepatocellular dyscholia, which persists after surgery. In most patients after cholecystectomy, lithogenic bile with a low cholesterol coefficient is determined. The loss of the physiological role of the gallbladder, namely the concentration of bile in the interdigestive period and its release into the duodenum during meals, is accompanied by a violation of the passage of bile into the intestines and indigestion. Changes in the chemical composition of bile and its chaotic flow into the duodenum disrupt the digestion and absorption of fat and other lipid substances, reduce the bactericidal capacity of the duodenal contents, which leads to microbial contamination of the duodenum, weakening the growth and functioning of normal intestinal microflora, disorders of the hepatic-intestinal circulation and a decrease the total pool of bile acids. Under the influence of microflora, bile acids undergo premature deconjugation, which is accompanied by damage to the mucous membrane of the duodenum, small and large intestine with the development of duodenitis, reflux gastritis, enteritis and colitis. Duodenitis is accompanied by duodenal dyskinesia and, first of all, duodenal hypertension with the development of duodeno-gastric refluxes and the reflux of contents into the common bile duct and pancreatic duct.

As a result, dyskinesias of the sphincter of the hepato-pancreatic ampulla, bile and pancreatic ducts (sphincter of Oddi) are formed, and deconjugated bile acids cause the development of diarrhea. Thus, in patients with a removed gallbladder, the existing clinical manifestations may be associated with a change in the chemical composition of bile, its impaired passage into the duodenum, dyskinesia of the sphincter of Oddi, as well as with excessive bacterial growth in the intestine, maldigestion and malabsorption syndromes, duodenitis and other pathological disorders in the digestive system. In addition, in a number of patients, organic obstacles to the outflow of bile associated with the performed cholecystectomy may persist or develop again. The pathological conditions that are observed in patients after cholecystectomy can be divided into 3 groups.

• Functional disorders of the sphincter of Oddi - increased tone of the sphincter of the common bile duct or pancreatic duct or the common sphincter as a result of the loss of a functioning gallbladder.
• Biliary hypertension with the presence of organic obstructions to the flow of bile, in the presence of which recurrent or residual choledocholithiasis is detected in 5-20% of patients, in 11-14% - stenosis of the large duodenal papilla, in 6.5-20% - strictures bile ducts and bile-diverting anastomoses, in 0.1-1.9% - an excessive cystic duct stump.
• Concomitant diseases that developed before or after surgery. The main ones are chronic pancreatitis, duodenal dyskinesia, irritable bowel syndrome, duodenitis, peptic ulcer, gastroesophageal reflux disease, hiatal hernia.

Currently, the term "postcholecystectomy syndrome" is used to denote only the dysfunction of the sphincter of Oddi, caused by a violation of its contractile function and preventing the normal outflow of bile and pancreatic secretion into the duodenum in the absence of organic obstacles. At the same time, it is proposed, instead of the previously accepted definitions of "postcholecystectomy syndrome", "biliary dyskinesia", etc., to use the term "sphincter of Oddi dysfunction".

The clinical manifestations of dysfunction of the sphincter of Oddi depend, first of all, on the involvement in the process of one or another of its structures. With isolated dysfunction of the sphincter of the common bile duct, biliary pain develops, with the predominant involvement of the sphincter of the pancreatic duct in the process, pancreatic pain, and with pathology of the common sphincter, combined biliary-pancreatic pain. Dysfunction of the sphincter of Oddi is characterized by recurrent attacks of severe or moderate pain lasting 20 minutes or more, repeated for 3 or more months. In the biliary type, the pain is localized in the epigastrium or right hypochondrium with irradiation to the back and right scapula, in the pancreatic type - in the left hypochondrium with irradiation to the back, decreasing when bending forward, in the combined type it has a shingles in nature. Pain can be combined with the following symptoms: a) onset after eating; b) appearance at night; c) nausea and / or vomiting.

However, the assessment of clinical symptoms alone is insufficient to exclude organic pathology of the biliary system. For this purpose, a number of screening and clarifying methods are used (table).

Non-invasive methods that suggest dysfunction of the sphincter of Oddi include measuring the level of bilirubin in the blood, alkaline phosphatase, aminotransferases, amylases and lipases. Laboratory studies must be carried out during or no later than 6 hours after the end of the painful attack, as well as in dynamics. A transient increase of 2 or more times in the level of hepatic or pancreatic enzymes in a period of at least 2 consecutive bouts of pain is important in confirming the dysfunction of the sphincter of Oddi.

A provocative morphine-prostigmine test is of similar importance, when parenteral administration of drugs provokes the development of a painful attack, more often of a mixed biliary-pancreatic type in combination with an increase in the blood level of aminotransferases, alkaline phosphatase, and pancreatic enzymes. However, the diagnostic value of this test is limited by its low sensitivity and specificity.

With ultrasound, great importance is attached to the expansion of the common bile duct and the main pancreatic duct, which indicates a violation of the flow of bile and pancreatic secretion at the level of the sphincter of Oddi. At the same time, 3-4% of patients who have undergone cholecystectomy and do not have symptoms, there is an expansion of the common bile duct. Of particular importance is ultrasound examination of the diameter of the common bile duct using fatty breakfasts that stimulate the production of endogenous cholecystokinin and increase choleresis. After a test breakfast, the diameter of the common bile duct is measured every 15 minutes for 1 hour. An increase in its diameter by 2 mm or more compared to the initial one suggests the presence of incomplete obstruction of the common bile duct, both as a result of dysfunction of the sphincter of Oddi and because of the organic pathology of the biliary system.

To assess the state of the pancreatic ducts, a test with the introduction of secretin at a dose of 1 mg / kg is used. Normally, after stimulation of pancreatic secretion with secretin, ultrasound examination of the pancreatic duct expands within 30 minutes, followed by its decrease to the initial level. If the duct remains dilated for more than 30 minutes, this indicates a violation of its patency.

With biliscintigraphy, the presence of dysfunction of the sphincter of Oddi is evidenced by an increase in the transit time of the radiopharmaceutical from the gate of the liver to the duodenum, while it is proportional to the level of basal pressure of the sphincter of Oddi. At the same time, with enlarged common bile duct, this study is not very informative for assessing the function of the sphincter of Oddi.

An indirect method - endoscopic retrograde cholangiopancreatography (ERCP) - is an invasive method for assessing the function of the sphincter of Oddi. Indirect signs of increased tone of the sphincter of Oddi are the diameter of the common bile duct more than 12 mm, the contrast delay in the common bile duct for more than 45 minutes. Dysfunction of the sphincter of the main pancreatic duct is evidenced by the expansion of the latter to more than 5 mm and a slowdown in the evacuation of contrast from its lumen. However, similar changes can be observed in the presence of organic pathology.

The most accurate method to confirm dysfunction of the sphincter of Oddi is manometry. In this case, it is possible to cannulate the common bile duct and Wirsung duct separately with the manometry of their sphincters, which makes it possible to distinguish mainly the biliary or pancreatic type of disorders, as well as to establish the etiology of recurrent pancreatitis in patients who underwent cholecystectomy and papillotomy. Signs of dysfunction of the sphincter of Oddi in a manometric study are:

• increased basal pressure in the lumen of the sphincters;
• an increase in the amplitude and frequency of phase contractions (tachyoddia);
• an increase in the frequency of retrograde contractions;
• paradoxical response to the administration of cholecystokinin analogs.

Sphincter of Oddi manometry is not shown to all patients. The choice of this study is based on an assessment of the severity of clinical manifestations and the effectiveness of conservative therapy.

Thus, it can be assumed that we are talking about dysfunction of the sphincter of Oddi in the following situations:

• the presence of pain in the epigastric region in patients who have undergone cholecystectomy, in cases where other reasons are not identified that can explain their origin (concomitant diseases, structural changes in the biliary and pancreatic ducts);
• the presence of idiopathic recurrent pancreatitis;
• with recurrent biliary colic in patients with an unchanged gallbladder and common bile duct and with a normal composition of gallbladder bile.

Approximate formulations of diagnoses in patients who underwent cholecystectomy:

Diagnosis: cholelithiasis, cholecystectomy in 1994 (for cases in which there are no clinical symptoms).

Diagnosis: dysfunction of the sphincter of Oddi, biliary type. Cholelithiasis, cholecystectomy in 1999

Diagnosis: chronic recurrent (obstructive) pancreatitis with exocrine and endocrine insufficiency in the acute phase.

Concomitant disease: cholelithiasis, cholecystectomy in 1994

Diagnosis: irritable bowel syndrome with a predominance of constipation in the acute phase.

Concomitant diagnosis: cholelithiasis, cholecystectomy in 1994

Management of patients undergoing cholecystectomy. Purpose of treatment: to restore the normal flow of bile and pancreatic secretions from the biliary and pancreatic ducts into the duodenum. Treatment objectives: to normalize the chemical composition of bile; restore the patency of the sphincter of Oddi; restore the normal composition of the intestinal microflora; normalize digestion processes and small intestine motility for the prevention of duodenal hypertension.

To prevent the formation of bile sludge or stones in the extrahepatic biliary system, it is recommended:

• restriction (but not a complete exclusion) of the intake of products containing cholesterol (fats of animal origin) and fatty acids (fats that have undergone heat treatment over 100 ° C - fried foods);
• regular 4-6 meals a day;
• slow weight loss. When using low-calorie diets (2110 kJ / day and below), during fasting, during shunting operations, an additional appointment of ursodeoxycholic acid at a dose of 10 mg / kg / day is necessary;
• adding to the diet of dietary fiber contained in foods of plant origin or food additives (bran, etc.). Moreover, vegetables, fruits, herbs are best used after heat treatment (boiled, baked). Bran can be used in the form of breakfast cereals (porridge, bread) and proprietary preparations;
• providing daily stool.

Drug treatment of dysfunction of the sphincter of Oddi is aimed at relieving spasm of the smooth muscles of the latter. For this purpose, a number of drugs are used that have an antispasmodic effect. Nitrates: nitroglycerin is used to quickly relieve pain, nitrosorbitol is used for a course of treatment. The mechanism of action of nitrates is reduced to the formation of free radicals of nitric oxide (NO) in smooth muscles, which activate guamylate cyclase and increase the content of cGMP, which leads to their relaxation. However, pronounced cardiovascular effects, side effects and the development of tolerance make them unacceptable for long-term therapy of sphincter of Oddi dysfunction.

Anticholinergics block muscarinic receptors on the postsynaptic membranes of target organs. As a result, calcium channels are blocked, the entry of calcium ions into the cytoplasm of smooth muscle cells stops and, as a result, muscle spasm is relieved. As antispasmodics, both non-selective (belladonna preparations, metacin, platifillin, buscopan, etc.) and selective M-anticholinergics (gastrocepin, etc.) are used. However, when taking drugs of this group, a fairly wide range can be observed. side effects: dry mouth, urinary retention, visual impairment, increased intraocular pressure, tachycardia, constipation, drowsiness. The combination of rather low efficiency with a wide range of side effects limits the use of drugs of this group for dysfunction of the sphincter of Oddi.

Slow calcium channel blockers - phenylalkylamines (verapamil, gallopamil), 1,4-dihydroperidines (nifedipine, amlodipine) and benzothiazepines (diltiazem, etc.) close the calcium ("slow") channels of cell membranes, prevent the entry of calcium ions into the cytoplasm of smooth muscle cells and cause her relaxation. The drugs have numerous cardiovascular effects, primarily vasodilating, and therefore have not been widely used in the treatment of sphincter of Oddi dysfunction. There are only a few publications on the use of nifedipine for dysfunction of the sphincter of Oddi, and the feasibility of their use requires further study.

Myotropic antispasmodics, the mechanism of action of which is reduced to inhibition of phosphodiesterase, or to activation of adenylate cyclase, or to blockade of adenosine receptors, which leads to a decrease in the tone and motor activity of smooth muscles. Representatives of this group of drugs are drotaverin (no-shpa, no-shpa forte), bencyclan (halidor), dicycloverin (trigan-D), alverin (meteospazmil), etc.

The main disadvantages of the drugs of all the above groups are:

• significant differences in the effectiveness of the treatment of sphincter of Oddi dysfunction in each case;
• lack of a selective effect on the sphincter of Oddi;
• the presence of undesirable effects due to the effect on the smooth muscles of the vessels, urinary system and all parts of the digestive tract.

In contrast, gimecromone (odeston) has a selective antispasmodic effect on the sphincter of Oddi and the sphincter of the gallbladder. In addition, the drug does not increase the pressure in the biliary tract, does not affect the secretory function of the digestive glands and the processes of intestinal absorption.

In restoring the normal outflow of bile in the absence of the gallbladder, along with the patency of the sphincter of Oddi, the level of pressure in duodenum... If it exceeds the secretory pressure of bile and pancreatic juice, they will be deposited in the biliary and pancreatic ducts with corresponding consequences.

In this regard, the resolution of duodenal hypertension is considered an indispensable condition for the management of patients with sphincter of Oddi dysfunction. When choosing a treatment strategy, it should be borne in mind that the main pathogenetic mechanism of the development of duodenal hypertension is an excess content of liquid and gas in the duodenal lumen as a result of fermentative and putrefactive processes caused by microbial contamination.

For decontamination of the duodenum, 1-2 seven-day courses of antibiotic therapy are carried out with a change in the drug during the next course of treatment. The drugs of choice are: doxycycline 0.1 g 2 times a day, tetracycline 0.25 g 4 times a day, biseptol 960 mg 2 times a day, furazolidone 0.1 g 3 times a day, ersefuril 0.2 g 4 times a day day, ciprofloxacin 250 mg 2 times a day, metronidazole 0.25 g 4 times a day, intetrix 1 capsule 4 times a day, less often - levomycetin 0.25 g 4 times a day.

The selection of medicines is carried out, as a rule, empirically. With severe symptoms of dyspepsia, 2 drugs are prescribed at once, one of which should act mainly on the anaerobic microflora (for example, metronidazole). Simultaneously with the intake of intestinal antiseptics, in some cases prebiotics are prescribed: in the presence of diarrhea - hilak forte 60 drops 3 times a day for 1 week, then 30 drops 3 times a day for 2 weeks; in cases of predominance of constipation - lactulose, 1-2 tablespoons 1 time per day until the stool is normalized.

After the end of antibiotic therapy, probiotics are indicated (preparations containing normal strains of intestinal flora). One of the known representatives of the group of probiotics is bifiform, containing in one capsule, coated with an enteric coating, enterococci 107, bifidumbacteria 107 and a nutrient medium that promotes their growth in the small and large intestines. The drug is prescribed 1 capsule 2 times a day for 2 weeks. In combination with antibacterial agents, it is necessary to prescribe aluminum-containing buffer antacids (alugastrin, alumag, maalox, phosphalugel, smecta, etc.). Any of the drugs is taken in 1 dose 1 hour after breakfast, lunch and dinner and before bedtime (not combined with hilak forte). The duration of treatment is 5-7 days. The feasibility of using these drugs is due to their following abilities:

• bind organic acids, which leads to a decrease in the osmolarity of the intestinal contents and the cessation of the flow of fluid into the intestinal lumen;
• increase the intraduodenal pH level, which creates conditions for normal digestion processes;
• bind deconjugated bile acids, which reduces secretory diarrhea and their damaging effect on the mucous membrane;
• reduce the absorption of antibacterial drugs, which increases their concentration in the intestinal lumen and enhances the antibacterial effect, and also reduces the side effects of drugs.

The presence in the majority of patients of relative enzyme deficiency as a result of the destruction of digestive enzymes by the duodenal and small intestinal microflora, a decrease in the intraduodenal pH level, and also a violation of the process of mixing them with food chyme is the rationale for the appointment of enzyme preparations. With a tendency to diarrhea, pancreatin preparations are prescribed: mezim forte, creon, lycrease, pancitrate and others, 1 dose 2-3 times a day at the beginning of a meal; with a tendency to constipation - combined agents containing pancreatin, bile acids, hemicellulose: festal, enzistal, digestal, 1 tablet 2-3 times a day at the end of a meal. The duration of treatment is individual and, as a rule, does not exceed 10 days.

Here are the indicative schemes for managing patients with sphincter of Oddi dysfunction.

Diagnosis: dysfunction of the sphincter of Oddi, biliary type. Cholelithiasis, cholecystectomy in 1996

• Gimecromon (odeston) 200 mg 3 times a day 30 minutes before meals for 7-14 days.
• Exclusion of drugs with choleretic and hydrocholeretic effect (bile acids, including in enzyme preparations, infusions and decoctions of choleretic herbs, synthetic choleretic, gastric juice, etc.).

Diagnosis: dysfunction of the sphincter of Oddi, biliary type. Cholelithiasis, cholecystectomy in 1989. Concomitant diseases: chronic catarrhal, mainly distal duodenitis. Syndrome of bacterial overgrowth in the small intestine.

• A diet low in fat (40 g / day of vegetable fats), excluding fried, spicy, acidic foods.
• Gimecromon (Odeston) 200-400 mg 3 times a day for 30 minutes. before meals - 1-2 weeks.
• Biseptol 480 2 tablets 2 times a day for 5-7 days, from the 6-8th day doxycycline 0.1 g 2 times a day or ciprofloxacin 250 mg 2 times a day for 5 days, followed by taking bifiform according to 1 capsule 2 times a day for 2 weeks.
• Pancreatin 250-500 mg, or mezim forte, or creon, or lycrease, or pancitrate, 1 tablet or 1 capsule 3 times a day with meals - up to 2 weeks, then “on demand”.
• Alumag (maalox protab, phosphalugel, etc.) 1-2 doses 3 times a day 1 hour after meals for 1 week.

Thus, timely and correct assessment of the clinical symptoms that develop in patients after cholecystectomy surgery makes it possible to choose an adequate therapy and, as a result, significantly improve the quality of life of patients with diseases of the hepatobiliary system.

For literature questions, please contact the editorial office.

P. Ya.Grigoriev, , E.P. Yakovenko, Doctor of Medical Sciences, Professor
N. A. Agafonova, Candidate of Medical Sciences, A. S. Pryanishnikova, Candidate of Medical Sciences
I. P. Soluyanova, Candidate of Medical Sciences, Z. V. Bekuzarova, A. V. Yakovenko, Candidate of Medical Sciences
Russian State Medical University, Moscow

Let's talk about the symptoms and treatment of postcholecystectomy syndrome. This pathological condition can develop after removal of the gallbladder. The clinical picture is manifested by pain and other unpleasant symptoms.

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The site provides background information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious physician. Any drugs have contraindications. A specialist consultation is required, as well as a detailed study of the instructions! ...

Symptoms and Treatment

The postcholecystectomy syndrome does not include the consequences of operations that were performed with impairments, postoperative pancreatitis or cholangitis.

This group does not include patients with stones in the bile ducts and when they are squeezed. The development of the disease affects about 15% of patients.

In older people, this figure reaches about 30%. Women get sick 2 times more often than men.

Typical symptoms

The symptoms of the development of the syndrome are as follows:

1. Pain attacks. According to the difference in intensity, they will be both strongly pronounced and subside. Dull or cutting pains develop in almost 70% of patients.
2. Dyspeptic syndrome is defined by nausea, vomiting, heartburn, diarrhea, and bloating. Belching is observed with a bitter taste.
3. Malabsorption syndrome develops due to impaired secretory function. Food is poorly absorbed in the duodenum.
4. Decreases in body weight, and at a rate not typical for the characteristics of the patient's body.
5. Hypovitaminosis is the result of poor absorption of healthy foods and vitamins.
6. An increase in temperature is characteristic during moments of acute conditions.
7. Jaundice is a sign of liver damage and dysfunction.

Peculiarities of PCES treatment

The principles of treatment should be based on the manifestation of the symptomatic picture.

The syndrome develops due to disturbances in the activity of the digestive system.

All therapeutic therapy is selected only in a strict individual order. The gastroenterologist prescribes medications that support the treatment of the underlying pathology.

Mebeverin or Drotaverin help to stop pain attacks. In surgical treatment, the methods are determined by the medical council.

Causes of the disease

The operation provokes a certain restructuring in the work of the biliary system. The main risk in the development of the syndrome concerns people who have suffered from gallstone disease for a long time.

As a result, various pathologies of other organs develop in the body. These include gastritis, hepatitis, pancreatitis, duodenitis.

If the patient, before the operation, was examined correctly and the cholecystectomy itself was performed technically flawlessly, the syndrome does not occur in 95% of patients.


Postcholecystectomy syndrome occurs for the reasons:

• Infectious processes in the biliary tract;
• Chronic pancreatitis - secondary;
• With adhesions in the area below the liver, provoking a deterioration in the work of the common bile duct;
• Granulomas or neuromas in the area of \u200b\u200bthe postoperative suture;
• New stones in the bile ducts;
• Incomplete removal of the gallbladder;
• Injuries in the area of \u200b\u200bthe bladder and ducts as a result of surgical procedures.

Pathological disorders in the circulation of bile directly depend on the gallbladder.

If it is removed, then a failure occurs in the reservoir function and deterioration in general well-being is possible.

Not always experts can accurately determine the reasons for the development of this syndrome. They are diverse, and not all of them are fully understood.

In addition to the reasons described, it is impossible to establish the real one. The syndrome can occur both immediately after the operation, and after many years.

Halperin classification

Damage to the bile ducts is early and late. The early ones are also called fresh, obtained during the operation itself to remove the gallbladder. Late ones are formed as a result of subsequent interventions.

Damage to the ducts, unnoticed immediately after the operation, provoke difficulties with health.

The syndrome can manifest itself during any period of recovery.

The famous surgeon E.I. Halperin in 2004 proposed a classification of injuries of the bile ducts, which are one of the main causes of the development of postcholecystectomy syndrome.

The first classification is determined by the complexity of the damage and the nature of the flow of bile:

1. Type A develops when the bile contents leak from the duct or hepatic branches.
2. Type B is characterized by significant damage to the ducts, with increased bile secretion.
3. Type C is observed in the case of pathological obstruction of the bile or hepatic ducts, if they are clipped or ligated.
4. Type D occurs when the bile ducts are completely crossed.
5. Type E is the most severe type, in which the outflow of bile contents develops outward or into the abdominal cavity, and peritonitis develops.

The second depends on the time at which the damage was discovered:

• Damage during the operation itself;
• Damages that have been recognized in postoperative period.

This classification is important for a thorough diagnosis and identification of methods of surgical treatment of postcholecystectomy syndrome.

Clinical and ultrasound signs

When diagnosing the syndrome, it is necessary to analyze the anamnesis of the disease and the patient's complaints. How long the symptomatic picture lasts, at what period after the operation the symptoms appeared.

A consultation of doctors reveals the complexity and duration of previous surgical interventions.

It matters what degree of development of gallstone disease was before removal of the gallbladder to determine the main methods of treatment.

It is important for specialists to find out about the hereditary predisposition to diseases of the gastrointestinal tract.

Laboratory examination includes the following list:

1. A clinical blood test is necessary to determine the presence of inflammatory lesions, to detect the level of leukocytes and possible anemia.
2. A biochemical blood test is performed to monitor the level of digestive enzymes, which may indicate abnormalities in the functioning of the liver, pancreas, or dysfunction of the sphincter of Oddi.
3. General urine analysis to prevent complications in the genitourinary system.
4. Coprogram and analysis of feces for ovipositor.

Ultrasound abdominal cavity necessary for a thorough study of the state of the bile ducts, liver, intestines. The method allows you to detect stagnation of bile in the ducts and the presence of their deformation.

Retrograde cholecystopancreatography is indicated if stones in the bile ducts are suspected; their simultaneous removal is possible. Computed tomography helps to identify various lesions and the formation of tumors of different localization.

Video

Differential diagnosis of pathology

For an accurate and correct diagnosis, differential diagnosis is required. Through this research method, it is possible to distinguish a disease from another with an accuracy of 100 percent.

A similar symptomatic picture of the course of the disease may indicate different diseases that require different treatment.

These differences are sometimes difficult to define and require a detailed study of the entire history.

Differential diagnosis consists of 3 stages:

1. At the first stage, it is important to collect all these about the disease, the study of the history and causes of development, a necessary condition for a competent choice of diagnostic methods. The causes of some diseases will be the same. Similar to the syndrome, other problems with the digestive tract can develop.
2. At the second stage, it is necessary to examine the patient and identify the symptoms of the disease. The stage is of the utmost importance, especially when providing first aid. Lack of laboratory and instrumental research complicate the diagnosis, and doctors must provide an ambulance.
3. At the third stage, this syndrome is investigated in the laboratory and using other methods. The final diagnosis is established.

In medicine, there are computer programs that facilitate the work of doctors. They allow differential diagnosis fully or partially.

Doctors advise in the treatment of the syndrome to rely on the elimination of the causes of pain. Functional or structural disturbances in the work of the gastrointestinal tract, liver or biliary tract often provoke paroxysmal pain.

To eliminate them, antispasmodic drugs are shown:

• Drotaverin;
• Mebeverine.

Enzyme deficiency is the cause of digestive problems and causes pain.

Then the intake of enzyme drugs is shown:

• Creon;
• Festal;
• Panzinorm forte.

As a result of the operation, the intestinal biocenosis is disrupted.


There is a need to restore the intestinal microflora with the help of antibacterial drugs:

• Doxycycline;
• Furazolidone;
• Intetrix.

Course therapy with these drugs is required for 7 days.

Then, treatment is necessary with the help of agents that activate the bacterial level:

• Bifidumbacterin;
• Linex.

Drug therapy is carried out taking into account the underlying pathology causing the syndrome.

Indications for the use of any drugs are possible only on the basis of the recommendations of a gastroenterologist. Principles drug treatment can be replaced by surgical procedures.

Characteristic signs of exacerbation

After removal of the gallbladder in the body, the process of stone formation does not stop. Especially if earlier the provoking factors were serious pathologies of the liver and pancreas.

Exacerbations of postcholecystectomy syndrome can occur against the background of non-compliance with the diet. Overeating and fatty foods are dangerous.

The patient's food system cannot cope with the digestion of heavy foods. An exacerbation develops with diarrhea, fever, deterioration in general health.

The most dangerous symptom is a pain attack. It can come on suddenly, and are distinguished by a strong, often growing localization almost throughout the abdomen.

Improper use of medications, ignoring the recommendations of doctors, the use of folk remedies also cause an exacerbation. A severe course is characterized by difficulty in diagnosis and treatment.

Another cause of exacerbation is sometimes blockage of the ducts with new stones.

A painful attack factor develops suddenly and strongly. Pain relievers don't help.
The patient sweats, dizziness develops, fainting occurs. Urgent hospitalization is required.

Urgent diagnosis is important already in the first hours after an exacerbation. Treatment will consist of an operation.

Features of nutrition and diet

A prerequisite for the treatment of the disease is adherence to a balanced diet. To improve the functioning of the digestive system, nutrition is shown according to the principle of diet No. 5.


Its main features are in meeting the requirements:

• The optimal diet is in fractional parts, at least 6 times a day;
• Hot and cold dishes are contraindicated;
• Mandatory inclusion of products containing fiber, pectin, lipotropic substances;
• Drinking liquid at least 2 liters per day;
• Fats and proteins should be about 100 g;
• Carbohydrates about 450 g;
• Fried, fatty and smoked foods are prohibited;
• Dishes are indicated for consumption: vegetable and cereal soups, low-fat boiled or baked meats;
• Green vegetables, pastries, sweet foods, fatty dairy products, legumes, and mushrooms are not recommended.

Pay attention to adequate intake of vitamins, especially groups A, K, E, D and folic acid... An increased intake of iron preparations is mandatory.

Doctors advise to reduce body weight slowly. Any physical and emotional stress is contraindicated.

Need for surgical treatment

Conservative treatment will be ineffective if large stones form in the ducts. Then appointed surgery... This method is also shown for rapid weight loss, strong pain attackscombined with vomiting.

The most gentle method is endoscopic papillosphincterotomy.

Through surgical techniques restoration of the bile ducts and their drainage are carried out. Diagnostic operations are prescribed less often when the methods already mentioned to identify the problem did not help.

Surgical operations are prescribed for the development of scars in previously operated areas. Surgical treatment of the syndrome is accompanied by various complications.

Poor-quality seams that have parted along the edges of the wound provoke the spread of bile throughout the body. They need to be reapplied. Infection in the operating wound will cause purulent lesions.

All preventive measures should consist in a careful examination of the patient in the first days after surgical treatment. It is important to avoid inflammatory processes in the pancreas, stomach and biliary tract.

5 / 5 ( 5 votes)

EV BYSTROVSKAYA, MD, DSc, Head of the Laboratory for Functional Diagnostics of Biliary Pathology. Central Research Institute of Gastroenterology, Moscow

POSTCHOLECYSTEKTOMIC SYNDROME:

PATHOGENETIC AND THERAPEUTIC ASPECTS OF THE PROBLEM

Successful treatment of patients with postcholecystectomy syndrome with various clinical manifestations to a large extent depends on the correct understanding by clinicians of the physiology and pathophysiology of the processes of bile formation and bile secretion in the absence of the gallbladder. The review provides information on the current state of the problem of postcholecystectomy syndrome. The main pathogenetic links of various functional disorders and organic pathology underlying it are considered.

Key words: cholecystectomy, sphincter of Oddi, biliary insufficiency, duodenal hypertension, postcholecystectomy syndrome

The history of the development of biliary tract surgery has more than two centuries. Until the end of the 19th century. medicine could offer practically nothing to patients with cholelithiasis. Alleviating the suffering of these patients was at that time an exclusively therapeutic problem. On July 15, 1882, the German surgeon Karl Langenbuch removed the gallbladder for the first time in the world, thus opening a new era in the treatment of gallstone disease. In Russia, cholecystectomy was first performed in 1889 by Yu.F. Kosinsky. 100 years later, in 1985, an important revolutionary event took place in biliary tract surgery - laparoscopic cholecystectomy was performed. The German surgeon Erich Muhe became a pioneer in this field. Stormy debate over choice is a thing of the past operational access (laparotomic or laparoscopic) with cholecystolithiasis. In the last two decades, laparoscopic cholecystectomy has become widespread and the status of the "gold standard" for surgical treatment of cholelithiasis (CL). The indisputable advantages of laparoscopic cholecystectomy (LCE) are minimal trauma, reduction of the bed-day by 2-3 times, rehabilitation period... However, an important criterion for the effectiveness of new medical technologies is the quality of life of patients in the long term after surgical treatment. Improvement of the surgical technique for performing cholecystectomy did not significantly affect the long-term results of gallstone disease. It is obvious that, along with the increase in surgical activity in relation to patients with cholelithiasis, there is an increase in the number of patients who underwent cholecystectomy and need

further examination and medical correction. According to various authors, from 20 to 40% of patients who underwent cholecystectomy, within the next 5 years after the operation, they note the appearance of abdominal pain or dyspeptic symptoms. As a rule, such patients are diagnosed with postcholecystectomy syndrome (PCES).

For the first time this term was proposed by B. Pnhrach in 1950 by analogy with post-gastro-resection syndrome, believing that it explains the clinical picture after removal of a previously functioning organ. Since then, there have been endless discussions about the structure, pathogenetic and therapeutic aspects of postcholecystectomy syndrome.

STRUCTURE OF POSTCHOLECYSTEKTOMIC SYNDROME

Since the first operation, the debate continues about the causes of pain and dyspeptic disorders that occur after removal of the gallbladder. According to surgeons, the basis of the "postcholecystectomy syndrome" is choledocholithiasis, chronic recurrent pancreatitis, diseases of the major duodenal papilla (BDS), and duodenal diverticula. Surgeons defend the opinion that the complaints that persist after the operation are the result of poor-quality preoperative examination, as a result of which timely correction of violations that occurred before the operation was not made. Until now, there is an opinion in surgical circles that patients after cholecystectomy do not need further medical correction, since the removal of the gallbladder eliminates the factors of development and progression of the disease.

According to therapists, cholecystectomy, regardless of the type of surgical treatment performed, does not compensate for complex pathophysiological disorders that occur

PRACTICE

PRACTICE

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SOVЄT №2 2012

with gallstone disease, the main of which are hepatocellular dyscholia, persisting lithogenicity of bile. After the operation, the pathological processes characteristic of this disease proceed in new anatomical and physiological conditions, characterized by the loss of the physiological role of the gallbladder, disruption of the sphincter apparatus of the biliary tract, disorder of the neurohumoral regulation of bile formation and biliary excretion. In this regard, the diseases of the digestive system existing before the operation are exacerbated and steadily progressing.

According to the prevailing opinion to date, the symptomatic complex that develops after cholecystectomy may be due to:

■ functional disorders of the biliary tract motility associated with the removal of the gallbladder;

■ changes in the chemistry of bile that persist after the operation, characteristic of gallstones;

■ the presence of organic obstacles to bile outflow.

Therefore, "postcholecystectomy syndrome"

includes both functional and organic pathology of the biliary tract, which, of course, provoke the development of a history of diseases of the gastrointestinal tract (GIT). In this case, after removal of the gallbladder, there may be a combined effect of two or more factors that disrupt the normal functioning of the biliary system. Consequently, when formulating the diagnosis of "postcholecystectomy syndrome", it is necessary to give its detailed characteristics indicating the time, type and volume of the surgical intervention, the nature (functional or organic) of the disorders that occur in a particular situation, as well as concomitant pathology from the gastrointestinal tract.

PATHOGENESIS OF POSTCHOLECYSTEKTOMIC SYNDROME

Disorders of the motor function of the biliary tract

The main proportion among patients with PCES falls on patients with functional motor disorders. Motor disorders of the gallbladder and the sphincter apparatus of the biliary tract are an integral part of the pathogenesis of gallstone disease. The data presented by various researchers indicate the presence of motor dysfunctions in more than 2/3 of patients with cholelithiasis.

The main principle of regulation of any system is multilevel self-regulation. It is absolutely obvious that surgical interventions lead to significant disruptions in the functioning of this system. Experimental and clinical observations indicate that the removal of a functioning gallbladder leads to dysfunction of the sphincter apparatus of the biliary tract, since the gallbladder is the coordinator of the activity of the sphincters of the biliary tract. Pain in patients after surgery in most cases is associated with an increase in pressure in the biliary tract, and the latter is based on violations

functions of the sphincter of Oddi, through which a close anatomical and physiological connection between the biliary tract, the pancreas and the duodenum is carried out.

The physiological control of the sphincter of Oddi involves many neural and hormonal stimuli. An important role in the regulation of bile secretion is played by gastrointestinal hormones, of which cholecystokinin (pancreosimin) (CCK-PZ) and secretin are of particular importance. CCK-PZ stimulates pancreatic secretion, contraction of the gallbladder, reduces the tone of the sphincter of Oddi, reduces pressure in the biliary tract.

The contraction of the gallbladder and the synchronous relaxation of the sphincter of Oddi promote the flow of concentrated bile into the duodenum. At the same time, pancreatic juice stimulated by cholecystokinin is released, which creates optimal conditions for the breakdown of food. CCK-PZ has a weak effect on the muscle fibers of the common bile duct. Cholecystokinin has not only cholekinetic effect, but also to some extent choleretic effect, promoting the secretion of bile by hepatocytes. Secretin enhances the effect of CCK-PZ, but unlike CCK-PZ, it has little effect on the motility of the biliary system directly. The choleretic effect of secretin is many times greater than that of CCK-PZ.

It is known that the gallbladder is actively involved in modulating the response of the sphincter of Oddi to the effects of gastrointestinal hormones. A decrease in the reaction of the sphincter of Oddi in response to cholecystokinin after removal of the gallbladder has been experimentally proven. Currently, there is no consensus on whether and in what direction the level of cholecystokinin and secretin changes after cholecystectomy, when the sphincter apparatus of the biliary tract is deprived of its main response modulator. The question of the timing and duration of these changes, depending on the timing of the operation, the nature of functional disorders, is debatable.

Long time there were disputes about the nature of the functional state of the sphincter of Oddi after cholecystectomy. Some authors pointed to an increase in tone and this explained the expansion of the common bile duct after surgery. Others believed that as a result of cholecystectomy, its insufficiency develops. the sphincter of Oddi is not able to withstand the high secretory pressure of bile for a long time. The existing contradictions in judgments about the state of the sphincter of Oddi are associated with the study of its function at various times after cholecystectomy. This is evidenced by the results of studies showing that the quality of life after cholecystectomy in patients with reduced gallbladder contractile function before surgery is better than with preserved or increased one. In patients with “disconnected gallbladder”, dilatation of the common bile duct is rarely observed both before and after surgery. Gradual adaptation of the body to work in conditions of "disabled

gallbladder "leads to the fact that in such patients less often develop and PCES. It cannot be ruled out that this fact is due to adaptive and compensatory mechanisms that have formed over time in the absence of the gallbladder.

To assess the functional state of the sphincter apparatus of the biliary tract, dynamic cholescintigraphy (DCSG) is widely used. The value of the method lies in the possibility of continuous long-term observation of the processes of redistribution of the radiopharmaceutical (RP) in the hepatobiliary system under physiological conditions, which allows one to quantitatively assess the motor activity of the biliary tract sphincters.

An objective method that confirms the presence of dysfunctions of the sphincter of Oddi is endoscopic perfusion papillosphincteromanometry (EPSM). This method allows the measurement of papilla pressure at different levels through a three-lumen catheter. The complexity of the technique and its invasiveness limit the widespread use of EPSM in clinical practice.

Thus, the presence of dysfunction of the sphincter apparatus of the biliary tract - an integral part of the pathogenesis of gallstone disease, undoubtedly, there is also a tendency to progression after cholecystectomy. The task of the clinician is to determine the nature and severity of motor disorders, which predetermines the strategy and tactics of treatment of patients with postcholecystectomy syndrome.

Violation of the chemistry of bile

Recent studies have shown that almost all patients with cholelithiasis have morphofunctional abnormalities in the hepatocyte that underlie hepatocellular dyscholia, the formation of lithogenic bile and determine the degree of biliary insufficiency (BN).

From a pathophysiological point of view, BN is characterized by a change in the qualitative composition of bile and a decrease in its amount. The qualitative change in the composition of bile is based on the ratio between the content of cholesterol (CS) and bile acids (FA). The enzyme responsible for the synthesis of bile acids is cholesterol-7a-hydroxylase, which converts CS into FA. A decrease in the activity of this enzyme is the cause of the secretion of lithogenic bile, the development of BN and, as a consequence, disruption of the digestive processes.

After cholecystectomy, a compensatory acceleration of enterohepatic circulation of bile acids is noted. However, this process entails suppression of the synthesis of bile acids, which leads to an imbalance of the main components of bile and a violation of the solubilizing properties of bile. The prolapse, due to cholecystectomy, of the concentration function of the gallbladder leads to a change in the chemical composition of bile (aggravation of the existing BN) entering the duodenum. Biliary insufficiency accompanies primarily cholesterol cholelithiasis. When evaluating the long-term results of cholecystectomy, our own studies found that

patients operated on for pigmented gallstones are less likely to require medical correction after removal of the gallbladder. Obviously, this group of patients does not have a symptom complex due to the presence of biliary insufficiency.

Bacterial overgrowth syndrome

The entry of unconcentrated bile into the duodenum reduces the bactericidal activity of the duodenal contents and leads to microbial contamination of the duodenum, weakening the growth and functioning of normal intestinal microflora, and is the cause of the development of bacterial overgrowth syndrome (SIBO). Under the influence of microflora, bile acids undergo premature deconjugation, which is accompanied by damage to the duodenal mucosa with the development of duodenitis. Duodenitis is accompanied by duodenal dyskinesia, functional duodenal insufficiency, hypertension, duodenogastric reflux and the reflux of contents into the common bile and pancreatic ducts. In turn, deconjugated bile acids, being powerful secretory agents (activate the cyclic monoaminophosphate of secretory cells), affect the motor evacuation function of the intestine, leading to the development of motor disorders, in particular secretory diarrhea. Thus, the resolution of duodenal hypertension, which is a consequence of SIBO, is a necessary condition for the normal functioning of the sphincter apparatus of the biliary tract.

Indigestion Syndrome

The syndrome of impaired digestion in gallstones is a consequence of a violation of the synthesis and excretion of bile, microbiocenosis of the gastrointestinal tract, a decrease in the exocrine activity of the pancreas.

Gallstone disease most of all affects the function of the pancreas. The development of chronic pancreatitis in CL and PCES is promoted by:

■ dysfunction of the sphincter apparatus of the biliary tract, accompanied by biliary-pancreatic reflux;

■ passage of the biliary sludge along the common bile duct and the sphincter of Oddi;

■ organic changes in the duct system, disrupting the passage of bile.

The main pathogenetic link of biliary pancreatitis is biliary pancreatic reflux. Long-term inflammatory changes in the pancreas lead to edema of the interstitial tissue as a result of inflammation, followed by degenerative processes that lead to restructuring of the gland tissue with the development of fibrosis. These changes are reflected in the functional state of the pancreas: the volume of secretion, the debit of enzymes and bicarbonates decreases. In this regard, one of the reasons for the unsuccessful outcomes of the operation are persistent disorders of the enzyme-forming function of the gland.

PRACTICE

PRACTICE

Organic lesions of the biliary tract When examining patients with PCES, it is strategically important to identify patients requiring surgical treatment, that is, those patients who have organic obstacles to bile outflow. The reasons postoperative complications in LCE, there are complex anatomosurgical conditions in the intervention area, a combination of diseases of organs of the same anatomical and functional zone, which changes the conditions for performing LCE, affects the surgical tactics and results of surgical treatment. According to the literature, the frequency of repeated surgical interventions reaches 10-15%. It is obvious that the need to perform repeated operations on the biliary tract arises due to diagnostic, tactical, and technical errors made at the preoperative stage and during the operation. The main causes of mechanical disturbance of bile secretion in patients with

YPKES are:

■ residual and recurrent choledocholithiasis;

■ non-liquidated during surgery or newly emerged cicatricial stenosis of the large duodenal papilla, distal common bile duct (CBD);

■ cicatricial stricture of the common bile duct;

■ pathologically altered cystic duct stump.

■ CLINICAL FEATURES OF PCES

The clinical symptoms of PCES are characterized by wide polymorphism. Depending on the prevalence of certain complaints, as well as the severity of clinical symptoms, the following clinical variants of PCES are identified:

■ dyspeptic variant - the phenomenon of dyspepsia in the form of nausea, a feeling of bitterness in the mouth, flatulence, loosening of the stool;

■ pain variant - pain syndrome of varying severity;

■ icteric variant - periodic subicterity skin sclera with or without pain;

■ clinically asymptomatic variant - no complaints, presence of changes biochemical parameters blood (alkaline phosphatase, bilirubin, ALT, amylase) and / or dilatation of CBD according to TUS more than 6 mm.

There are biliary, pancreatic and mixed types of pain. With the biliary type, pain is localized in the epigastrium or right hypochondrium, and may radiate to the back and right scapula. When pancreatic - in the epigastrium or left hypochondrium with irradiation to the back. With a mixed type, pain is often shingles in nature.

■ TREATMENT

Speaking about therapeutic measures, it should be noted the importance of normalizing body weight and ensuring daily bowel movements. The dietary advice is

frequent (up to 5-6 times a day) and fractional nutrition, limiting fat to 60-70 g / day (table number 5).

Drug therapy is aimed at regulating the motor function of the sphincter apparatus of the biliary tract, restoring normal bile outflow, correcting biliary insufficiency, and ensuring adequate secretion of the pancreas.

A sufficient number of drugs, such as nitrates, calcium channel blockers, have a positive effect on the tone of the sphincter apparatus. The use of many of them is limited by the presence of cardiovascular side effects. Myotropic antispasmodics are widely used. The main representatives of this group of drugs are drotaverin, mebeverin, otylonia citrate. Odeston does not have a direct choleretic effect, but facilitates the flow of bile into the digestive tract and thereby enhances the enterohepatic circulation of bile acids. Domperidone, being a prokinetic, normalizes gastrointestinal motility, indirectly reduces manifestations of duodenal hypertension, improves bile outflow, and prevents duode-nogastric reflux.

The drug Domperidone-Teva is a highly selective blocker of peripheral dopamine receptors (fA2 receptors). The drug interacts mainly with peripheral DA2 receptors, which, due to interaction with the cholinergic system, cause the inhibitory effect of dopamine on muscle fibers in the gastrointestinal tract.

When used in therapeutic doses (about 10-20 mg every 4-8 hours), domperidone practically does not penetrate the blood-brain barrier. After oral administration, domperidone is rapidly absorbed from the gastrointestinal tract, however, the reduced acidity of the gastric contents reduces the absorption of domperidone. Domperidone-Teva is widely used in clinical practice. Even in countries with strict requirements for dispensing OTC drugs, this drug is usually sold without a prescription, for example, it is available in the UK provided that the total dose of domperidone in the package does not exceed 200 mg. Compared to other prokinetics, domperidone appears to be the safest drug. In terms of the frequency and severity of extrapyramidal effects, Domperidone-Teva is significantly safer than another popular first-generation prokinetics in our country - metoclopramide, when taken, convulsions of facial muscles, trismus, involuntary protrusion of the tongue, convulsions are described oculomotor muscles, often manifested in the form of involuntary rotation of the eyes, unnatural position of the head and shoulders, opistho-nus. In clinical studies of Domperidone-Teva, extrapyramidal disorders were observed in only 0.05% of patients.

In order to sanitize the biliary tract, as well as to resolve duodenal hypertension caused by the syndrome of bacterial overgrowth, antibiotic therapy is prescribed.

Depending on the severity of the disease, use:

■ nitrofurans: nitroxoline (0.05 g) 0.1 g (2 tablets) 3-4 times a day, 10-12 days; furazolidone (0.05 g) 0.1 g (2 tablets) 4 times a day, 10 days;

■ macrolides: clarithromycin 250-500 mg 2 times a day, 7 days;

■ fluoroquinolones: ciprofloxacin 500-750 mg 2 times a day, 7 days; pefloxacin 400 mg 2 times a day;

■ cephalosporins: cefazolin or cefotaxime 1.0 g 2 times a day, 7 days.

The use of buffer antacids prevents the damaging effect of deconjugated fatty acids on the intestinal mucosa and sets the optimal pH level for pancreatic enzymes. Aluminum-containing preparations of this group must be used to bind bile and other organic acids, especially in the presence of cold diarrhea.

In order to correct BN, courses of replacement therapy with ursodeoxycholic acid preparations are shown in a daily dose of 10-15 mg / kg of body weight. Evening intake of the drug is most effective. Recommended 3-month courses of therapy under the control of liver function tests.

Hepatoprotectors with choleretic and antispasmodic action increase choleresis and the flow of bile into the duodenum, helping to resolve duodenal hypertension, while improving the chemistry of bile.

With exacerbation of chronic pancreatitis, it is necessary to use enzymatic drugs (pancreatin group),

PREVENTION

One of the conditions for the prevention of PCES is a timely performed surgical intervention before the development of complications of diseases, as well as a comprehensive examination of patients in the process of preparing for the operation. In the preoperative period, it is necessary to fully correct the revealed disorders of the hepatopancreatobiliary system, which makes it possible to reduce the frequency of exacerbations, for example, pancreatitis, by 3-4 times.

Taking into account the morphological changes in hepatocytes in gallstones, patients in the preoperative and early postoperative period are indicated for therapy with hepatoprotectors. In the presence of BN, drugs of choice are UDCA and hepabene.

Patients in the postoperative period need medical supervision and active rehabilitation measures, which should be selected together with a therapist and surgeon. A complex of early rehabilitation measures is widely used, in particular, the intake of low-mineralized sulphate-chloride-sodium mineral water, sanatorium-resort treatment using bromine chloride sodium baths.

LITERATURE

1. Abdullaev A.A. Historical aspects of postcholecystectomy syndrome // Surgery. 1988. No. 1. S. 99-105.

2. Burkov S.G. On the consequences of cholecystectomy or postcholecystectomy syndrome // Appendix gastroenterology // Consilium medi-cum. 2004. Vol.6, No.1. S. 1-8.

3. Bystrovskaya E.V., Ilchenko A.A. Long-term results of cholecystectomy // Experimental and clinical gastroenterology. 2008. No. 5. S. 23-27.

4. Grigoriev P.Ya., Soluyanova I.P., Yakovenko A.V. Cholelithiasis and the consequences of cholecystectomy: diagnosis, treatment and prevention // Attending physician. 2002. - No. 6. S. 26-32.

5. Balalykin VD, Balalykin V.S. Modern principles of diagnosis and treatment of "postcholecystectomy syndrome" // Endoscopic surgery. 2006, no. 2. P. 14.

6. Zhegalov PS, Vinnik I.S., Cherdantsev D.V. Epidemiology and correction of postcholecystectomy syndrome // Endoscopic surgery. 2006. No. 2. Materials of the IX All-Russian Congress on Endoscopic Surgery (Moscow, February 15-17, 2006). P. 47.

7. Ilchenko AA Diseases of the gallbladder and biliary tract: A guide for doctors // M .: Anacharsis, 2006. - 448 p.

8. Lazebnik LB, Kopaneva MI, Ezhova TB. The need for medical care after surgical interventions on the stomach and gallbladder (literature review and own data) // Therapeutic archive. - 2004. No. 2. - S. 83.

9. Brekhov E.I., Kalinnikov V.V. Motor-evacuation disorders and their drug correction in postcholecystectomy syndrome // Materials of the scientific-practical conference dedicated to the 35th anniversary of the UMTS UD of the President of the Russian Federation. M., 2003 .-- S. 174-175.

10. Gall C.A., Chamberes J. Choleecystectomy for gall bladder dyskinesia: symptom resolution and satisfaction in a rural surgical practice // ANZ J. Surg. 2002. V. 72. No. 10. P.731-734.

11. Tkachenko E.V., Varvanina G.G. Hormonal regulation of the processes of formation and secretion of bile // Experimental and clinical gastroenterology. - No. 5, 2003. P. 167.

12. McDonnell C.O. The effect of choleecystectomy on plasma cholecystokinin // Am. J. Gastroenterol. 2002. Vol.97. No. 9. P.2189-2192.

13. Bystrovskaya E.V., Tkachenko E.V., Varvanina G.G., Ilchenko A.A. The role of secretin in the formation of sphincter dysfunction of Oddi and its drug correction // Hepatology. 2006. No. 1-2. - S. 44-46.

14. Tkachenko E.V., Varvanina G.G. Hormonal regulation of biliary pathology // Experimental and clinical gastroenterology. - No. 1.

15. Bystrovskaya E.V. Postcholecystectomy syndrome: clinical options, prognosis and prevention / E.V. Bystrovskaya // Abstract dis. ... doct. honey. sciences. - 2010 .-- 39 p.

16. Chernyakevich S.A., Babkova I.V., Orlov S.Yu. Functional research methods in surgical gastroenterology. Textbook for postgraduate education // M .: JV CJSC "Contract RL". - 2003 .-- 176 p.

You can request a complete list of references from the editorial office.

The number of surgical interventions for chronic calculous cholecystitis and its complications is growing every year. In Russia, the annual number of such operations tends to 150 thousand, while in the USA it is approaching 700 thousand. More than 30% of patients who underwent cholecystectomy (removal of the gallbladder) develop various organic and functional disorders of the biliary tract and organs interconnected with them. All the variety of these disorders is united by a single term - "postcholecystectomy syndrome", "PCES". You will learn about why these conditions develop, what symptoms manifest themselves, and the principles of diagnosis and treatment, including therapy with physical factors, from our article.

Causes and types of PCES

With a complete examination of the patient before the operation, correctly defined indications for it and technically flawless cholecystectomy, 95% of patients with PCES do not develop.

Depending on the nature of the disease, there are:

• true postcholecystectomy syndrome (also called functional; it arises as a result of the absence of the gallbladder and the functions it performs);
• conditional postcholecystectomy syndrome (the second name is organic; in fact, this symptom complex arises due to technical errors during the operation or an incomplete set of diagnostic measures at the stage of its preparation - the presence of some complications of calculous cholecystitis that were not diagnosed in a timely manner).

The number of organic forms of PCES significantly prevails over the number of true ones.

The leading reasons for a functional PCES are:

• dysfunction of the sphincter of Oddi, which regulates the flow of bile and pancreatic secretions into the duodenum;
• syndrome of chronic duodenal obstruction, which in the compensated stage leads to an increase in pressure in the duodenum, and in the decompensated stage - to its decrease and dilatation (expansion) of the duodenum.

The reasons for the organic form of PCES can be:

Symptoms

After cholecystectomy, patients may be concerned about pain or heaviness in the right hypochondrium.

There are many clinical manifestations of postcholecystectomy syndrome, but all of them are not specific. They can occur both immediately after the operation, and after a while, forming the so-called luminous gap.

Depending on the cause of PCES, the patient may complain about:

• sudden intense pain in the right hypochondrium (biliary colic);
• pains of the type of pancreatic - shingles, radiating to the back;
• yellowing of the skin, sclera and visible mucous membranes, itching;
• a feeling of heaviness in the right hypochondrium and stomach;
• nausea, bitterness in the mouth, vomiting mixed with bile, belching of air or bitterness;
• a tendency to constipation or diarrhea (this is the so-called cold diarrhea, which occurs after errors in the diet - eating a lot of fatty, spicy, fried foods or cold drinks with a high degree of carbonation);
• persistent flatulence;
• disorders of psycho-emotional status (internal discomfort, tension, anxiety);
• fever, chills;
• severe sweating.

Diagnostic principles

The doctor will suspect PCES on the basis of the patient's complaints and data from the anamnesis of his life and disease (an indication of a recent cholecystectomy). To confirm or deny the diagnosis, the patient will be assigned a number of laboratory and instrumental methods survey.

Among laboratory methods plays the main role biochemical analysis blood with the determination of the level of total, free and bound bilirubin, ALT, ASAT, alkaline phosphatase, LDH, amylase and other substances.

Great importance in the diagnosis of various forms of PCES is attached to instrumental diagnostic techniques, the main ones among which are:

• intravenous and oral cholegraphy (introduction into the biliary tract contrast agent followed by X-ray or fluoroscopy);
• transabdominal ultrasonography (ultrasound);
• endoscopic ultrasonography;
• functional ultrasound tests (with nitroglycerin or fat test breakfast);
• esophagogastroduodenoscopy (EFGDS) - examination of the upper parts of the digestive tract using an endoscope;
• endoscopic cholangiography and sphincteromanometry;
• computerized hepatobiliscintigraphy;
• endoscopic retrograde cholangiopancreatography (ERCP);
• magnetic resonance cholangiopancreatography (MR-CPG).

Treatment tactics

The true forms of postcholecystectomy syndrome are treated with conservative methods.

He should also follow a diet within the framework of tables No. 5 or 5-p according to Pevzner. The fractional food intake suggested by these recommendations improves the flow of bile and prevents the development of stagnation in the biliary tract.

Prescribing drugs requires a differentiated approach:

1. With spasm of the sphincter of Oddi and its increased tone, myotropic antispasmodics (no-shpa, spasmomen, duspatalin and others) and peripheral M-anticholinergics (gastrocepin, buscopan) are used, and after elimination of hypertonicity - cholekinetics or drugs that accelerate the excretion of sorbitol (magnesium sulfate, , xylitol).
2. With a reduced tone of the sphincter of Oddi, the patient is prescribed prokinetics (domperidone, metoclopromide, ganaton, tegaserod).
3. To eliminate the functional forms of the syndrome of chronic duodenal obstruction, prokinetics (motilium, tegaserod and others) are also used, and in the decompensated stage of the disease, repeated washing of the duodenum through a probe with disinfectants is added to them with the extraction of the intestinal contents and the introduction of intestinal antiseptics into its cavity (Intetrix, Dependal-M and others) or antibiotics of the fluoroquinolone group (sparfloxacin, ciprofloxacin and others).
4. If there is a lack of production of the hormone cholecystokinin, a substance similar to it is injected - ceruletide.
5. In case of somatostatin insufficiency, octreotide is prescribed - its synthetic analogue.
6. With the symptoms of intestinal dysbiosis, pre- and probiotics are used (bifiform, sub-simplex, duphalac and others).
7. If secondary (biliary-dependent) pancreatitis is diagnosed, the patient is recommended polyenzyme drugs (panzinorm, creon, mezim-forte and others), analgesics (paracetamol, ketans), myotropic antispasmodics.
8. If there is somatized depression or signs of dystonia of the autonomic nervous system,
   effective will be "daytime" tranquilizers and autonomic regulators (grandaxin, coaxil, eglonil).
9. To prevent recurrent stone formation, preparations of bile acids (ursofalk, ursosan) are recommended.

In organic forms of postcholecystomy syndrome, conservative treatment is usually ineffective, and the patient's condition can be improved only through surgical intervention.

Physiotherapy

Today, experts attach great importance to the techniques as part of the complex treatment of postcholecystectomy syndrome. Their tasks:

• optimize the motor function of the gallbladder;
• to correct the regulation of the autonomic nervous system of the motility of the biliary tract and disorders of the patient's psycho-emotional state;
• normalize the composition of bile, stimulate the processes of its formation;
• restore the outflow of bile from the biliary tract;
• to activate the processes of tissue repair and regeneration in the area of \u200b\u200bsurgical intervention;
• eliminate pain syndrome.

As reparative-regenerative methods of physiotherapy, the patient can be assigned:

• ultrasound therapy (exposure to vibrations with a frequency of 880 kHz is carried out on the projection zone of the gallbladder and biliary tract - the right hypochondrium, and behind the region IV-X of the thoracic vertebrae; repeat the procedures 1 time in 2 days, they are carried out in a course of 10-12 sessions);
• low frequency;
• (a cylindrical or rectangular emitter is placed in contact or 3-4 cm above the abdominal skin in the liver projection zone; the duration of 1 procedure is from 8 to 12 minutes, they are performed every other day in a course of 10-12 exposures);
• infrared;
• carbonic or.

For the purpose of anesthesia, the following are used:

• medicinal analgesic drugs;
• theirs.

To reduce spasm of the biliary tract muscles use:

• medicinal electrophoresis of antispasmodic drugs (no-shpa, platifillin and others);
• galvanization of the same media;
• high-frequency magnetotherapy;

Drinking mineral waters improves the condition of patients with PCES.

The following methods accelerate the excretion of bile into the intestines:

nitrogen baths.

Contraindications to therapy with physical factors are:

• cholangitis in the acute stage;
• advanced cirrhosis of the liver with ascites;
• acute liver dystrophy;
• stenosis of the large papilla of the duodenum (duodenum).

Physiotherapy can be recommended for a person who has undergone cholecystectomy, not only when he already has symptoms of PCES, but also in order to reduce the risk of their occurrence. As methods of physioprophylaxis, sedative, vegetative-correcting, antispasmodic and improving the outflow of bile techniques are used.

Spa treatment

After 14 days after the operation to remove the gallbladder, the patient can be sent for treatment to a local sanatorium, and a month later - to remote resorts. The condition for this is a satisfactory human condition and a strong postoperative scar.

Contraindications for in this case are similar to those for physiotherapy with PCES.

Prevention

To prevent the development of postcholecystectomy syndrome, the doctor should carefully examine the patient before and during the operation to remove the gallbladder, in order to timely detect diseases that can affect the quality of the patient's later life, causing organic PCES.

The qualifications of the operating surgeon and minimal trauma to the tissues of the patient's body during the cholecystectomy are important.

Of no less importance is the patient's lifestyle after surgery - refusal bad habits, proper nutrition, dispensary observation in compliance with all the recommendations of the attending physician.

Conclusion

PCES today is a collective term that combines the disorders of the functions of one or another digestive organ of a functional and organic nature. The symptoms of PCES are extremely diverse and non-specific. Functional forms of the disease are subject to conservative treatment, while organic forms require surgical intervention. For both, the patient can be prescribed physiotherapy, the techniques of which alleviate his condition, eliminating pain, relieving muscle spasm, activating the processes of reparation and regeneration, improving the outflow of bile, and soothing.

Only a full-fledged comprehensive examination of the patient before and during the operation using all possible modern diagnostic methods will help to significantly reduce the risk of PCES development.

Report of the teacher of the International Medical Association "DETA-MED" Gilmutdinova FG on the topic "Postcholecystectomy syndrome":

Postcholecystectomy syndrome (sphincter of Oddi dysfunction, PCES) is a rather rare pathology, but very unpleasant. Most ordinary people, far from medicine, have not even heard of it, and the most curious, having discerned the familiar words, would venture to suggest that PCES is one of the diseases of the gallbladder. In a sense, it is, but with only two significant reservations. First, postcholecystectomy syndrome is not a disease in the usual sense of the word, but a complex of clinical manifestations. Secondly, it develops only after resection (removal) of the gallbladder or any other surgical intervention on the bile ducts.

Many, after such an introduction, will decide that they have nothing to worry about personally, and thus will render themselves a service of a very dubious nature. The fact is that the treatment of gallstone disease (especially in an advanced form) with conservative methods is not always possible. Some patients endure unbearable pain to the last, but when at one not very pleasant moment they are literally put to bed by a severe attack, doctors have to resort to radical methods of therapy to save lives.

And given that recommendations regarding a healthy lifestyle (diet, adherence to the daily regimen, rejection of bad habits) are most often ignored by the majority of our fellow citizens, everyone can be in the conditional risk zone. This is especially true for children who demand from their parents not healthy, but delicious dishes. Hot dog replaces normal borscht or soup, chips - vitamin vegetable salad, and sweet soda - just cooked compote.

Based on this, we decided that postcholecystectomy syndrome was worthy of a detailed detailed discussion (classification, symptoms, treatment and recommended diet), and not a short news-format article. The proposed material is especially useful for parents of those children who eat breakfast and lunch outside the home, since modern school canteens in most cases present a rather sad picture in terms of the richness of the diet and the volume of the offered portions. Because of this, the body of students does not receive critical substances and microelements that are critical for full development, and a chronic feeling of hunger forces them to "get" the required amount in the nearest McDonald's.

The essence of the problem

Unfortunately, there is still no clear understanding of what postcholecystectomy syndrome is, although the pathology itself has been known in medicine since the 1930s. According to the latest data (the so-called "Roman criteria", 1999), PCES is a dysfunction of the sphincter of Oddi, associated with a violation of its contractile function, which significantly complicates the normal outflow of pancreatic secretion and bile into the duodenum. At the same time, there are no organic disorders that could explain such a pathology.

Many practicing doctors interpret postcholecystectomy syndrome much narrower, understanding it exclusively as symptoms of recurrent hepatic colic. To which, in their opinion, the previous treatment may lead (defective, incomplete or incorrectly performed cholecystectomy). Some experts, on the contrary, classify not only typical clinical manifestations as PCES, but also pathologies of the hepatopancreatobiliary zone that have taken place in the past.

The classification of such terminological subtleties is beyond the scope of this material, especially since most patients do not care about this. And patients who have encountered unpleasant symptoms after cholecystectomy can be advised to be optimistic and follow all the recommendations of the attending physician, rather than looking for the causes of PCES.

Postcholecystectomy syndrome is a disease that does not have a clearly defined age or gender framework, but is relatively rare in children. However, this does not mean that parents can constantly feed their children with hamburgers or fries. Stones in the gallbladder (the removal of which led to the appearance of PCES) in the vast majority of cases arise from neglect of the rules of healthy eating. Therefore, by the age of 20-30, children who enthusiastically eat harmful foods have every chance of knowing what it is - Oddi's sphincter dysfunction. Whether it is worth taking such a risk is up to you.

Classification

Dysfunction of the sphincter of Oddi (if we understand it exclusively as a dysfunction of the annular muscle) does not have any forms. But as we have already found out, there is still some confusion in the medical community on this issue, which is why many diseases accompanied (or explained) by PCES remain, as it were, in the shadows:

This list cannot be called a classification of PCES in the usual sense of the word, but it gives an idea of \u200b\u200bthe pathologies under which characteristic clinical manifestations can occur. Because of this, postcholecystectomy syndrome is, in a sense, a "convenient" pathology for a doctor, since it allows one to "squeeze" various (and often unrelated) pathologies into the framework of one diagnosis. Needless to say, such an attitude is unlikely to bring real benefits, especially when the conversation concerns children and the elderly.

The reasons

Many factors can provoke PCES. Some of them can be called rare with some reservations, while others, on the contrary, are quite common. But without finding out the reasons due to which PCES developed, count on effective treatment not necessary.

1. Problems one way or another related to the preparation for surgical intervention (lead to an insufficient volume of surgery and the occurrence of relapses)

• defective preliminary examination;
• insufficient medical or physiological preparation of the patient.

2. Unsatisfactory technical performance of the operation

• improper introduction and implantation of drains;
• damage to the vessels of the gallbladder;
• stones remaining after the intervention in the biliary tract;
• insufficient amount of surgical intervention.

3. Decrease (up to complete loss) of the functions of the gallbladder

4. Decrease in bactericidal activity of duodenal contents

• microbial seeding of the duodenum;
• negative changes in the normal intestinal microflora;
• a decrease in the total volume required for normal digestion, bile acids;
• disorder of the intestinal-hepatic circulation.

5. Narrowing up to complete obstruction of the duodenal ulcer (nipple vaters), from where bile enters the intestines.

6. Various concomitant pathologies (may occur both before and after surgery)

• inflammation (duodenitis), dyskinesia or duodenal ulcer;
• GDR - duodenogastric reflux disease (reverse reflux of the alkaline contents of the intestine into the stomach);
• GERD - gastroesophageal disease (the entry of acidic stomach contents into the esophagus);
• IBS - irritable bowel syndrome (a wide range of symptoms characteristic of intestinal disorders);
• chronic pancreatitis.

Symptoms

The clinical manifestations of postcholecystectomy syndrome are extremely wide. At times, even specialists are confused in them, which is why a patient who first appears at a doctor's appointment causes a poorly hidden negative reaction in the latter. Agree, it is much easier to identify a cold or sore throat than to assess a group of ambiguous symptoms. Therefore, many doctors follow the path of least resistance and diagnose gastritis in their medical records. Manifestations that do not fit into the "necessary" diagnosis are often deliberately ignored. The sad results of such therapy are expectedly deplorable (for more details, see the corresponding section), but in this case, of course, there is no need to talk about the normalization of the patient's well-being. But before proceeding directly to the symptoms, I would like to briefly dwell on what pain sensations characteristic of PCES should be the reasons for an early appeal for qualified help.

1. Attacks last at least 20 minutes.

2. Pain sensations are much worse after eating or at night.

3. Most often, attacks are accompanied by a single vomiting and / or moderate nausea.

4. Possible types of pain:

The symptoms themselves may be as follows:

1. Frequent and loose stools (secretory diarrhea). It is caused by the premature production of digestive juices and accelerated, without delay in the gallbladder, the passage of bile acids.

2. A group of dyspeptic manifestations (may be one of the signs of bacterial overgrowth):

• increased gas production (flatulence);
• recurrent diarrhea;
• rumbling in the stomach.

3. Weight loss

• 1st degree: 5-8 kg;
• 2nd degree: 8-10 kg;
• Grade 3: more than 10 kg (in the most extreme cases, clinical manifestations of cachexia - extreme exhaustion can be observed).

4. Difficulty absorption of nutrients in the duodenum (can lead to malabsorption syndrome):

• frequent, sometimes up to 15 times a day, stools of a watery or mushy consistency with a very unpleasant, offensive odor (diarrhea);
• syndrome of "fatty stools" arising from a violation of intestinal absorption of fat (steatorrhea);
• the formation of cracks in the corners of the mouth;
• significant deficiency of essential vitamins.

5. Signs of CNS damage:

• increased fatigue;
• severe weakness;
• decreased performance;
• drowsiness.

Diagnostics

1. Medical history

• time of appearance of the first symptoms of PCES;
• the amount of cholecystectomy performed and the surgical method used;
• subjective complaints of discomfort in the right hypochondrium or jaundice.

2. Life history

• "Experience" of gallstone disease;
• the most typical clinical manifestations;
• treatment received by the patient prior to surgery.

3. Family history (characteristic pathologies in the next of kin)

• malabsorption syndrome;
• crohn's disease;
• other gastrointestinal diseases.

4. Laboratory research

• clinical blood test: identification of possible leukocytosis and anemia;
• biochemical blood test: the content of essential trace elements (sodium, potassium, calcium), control of liver function and an increase in digestive enzymes;
• general urine analysis: the state of the urogenital organs;
• analysis of feces for undigested food debris, as well as eggs of worms and protozoa (pinworms, ascaris, amoebas and lamblia).

• general condition of the abdominal organs (gallbladder, pancreas, biliary tract, intestines and kidneys);
• measurement of the diameter of the common bile duct with the so-called "fatty test" (the study is carried out after a breakfast of fried eggs and several sandwiches with butter every 15 minutes for an hour).
• determination of the size of the pancreatic duct with secretin test.

6. Other instrumental studies

• RCPG (retrograde cholecystopancreatography): endoscopic examination bile ducts with visualization of the results on a special monitor (allows you to detect even minor stones);
• EGDS (esophagogastroduodenoscopy): examination of the mucous membrane of the stomach, esophagus and duodenum 12 using a special endoscope and simultaneously taking a tissue sample for biopsy;
• manometric examination of the sphincter of Oddi;
• CT or MRI of the abdominal organs.

Treatment

1. Conservative

• slow (!) weight loss;
• enhanced vitamin therapy;
• minimization of psycho-emotional and physical stress;
• giving up bad habits (alcohol, smoking).

2. Medication

• nitrates (the most famous is nitroglycerin): control of the sphincter of Oddi;
• antispasmodics: removal of possible spasms;
• analgesics: relief of pain attacks;
• enzymes: stimulation of digestion;
• antacids: lowering the acidity of gastric juice;
• antibacterial drugs: prevention of a possible infection, stopping SIBO (see above).

3. Surgical

• removal of scars and stones left after the first surgery;
• in the event of a significant deterioration in well-being and a confirmed relapse, a second operation may be required.

Diet number 5

In addition to PCES itself, it can help patients with various diseases of the gastrointestinal tract (provided that there are no pronounced problems with the intestines and stomach):

• acute cholecystitis, hepatitis and gallstone disease in remission;
• cirrhosis of the liver without pronounced signs of its failure;
• chronic hepatitis outside the exacerbation period.

1. Main features:

2. Chemical composition

• proteins: from 90 to 100 g (of which 60% are of animal origin);
• carbohydrates: from 400 to 450 g (sugar no more than 70-80 g);
• fats: 80 to 90 g (about 1/3 of them are vegetable);
• sodium chloride (salt): 10 g;
• free liquid: not less than 1.5-2 liters.

Estimated energy value ranges from 2800 to 2900 kcal (11.7-12.2 mJ). If the patient is accustomed to sweet foods, sugar can be replaced with sorbitol or xylitol (no more than 40 g).

Allowed and prohibited foods

1. First courses

• you can: vegetable, cereal, milk and fruit soups, borscht, beetroot soup;
• not allowed: green cabbage soup, okroshka, fish, meat and mushroom broths.

2. Flour products

• you can: wheat and rye bread 1 and 2 grades, uncomfortable pastries with fish, boiled meat, apples and cottage cheese, dry biscuit, lingering cookies;
• not allowed: fresh bread, fried pies, pastries and puff pastry.

3. Meat and poultry

• you can: lean young lamb, beef, rabbit, turkey, chicken (the meat should be lean: boiled or baked);
• not allowed: goose and duck, pork. Exclude any by-products (brains, liver, kidneys), sausages, canned food, sausages and wieners.

• you can: any low-fat types of fish, cooked by baking or boiling (meatballs, dumplings, soufflé) with minimal use of salt;
• not allowed: fatty fish, canned food, smoked meats.

5. Milk products

• you can: kefir, milk, acidophilus, cottage cheese and cheese (low-fat or semi-fat varieties);
• with care: cream, fermented baked milk, sour cream, milk, cottage cheese and hard cheese with a high percentage of fat.

6. Side dishes

• you can: any cereals, especially oatmeal and buckwheat;
• not allowed: legumes, mushrooms.

• you can: almost any (see exceptions below) in boiled, baked or stewed form, slightly acidic sauerkraut, boiled onions, mashed green peas;
• not allowed: sorrel, radish, garlic, spinach, radish, green onion and any pickled vegetables.

8. Drinks

• you can: berry, fruit and vegetable juices, rosehip broth, a drink made from wheat bran, coffee with milk, tea, unsweetened compotes, jelly;
• not allowed: cocoa, black coffee, any cold drinks.

9. Snacks

• you can: vinaigrette, fruit and vitamin salads, squash caviar;
• not allowed: fatty and spicy snacks, smoked meats, canned food.

10. Sauces and spices

• you can: vegetable, fruit, dairy and sour cream gravies / parsley, cinnamon, dill, vanillin;
• not allowed: pepper, mustard, horseradish.

11. Sweets

• you can: all fruits and berries (except sour ones), dried fruits / mousses, jellies, sambuca / marmalade, sweets without chocolate, honey, candy, jam (if sugar in it is replaced with xylitol or sorbitol);
• not allowed: chocolate, ice cream, cream products and fatty cakes.

Sample menu

Complications

1. Consequences of surgical intervention

• insolvency postoperative sutures can lead to the divergence of the edges of the wound, its infection and problems in the functioning of the biliary system;
• the formation of abscesses (abscesses);
• postoperative pneumonia (pneumonia).

2. SIBO - syndrome of excessive (pathological) bacterial growth caused by a temporary decrease in immunity.

3. Activation of chronic arterial diseases (premature development of atherosclerosis). It is explained by a violation of lipid metabolism and is expressed by the deposition of cholesterol on the walls of blood vessels.

4. Pathological complications of malabsorption syndrome:

• decrease in body weight;
• deformation of the skeleton;
• a decrease in the level of erythrocytes and hemoglobin in the blood;
• severe vitamin deficiency;
• in men - persistent erectile dysfunction.

Prevention