JVP – a clinical symptom complex caused by impaired motility of the gallbladder, bile ducts and their sphincters, as a result of which the hepatocyte and bile production suffer. Etiology: 1) primary ADHD - caused by dietary errors (consuming a large amount of fatty, spicy foods), a sedentary lifestyle, injuries; 2) secondary GIBs – are more common and are a manifestation of other gastrointestinal diseases (gastroduodenitis, duodenitis, ulcerative disease, hepatitis, etc.) or endocrine problems (obesity, diabetes). Pathogenesis: 1) due to neurosis with dominance of the tone of the sympathetic and parasympathetic parts of the central nervous system, persistent spasm or hypotension of the biliary sphincters occurs. 2) When forgetting 12-p. when the secretion of cholecystokinin is disrupted, and in diseases of the gall and intestines - gastrin, neurohormones --> regulation and motor activity of the biliary tract is disrupted --> long-term dyskinesia causes stagnation and infection of bile, reflux of intestinal contents into the gallbladder ( reflux). Clinic: 1) with hypomotor JVP– pain in the right hypochondrium, “+” symptoms of the gallbladder, dull pain after eating, maybe. combined, in the stomach, epigastrium, combined with nausea, loss of appetite, belching. M.b. dyspeptic intestinal disorders - diarrhea, flatulence. General symptoms of intoxication: fatigue, headaches, sweating from the cardiovascular system - increased blood pressure, increased heart rate. 2) With hypermotor movement disorder– pain, paroxysmal, acute, occurs 30-40 minutes after eating, lasts about 30 minutes; dyspeptic manifestations; on the part of the cardiovascular system – decreased heart rate, decreased blood pressure (hypotension). Diagnostics. 1) Inspection; 2) anamnesis; 3) UAC (d.b. N); 4) OAM (d.b.N); 5) used chemical blood test (protein and fractions in N, bilirubin, enzymes, AlAt, AsAT, alkaline phosphatase may be changed); 6) Ultrasound (shape, size of the gallbladder, pancreas); 7) duodenal sounding: Stage 1- this is the time of the common bile duct, when light yellow bile flows from the common bile duct in response to irritation of the wall of the 12-p. use an olive probe, collect 3 portions, 5 minutes each. In N, portion A is released at 0.5-1 ml/min (if faster - hypotension, if slower - hypertension of the common bile duct). Then 33% magnesium sulfate solution is injected into the probe for 3 minutes --> the probe is closed for 3 minutes (a reflex closure of the sphincter of Oddi occurs --> the flow of bile stops). Stage 2– “time of closed sphincter of Oddi” (starts from the moment the probe is opened until bile appears) – if more than 7 minutes - sphincter spasm, if less than 4 minutes - hypotension. Stage 3– time of release of bile of portion A (from the moment the sphincter of Oddi opens and the appearance of light bile) – if more than 8 ml of bile flows out in 3-5 minutes – hypotension, if less than 5 ml flows out in 3-5 minutes – hypertension. Stage 4– time of release of bile of portion B (begins from the moment of release of dark gallbladder bile due to relaxation of the Lütkens sphincter and contraction of the gallbladder) – if in a time of more than 25 minutes there is less than 15 ml of bile – hypotension of the Lütkens sphincter, if in a time of less than 15 minutes there is less than 50 ml bile is secreted, then this is Lutkens sphincter hypertension. Stage 5– time of release of bile of portion C (after the expiration of dark bile, lighter bile than portion A is released) – at a rate of 0.5-1 ml/min. To check the degree of emptying, the irritant is reintroduced, and if dark bile comes out again (portion B), then the bladder is not contracting completely, i.e. There is hypertensive dyskinesia. 8) ??? Coprogram (with hypermotor type - type II steatorrhea, i.e. a lot of free fatty acids due to the fact that bile acids do not emulsify fats). Treatment. 1) Diet No. 5 (gentle character - mechanically, physically, chemically, i.e. food should be warm, in small portions, fractionally, not fatty, salty, spicy, fried, during an exacerbation, not fresh vegetables and fruits); 2) choleretic drugs: a) choleretics(stimulate bile production) – true choleretics(promote the production of the bile component directly) - cholenzyme, allahol, corn silk); products that increase the secretion of bile due to the water component - hydrocholeretics- mineral waters (Smirnovskaya, Truskovets), makes tubes (first, on an empty stomach, warm water without gas is given - 1 glass, then the child lies with a heating pad on the right side for 30 minutes, after which he gets up and squats until bitterness appears in the mouth). b) cholekinetics(stimulate bile secretion): products that cause an increase in tone gallbladder and decreased tone of the biliary tract - magnesium sulfate, cholecystokinin; pr-you, causing relaxation of tone biliary tract (antispasmodics) - atropine, platyphylline, to relieve an acute attack - duspatolin (relaxes the sphincter of Oddi). 3) Correction of vegetative status (we refer the child to a neurologist). 4) For vagotonics we give ginseng, eleutherococcus, pink radiola, cordiamine; for sympathotonics - tinctures of valerian, motherwort.

End of work -

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Neonatology. The concept of prematurity. Classification. Causes of prematurity. Prevention of miscarriage

The concept of prematurity, classification of the causes of prematurity, prevention.. premature babies born before the end of weeks of pregnancy and having a body weight of less than g and a length of less than cm.

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Biliary dyskinesia is a functional condition in which the flow of bile into the duodenum is disrupted due to uncoordinated functioning of the biliary tract. They are either in a constantly contracted, spasmodic state (hypermotor dyskinesia) or do not contract at all (hypomotor dyskinesia).

Doctors distinguish two main forms of dyskinesia. In the hyperkinetic form, the tone of the gallbladder is increased and its contractions occur too quickly and strongly. The sphincters (muscular “gates”) do not open enough. This causes sharp pain in the right hypochondrium. Attacks of pain are usually short-lived and rarely last more than one hour. As a rule, they do not occur on empty space, but are provoked by negative emotions, worries, and nervous overload. In women, exacerbations of the disease are associated with the menstrual cycle, since during menstruation the tone of the gallbladder is usually increased. The hyperkinetic form of dyskinesia is more common at a young age.

On the contrary, the hypokinetic form of dyskinesia most often affects older people. Its cause is insufficiently intense contraction of the gallbladder. This also manifests itself as pain in the right hypochondrium. True, the pain is usually not severe, but long-lasting, dull, and often bursting in nature. However, here, as in medicine in general, there is nothing absolute. All manifestations of the disease are very individual. Even an experienced doctor not so easy to put accurate diagnosis, based only on the patient's complaints.

Biliary dyskinesia consists of a series of exacerbations and improvements. After some time, an inflammatory process (cholecystitis, cholangitis) or gallstones may form in the gallbladder and ducts (cholelithiasis).

Diagnostics

· Biochemical analysis blood. During a severe exacerbation, a blood test reveals an increase in the level of liver enzymes (alkaline phosphatase, etc.).

· Ultrasound of the liver and gallbladder, which allows you to assess the condition of the gallbladder and its ducts and identify stones.

· Duodenal intubation - collection of bile for analysis using gastric tube. The procedure is also used with therapeutic purpose for washing the bile ducts during bile stagnation. To do this, after collecting the bile, heated mineral water is introduced into the probe. The procedure is carried out on an empty stomach.

· Tests using special preparations. A medicinal substance (for example, secretin) is administered, which enhances the production of bile. If there is a disease, then bile does not have time to be released into the intestines, but accumulates in the gallbladder and ducts. There is an expansion of the ducts and an increase in the volume of the bladder, which is recorded using ultrasound.

· X-ray methods– cholecystography.

It is important to establish the form of dyskinesia during the examination - the treatment method will depend on this. A necessary condition for the treatment of dyskinesia is diet.

The diet for the hyperkinetic form is frequent split meals (4-5 times a day), limiting foods that cause bladder contractions (fatty, meat products, vegetable oil, cakes and other products made from fatty dough, beer, carbonated drinks). Dishes should be mostly mashed and boiled, not too greasy or spicy. More fruits and berries in any form!

Among medications, antispasmodics (no-spa, etc.) are mainly used. Choleretic drugs (holosas, cholenzym, flamin) and medicinal drugs will also not be superfluous. herbal teas(corn silk, rose hips, peppermint, etc.).

Still widely used today the old way treatment - drinking mineral waters. For this form of the disease, waters with low and medium mineralization are recommended: Narzan, Navtusya, Slavyanovskaya, Smirnovskaya, Essentuki No. 4 and No. 20. You should drink hot water (40-25 degrees), ½ glass or 1 glass 3-4 times a day, half an hour before meals.

If all of the above does not help, the doctor may prescribe tubage - washing the bile ducts.

The diet for the hypokinetic form must necessarily include foods that have a choleretic effect: sour cream, butter and vegetable oil, cream, soft-boiled eggs, black bread, vegetables. They stimulate motor activity biliary tract. For the same purpose, aloe extract, eleutherococcus, and ginseng are used. Herbal choleretic infusions help well. They usually include immortelle flowers, yarrow, mint leaves, coriander fruits, etc.

Choleretic agents are used - cyclone, 10% solutions of xylitol or sorbitol, Carlsbad salt and herbs - parsley decoction, decoctions and infusions of dandelion, yarrow, calamus, barberry.

Mineral water are also used here, but only with a high degree of mineralization. For example, Batalinskaya, Arzni, Essentuki No. 17. They should be drunk cold, ½-1 glass 3-4 times a day for 30-60 minutes. before meals (within 3-4 weeks).

In addition, tubage with Carlsbad salt is used, magnesium sulfate or sorbitol.

Dyskinesia is also treated with physiotherapy. In recent years, laser and acupuncture have been increasingly used.

Biliary dyskinesia(dysfunctional disorders of the biliary tract) are changes in the tone of the gallbladder, bile ducts and their sphincters, manifested by a violation of the outflow of bile into the duodenum, accompanied by pain in the right hypochondrium.
Biliary dyskinesias are divided into primary and secondary. Primary refers to biliary dyskinesias without the presence of proven organic changes in the extrahepatic biliary system; they account for only 10-15%. Secondary dysfunctional disorders of the biliary tract occur in acalculous cholecystitis, cholelithiasis (GSD), hepatitis, cirrhosis of the liver, diseases of the stomach and duodenum, after surgical removal of the gallbladder (cholecystectomy) and gastrectomy, during pregnancy, premenstrual tension syndrome, diabetes mellitus, myotonia, when treated with somatostatin.
They play a role in the mechanisms of development of biliary dyskinesias. the following factors:

Disturbances of autonomic nervous regulation (increased tone of the parasympathetic or sympathetic department);

Disturbances of central nervous regulation;

Pathological (interoreceptive) reflexes with various departments digestive tract;

Disturbances of hormonal regulation.

The following clinical forms of biliary dyskinesia are distinguished:
1. By localization: a) gallbladder dysfunction; b) dysfunction of the sphincter of Oddi.
2. By causality: a) primary; b) secondary.
3. According to the functional state: a) hypotonic-hypokinetic form; b) hypertensive-hyperkinetic form.
Clinical picture. The main clinical symptoms of dysfunctional biliary tract disorders are pain, dyspepsia and neurotic disorders. In the hypotonic-hypokinetic form, a feeling of heaviness in the abdominal cavity, dull, prolonged pain in the right hypochondrium without clear irradiation (spread) are observed. They subside after eating, choleretic drugs, and duodenal intubation. Nausea, bitterness in the mouth, vomiting, and unstable stools (constipation, less often diarrhea) are also characteristic. In the hypertensive-hyperkinetic form, the pain is cramping, short-term, with typical irradiation. There may be nausea, vomiting, spastic constipation, signs of vagotonia (increased function of the parasympathetic nervous system).
The clinical picture of sphincter of Oddi dysfunction is characterized by recurrent attacks of severe or moderate pain for more than 20 minutes, repeated for more than 3 months and localized:
in the epigastrium or right hypochondrium with irradiation to the back and right scapula (biliary type);
in the left hypochondrium with irradiation to the back, decreasing when bending forward (pancreatic type);
encircling (combined type).
Pain can be combined with the following symptoms: onset after eating; appearance at night; nausea and/or vomiting.
Patients with sphincter of Oddi dysfunction are classified as:
Group I– diagnosed dysfunction (manometry is not necessary).
Criteria:
A. Classic attack of biliary pain.
B. Increase in ALT and/or alkaline phosphatase activity by 2 times, detected at least twice.
B. Slowing down the evacuation of contrast agent during endoscopic retrograde cholangiopancreatography (ERCP) for more than 45 minutes.
D. Dilation of the common bile duct more than 12 mm.
Group II– suspected dysfunction (manometry required).
Characteristic pain and one or two criteria of the first group.
III group– possible dysfunction (manometry is necessary if suspected surgical intervention).
Characteristic pain without other changes.
To diagnose dysfunctional biliary tract disorders, the following is used:
1. Non-invasive methods:
study of the level of liver and/or pancreatic enzymes during a painful attack;
provocative pain tests (for example, Nardi test);
Ultrasound with assessment of gallbladder and sphincter of Oddi function;
quantitative scintigraphy of the liver and biliary tract.
duodenal intubation;
X-ray methods(cholecystography, intravenous cholangiography) are currently rarely used, they provide information about the concentration and contractile function of the gallbladder;
fibrogastroduodenoscopy (FGDS): condition of a large duodenal papilla, the presence of diseases of the stomach and duodenum.
2. Invasive methods:
ERCP;
endoscopic manometry of the sphincter of Oddi.
Treatment. For dysfunctional disorders of the biliary tract, especially in primary forms, psychotherapy and the use of psychotropic and vegetative-stabilizing drugs are of particular importance.

Drug treatment depends on the type of dyskinesia. For hypotonic-hypokinetic dyskinesia the following is prescribed:

a diet rich in dietary fiber and vegetable oil, with an increase in foods that have a cholekinetic effect; tubazhi (“blind tubazh”); duodenal intubation with intraduodenal administration of mineral water 0.3-1 l (for severe hypotension - 1–2 times a week); physical therapy; choleretics and cholekinetics in courses of 1 month; motor regulators; drinking treatment with mineral waters (water of medium mineralization, cool (30–350 C) 1 glass 3 times a day 15-30 minutes before meals).

For secondary dyskinesias, it is necessary to treat the underlying disease. In some cases, according to indications, invasive methods of treating sphincter of Oddi dysfunction are used: endoscopic balloon dilatation; injection of botulinum toxin into the sphincter; setting the timing of the catheter-stent in bile duct;excision of the sphincter.

INTESTINAL OBSTRUCTION

28) intestinal obstruction: concept, classification, etiopathogenesis, diagnosis.
intestinal obstruction- a disease characterized by partial or complete disruption of the movement of contents along the digestive tract.
classification: according to the factor of innateness: congenital and acquired.
according to the mechanism of occurrence: a) dynamic (functional): 1) spastic 2) paralytic b) mechanical: 1) obstructive, 2) strangulation 3) mixed.
by level of obstruction: a) small intestine: 1) high 2) low, b) colon
according to the course: acute, chronic
by stage: a) initial - 2-12 hours (neuroreflex), b) intermediate (toxic) - 12-36 hours, c) late (peritonitis) - later than 36 hours.

Etiology: distinguish predisposing and producing factors. Congenital predisposing factors include: 1) malrotation syndrome, 2) common mesentery of the cecum and ileum, 3) Dolichosigma (elongation of the sigmoid colon), 4) Long mesenteries, ligaments, large pouches (Treitz). Acquired predisposing factors include: 1) adhesions, 2) scars, 3) inflammatory infiltrates, 4) foreign bodies, 5) gallstones and fecal stones, 6) helminthiasis, 7) surgical defects.
producing factors: 1) a sharp change in the motor activity of the gastrointestinal tract (food load, fasting, drug stimulation, dyskinesia, infectious diseases, enterocolitis) 2) an increase in intra-abdominal pressure during physical activity.
Pathogenesis: three theories: 1) theory of stercoremia (toxic) - with the development of ileus, intoxication gradually increases due to the absorption of toxins from stagnant intestinal contents in the afferent segment of the intestine (above the site of obstruction)
2) the theory of biochemical changes - it is based on dyscrasia of digestive juices. Normally, about 10 liters of digestive juices are secreted in the digestive tract. Their loss through vomiting, combined with impaired absorption and digestion, aggravates the loss from the body useful substances. All this determines deep violations protein, carbohydrate, lipid, water-electrolyte and vitamin metabolism, acid-base state of the body.
3) Neuro-reflex theory - powerful afferent impulses come from the afferent loop to the central nervous system when intestinal obstruction. First, a focus of excitation is formed, then a focus of inhibition. The blood circulation of the intestinal wall and trophism are disrupted, and paresis deepens.
stages of pathogenesis: 1) disturbance of mesenteric and organ hemocirculation (ischemia of the intestinal wall)
2) development of proximal microbial hypercolonization of the intestine (intensive proliferation of intestinal microflora)
3) development of enteral insufficiency syndrome with disruption of all intestinal functions. 4) disturbances in immune system Gastrointestinal tract
5) development and progression of peritonitis 6) progression of endogenous intoxication
7) development of multiple organ failure
Diagnostics: includes assessment of the patient’s complaints and medical history, examination, palpation, percussion of the abdomen. Important is a rectal examination, assessment of changes in the UBC, OAM, biochemical blood test. Special methods include fluoroscopy (graphy) of the abdominal cavity, assessment of barium passage or irrigoscopy. They can use fibrogastroduodenoscopy, colonoscopy, ultrasound, CT and NMR tomography, mesentericography, and gastrointestinal scintigraphy.

29) General principles of treatment of acute intestinal obstruction, indications for surgical treatment, types operations.
The canned food should be treated to influence the pathogenesis of intestinal obstruction. Principles: First, proximal decompression should be achieved gastrointestinal tract by aspiration of the contents through a nasogastric or nasointestinal (installed during surgery) tube. Placing a cleansing and siphon enema, if they are effective (“washing out” dense feces), allows you to empty the large intestine located above the obstruction and, in some cases, resolve the obstruction. In case of tumor colonic obstruction, intubation of the narrowed section of the intestine is desirable to unload the adductor section. Secondly, correction is necessary water and electrolyte disturbances and elimination of hypovolemia. The general rules for such therapy are set out in Chapter III; here we only note that the volume of infusion therapy carried out under the control of central venous pressure and diuresis (catheterization of one of the central veins and the presence of a catheter in the bladder is desirable) should be at least 3-4 liters. It is imperative to replenish potassium deficiency, as it contributes to the worsening of intestinal paresis. Thirdly, to eliminate hemodynamic disorders, in addition to adequate rehydration, rheological active agents- rheopolyglucin, pentoxifylline, etc. Fourthly, it is highly desirable to normalize the protein balance through the transfusion of protein hydrolysates, a mixture of amino acids, albumin, protein, and in severe cases, blood plasma. Fifthly, it is necessary to influence the peristaltic activity of the intestine: with increased peristalsis and cramping pain in the abdomen, antispasmodics (atropine, platiphylline, no-shpu, etc.) are prescribed; for paresis, agents stimulating the motor-evacuation ability of the intestinal tube: intravenous administration hypertonic solution sodium chloride (at the rate of 1 ml/kg of the patient’s body weight), ganglion blockers, proserin, ubretide, polyhydric alcohols, for example, sorbitol, Bernard currents to the anterior abdominal wall). And finally, last but not least, measures that ensure detoxification and prevention of purulent-septic complications are vital. For this purpose, in addition to transfusion of significant amounts of liquid, it is necessary to use infusion of low molecular weight compounds (hemodez, sorbitol, mannitol, etc.) and antibacterial agents.
indications for surgical treatment:
1) if there are signs of peritonitis.
2)if available obvious signs or suspected strangulation or mixed intestinal obstruction.
In other cases: a diagnostic and treatment appointment is carried out, if negative, surgical treatment is performed, if positive, conservative treatment is performed. The treatment includes: subcutaneous administration of atropine, perinephric novocaine blockade, gastric lavage, administration of a siphon enema. It is assessed in the following way: if the gases have passed, there has been stool, the stomach has decreased in size, the pain has disappeared - the reception is considered positive.

Types of operations:Most authors divide all surgical interventions for intestinal obstruction into three groups:
- elimination of the cause of mechanical intestinal obstruction (untwisting during volvulus, disinvagination during intussusception, dissection of strangulation adhesions, intestinal resection, etc.);
- overlay various kinds anastomoses to bypass the obstacle;
- the imposition of an intestinal fistula above the site of obstruction.
For each method of surgical intervention, an individual approach is required, taking into account the type of obstruction, the nature of changes in the intestine, etc.
For favorable outcome surgery for intestinal obstruction great value has the correct management of patients in the postoperative period. Here, as necessary, the fight against hemodynamic disorders, disorders of water-salt, protein and carbohydrate metabolism continues, and measures are taken to quickly restore peristalsis.

30) Dynamic intestinal obstruction: causes, clinical picture, diagnosis, treatment.
Causes: paralytic obstruction develops with peritonitis, acute pancreatitis, perforation of a hollow organ, hypokalemia after operations on the abdominal organs and drainage of the abdominal cavity. Its occurrence is possible after resolution of spastic obstruction, with dysentery, dyspepsia and damage vagus nerve.
reasons spastic obstruction may be reflexes from other organs of the chest and abdominal cavities, retroperitoneal space, damage to the central nervous system (tabes dorsalis), spasm of mesenteric vessels (abdominal toad), lead poisoning, nicotine, morphine.
Clinic: The disease is characterized by a sudden onset. The leading symptom is severe cramping pain. The pain does not have a specific localization and usually spreads throughout the abdomen. During contractions, the patient rushes around the bed and screams. Dyspeptic disorders are not typical. Retention of stool and gases is not observed in all patients; they are never persistent. General state the patient is slightly impaired. The abdomen upon examination has a normal configuration. Sometimes the abdominal wall is elongated and the abdomen takes on a scaphoid shape.
diagnostics: includes assessment of the patient’s complaints and medical history, examination, palpation, percussion of the abdomen. Important is a rectal examination, assessment of changes in the UBC, OAM, biochemical blood test. Special methods include fluoroscopy (graphy) of the abdominal cavity, assessment of barium passage or irrigoscopy. They can use fibrogastroduodenoscopy, colonoscopy, ultrasound, CT and NMR tomography, mesentericography, and gastrointestinal scintigraphy.

A general X-ray examination of the abdomen reveals a spastic-atonic state of the intestine. Sometimes along the small intestine small cups of Kloiber are visible, located in a chain from left to top to bottom and to the right. A contrast study of the gastrointestinal tract with barium determines the slow passage of the barium suspension through the small intestine.
treatment: conservative. Patients are prescribed antispasmodics, physiotherapeutic procedures, heat on the stomach, and treatment of the underlying disease. Held diagnostic and treatment appointment according to Vishnevsky, allowing early dates differentiate mechanical CI from dynamic one; if the result is negative, surgical treatment is performed; if the result is positive, conservative treatment is performed. The treatment includes: subcutaneous administration of atropine, perinephric novocaine blockade, gastric lavage, administration of a siphon enema. It is assessed in the following way: if the gases have passed, there has been stool, the stomach has decreased in size, the pain has disappeared - the reception is considered positive.
2) 250 ml of liquid barium sulfate is given orally.
3) is carried out infusion therapy.
4) the passage of barium is assessed - when it passes (after 6 hours into the colon, after 24 into the rectum), the diagnosis of intestinal obstruction is removed, and the patient undergoes a detailed examination.

Bile is a special liquid that is produced in the liver. Its main tasks are to improve the absorption of fats and activate the movement of food through the intestines.

Before bile enters the intestines, it passes through a complex path through the biliary tract. First, from the liver it enters the hepatic ducts, from there into the common bile duct, which connects to the gallbladder through the cystic duct. The place where the common bile duct enters the duodenum is called the papilla of Vater. It has its own muscle (sphincter of Oddi), which regulates the flow of bile into the intestines.

Biliary dyskinesia is a disease in which, due to impaired contractions of the gallbladder and its ducts, as well as defects in the functioning of the sphincter of Oddi, problems arise with the excretion of bile.

According to statistics, women are more likely to suffer from biliary dyskinesia.

Causes

The development of the disease is promoted by:

• poor nutrition (a lot of fatty, spicy food, long breaks between meals);
• diseases of the gastrointestinal tract (gastritis, duodenitis, peptic ulcer, pancreatitis);
• hormonal disorders;
• menopause;
• nervous experiences, stress.

2 main forms of dyskinesia:

At hyperkinetic form, the tone of the gallbladder is increased and its contractions occur too quickly and strongly. The sphincters do not open enough. This causes sharp pain in the right hypochondrium. Attacks of pain are usually short-lived and rarely last more than one hour. As a rule, they do not arise out of nowhere, but are provoked by negative emotions, worries, and nervous overload. The hyperkinetic form of dyskinesia is more common at a young age.

Hypokinetic On the contrary, older people are more likely to suffer from a form of dyskinesia. Its cause is insufficiently intense contraction of the gallbladder. This also manifests itself as pain in the right hypochondrium. True, the pain is usually not severe, but long-lasting, dull, and often bursting in nature.

Biliary dyskinesia consists of a series of exacerbations and improvements. After some time, an inflammatory process (cholecystitis, cholangitis) or gallstones may form in the gallbladder and ducts (cholelithiasis).

Warning signs: constipation or diarrhea, bad dream and appetite, decreased libido and impaired menstrual cycle(among women).

Diagnostics

1. Blood chemistry. During a severe exacerbation, a blood test reveals an increase in the level of liver enzymes (alkaline phosphatase, etc.).
2. Ultrasound of the liver and gallbladder, which allows you to assess the condition of the gallbladder and its ducts and identify stones.
3. Duodenal intubation - collection of bile for analysis using a gastric tube. The procedure is also used for medicinal purposes to flush the bile ducts during bile stagnation. To do this, after collecting the bile, heated mineral water is introduced into the probe. The procedure is carried out on an empty stomach.
4. Tests using special preparations. A medicinal substance (for example, secretin) is administered, which enhances the production of bile. If there is a disease, then bile does not have time to be released into the intestines, but accumulates in the gallbladder and ducts. There is an expansion of the ducts and an increase in the volume of the bladder, which is recorded using ultrasound.
5. X-ray methods – cholecystography.

It is very important not to confuse biliary dyskinesia with other serious diseases that have similar symptoms!

Treatment

It is important to establish the form of dyskinesia during the examination - the treatment method will depend on this. A necessary condition for the treatment of dyskinesia is diet.

Diet with hyperkinetic form - this is frequent split meals (4-5 times a day), limiting foods that cause bladder contractions (fatty, meat products, vegetable oil, cakes and other products made from fatty dough, beer, carbonated drinks). Dishes should be mostly mashed and boiled, not too greasy or spicy. More fruits and berries in any form!

Among medications, antispasmodics (no-spa, etc.) are mainly used. Choleretic drugs (holosas, cholenzym, flamin) and medicinal herbal preparations (corn silk, rose hips, peppermint, etc.) will also not be superfluous.

To this day, the ancient method of treatment is widely used - drinking mineral waters. For this form of the disease, waters with low and medium mineralization are recommended: Narzan, Navtusya, Slavyanovskaya, Smirnovskaya, Essentuki No. 4 and No. 20. You should drink hot water (40-25 degrees), ½ glass or 1 glass 3-4 times a day, half an hour before meals.

Diet in hypokinetic form must necessarily include products that have a choleretic effect: sour cream, butter and vegetable oil, cream, soft-boiled eggs, black bread, vegetables. They stimulate the motor activity of the biliary tract. For the same purpose, aloe extract, eleutherococcus, and ginseng are used. Herbal choleretic infusions help well. They usually include immortelle flowers, yarrow, mint leaves, coriander fruits, etc.

Choleretic agents are used - cyclone, 10% solutions of xylitol or sorbitol, Carlsbad salt and herbs - parsley decoction, decoctions and infusions of dandelion, yarrow, calamus, barberry.

Mineral waters are also used here, but only with a high degree of mineralization. For example, Batalinskaya, Arzni, Essentuki No. 17. They should be drunk cold, ½-1 glass 3-4 times a day for 30-60 minutes. before meals (within 3-4 weeks).

Essay
« Diseases of the biliary system in children»

Introduction
In recent years, there has been a steady upward trend in the number of children with chronic inflammatory diseases digestive organs. Pathology of the gallbladder and biliary tract occupies one of the leading places in the structure of gastroenterological diseases. Hepatobiliary pathology is diagnosed in most school-age children, with girls getting sick 2-3 times more often than boys, and accounting for 80% of all gastrointestinal diseases.
Functional disorders of the biliary tract (dyskinesia) are currently considered as a premorbid condition, which, if prolonged, can lead to the development of chronic diseases of the biliary system - cholecystitis, cholecystocholangitis, cholelithiasis. Inflammatory diseases of the gallbladder and biliary tract in childhood have high specific gravity in the structure of diseases of the digestive tract of non-infectious etiology. The prevalence of this pathology in the Republic of Belarus is 242.9 cases per 100 thousand children.
All this testifies to the great medical and social significance early diagnosis, rational therapy and improvement of dispensary observation of this group of patients.
Biliary dyskinesia

Dyskinesiabiliary tract(JVP)- a functional disease characterized by impaired motility of the gallbladder and sphincter apparatus and clinically manifested by pain in the right hypochondrium.
In pediatric practice, the most common combinations are pathological conditions, characterized by biliary dyskinesia and changes in adjacent digestive organs. It must be taken into account that biliary dyskinesia may be only one of the special cases of impaired motility of the entire gastrointestinal tract.
Etiology

Currently, biliary dyskinesias are divided into primary and secondary. Primary dyskinesias include diseases based on neurohumoral disorders. regulatory mechanisms. Secondary dyskinesias are caused by organic lesions of the liver, stomach, duodenum and occur as viscero-visceral reflexes.
There are a number of exogenous and endogenous factors, causing various disorders of motility of the biliary tract. Particular importance is given to giardiasis. Vegetating in the mucous membrane of the duodenum, Giardia attaches to microvilli and causes pronounced dystrophic changes in the intestinal epithelium, which ultimately disrupts the coordination of the sphincter apparatus of the duodenum and bile ducts. There is a clear dependence of the occurrence of dyskinesias on previous infectious diseases: viral hepatitis, salmonellosis, dysentery. Foci play a certain role in the occurrence and development of biliary dyskinesia chronic infection, especially chronic pathology ENT organs - chronic tonsillitis, sinusitis, etc. The spread of functional diseases of the biliary tract is known to depend on various neurotic conditions. The causes of dyskinesia may be poor nutrition, intestinal dysbiosis, food allergy, hypokinesia, etc.
Pathogenesis

The basis for the formation of biliary dyskinesia is a violation of the interaction of the innervation and endocrine systems, which carry out the sequence of contraction and relaxation of the gallbladder and the sphincter system of Oddi, Lutkens, Mirizzi, which leads to discoordination of their activity and disruption of the passage of bile into the intestine.
In the pathogenesis of primary dyskinesias, the main link is a disorder of neurohumoral regulation, mainly carried out by intestinal peptide hormones. Cholecystokinin-pancreozymin contracts the gallbladder, promoting the flow of bile into the duodenum. Gastrin, secretin, and glucagon have a slightly less stimulating effect. Enkephalins, angiotensins, and neurotensin inhibit gallbladder motility. Production disruption peptide hormones and disorders of their relationship change the contractile function of not only the gallbladder, but also other parts of the biliary system and pancreatic ducts. All this contributes to increased pressure in the gallbladder and hypertonicity of the sphincter apparatus, which is manifested by pain of various types.
Endocrine disorders, especially pronounced during puberty, play a certain role in the development of dyskinesias.
Irritation of the vagus nerve leads to contraction of the gallbladder and spasm of the sphincters of the cystic and common ducts. Irritation of the sympathetic nerve, on the contrary, leads to a weakening of the tone of the gallbladder and relaxation of the sphincters.
Classification of biliary dyskinesia(ByA.A.Mazurin, A.M.Zaprudnov, 1984; V.L.Paykovet al., 1998)

1. For the sphincter apparatus of the biliary tract: hypertonic (spasm of the sphincters), hypotonic (sphincter insufficiency), atonic, mixed.
2. For gallbladder motility and bile ducts: hyperkinetic, hypokinetic, mixed.
Clinic

There are two main forms of biliary dyskinesia: hypertonic and hypotonic, which still seems somewhat arbitrary, since there are many options for combining altered tone of the gallbladder and the sphincter apparatus of the biliary system.
The course of dyskinesias in children is characterized by pronounced polymorphism. Biliary dyskinesia is characterized by aching or cramping pain in the abdomen, mainly in the right hypochondrium, sometimes radiating to the right shoulder, and dyspeptic disorders. General neurological disorders are common in sick children. A characteristic feature of dyskinesia is the connection of pain with neuropsychic and physical stress, and the intake of fatty foods.
When palpating the abdomen with biliary dyskinesia, maximum pain is noted in the right hypochondrium, and in the presence of gastroduodenitis or peptic ulcer - in the pyloroduodenal zone. Along with local pain on palpation in the right hypochondrium, symptoms from the gallbladder are determined (Kehr's, Ortner's, Murphy's symptoms), and lung muscle tension. Typical symptom Biliary dyskinesia in children is an enlargement of the liver up to 2-3 cm below the costal arch.
Differential diagnosis of various forms of biliary dyskinesia in children is possible on the basis of clinical data and data from instrumental research methods.
In the hypertensive form, the pain is usually sharp, paroxysmal, cutting, stabbing. Pain occurs 30-40 minutes after eating food, especially cold food, or after emotional stress. The pain is localized in the right hypochondrium, less often in the right hypochondrium and the umbilical region. The duration of an attack of pain usually does not exceed 5-15 minutes. This form of dyskinesia is characterized by a shorter duration of the disease (up to 6 months), lability of the autonomic nervous system, and associated neurotic conditions. On palpation of the abdomen, pain is noted in the right hypochondrium. Liver enlargement is rare. Blistering symptoms weakly positive.
With the hypotonic form of dyskinesia, patients complain of pain in the right hypochondrium, weakness, fatigue, periodic nausea. The pain is constant and periodically intensifies. The pain is dull, aching, pressing. They occur 60-90 minutes after eating a meal, especially a fatty one, or after exercise. The duration of the pain syndrome is from 1 to 2 hours. Neurovegetative symptoms are rare. When palpating the abdomen, pain is most often noted in the area of ​​the right hypochondrium or the right hypochondrium and the navel. Blistering symptoms are positive. There is an enlargement of the liver. The duration of the disease is 1-1.5 years.
Diagnostics

Recognition of biliary dyskinesia presents certain difficulties and requires comprehensive examination. The most accessible method of laboratory diagnosis is continuous fractional duodenal intubation according to F. Lopez et al. (1950). For the first time in domestic pediatric practice, this examination method was tested by V.L. Paikov and L.I. Kravchenko in 1973. However, it should be pointed out that there is a need for a critical attitude towards the results of duodenal intubation due to its insufficient physiology associated with the introduction into the duodenum and the long-term presence in it of a duodenal probe with a metal olive at the end.
Most important in the diagnosis of biliary dyskinesia in modern stage has an ultrasonic method. When conducting an ultrasound examination of the gallbladder and biliary tract, the shape, position and emptying of the gallbladder changes depending on the type of dyskinesia.
To determine the type of gallbladder dyskinesia, use the indicator of gallbladder motor function (PDF) (Table 1), which is calculated by the formula:
PDF = (d 2 x l 1) / (d 1 x l 2),
where d 1 is the diameter of the gallbladder before taking a choleretic breakfast; l 1 - length of the gallbladder before breakfast; d 2 - diameter of the gallbladder after eating breakfast; l 2 - length of the gallbladder after eating breakfast.
In healthy children, the PDF is 0.59-0.75 (59-75%). In the hypertensive form, a reduced gallbladder is detected. Its emptying is accelerated. In the hypotonic form, the gallbladder is enlarged in size, and its emptying is slow even after repeated administrations of choleretic stimulants.
Table 1. Types of disorders of the motor function of the biliary system

Types of bowel movements	Type of coordination disorder
Delayed emptying: the diameter of the gallbladder is reduced by less than half	1. Spasm of the sphincters of the biliary tract, PDF > 0.75 2. Weak contraction of the muscular layer of the gallbladder, PDF< 0,75
Accelerated emptying: the diameter of the gallbladder is reduced by more than half	1. Lack of tone of the biliary sphincters, PDF< 0,59 2. Strong contraction of the muscular layer of the gallbladder, PDF > 0.59
Timely emptying: the diameter of the gallbladder is reduced by half	1. Weak contraction of the gallbladder with insufficiency of the biliary sphincters, PDF<0,59 2. Strong contraction of the gallbladder with sphincter spasm, PDF > 0.75

The results of an ultrasound examination confirm the presence of functional changes in the biliary system, while excluding abnormalities in the development of the gallbladder and biliary tract, cholelithiasis and inflammatory process in the biliary system.
X-ray and scintigraphic studies are also highly informative methods. However, taking into account the radiation exposure on the child’s body, these methods for diagnosing functional diseases of the biliary system are used extremely rarely.
Differential diagnosis

Differential diagnosis of various forms of biliary dyskinesia among themselves and with inflammatory diseases of the biliary tract is presented in Table. 2.
Table 2. Differential diagnostic criteria for diseases of the liver and biliary tract

Criterion	Form of dyskinesia	Chronic cholecystocholangitis
	hypotonic	hypertensive
1	2	3	4
Anamnesis Family predisposition Seasonality exacerbation Duration of the disease Nature of pain Connection with dietary errors Irradiation pain Vomit Nausea Constipation Belching Muscular voltage	Neurotic reactions, emotional stress, lability of the autonomic nervous system Characteristic Autumn-spring period Up to 1 year Paroxysmal, fickle In 30-40 minutes after eating cold food Uncharacteristic Characteristic Characteristic Uncharacteristic Uncharacteristic Absent	Negative emotions, physical activity Characteristic Uncharacteristic 1 - 1.5 years Aching, dull, permanent 1-1.5 hours after eating, especially fatty foods Uncharacteristic Rarely Characteristic Characteristic Characteristic Absent	Weakness, lethargy, signs of intoxication, polyhypovitaminosis Characteristic Autumn-spring period 1 - 1.5 years Paroxysmal, dull, constant 1.5-2 hours after eating food, especially fatty and fried foods To the right shoulder and spatula Characteristic Characteristic Characteristic Characteristic Characteristic
Blister symptoms Increase liver Intoxication Changes in biochemical blood parameters Changes in general analysis blood	Not clearly expressed Uncharacteristic None None None	Not clearly expressed Sometimes None Slight increase in alkaline phosphatase activity None	Positive Characteristic Expressed Increased activity of transaminases, alkaline phosphatase, bilirubin Leukocytosis, neutrophilia, increased ESR, anemia

Treatment

Treatment of biliary dyskinesia should be comprehensive, taking into account all diseases and functional disorders of organs digestive system. Treatment tactics determined by the nature of dyskinetic disorders and the severity of autonomic reactions.
All patients, regardless of the form of dyskinesia, are recommended to have therapeutic nutrition (diet No. 5) with the exception of spicy, salty, smoked and fried foods, extractive substances, and refractory fats. It is necessary to ensure the optimal age-related needs for proteins, fats, carbohydrates, and vitamins. Animal proteins must make up at least 60% of the total protein. Food should be steamed. It is recommended to eat at least 5 times a day.
In case of hypotonic form of biliary dyskinesia, food products having a choleretic effect. Recommended are butter and vegetable oil, cream, sour cream, and eggs. It is recommended to consume a significant amount of fruits, vegetables, and black bread, which reflexively stimulates the evacuation function of the intestines and gall bladder.
One of the leading places in the complex therapy of patients with biliary pathology is the prescription of choleretic drugs, which can be divided into 2 groups:
I. Increasing the formation of bile by the cells of the liver parenchyma (choleretics).
II. Promoting the movement of bile along the biliary tract and its release into the intestines (cholekinetics).
Choleretics include:
1. Drugs that enhance the secretion of bile and stimulate the formation of bile acids (true choleretics):
a) preparations containing bile acids - allochol, cholenzyme, dehydrocholic acid, hologon;
b) preparations of chemical synthesis - nicodine, oxafenamide, cyclone, etc.;
c) preparations of plant origin (holosas, flamin, holagol, holaflux, holagogum) and decoctions of medicinal herbs (immortelle, corn silk, mint, tansy, rose hips, turmeric, etc.).
2. Drugs that increase the secretion of bile mainly due to the water component - sodium salicylate, mineral waters, corn silk extract, valerian extract, etc.
The group of cholekinetics includes:
1. Drugs that cause an increase in the tone of the gallbladder and a decrease in the tone of the bile ducts - magnesium sulfate, xylitol, cholecystokinin, herbal preparations from barberry, turmeric, including cholagogum.
2. Drugs that cause relaxation of the tone of the biliary tract - atropine sulfate, platiphylline hydrotartrate, aminophylline, metacin, belladonna extract.
Choleretic therapy must be carried out over a long period of time, in intermittent courses, systematically alternating choleretic agents, which prevents degeneration of hepatocytes and the body’s addiction to drugs.
When choosing a drug, first of all, it is necessary to take into account the form of biliary dyskinesia, the initial tone of the gallbladder and sphincter apparatus. In children, the best choleretic agents are herbal preparations that have a gentle physiological effect and rarely cause side effects.
Treatment tactics children With hypertensive form of biliary dyskinesia. Choleretics are widely used in the treatment of patients, gradually switching to choleretic herbs. Taking into account the frequent dysfunction of the autonomic nervous system, bromine preparations, rudotel, trioxazine, and a sedative mixture are prescribed. It is advisable to include phenobarbital, which stimulates the secretion of bile, the exchange of bilirubin, the excretion of exogenous substances by bile, and has a sedative effect. All patients need to be prescribed antispasmodics. Physiotherapeutic procedures include ozokerite applications and papaverine electrophoresis on the right hypochondrium. When carrying out physical therapy, heavy loads on the abdominal muscles are avoided. Good effect observed when using mineral waters of low salinity, without gases, heated 4-5 times a day in small portions (40-50 ml).
Treatment tactics children With hypotonic a form of biliary dyskinesia. With this form of dyskinesia, it is necessary to correctly select choleretic agents. The most effective combination is true choleretics and cholekinetics or magnesium sulfate in the form of tubage according to Demyanov. After 2 courses of treatment with choleretic drugs, they switch to choleretic herbs. Physiotherapeutic procedures in the acute period include applications of ozokerite, electrophoresis of magnesium sulfate, and sinusoidal modulated currents (SMC) to the area of ​​the right hypochondrium. Mineral waters of high mineralization at room temperature are prescribed at the rate of 3-4 ml/kg body weight in 2-3 doses.
Clinical examination

Dispensary observation is carried out by a local pediatrician at the clinic for 1 year. After discharge from the hospital, preventive treatment is carried out for 2 months. The complex of measures during dispensary observation includes: control and recommendations of a doctor on diet therapy, periodic prescription of choleretic drugs for 2 weeks and physiotherapeutic procedures (at least 2 times a year), regular sanitation of foci of chronic infection. During the period of stable remission (in the absence of exacerbations of the disease for more than 1 year), anti-relapse treatment is not carried out.
Spicycholecystocholangitis
Isolated damage to the gallbladder and biliary tract in children is diagnosed extremely rarely, since clinical picture cholecystitis and cholangitis are of the same type and their topical diagnosis is difficult. Therefore, it is most appropriate and correct to use the term “cholecystocholangitis”.
Cholecystocholangitis- This is a simultaneous inflammation of the gallbladder and bile ducts.
Etiopathogenesis

In most cases, the cause of the disease is Escherichia coli, coccal flora (staphylococcus, streptococcus), less often - opportunistic gram-negative flora (Proteus, Klebsiella, Pseudomonas aeruginosa). In some cases, infestation by helminths (roundworms, opisthorchises, etc.) is important. Viral gastroenteritis and acute respiratory viral infections can contribute to the development of the disease. Penetration of infection into the gall bladder, etc.................