Chronic calculous cholecystitis. Acute cholecystitis

Difficulties in diagnosis arise with an atypical course of the disease, when there is no parallelism between pathomorphological changes in the gallbladder and clinical manifestations, as well as with complications acute cholecystitis unconfined peritonitis, when due to severe intoxication and diffuse nature of abdominal pain it is impossible to determine the source of peritonitis.

Diagnostic errors in acute cholecystitis occur in 12-17% of cases. Erroneous diagnoses may include diagnoses of acute diseases of the abdominal organs, such as acute appendicitis, perforated gastric or duodenal ulcer, acute pancreatitis, intestinal obstruction and others. Sometimes the diagnosis of acute cholecystitis is made with right-sided pleuropneumonia, paranephritis, pyelonephritis. Errors in diagnosis lead to the wrong choice of treatment method and delayed surgical intervention.

Most often on prehospital stage instead of acute cholecystitis, acute appendicitis, intestinal obstruction and acute pancreatitis are diagnosed. Noteworthy is the fact that when patients are referred to a hospital, diagnostic errors occur more often in the older age group (10.8%) compared to the group of patients under 60 years of age.

Errors of this kind made at the prehospital stage, as a rule, do not entail any special consequences, since each of the diagnoses listed above is an absolute indication for emergency hospitalization of patients in a surgical hospital. However, if such an erroneous diagnosis is confirmed in the hospital, this may be the cause of serious tactical and technical miscalculations (incorrectly chosen surgical access, erroneous removal of a secondarily changed vermiform appendix and etc.). That is why differential diagnosis between acute cholecystitis and clinically similar diseases is of particular practical importance.

Distinguishing acute cholecystitis from acute appendicitis in some cases is a rather difficult clinical task. The differential diagnosis is especially difficult when the gallbladder is located low and its inflammation simulates acute appendicitis or, conversely, when the appendix is ​​located high (subhepatic) acute appendicitis is clinically similar in many ways to acute cholecystitis.

When examining patients, it should be taken into account that acute cholecystitis most often affects patients in the older age group. In the anamnesis, patients with acute cholecystitis often have repeated attacks of pain in the right hypochondrium with characteristic irradiation, and in some cases direct indications of cholelithiasis. Pain in acute appendicitis is not as intense as in acute cholecystitis and does not radiate to the right shoulder girdle, shoulder and scapula. The general condition of patients with acute cholecystitis, other things being equal, is usually more severe. Vomiting in acute appendicitis is one-time, in acute cholecystitis it is repeated. Palpation examination of the abdomen allows us to identify the localization of pain and muscle tension characteristic of each of these diseases abdominal wall. The presence of an enlarged and painful gallbladder completely eliminates diagnostic doubts.

There is much in common in the clinical manifestations of acute cholecystitis and acute pancreatitis: anamnestic indications of cholelithiasis, acute onset of the disease after an error in diet, localization of pain in the upper abdomen, repeated vomiting. Distinctive features of acute pancreatitis are: the girdling nature of the pain, sharp pain in the epigastric region and much less pronounced in the right hypochondrium, absence of enlargement of the gallbladder, diastasuria, severity of the patient’s general condition, which is especially characteristic of pancreatic necrosis.

Since repeated vomiting is observed in acute cholecystitis, and there are often symptoms of intestinal paresis with bloating and stool retention, acute obstructive intestinal obstruction may be suspected. The latter is distinguished by the cramping nature of the pain with a localization uncharacteristic for acute cholecystitis, resonating peristalsis, “splashing noise”, positive Val’s sign and other specific signs of acute intestinal obstruction. Of decisive importance in the differential diagnosis is a survey fluoroscopy of the abdominal cavity, which makes it possible to identify distension of intestinal loops (symptom of “organ pipes”) and fluid levels (Kloiber cups).

The clinical picture of a perforated ulcer of the stomach and duodenum is so characteristic that it rarely has to be differentiated from acute cholecystitis. The exception is covered perforation, especially if it is complicated by the formation of a subhepatic abscess. In such cases, one should take into account a history of ulcers, the most acute onset of the disease with “dagger” pain in the epigastrium, and the absence of vomiting. Significant diagnostic assistance is provided by x-ray examination, which makes it possible to identify the presence of free gas in the abdominal cavity.

Renal colic, as well as inflammatory diseases of the right kidney and perinephric tissue (pyelonephritis, paranephritis, etc.) can be accompanied by pain in the right hypochondrium and therefore simulate the clinical picture of acute cholecystitis. In this regard, when examining patients, it is necessary to pay attention to the urological history, carefully examine the kidney area, and in some cases there is a need to use a targeted study of the urinary system (urinalysis, excretory urography, chromocystoscopy, etc.).

Instrumental diagnosis of acute cholecystitis

Reducing the frequency of erroneous diagnoses in acute cholecystitis is an important task in practical surgery. It can be successfully solved only with the widespread use of modern diagnostic methods such as ultrasound, laparoscopy, and retrograde cholangiopancreatography (RPCP).

Echo signs of acute cholecystitis include thickening of the gallbladder wall and an echo-negative rim around it (doubling of the wall) (Fig. 9).

Rice. 9. Ultrasound picture of acute cholecystitis. Visible thickening of the gallbladder wall (between black and white arrow) and a small amount of fluid around it (single white arrow)

The high diagnostic accuracy of laparoscopy for “acute abdomen” allows the method to be widely used for differential diagnostic purposes. Indications for laparoscopy for acute cholecystitis are as follows:

1. Uncertainty of the diagnosis due to the inconclusive clinical picture of acute cholecystitis and the inability to establish the cause by other diagnostic methods “ acute abdomen».

2. Difficulties in determining by clinical methods the severity of inflammatory changes in gallbladder and abdominal cavity in patients with a high degree of surgical risk.

3. Difficulties in choosing a treatment method (conservative or surgical) with a “blurred” clinical picture of acute cholecystitis.

Carrying out laparoscopy according to indications in patients with acute cholecystitis allows not only to clarify the diagnosis and the depth of patho morphological changes in the gallbladder and the prevalence of peritonitis, but also to correctly resolve treatment and tactical issues. Complications during laparoscopy are extremely rare.

When acute cholecystitis is complicated by obstructive jaundice or cholangitis, it is important before surgery to have accurate information about the reasons for their development and the level of obstruction of the bile ducts. To obtain this information, RPCG is performed by cannulating the large duodenal nipple under the control of a duodenoscope (Fig. 10, 11). RPCG should be performed in every case of acute cholecystitis, which occurs with pronounced clinical signs of impaired outflow of bile into the intestine. If a contrast study is successfully performed, it is possible to identify bile duct stones, determine their location and the level of blockage of the duct, and determine the extent of narrowing of the bile duct. Determining the nature of the pathology in the bile ducts using endoscopic method allows you to correctly resolve questions about the timing of the operation, the volume of surgical intervention on the extrahepatic bile ducts, as well as the possibility of performing endoscopic papillotomy to eliminate the causes. causing obstructive jaundice and cholangitis.

When analyzing cholangiopancreatograms, it is most difficult to correctly interpret the condition terminal department common bile duct due to the possibility of false signs of its damage appearing on radiographs. Most often, cicatricial stenosis of the large duodenal papilla is mistakenly diagnosed, while the X-ray picture of stenosis can be caused by functional reasons"(swelling of the nipple, persistent sphincterospasm). According to our data, an incorrect diagnosis of organic stenosis of the major duodenal papilla is made in 13% of cases. An erroneous diagnosis of nipple stenosis may lead to incorrect tactical actions. In order to avoid unnecessary surgical interventions on the large duodenal nipple, the endoscopic diagnosis of stenosis must be verified during surgery using an optimal set of intraoperative studies.

Rice. 10. RPCG is normal. PP - pancreatic duct; G - gallbladder; O - common hepatic duct

Rice. 11. RPCG. A stone in the common bile duct is visualized (marked with an arrow).

In order to shorten the preoperative period in patients with obstructive jaundice and cholangitis, endoscopic retrograde cholangiopancreatography is performed on the first day after patients are admitted to the hospital.

Therapeutic tactics for acute cholecystitis

The main provisions on therapeutic tactics for acute cholecystitis were developed at the VI and supplemented at the XV plenums of the Board of the All-Union Society of Surgeons (Leningrad, 1956 and Chisinau, 1976). According to these provisions, the surgeon’s tactics for acute cholecystitis should be active and expectant. The wait-and-see approach is considered flawed, because the desire to resolve the inflammatory process with conservative measures leads to serious complications and delayed operations.

The principles of active expectant treatment tactics are as follows.

1. Indications for emergency surgery, which is performed in the first 2-3 hours from the moment of hospitalization of the patient, are gangrenous and perforated cholecystitis, as well as cholecystitis complicated by diffuse or diffuse peritonitis.

2. Indications for urgent surgery, which is performed 24-48 hours after the patient’s admission to the hospital, are the lack of effect from conservative treatment while symptoms of intoxication and local peritoneal phenomena persist, as well as cases of increasing general intoxication and the appearance of symptoms of peritoneal irritation, which indicates about the progression of inflammatory changes in the gallbladder and abdominal cavity.

3. In the absence of symptoms of intoxication and local peritoneal phenomena, patients are treated conservatively. If, as a result of conservative measures, it is possible to stop inflammatory phenomena in the gallbladder, the question of surgery in these patients is decided individually after a comprehensive clinical examination, including x-ray examination of the bile ducts and gastrointestinal tract. Surgical intervention in this category of patients is performed during the “cold” period (no earlier than 14 days from the onset of the disease), as a rule, without discharging patients from the hospital.

From the listed indications it follows that the conservative method of treatment can be used only for the catarrhal form of cholecystitis and in cases of phlegmonous cholecystitis occurring without peritonitis or with mild signs of local peritonitis. In all other cases, patients with acute cholecystitis should be operated on urgently or urgently.

The success of surgery for acute cholecystitis largely depends on the quality of preoperative preparation and the correct organization of the operation itself. In case of emergency surgery, patients need short-term intensive therapy aimed at detoxifying the body and correcting metabolic disorders. Preoperative preparation should not take more than 2-3 hours.

Emergency surgery performed for acute cholecystitis has its shadow sides, which are associated with insufficient examination of the patient before surgery and the inability, especially at night, to conduct a full examination of the bile ducts. As a result of incomplete examination of the bile ducts, stones and strictures of the large duodenal nipple are viewed, which subsequently leads to relapse of the disease. In this regard, it is advisable to perform emergency operations for acute cholecystitis in the morning and daytime, when it is possible for a qualified surgeon to participate in the operation and use special methods for diagnosing lesions of the bile ducts during the operation. When patients are admitted at night and do not require immediate surgery, they need to receive intensive infusion therapy during the remaining hours of the night.

Conservative treatment of acute cholecystitis

Carrying out conservative therapy in full and early dates The disease usually allows you to stop the inflammatory process in the gallbladder and thereby eliminate the need for urgent surgical intervention, and in case of a long period of the disease, prepare the patient for surgery.

Conservative therapy, based on pathogenetic principles, includes a set of therapeutic measures that are aimed at improving the outflow of bile into the intestines, normalizing disrupted metabolic processes and restoring the normal functioning of other body systems. The complex of treatment measures must include:

fasting for 2-3 days;

local hypothermia - application of an ice pack to the area of ​​the right hypochondrium;

gastric lavage while nausea and vomiting persist;

prescription of antispasmodics (atropine, platyphylline, no-spa, or papaverine) by injection;

antihistamine therapy (diphenhydramine, pipolfen or suprastin);

antibacterial therapy. For antibacterial therapy, drugs should be used that can act against etiologically significant microorganisms and penetrate well into bile.

Ceftriaxone 1-2 g/day + metronidazole 1.5-2 g/day;

Cefopirazone 2-4 g/day + metronidazole 1.5-2 g/day;

Ampicillin/sulbactam 6 g/day;

Amoxicillin/clavulanate 3.6-4.8 g/day;

Gentamicin or tobramycin 3 mg/kg per day + ampicillin 4 g/day + metronidazole 1.5-2 g/day;

Netilmicin 4-6 mg/kg + metronidazole 1.5-2 g/day;

Cefepime 4 g/day + metronidazole 1.5-2 g/day;

Fluoroquinolones (ciprofloxacin mg intravenously) + metronidazole 1.5-2 g/day;

to correct impaired metabolic processes and detoxification, 1.5-2 liters of infusion media are administered intravenously: Ringer-Locke solution or lactasol - 500 ml, glucose-novocaine mixture - 500 ml (novocaine solution 0.25% - 250 ml and 5% glucose solution - 250 ml), hemodez - 250 ml, 5% glucose solution - 300 ml together with 2% potassium chloride solution - 200 ml, protein preparations - casein hydrolyzate, aminopeptide, alvesin and others;

prescribe vitamins B, C, calcium supplements;

Taking into account the indications, glycosides, cocarboxylase, panangin, aminophylline and antihypertensive drugs are used.

The prescription of painkillers (promedol, pantopon, morphine) for acute cholecystitis is considered unacceptable, since pain relief often smoothes out the picture of the disease and leads to viewing the moment of perforation of the gallbladder.

An important component of treatment for acute cholecystitis is the blockade of the round ligament of the liver with a 0.25% solution of novocaine in the amount of ml. It not only relieves pain, but also improves the outflow of infected bile from the gallbladder and bile ducts due to “increasing the contractility of the bladder and relieving spasm of the sphincter of Oddi. Recovery drainage function gallbladder and its emptying of purulent bile contribute to the rapid subsidence of the inflammatory process.

Surgical treatment of acute cholecystitis

Surgical approaches. To access the gallbladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the most common are the Kocher, Fedorov, Cherny incisions and upper midline laparotomy.

Scope of surgery. With acute cholecystitis, it is determined by the general condition of the patient, the severity of the underlying disease and the presence of concomitant changes in the extrahepatic bile ducts. Depending on these circumstances, the nature of the operation may consist of cholecystostomy or cholecystectomy, which, if indicated, is supplemented by choledochotomy and external drainage of the bile ducts or the creation of a biliodigestive anastomosis.

The final decision on the extent of surgical intervention is made after a thorough inspection of the extrahepatic bile ducts, which is carried out using simple and accessible research methods (inspection, palpation, probing through the stump of the cystic duct or opening the common bile duct), including intraoperative cholangiography. Carrying out intraoperative cholangiography can reliably judge the condition of the bile ducts, their location, width, presence or absence of stones and strictures. Based on cholangiographic data, intervention on the common bile duct and the choice of a method for correcting its damage are argued.

Cholecystectomy. Removal of the gallbladder is the main intervention for acute cholecystitis, leading to complete recovery of the patient. This operation was first performed by K. Langenbuch in 1882. There are two methods of cholecystectomy - “from the neck” and “from the bottom”. The method of removing the gallbladder “from the neck” has undoubted advantages (Fig. 12).

Differential diagnosis of acute cholecystitis

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Acute cholecystitis is distinguished from acute inflammation of the pancreas, renal colic, perforated ulcer of the stomach and duodenum, or appendicitis.

Renal colic differs from acute cholecystitis in that it causes acute pain in the lumbar region. This pain radiates to the genital area and thighs. At the same time, there is a violation of urination. With renal colic, the temperature does not rise, and leukocytosis is not recorded. A urine test shows the presence of formed blood components and salts. There are no symptoms of peritoneal irritation, but Pasternatsky's symptom is detected.

Acute appendicitis with a high location of the appendix can provoke acute cholecystitis. The difference between acute cholecystitis and acute appendicitis is that with it there is vomiting of bile, and the pain radiates to the right shoulder blade and shoulder area. In addition, with appendicitis, the Mussi-Georgievsky symptom is not detected. Diagnosis is simplified by the presence of information in the medical history that the patient has gallstones. Unlike acute cholecystitis, acute appendicitis is more severe, with the rapid development of peritonitis.

In some cases, a perforated ulcer of the stomach and duodenum is disguised as acute cholecystitis. However, in acute cholecystitis, unlike ulcers, the medical history usually contains indications of gallstones.

Acute cholecystitis is characterized by vomiting containing bile and pain radiating to other parts of the body. Initially, pain is localized in the right hypochondrium, gradually increases, and fever begins.

Hidden perforated ulcers begin acutely. In the first few hours of illness, the muscles of the anterior abdominal wall become very tense. The patient complains of localized pain in the right iliac region due to the contents of the stomach leaking into the cavity. Similar phenomena are not observed in acute cholecystitis. In addition, in acute cholecystitis, liver dullness persists.

Acute pancreatitis is characterized by increasing intoxication, rapid heartbeat, and intestinal paresis - this is its main difference from acute cholecystitis. Painful sensations are observed mainly in the left hypochondrium or above the stomach, and are encircling in nature. Pain due to inflammation of the pancreas is often accompanied by severe vomiting. The distinction between acute pancreatitis and acute cholecystitis is very difficult, so diagnosis must be carried out in an inpatient setting.

Differential diagnosis

Acute cholecystitis is differentiated from the following diseases:

1) Acute appendicitis. In acute appendicitis, the pain is not so intense, and, most importantly, does not radiate to the right shoulder, right scapula, etc. Also, acute appendicitis is characterized by migration of pain from the epigastrium to the right iliac region or throughout the entire abdomen; with cholecystitis, the pain is precisely localized in the right hypochondrium; vomiting with appendicitis is one-time. Typically, palpation reveals a thickened consistency of the gallbladder and local tension in the muscles of the abdominal wall. Ortner's and Murphy's symptoms are often positive.

2) Acute pancreatitis. This disease is characterized by girdling pain and sharp pain in the epigastrium. A positive Mayo-Robson sign is noted. The patient's condition is characteristically grave; he assumes a forced position. The level of diastase in urine and blood serum is of decisive importance in diagnosis; figures above 512 units are conclusive. (in urine).

With stones in the pancreatic duct, the pain is usually localized in the left hypochondrium.

3) Acute intestinal obstruction. In acute intestinal obstruction, the pain is cramping and non-localized. There is no increase in temperature. Enhanced peristalsis, sound phenomena (“splashing noise”), and radiological signs of obstruction (Kloiber cups, arcades, symptom of pinnateness) are absent in acute cholecystitis.

4) Acute obstruction mesenteric arteries. With this pathology, severe pain of a constant nature occurs, but usually with distinct intensification, and is less diffuse in nature than with cholecystitis (more diffuse). A history of pathology of the cardiovascular system is required. The abdomen is easily accessible for palpation, without pronounced symptoms of peritoneal irritation. Fluoroscopy and angiography are decisive.

5) Perforated ulcer of the stomach and duodenum. Men are more likely to suffer from this, while cholecystitis most often affects women. Cholecystitis is characterized by intolerance to fatty foods, frequent nausea and malaise, which does not happen with a perforated ulcer of the stomach and duodenum; pain is localized in the right hypochondrium and radiates to the right scapula, etc., with an ulcer the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). The picture is clarified by the presence of a history of ulcers and tarry stools. X-ray reveals free gas in the abdominal cavity.

6) Renal colic. Pay attention to the urological history. The kidney area is carefully examined, Pasternatsky's symptom is positive, a urine test, excretory urography, and chromocystography are performed to clarify the diagnosis, since renal colic often provokes biliary colic.

Osteomyelitis (inflammation of the bone marrow and bones) Acute osteomyelitis. It is most often caused by staphylococci entering the bone marrow cavity with current from another purulent focus or through open injuries (abrasions, scratches, etc.).

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Clinical diagnosis:

Gallstone disease, chronic calculous cholecystitis.

Rationale for diagnosis:

The diagnosis was made based on:

The patient complains of discomfort and periodic dull pain of a girdle nature, appearing after eating any type of food, in the right hypochondrium, spreading to the epigastric region;

History of the disease: the appearance of similar pain about 1 year ago, in September 2015, after taking mostly fatty foods, which were not relieved by painkillers. As a result of inpatient treatment at the Central District Hospital in Ussuriysk for acute cholecystitis, she was admitted for planned surgical treatment;

Objective examination data:

1. the general condition of the patient is satisfactory, the skin and visible mucous membranes are pink, clean,

2.peripheral lymph nodes are not enlarged,

3.vesicular breathing is heard in the lungs, there are no wheezes,

4.heart sounds are clear, rhythmic, blood pressure 120/80 mmHg, pulse 76 beats per minute,

5. the tongue is moist, the abdomen is not swollen, soft, painless in all parts, the liver is not enlarged, stool and diuresis are regular (normal);

Instrumental studies: Ultrasound of the abdominal organs - the presence of stones up to 2-3 cm, enlargement and diffuse changes in the liver;

Laboratory research:; increase in the level of bilirubin in the blood, largely due to direct; the presence of leukocytosis, a sharp shift in the leukocyte formula to the left, and an increase in ESR.

All of the above is in favor of the diagnosis: cholelithiasis. Chronic calculous cholecystitis.

Differential diagnosis should be carried out with those nosological entities that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis.

With cholelithiasis, chronic calculous cholecystitis - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall, painful symptoms of Murphy, Georgievsky-Mussi, Ortner-Grekov. Increased pain and deterioration of the condition are associated with errors in diet and intake of fatty foods.

At peptic ulcer DPC-, daily circadian rhythm of pain, hunger - pain, eating - pain subsides, hunger - pain. On palpation there is pain in the right upper quadrant of the abdomen. The condition worsens significantly in the spring and autumn periods.

In chronic pancreatitis, pain is localized in the epigastric region, is dull in nature and radiates to the back. The pain intensifies after eating or drinking alcohol. Palpation of the abdomen usually reveals bloating, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation pain is noted at the Desjardins point or in the Choffard area. Often a painful point is detected in the left costovertebral angle (Mayo-Robson symptom). Sometimes a zone of skin hyperesthesia is determined corresponding to the zone of innervation of the 8-10 thoracic segment on the left (Kach's sign) and some atrophy of the subcutaneous fat layer in the area of ​​​​the projection of the pancreas onto the anterior abdominal wall (Groth's sign).

With choledocholithiasis - pain in the upper abdomen, more on the right, with radiation to the back.

With cholelithiasis, chronic calculous cholecystitis - dryness, bitterness in the mouth, nausea, sometimes vomiting, stool disorders (usually diarrhea), there is a natural connection with the intake of fatty foods. Patients are usually adequately nourished.

In case of duodenal ulcer, the symptoms are similar. Vomiting brings relief, the condition worsens with fasting. Patients are often asthenic.

For chronic pancreatitis - characteristic symptoms, there is a natural relationship with the consumption of alcohol, spicy, fried foods. Stool disorders - diarrhea, steato-amylocreatorhea. The patients are asthenic.

With cholelithiasis and choledocholithiasis, the dyspeptic syndrome is similar to chronic cholecystitis.

In case of cholelithiasis, chronic calculous cholecystitis - normal blood and urine values, there may be slight leukocytosis, ESR increases. In blood biochemistry - transaminases, hepatic fraction of alkaline phosphatase, amylase increase slightly, total bilirubin may increase (due to direct bilirubin) - cholestatic syndrome is slightly expressed.

In case of duodenal ulcer - iron deficiency, normal urine values, with exacerbation of the disease, slight leukocytosis in the CBC is possible, transaminases are within normal limits, bilirubin is normal. Cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase, alkaline phosphatase are increased, transaminases may be increased, dysproteinemia, in urine - normal, feces - steatorrhea, creatorrhea, amilorrhea. Coagulogram without features.

With cholelithiasis, choledocholithiasis, slight leukocytosis is possible in the UAC, ESR increases, bilirubin is present in the urine, urobilin will be absent, and stercobilin will also be absent in feces. Feces like white clay. Biochemistry - transaminases increase sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Cholestatic syndrome is pronounced. In the coagulogram, changes include an increase in bleeding time, a decrease in the prothrombin index (lower limit of normal), and an increase in INR.

Instrumental methods: ultrasound, FGDS.

In case of cholelithiasis, chronic calculous cholecystitis, the gallbladder is enlarged, the wall of the bladder is compacted, and in the lumen there is hyperechoic bile (suspension) and stones. Diffuse changes in the parenchyma of the liver and pancreas are possible. On X-ray positive stones, with cholecystography - stones (filling defects), enlargement, dystopia of the gallbladder is possible. Duodenal intubation - inflammatory changes in bile (portion B).

In the case of duodenal ulcer, FGDS is used (ulcerative defect, cicatricial changes, stenosis), and pH-metry and urease test are also carried out in parallel. During duodenal intubation, inflammatory altered bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to perform FGDS - barium X-ray - a niche symptom is detected.

In chronic pancreatitis, ultrasound shows diffuse changes in the gland, calcification, fibrosis, cystic changes, reduction in size of the gland, decreased patency of the Wirsung duct (inflammatory change in the wall, possible calcifications in the duct).

With cholelithiasis, choledocholithiasis, ultrasound shows diffusely altered liver, dilation of the intrahepatic ducts, stones in the common bile duct. During duodenography under conditions of artificial controlled hypotension, pathology of the organs of the pancreaticoduodenal zone is revealed. RPCG - the ability to see the external and internal hepatic ducts, as well as the pancreatic ducts. CRCP - it is possible to determine both the nature and localization of obstruction in the hepatoduodenal zone.

Etiology and pathogenesis of the underlying disease.

Calculous cholecystitis is a disease caused by the presence of stones in the gallbladder and bile ducts. There are cholesterol, pigment and mixed stones (calculi).

Etiology The following main groups of etiological factors leading to the development of calculous cholecystitis are distinguished: 1. Inflammatory process in the wall of the gallbladder of bacterial, viral (hepatitis virus), toxic or allergic etiology. 2. Cholestasis. 3. Disorders of lipid, electrolyte or pigment metabolism in the body. 4. Dyskinesia of the gallbladder and biliary tract, which is often caused by disturbances in the neuroendocrine regulation of motility of the biliary tract and gallbladder, and physical inactivity. 5. Nutritional factor (unbalanced nutrition with a predominance of coarse animal fats in the diet to the detriment of plant fats). 6. Congenital anatomical features of the structure of the gallbladder and biliary tract, anomalies of their development. 7. Parenchymal liver diseases.

Pathogenesis There are two main concepts of the pathogenesis of calculous cholecystitis: 1) the concept of metabolic disorders; 2) inflammatory concept.

Today, these two concepts are considered as possible pathogenetic options (mechanisms) for the development of calculous cholecystitis - hepatic-metabolic (metabolic disorder concept) and vesical-inflammatory (inflammatory concept). According to the concept of metabolic disorders, the main mechanism of gallstone formation is associated with a decrease in the cholate-cholesterol ratio (bile acids / cholesterol), i.e. with a decrease in the content of bile acids in bile and an increase in cholesterol. A decrease in the cholate-cholesterol coefficient can be caused by lipid metabolism disorders (general obesity, hypercholesterolemia), nutritional factors (excess animal fats in food), and damage to the liver parenchyma of toxic and infectious origin. A decrease in the cholate-cholesterol ratio leads to a violation of the colloidal properties of bile and to the formation of cholesterol or mixed stones. According to the inflammatory concept, gallstones are formed under the influence of the inflammatory process in the gallbladder, leading to physico-chemical changes in the composition of bile. A change in the pH of bile towards the acidic side, characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular the protein fractions of bile, and the transition of bilirubin micelles from a suspended to a crystalline state. In this case, a primary crystallization center is formed, on which desquamated epithelial cells, microorganisms, mucus, and other components of bile are layered. According to modern concepts, one of these mechanisms may dominate in the initial stage of development of calculous cholecystitis. However, in the later stages of the disease, both mechanisms function. The formation of stones initiates stagnation of bile, an inflammatory process, the stones serve as centers for crystallization of bile. Thus, the vicious circle closes and the disease progresses.

Calculous cholecystitis: signs, treatment, diet. Differential diagnosis of calculous cholecystitis

Calculous cholecystitis is a disease of the gallbladder, which is characterized by serious inflammatory processes. Compared to other abdominal diseases, this disease is very common.

Today, about 20% of the population is affected by this disease, and these figures are rapidly increasing. This is due to the fact that many people eat foods high in fat - butter, lard, fatty meat, eggs, and also adhere to a sedentary lifestyle. In addition, many people have a disorder endocrine system as a result of diabetes or obesity. Most often, women suffer from cholecystitis - this is due to the use of oral contraception and pregnancy.

Main reasons

Calculous cholecystitis has a main cause - this infectious diseases. The human intestine contains microorganisms that help improve the digestion process, but they can sometimes pose considerable danger.

Calculous cholecystitis has a fairly extensive etiology. The development of the disease is also observed against the background of autoimmune diseases and allergic reactions.

Many people are suffering chronic cholecystitis due to prolapse of organs located in the abdominal cavity, or as a result of a congenital disorder of the structure of the gallbladder. Very often, this disease develops against the background of pancreatitis, as a result of a failure in secretion production.

Symptoms

By clinical course Calculous cholecystitis can be chronic and acute, and in the first case, remission is replaced by exacerbation. The period of exacerbation quite often resembles clinical manifestation acute inflammation of the organ.

The primary symptoms suggestive of cholecystitis are:

• Vomiting and nausea.
• Heartburn.
• There is a bitterness in the mouth.
• Feeling of pain in the right hypochondrium.
• Belching.

The most striking manifestation is hepatic colic, which has the following clinical signs of chronic calculous cholecystitis:

• During palpation of the abdomen, sharp pain is felt.
• Dizziness.
• Bloating (flatulence).
• Nausea accompanied by repeated vomiting.
• The appearance of pain, which is associated with provoking factors, such as errors in diet, fast walking, running, shaking while driving, drinking alcohol.
• The pain is characterized by irradiation to the scapular, shoulder and lower back areas.
• The appearance of sharp, sudden pain in the upper abdomen.

An objective examination may reveal certain symptoms indicating the presence of of this disease. All of them consist in the fact that during palpation a sharp pain occurs.

At the remission stage, calculous cholecystitis in most cases is asymptomatic. Remission due to errors in diet is replaced by exacerbation.

Diagnostics

If this disease is suspected, the diagnostic search consists of additional research methods:

• Ultrasonic.
• X-ray.
• Biochemical blood test with determination general level protein, its fractions, as well as cholesterol, triglycerides.
• Fibrogastroduodenoscopy and others.

Complications

In case of delayed diagnosis or late treatment, calculous cholecystitis can result in the following complications:

• Dropsy.
• Purulent inflammation (empyema).
• Acute inflammatory process in the biliary tract, acute cholangitis.
• Perforation of the bile wall with further development peritonitis.
• Malabsorption in the intestine with all the ensuing consequences.
• Malignant oncological processes.
• Repeated inflammation of the pancreas.
• Narrowing (stenosis) of the papilla of Vater (major duodenal papilla).
• Obstructive jaundice, which develops when the function of the outflow of bile is impaired (blockage of the gallbladder, its outflows or the large duodenal nipple).
• Stone formation (choledocholithiasis).

Differential diagnosis of chronic calculous cholecystitis

Cholecystitis is distinguished from renal colic, inflammation of the pancreas, appendicitis, perforated ulcer of the duodenum and stomach.

Compared to acute cholecystitis, renal colic causes acute pain in the lumbar region. The pain radiates to the thigh and genital area. Along with this, there is a violation of urination. With renal colic, leukocytosis is not recorded and the temperature does not rise. A urine test indicates the presence of salts and formed blood components.

If the appendix is ​​located high, acute appendicitis can provoke acute calculous cholecystitis (the diet is described below). The difference between acute appendicitis and cholecystitis is that in the latter case the pain radiates to the shoulder and right shoulder blade, and there is also vomiting with bile. With appendicitis, there are no Mussi-Georgievsky symptoms.

In addition, acute appendicitis is much more severe, and peritonitis develops actively. Differential diagnosis Chronic calculous cholecystitis in this case is simplified by the presence in the medical history of information that the patient has stones in the gall bladder.

In some cases, a perforated ulcer of the duodenum and stomach is disguised as acute cholecystitis. However, unlike ulcers in acute cholecystitis, the medical history, as a rule, contains indications of the presence of stones in the organ.

Acute cholecystitis is characterized by painful sensations, radiating to the rest of the body, as well as vomiting containing bile. Initially, the feeling of pain is localized in the hypochondrium on the right, gradually increasing, and fever begins.

Hidden perforated ulcers manifest themselves acutely. In the first hours of the illness, the muscles of the anterior abdominal wall are very tense. Very often, patients complain of pain in the right ilium, due to the fact that the contents of the stomach leak into the cavity. With cholecystitis, liver dullness is observed.

In acute pancreatitis, intoxication increases, intestinal paresis and rapid heartbeat are observed - this is precisely its main difference from cholecystitis. In the case of inflammation of the pancreas, the pain is often accompanied by severe vomiting. It is quite difficult to distinguish acute gangrenous calculous cholecystitis from acute pancreatitis, so diagnosis is carried out in an inpatient setting.

Diet

Cholecystitis is a rather serious disease. Proper nutrition with such a diagnosis contributes to a quick recovery. In this case, therapeutic nutrition should be aimed at reducing acidity and secretion of bile.

Smoked and fried foods are excluded from the diet. It is necessary to include fresh vegetables and fruits in the menu, vegetable oil, porridge.

What should you not eat if calculous cholecystitis is diagnosed? The menu must be compiled taking into account certain requirements:

• You should avoid fried and fatty foods.
• You need to eat often, and the portions should be small.
• Reduce consumption of sweet and flour products.
• Avoid hot and cold food.
• Give preference to baked, boiled and stewed foods.
• Minimize strong tea and coffee.
• Eat no more than three eggs per week, and it is advisable to exclude the yolk.
• Consume more plant and dairy foods, as fiber improves motor skills and normalizes stool, and milk normalizes the acid-base balance.
• Stick to your diet and eat at the same time every day.

With a disease such as calculous cholecystitis, the diet after surgery should be the same as for the chronic form of the disease.

Nutrition

Proper nutrition for this disease can provide a long period of remission. You should remove foods from your diet that contribute to the formation of stones and burden the liver.

It is necessary to include in the menu foods containing fiber, milk proteins, vegetable oil, and consume large amounts of liquid. Reduce the amount of foods high in fat and cholesterol.

List of approved products

To prevent a possible attack of calculous cholecystitis, it is advisable to familiarize yourself with the list of permitted products:

• Milk products.
• Vegetable and cereal soups, greens (except for rhubarb, sorrel and spinach), vegetables, cereals, boiled meat and fish.
• Cheese, cod liver, soaked herring.
• Wheat and Rye bread yesterday's baking, uneaten cookies.
• Sunflower, olive and butter (small amount).

Calculous cholecystitis: how to treat?

The classic treatment for this disease is pain relief and hospitalization. In the case of a chronic form, treatment can be carried out outpatient. Bed rest, sulfa drugs or antibiotics, as well as fractional dietary food. When the inflammation subsides, physiotherapeutic procedures are allowed.

Treatment (exacerbation of calculous cholecystitis) is carried out as follows:

1. Based on prescribed tests, the doctor determines the stage and form of the disease.
2. A diagnosis is made.
3. If an acute inflammatory process is detected, the patient is prescribed anti-inflammatory drugs (“No-spa”, “Papaverine hydrochloride”) and antibiotics that have a wide spectrum of action.
4. After the inflammation has been relieved and the source of infection has been suppressed, choleretic drugs are prescribed to speed up the emptying of the gallbladder and weaken the inflammatory process.

If stones are found in the ducts of the gallbladder or in the organ itself, and the inflammatory process is pronounced, then surgery is prescribed. Depending on the location of the stones and their size, either the deposits or the gallbladder as a whole are removed. Failure of conservative treatment or the diagnosis of gangrenous calculous cholecystitis are absolute indicators for this purpose.

ethnoscience

When the acute process subsides, it is allowed to use traditional treatment. To restore organ function, decoctions and infusions (from corn silk, immortelle, etc.) are used, which have an antimicrobial and astringent effect.

• It is useful for the patient to include mineral waters (Essentuki No. 4 and No. 17, Slavyanskaya, Naftusya, Mirgorodskaya) and choleretic teas in the diet. From medications based on plants, it is allowed to use “Allohol” and “Holagol”.
• For chronic cholecystitis, tubeless tubes should be used 2-3 times a week. Drink warm water or decoction (1 glass) on an empty stomach. After 30 minutes, you need to drink Allohol, and then again a decoction of herbs. Next, you need to lie on your left side, while placing a heating pad on your right. It is recommended to stay in this position for 1.5-2 hours.

Therapy for a disease such as calculous cholecystitis (treatment and diet should be carried out only under the supervision of specialists) involves the use of traditional medicine. In the chronic form, such treatment significantly alleviates the condition, and most importantly, leads to positive results.

In general, treatment with traditional medicine can be divided into two main areas:

1. Through choleretic herbs.
2. Homeopathic medicines that involve influencing stones that have a certain chemical composition with a similar composition. For example, if phosphate or oxolinic acid was detected in a urine test, then the same acids are prescribed during the treatment process. For cholecystitis without stones, drugs are used that activate the immune system.

Decoction recipes

1. Oregano herb (a teaspoon) should be brewed with boiling water (a glass), and then left for two hours. In case of disease of the biliary tract, you need to drink 1/4 cup 3 times throughout the day.
2. Medicinal sage leaves (2 tsp) are brewed with boiling water (2 cups), then infused and filtered for half an hour. For inflammatory processes in the liver or gall bladder, you need to drink 1 tbsp. spoon every two hours.
3. Veronica brook (a teaspoon) is brewed with boiling water (a glass), and then infused for half an hour. You need to drink 3 times a day, 1/4 cup.
4. Corn silks (a tablespoon) are brewed with boiling water (a glass), and then infused for 60 minutes and filtered. You should drink 1 tbsp every 3 hours. spoon.
5. Agrimony herb (10 g) is brewed with water (3 cups) and boiled for 10 minutes. You should drink a glass of the decoction before meals three times a day.
6. Wheatgrass rhizomes (20 g) are brewed with boiling water (1.5 cups) and infused for several hours, and then filtered. For cholecystitis, take one glass 3 times a day. The course is 1 month.
7. St. John's wort herb (a tablespoon) is brewed with boiling water (a glass), boiled for 15 minutes, and then filtered. You need to drink 3 times a day, 1/4 cup. This decoction is characterized by choleretic and anti-inflammatory effects.
8. A hop seed (2 tbsp) is brewed with boiling water (1.5 cups), wrapped and infused for 3 hours. For cholecystitis, drink the decoction half an hour before meals, 1/2 cup 3-4 times a day.
9. Thoroughly grind chamomile, immortelle, trefoil, dill seed and joster flowers taken in equal quantities. Mix everything and pour the resulting mixture (3 tsp) with boiling water (2 cups). Next, the contents of the glass are infused for 20 minutes and filtered. Take 1/2 or 1/4 cup daily after meals in the morning and evening before bed.
10. Finely chop 3 parts of sandy immortelle flowers, 2 parts each of fennel fruits, wormwood herb, yarrow herb or mint leaf and dill. Pour the resulting mixture (2 tsp) with boiling water (2 cups). Leave for 8-12 hours and strain. Drink 1/3 cup before meals 3-4 times a day.
11. Chamomile flowers (a tablespoon) are brewed with boiling water (a glass). For cholecystitis, use warm for enemas. Do enemas 2-3 times throughout the week.
12. Ivy budra (a teaspoon) is brewed with boiling water (a glass) and infused for about 60 minutes, then filtered. You need to drink 3 times a day, 1/3 cup (before meals).
13. Peppermint (a tablespoon) is brewed with boiling water (a glass) and left for half an hour. Drink in small sips throughout the day (at least three times).

In most cases, people suffer from chronic cholecystitis for for long years. Its course and frequency of exacerbations are directly related to a person’s desire to overcome this disease by all possible methods and means. If you are sick, try to adhere to a healthy and proper lifestyle ( exercise stress, balanced nutrition, proper rest and work regime). Also, do not forget about drug treatment, while during periods of remission it is advisable to additionally use traditional medicine.

Classification:

Catarrhal

Phlegmonous

Gangrenous

Perforated with development

a) perivesicular abscess;

b) encysted peritonitis;

c) diffuse peritonitis.

Clinical picture

Acute cholecystitis develops mainly in people over 50 years of age; elderly and senile patients make up more than 50% of cases. The ratio of men to women among patients is 1:5. Acute cholecystitis occurs suddenly with the appearance of intense abdominal pain. Development of acute inflammatory phenomena in the gallbladder is often preceded by an attack of biliary colic. The pain is constant and increases in intensity as the disease progresses. They are localized in the right hypochondrium and epigastric region, radiating to the right supraclavicular region, shoulder or scapula. Sometimes the pain radiates to the heart area, which can be regarded as an attack of angina (cholecystocardiac syndrome of SP. Botkin). Constant symptoms acute cholecystitis - nausea and repeated vomiting, which does not bring relief to the patient. An increase in body temperature is noted from the first days of the disease, its nature depends on the depth of pathomorphological changes in the gallbladder. Destructive forms are characterized by chills. The skin is of normal color. Moderate yellowness of the sclera may be due to the transition of inflammation from the gallbladder to the liver and the development of local hepatitis. The appearance of bright jaundice of the skin and sclera indicates the mechanical nature of extrahepatic cholestasis. The pulse rate ranges from 80 to 120 per minute and higher. A rapid pulse is an ominous symptom, indicating severe inflammatory changes in the gallbladder and abdominal cavity.

Specific symptoms diseases:

Ortner - pain when tapping the right costal arch with the edge of the hand;

Murphy - involuntary holding of breath while inhaling during palpation of the right hypochondrium;

Kera - pain at the height of inspiration during palpation of the right hypochondrium;

Mussi-Georgievsky (phrenicus symptom) - pain when pressing with a finger between the legs of the right sternocleidomastoid muscle;

Shchetkin-Blumberg - in case of involvement of the peritoneum in the inflammatory process.

The frequency of detection of the listed symptoms is not the same; it depends on the nature of the morphological changes in the gallbladder and the transition of inflammation to the peritoneum. The patient's condition may be different, depending on the form of the disease. Catarrhal cholecystitis Catarrhal cholecystitis is the mildest form of the disease, characterized by moderate constant pain in the right hypochondrium, nausea and single or double vomiting. The general condition of the patient suffers little. The pulse can increase to 90 per minute. The tongue is moist, covered with a white coating, and upon palpation of the abdomen, mild pain occurs in the right hypochondrium. Signs of the disease (Ortner's, Murphy's, Kehr's, Mussi-Georgievsky's symptoms) are weak or absent, Shchetkin-Blumberg's symptom is not detected. The gallbladder is not palpable, but the area of ​​its projection is painful. A blood test reveals moderate leukocytosis (9-11*10^9/l). The mild clinical picture of catarrhal cholecystitis can be mistakenly regarded as a resolved attack of biliary colic caused by cholecystolithiasis. For correct diagnosis, you should pay attention to signs of inflammation (hyperthermia, tachycardia, leukocytosis). When the inflammatory process subsides, if the microbial flora dies, but obstruction of the cystic duct remains, hydrocele of the gallbladder develops. In this case, the absorption of the constituent components of bile occurs in it, its contents become colorless and mucous in nature. When palpating the abdomen, it is possible to determine the bottom of the enlarged, stretched and painless gallbladder.

Differential diagnosis. With similar clinical symptoms a covered perforated ulcer of the stomach or duodenum, acute pancreatitis, acute appendicitis with a subhepatic location of the appendix, right-sided pleuropneumonia, renal colic and some other acute diseases of the abdominal organs may occur.

Diagnostics. Correct and timely diagnosis of acute cholecystitis is a necessary condition for improving treatment results. To clarify the diagnosis and adopt adequate treatment tactics, it is necessary to use the optimal set of laboratory and instrumental studies within the first 24 hours from the moment of hospitalization of the patient.

Ultrasound, plain radiography of the abdominal organs, intravenous cholangiography, ERCP, endoscopic retrograde cholangiopancreaticography, PCCG, hepatobiliary scanning, puncture cholecystocholangiography, intraoperative cholangiography, intraoperative ultrasound, fistulography, fibrocholedochoscopy, CT, MRI and MRCP, laparoscopy.

Mandatory studies: clinical blood and urine analysis, determination of bilirubin content in the blood, urine test for diastasis, ultrasound of the abdominal organs, chest x-ray, ECG. The results of these studies allow not only to exclude other acute diseases, but also to assess the severity physical condition patient, which is very important for choosing a treatment method. Ultrasound occupies a central place in the diagnosis of acute cholecystitis. The significance of ultrasound is determined by the highly informative nature of the method, its non-invasive nature, the possibility of repeated examination and the use of the method for medical procedures. To avoid diagnostic errors Ultrasound should be performed in every patient with suspected acute cholecystitis, regardless of the severity of the clinical symptoms of the disease. Ultrasound signs of acute cholecystitis: an increase in the size of the gallbladder, thickening of its walls, uneven contours and the presence of suspended small hyperstructures without an acoustic shadow in the bladder cavity. Detection of fluid in the subhepatic space and an area of ​​increased echogenicity of surrounding tissues indicates that inflammation has spread beyond the boundaries of the gallbladder and perivesical inflammatory infiltration of nearby organs and tissues. A fixed echostructure with an acoustic shadow in the area of ​​the bladder neck is a sign of an impacted stone and an obstructive form of acute cholecystitis. Based on the results of ultrasound, the condition of the extrahepatic bile ducts is also judged: a diameter of the common hepatic duct of 9 mm or more indicates biliary hypertension, which may be caused by a stone or stricture of the bile ducts. Repeated ultrasound is performed to assess the effectiveness of conservative treatment and identify signs of progression of the inflammatory process in the wall of the gallbladder and abdominal cavity.

Acute cholecystitis can be diagnosed by laparoscopy, during which the nature of inflammation of the gallbladder and the prevalence of peritonitis are judged by visual signs. Currently, laparoscopy is performed only when the diagnosis is unclear and it is impossible to determine the cause of the “acute abdomen” using non-invasive research methods.

When acute cholecystitis is complicated by obstructive jaundice, endoscopic retrograde cholangiopancreaticography (ERCP) is performed. It makes it possible to establish the cause of extrahepatic bile stasis, the localization of occlusion of the common bile duct, and, in the presence of a stricture of the distal bile duct, its extent. X-ray endoscopic examination must be performed in every case of acute cholecystitis complicated by extrahepatic cholestasis, if the severity of the inflammatory process in the abdominal cavity does not require urgent surgical intervention. In addition, it is advisable to conduct it in cases where the diagnostic stage of the study can be completed by performing therapeutic papillotomy and nasobiliary drainage to eliminate biliary stasis. If the cause of the violation of bile outflow into the intestine is eliminated by endoscopic intervention, it is subsequently possible to reduce the volume of the operation, limiting it only to cholecystectomy, which has a positive effect on the results of treatment. When an urgent operation is performed in patients with acute cholecystitis and concomitant obstructive jaundice, the cause of the latter is determined during the operation itself using cholangiography; based on its results, the nature of the intervention on the extrahepatic bile ducts is determined.

Treatment.

Conservative:

Patients with catarrhal cholecystitis are subject to conservative treatment; in most cases, therapeutic measures can stop the inflammatory process. Emergency surgery, performed within the next 6 hours from the moment of admission to the hospital, is indicated for all forms of destructive cholecystitis (phlegmonous, gangrenous), complicated by local or widespread peritonitis. The indication for urgent surgery, undertaken in the first 24 hours from the moment of hospitalization of the patient, is considered to be phlegmonous cholecystitis, not complicated by peritonitis.

A set of conservative measures based on pathogenetic principles includes the following therapeutic measures: fasting (alkaline drinking is allowed), local hypothermia (ice pack on the right hypochondrium), to reduce pain and relieve spasm of the sphincter of Oddi, non-narcotic analgesics and anticholinergic antispasmodic drugs (metamizole sodium) are prescribed , metamizole sodium + pitofenone + fenpiverine bromide, drotaverine, mebeverine, platyphylline). Detoxification and parenteral nutrition are provided with infusion therapy in a volume of 2.0-2.5 liters per day. The criteria for an adequate volume of infusion media administered at the rate of 30-50 ml per 1 kg of body weight are the normalization of hematocrit, central venous pressure and diuresis. When acute cholecystitis is complicated by obstructive jaundice or cholangitis, hemodez, a solution of amino acids, fresh frozen plasma, vitamins C, B1 and B6 are additionally prescribed. An important component of conservative treatment of acute cholecystitis is antibacterial drugs wide range actions (cevalosporins + metronidazole, cephalosporins + aminoglycosides) prescribed to prevent the generalization of abdominal infection. For patients with uncomplicated destructive cholecystitis undergoing emergency surgery, antimicrobial agents are administered intravenously in a maximum single dose 30-40 minutes before the start of surgery. To maintain the effective concentration of the drug in the tissues, when the operation lasts more than 2 hours, repeat the administration of half a single dose of this antibacterial agent. In the postoperative period, the use of antibiotics should be continued if patients have risk factors for the development of purulent-septic complications. Patients with complicated forms of destructive cholecystitis are advised to use antibiotics in the preoperative period and after surgery for 5-7 days. In such cases, the drugs of choice for both prophylactic and therapeutic use are cephalosporins and fluoroquinolones in combination with metronidazole or carbapenems. The use of tetracycline drugs and gentamicin should be limited, as they have hepatonephrotoxic properties.

For pain relief during operations for acute cholecystitis and its complications, multicomponent endotracheal anesthesia is used. Local anesthesia is used only when performing cholecystostomy.

Surgical treatment. Most patients can be treated conservatively to minimize the risk of complications and undergo surgery as planned.

Operation methods:

Biliary stenting

Nasobiliary drainage

Revision of the common bile duct

Choledochoduodenoanostomosis

Laparoscopic cholecystectomy

Open cholecystectomy from mini-laparotomy access

Cholecystectomy - radical surgery leading to complete recovery of the patient. It is carried out open method using traditional approaches, from mini-sparotomy access or using video laparoscopic techniques. Open cholecystectomy is performed from a wide laparotomy incision in the right hypochondrium (according to Kocher, Fedorov), transrectal or upper midline incision. The optimal incisions are in the right hypochondrium, providing wide access to the gallbladder, extrahepatic bile ducts and duodenum. At the same time, they cause significant trauma to the anterior abdominal wall, intestinal paresis, and impairment of external respiration, which complicates postoperative rehabilitation and prolongs the period of disability. It is advisable to use a superior midline incision in cases of unclear diagnosis or the impossibility of excluding pancreatic necrosis or perforated ulcer. The gallbladder is removed from the neck or from the fundus. The method of cholecystectomy from the cervix has advantages: initially the cystic artery and cystic duct are isolated, they are crossed and ligated. Separation of the gallbladder from the bile duct prevents the possible migration of stones into the ducts, and preliminary ligation of the artery ensures bloodless release of the gallbladder from the liver bed. Removal of the gallbladder from the bottom is resorted to in the presence of a dense inflammatory infiltrate in the area of ​​its neck and hepatoduodenal ligament, since it makes it difficult to identify important anatomical elements of this zone.

To perform cholecystectomy from a mini-laparotomy approach, a transrectal incision 4-5 cm long is made below the costal arch and 3-4 cm to the right of the midline. The operation is carried out using the mini-assistant instrumental complex. Removal of the gallbladder from a mini-access in acute cholecystitis is performed in cases where a dense inflammatory infiltrate has not yet formed in the subhepatic space, usually with a disease duration of no more than 72 hours. If the infiltrate does not allow identifying the anatomical relationships of the elements of the hepatoduodenal ligament, it is advisable to switch to a wide laparotomy.

The mini-access operation differs from traditional cholecystectomy in that it is less traumatic and has a low incidence of early and late complications, as well as rapid restoration of the patient’s ability to work.

Videolaparoscopic cholecystectomy for acute cholecystitis is performed when the disease lasts 48-72 hours. If the disease lasts longer, endoscopic surgery is often doomed to failure. Moreover, it is fraught with the threat of developing severe intraoperative complications due to inflammatory

infiltrate in the subhepatic region.

The use of laparoscopic surgery is contraindicated in complicated forms of acute cholecystitis - widespread peritonitis, obstructive jaundice, obstructive cholangitis. If technical difficulties arise during endoscopic surgery and there is a threat of iatrogenic damage, they switch to the open method of surgery. In acute cholecystitis, this happens quite often (up to 20% of cases).

Cholecystostomy is a palliative, low-traumatic operation that allows one to achieve a positive therapeutic effect and reduce mortality. It should be considered the standard of surgical treatment for patients with acute cholecystitis, in whom the risk of cholecystectomy is excessively high due to severe somatic diseases. The pathogenetic justification for the advisability of cholecystostomy is the removal of intravesical hypertension and the removal of infected bile to the outside, which eliminates blood flow disturbances in the wall of the gallbladder, thereby preventing the occurrence and progression of destructive changes. Cholecystostomy is performed by percutaneous drainage of the gallbladder under ultrasound guidance, laparoscopically or by open laparotomy. In all cases, local anesthesia is used for mandatory participation anesthesiologist.

The most gentle method is puncture and subsequent drainage of the gallbladder, performed percutaneously and transhepatically under ultrasound control. A drainage is installed into the cavity of the gallbladder, which allows purulent bile to be drained out and actively carried out its sanitation. Avoid using this method in cases of widespread peritonitis, gangrene of the gallbladder, and in cases where the entire cavity is filled with stones.

Laparoscopic cholecystostomy is performed under the control of video endoscopy after a visual assessment of the nature of the inflammatory process in the abdominal cavity and provided that the bottom of the gallbladder is free from adhesions with neighboring organs. Of the numerous modifications of this method, the technique of direct puncture of the gallbladder with a trocar catheter, leaving a balloon catheter in its cavity, which ensures the tightness of the stoma and creates access to the cavity of the gallbladder for its active sanitation and removal of stones, has proven itself. Despite the minimally invasive nature and effectiveness of laparoscopic cholecystostomy, it is rarely used, which is associated with the need to create pneumoperitoneum and the possible deterioration of the patient’s condition during the procedure.

Open cholecystostomy is performed under local anesthesia from laparotomy access in the right hypochondrium. A cholecystostomy is formed by suturing the bottom of the gallbladder to the parietal peritoneum, and if it is impossible to suture the gallbladder to the abdominal wall, it is delimited with tampons. With an open choleistostomy, a wide channel is formed for access to the cavity of the gallbladder and its sanitation, which is important in preventing relapse of the disease. However, this method of creating choleistostomy is the most traumatic due to the incision of the abdominal wall. With external drainage of the gallbladder, relief of the inflammatory process and its clinical signs occurs by 8-10 days. Further therapeutic tactics depends on the severity of the patient’s condition and the degree of surgical and anesthetic risk. If it is extremely high, cholecystostomy becomes the main and final treatment method. When the patient’s general condition improves and the risk decreases surgical intervention cholecystectomy is performed using minimally invasive technologies. Two-stage treatment of such patients with acute cholecystitis contributes to a sharp reduction in the incidence of death.

Operations on the gallbladder and bile ducts performed for acute cholecystitis are completed by installing a control drain in the subhepatic space. Drainage in the abdominal cavity is necessary for the outflow of bile and blood leaking from the bladder bed. In the case of intense blood and bile leakage, drainage allows for timely diagnosis of the failure of the ligatures of the stump of the cystic artery or duct. If there is no discharge through the drainage, it is removed on the 3rd postoperative day. Tampons are rarely inserted into the abdominal cavity for acute cholecystitis. This need arises when the disease is complicated by a subhepatic abscess or the inability to stop bleeding from the bladder bed in the liver. In case of an abscess, the tampons are tightened on the 5th day and removed on the 9th, the hemostatic tampon is removed on the 4-5th day after surgery.

In the postoperative period continue therapy aimed at correcting metabolic disorders and preventing infectious and thromboembolic complications. Infusion therapy in a volume of 2.0-2.5 liters of liquid per day must be carried out for at least 3 days. Timely execution of the operation and rational intensive care in the postoperative period ensure favorable outcome surgical treatment of patients with acute cholecystitis.

29. Complications of acute cholecystitis (empyema, peritonitis, cholecystopancreatitis) Clin. Diagnosis. Diff. Acute cholecystitis is one of the most common reasons diffuse peritonitis. Clinical picture: typical onset of the disease, usually on the 3-4th day there is a significant increase in pain, muscle tension of the entire abdominal wall, diffuse soreness and positive symptoms of peritoneal irritation throughout the abdomen. The clinical picture for perforated cholecystitis is somewhat different: at the time of perforation of the gallbladder bladder there may be a short-term reduction in pain (imaginary well-being) followed by an increase in peritoneal symptoms and increased pain. Empyema- acute purulent inflammation of the gallbladder. Empyema of the gallbladder is caused by blockage of the cystic duct with the development of infection in the gallbladder while maintaining barrier function mucous membrane. Perforation (15% of cases). Into the free abdominal cavity, acute course, mortality 30%. Local - leads to the development of a peri-vesical abscess, the course is subacute. In an adjacent organ (duodenum, jejunum, colon or stomach), the course is chronic with the formation of a vesico-intestinal fistula. survey X-ray examination of the abdominal and thoracic cavity organs reveals paresis of the colon, limited mobility of the right dome of the diaphragm, and possibly a slight accumulation of fluid in the sinus. Very rarely the fluid level in the abscess cavity is detected. Ultrasound of the liver and biliary tract helps in diagnosis. Under the influence of conservative therapy, the pain characteristic of acute cholecystitis decreases, but does not go away completely, a feeling of heaviness in the right hypochondrium, a slight increase in temperature, and there may be slight leukocytosis in the blood are disturbing. The abdomen is soft, a moderately painful gallbladder can be felt in the right hypochondrium, mobile, with clear contours. During surgery, puncture of the bladder produces pus without any admixture of bile in the form of its edema or necrosis. IN last years There is an increase in cases of acute pancreatitis and an increase in the number of destructive forms. Acute pancreatitis in patients with acute pancreatitis, stones and inflammation are found in the bile ducts and bladder, which suggests cholecystitopancreatitis. Occurs when the outflow from the pancreatic duct is disrupted due to its blockage with a stone or with stenosis of the major duodenal papilla.. Inflammation of the pancreas begins with an attack of pain in the epigastric region, often after an error in diet. The pain is girdling in nature, radiating to the back. Sometimes it is severe, which accompanied by a picture of shock. Simultaneously with the pain, indomitable vomiting occurs. With pancreatic necrosis, tachycardia, cyanosis of the mucous membranes, and a drop in blood pressure are noted. Upon examination, muscle tension in the epigastric region, severe pain, and positive symptoms of peritoneal irritation are observed. With swelling of the pancreas, all symptoms are less pronounced and signs of intoxication insignificant. During the examination, tenderness in the epigastric region and right hypochondrium, a positive Mayo-Robson sign (tenderness in the left costovertebral angle) are detected. laboratory diagnostics It is important to examine urine for diastase, which with pancreatitis increases from 32-64 to 1024-2048 units or more. Pancreatic necrosis is characterized by a drop in amylase from high levels to 2-4 units. The levels of lipase and trypsin in the blood are increased. Leukocytosis is detected (up to 30,000 in 1 μl), a shift of the leukocyte formula to the left, especially pronounced with necrosis of the gland. Differential diagnosis in acute pancreatitis it is necessary to carry out with a perforated ulcer, myocardial infarction, intestinal obstruction, acute cholecystitis. DiagnosticsSurvey radiography right hypochondrium region. In 10-70% of cases with acute cholecystitis, radiopaque stones and the shadow of an enlarged gallbladder are detected. Oral cholecystography is ineffective; the gallbladder is usually not contrasted due to blockage of the cystic duct. Intravenous cholecystocholangiography. Infusion-drip cholecystocholangiography contributes to a faster and more accurate diagnosis and facilitates the choice of treatment tactics. Ultrasound. ERCP (endoscopic retrograde cholangiopancreatography). Laparoscopy. Laparoscopy allows you to clarify the diagnosis, assess the degree of destruction of the gallbladder, the severity of peritonitis, and carry out a number of therapeutic measures. Laboratory diagnostics General blood and urine analysis. Total protein. Bilirubin. Transaminase. Alkaline phosphatase. Sublimate test. Prothrombin. Determination of aminotransferase activity. Blood sugar.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Gallstones with other cholecystitis (K80.1)

Gastroenterology, Surgery

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Chronic calculous cholecystitis- This inflammatory disease causing damage to the gallbladder wall and motor-tonic disorders of the biliary system, accompanied by the presence of gallstones in the cavity of the gallbladder. Housing and communal services are one of the manifestations of cholelithiasis.

Protocol name- Chronic calculous cholecystitis

Protocol code -

ICD-10 code(s)
K 80.1 Gallstones with other cholecystitis

Abbreviations
Cholelithiasis Gallstone disease
Gallbladder
CP Chronic pancreatitis
Pancreas Pancreas
MF Obstructive jaundice
ALT Alanine amine transferase
AST Aspartate aminotransferase
Ultrasound Ultrasound examination
ESR Erythrocyte sedimentation rate
ERCP Endoscopic retrograde cholangiopancreatography
EFGDS Endoscopic fibrogastroduodenoscopy
ECG Electrocardiogram
CT Computed tomography
MRI Magnetic resonance imaging
LCE Laparoscopic cholecystectomy
HKH Chronic calculous cholecystitis
CE Cholecystectomy
CDA Choledochoduodenoanastomosis

Date of protocol development- 2013

Protocol users: general practitioners, surgeons

Classification

Clinical classification
By stages

Clinical classification

With the flow
- asymptomatic (latent)
- symptomatic

Stage according to the presence of gallstones
- biliary sludge (prelithiasis)
- stone(s) (stone)*

Number of stones
- single
- multiple

Localization
- gallbladder
- bile ducts**

Complications

Cholecystitis:
- spicy
- chronic

Acute cholecystitis:
- empyema of the gallbladder
- paravesical abscess
- acute perforation of the gallbladder or cystic duct
- gallbladder fistula
- hydrocele of the gallbladder

Cholangitis:
- spicy
- chronic

Obstructive jaundice
- strictures of the bile ducts and sphincter of Oddi
- Mirizzi syndrome
- perforation of the common bile duct
- fistula of the common bile duct
- cholangiogenic abscesses
- intestinal obstruction caused by gallstones
- biliary pancreatitis

*The name of the stone stage is not included in the diagnosis; only its characteristics in terms of the number and location of gallstones are indicated.
**If possible, indicate which

Diagnostics

List of basic and additional diagnostic measures

Basic diagnostic measures
- General blood analysis
- General urine analysis
- Clotting time of capillary blood
- Coagulogram
- Bilirubin and its fractions
- Definition of AST
- Determination of ALT
- Determination of urea and creatinine
- Determination of total protein and protein fractions
- Determination of blood cholesterol
- Determination of blood sugar
- Microreaction
- HIV
- HbsAg, Anti-HCV
- Coprogram
- Determination of blood amylase
- Determination of alkaline phosphatase
- Determination of blood group and Rh factor
- ECG
- Plain radiography of the chest organs
- Ultrasound of the hepatoduodenal zone and abdominal organs
- EFGDS
- Examination by a therapist

Additional diagnostic measures:
- Duodenal sounding
- CT scan
- Magnetic resonance cholangiography
- Hepatobilioscintigraphy
- ERCP
- Bacteriological, cytological and biochemical examination of duodenal contents

Diagnostic criteria

Complaints and anamnesis:

For biliary dyspepsia:
- loss of appetite;
- feeling of bitterness and dryness in the mouth;
- nausea in the morning or after eating a certain type of food, sometimes vomiting bile, which does not bring relief;
- bloating, unstable stools with a tendency to constipation.

For moderately severe abdominal pain syndrome
- a dull aching pain or a feeling of heaviness or pressure in the right upper quadrant of the abdomen of a constant nature, intensifying with a deep breath, in a position on the left side, decreasing in a forced position - on the right side with the legs tucked to the stomach.

Biliary colic attack
- the attack occurs suddenly, against the background of complete well-being, usually in the evening or at night. It is characterized by sharp spasmodic pain, which patients describe as cutting, tearing or stabbing. The intensity of pain increases to maximum within a few minutes. The patient tosses about in bed, cannot find a position that would ease the suffering, groans, screams with a grimace of pain on his face. Pain shock may develop. Sometimes during an attack, painful sensations change in intensity in waves.
- increased sweating, tachycardia, nausea, mild vomiting of bile that does not bring relief, bloating
- pain in the right hypochondrium, most often in the projection of the gallbladder or epigastric region, with typical irradiation along the right half of the body - back and up - under the scapula, into the collarbone and supraclavicular region, shoulder, neck and jaw. Less commonly, the pain radiates to the left - behind the sternum, to the region of the heart, simulating (or provoking) an attack of angina (S.P. Botkin’s angina, or cholecystocardiac syndrome)
The duration of an attack of biliary colic varies from 15 minutes to 5 hours. After the end of the attack, the patient remains for some time unpleasant feeling in the liver area. The pain recurs at various intervals.
Some time after the pain associated with biliary colic subsides, signs of obstructive jaundice may appear. In uncomplicated cholelithiasis, jaundice is short-lived. Patients note mild yellowness of the sclera and skin, short-term darkening of urine and discoloration of feces.

Physical examination:
- severe pain on palpation in the epigastrium and right hypochondrium, radiating upward, into the right shoulder, neck and back under the right shoulder blade,
- bloating,
- pain on palpation at the point of the gallbladder.
- moderate tachycardia (up to 100 beats per minute).
- icteric discoloration of the skin and sclera
- a typical picture of obstructive jaundice: urine becomes dark, foamy, feces become discolored, persistent skin itching appears, depriving the patient of sleep, scratching on the skin.
- when a stone is pinched in the nipple of Vater, the pain is localized in the epigastrium with irradiation to the back and both hypochondriums.
- during an attack or immediately after it, the urine becomes dark (bile pigments are released into the blood and urine)
- fever (up to 39-40 ° C) with tremendous chills and sweating
- limited muscle tension in the right hypochondrium and sharp pain when palpating this area.
- positive phrenicus symptom (Mussi-Georgievsky symptom), Ortner and Murphy symptoms
- the bottom of a tense, sharply painful gallbladder is palpated
- with the progression of the inflammatory process, local peritonitis is observed
- sometimes a painful infiltrate is palpated in the right hypochondrium without local symptoms of peritoneal irritation
- Shchetkin-Blumberg symptom with perforation of the gallbladder or with a breakthrough of a formed peri-vesical abscess.

Laboratory research
- IN general analysis blood in acute cholecystitis or cholangitis, neutrophilic leukocytosis is detected with a shift in the leukocyte formula to the left, acceleration of ESR.
- In a general urine test for breast cancer, bile pigments are detected.
- In breast cancer, there is an increase in the level of total bilirubin due to its direct fraction
- In cases of liver failure, increased levels of aminotransferases (AlT and AST), increased activity of alkaline phosphatase, hypercholesterolemia, hypoproteinemia and disproteinemia. The coagulogram may show an increase in prothrombin and thrombin time
- When the pancreas is involved in the process, there is an increase in amylase and blood glucose levels.

Instrumental studies
Ultrasound is the main method for diagnosing cholelithiasis.
Oral cholecystography allows one to judge the functional state of the gallbladder, the radiolucency of stones and the degree of their calcification. This information is extremely important for selecting patients for litholytic therapy and extracorporeal lithotripsy (ECLT).
Intravenous cholegraphy makes it possible to obtain a clear image of not only the gallbladder, but also the extrahepatic bile ducts.
ERCP helps clarify the condition of the bile ducts.
Hepatobilioscintigraphy makes it possible to suspect the presence of stones or strictures in them, and to assess the functional state of the gallbladder and liver cells.
Indications for consultation with specialists:
Consultation with an oncologist if cancer of the bile ducts or head of the pancreas is suspected.

Differential diagnosis

Acalculous cholecystitis	In uncomplicated cholelithiasis, biliary colic is not preceded by dyspepsia; biliary colic goes away suddenly, after which patients immediately experience not only significant relief, but usually feel healthy. The liver and gall bladder are painless on palpation, usually there is no “temperature tail”, and there are no “elements of inflammation” in the duodenal contents. The method of contrast cholecystography and ultrasound is of great importance.
Biliary dyskinesia	With biliary dyskinesia, there is a clearer connection between the occurrence of pain syndrome and negative emotions, and the absence of tension in the abdominal wall during biliary colic; The diagnosis is confirmed by negative results of duodenal intubation and mainly by contrast cholecystography data, which does not reveal stones.
Right-sided renal colic	Irradiation of pain is characteristic: upward - with biliary colic; down, into the leg, into the groin, into the genitals - with kidney disease. The presence of dysuric phenomena in renal colic, hematuria or erythrocyturia following a painful attack is important.
Duodenal ulcer	In addition to the medical history, the results of deep palpation also indicate a peptic ulcer, which often reveals a dense, sharply painful cord - a spasmodic pyloroduodenal area. The diagnosis is confirmed radiographically and endoscopically.
Pancreatitis	Localization of pain to the left in the epigastric region and to the left of the navel with irradiation to the back, to the left side of the spine, left scapula, left half shoulder girdle characteristic of diseases of the pancreas and is usually not observed in gallstone disease. An increased level of amylase in the blood or diastase in the urine is also important.
Acute appendicitis	For subhepatic location of the appendix - diagnostic laparoscopy
Biliary tract and pancreatic cancer	The rapid development of jaundice, its connection with a previous pain syndrome, the presence of biliary colic in the anamnesis indicate cholelithiasis, while the relatively slow and gradual development of jaundice gives reason to suspect malignant tumor. X-ray (with contrast cholegraphy) reveals single or multiple stones. Less often, shadows of stones are visible on a plain radiograph. Will help in diagnostics: ultrasound, CT scan, blood test for tumor markers

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Treatment

Treatment goals:surgical removal of the gallbladder, removal (or dissolution) of stones from the bile ducts, creation of conditions for the unhindered outflow of bile

Treatment tactics:

Non-drug treatment

Used for uncomplicated cholelithiasis.
1) Maintaining sleep and rest patterns, eliminating negative emotions.
2) Diet No. 5

Drug treatment

Oral litholytic therapy.
1) Henofalk 750-1000 mg (3-4 capsules) once before bedtime.
2) Ursofalk 750-1000 mg (3-4 capsules) once before bedtime.
These drugs do not act on pigment stones; such treatment is carried out only for patients with non-calcified stones

Lithotripsy
Criteria for selecting patients with cholecystolithiasis (with symptomatic and asymptomatic forms of the disease) for lithotripsy:
1) single and few (2-4) stones, occupying less than 1/2 of the volume of the gallbladder;
2) preserved contractile-evacuation function of the gallbladder.
Contraindications to lithotripsy:
1) multiple cholecystolithiasis, occupying more than 1/2 of the volume of the gallbladder;
2) calcined stones;
3) decreased contractile-evacuation function of the gallbladder
4) “disabled” gallbladder;
5) bile duct stones and biliary obstruction;
6) impossibility of performing enteral litholysis after crushing stones (gastroduodenal ulcer, allergy);
7) pregnancy.
Lithotripsy is usually combined with the use of litholytic therapy.
Patients with an acute attack of cholelithiasis (hepatic colic) are prescribed antispasmodic and analgesic drugs until the pain disappears.
3) Papaverine (antispasmodic) 10-20 mg; IM, s/c or i/v; the interval between administrations is at least 4 hours.
4) No-spa (antispasmodic) 40-80 mg IV slowly, maximum daily dose - 120 mg
5) Platiphylline (antispasmodic) 1-2 ml of 0.2% solution s.c. maximum daily dose 0.03 g.
6) Atropine (antispasmodic) 0.25-1 mg 1-2 times a day IM, SC or IV; maximum daily dose 3 mg.
7) Baralgin (analgesic + antispasmodic) is administered intramuscularly or intravenously (very slowly!), 5 ml each (if necessary, injections are repeated after 6-8 hours). Daily dose 10 ml.
8) Analgin 1-2 ml of 50% or 25% solution IM or IV 2-3 times a day; no more than 2 g per day.

To enhance the therapeutic effect, antispasmodics can be combined with analgesics. If there is no effect in a hospital setting, they resort to novocaine blockade.

In the presence of inflammatory processes in the biliary tract, antibacterial therapy is used. In this case, you should use drugs that can act against etiologically significant microorganisms and penetrate well into the bile.

Drugs of choice:
1) Ceftriaxone (cephalosporin) IM or IV 1-2 g/day (maximum per day up to 4 g) + metronidazole (5-nitroimidazole derivative) 1.5-2 g/day.
2) Cefoperazone (cephalosporin) IM or IV 2-4 g/day (maximum per day up to 8 g) + metronidazole (5-nitroimidazole derivative) 1.5-2 g/day.
3) Ampicillin/sulbactam (combined penicillin) IM or IV 6 g/day, maximum daily dose 12 g/day.
4) Amoxicillin/clavulanate (combined penicillin) IM or IV 3.6-4.8 g/day; maximum daily dose 6 g.
Alternate mode:
1) Gentamicin or tobramycin 3 mg/kg per day + ampicillium 4 g/day + metronidazole 1.5-2 g/day
2) Netilmicin 4-6 mg/kg per day + metronidazole 1.5-2 g/day
3) Cefepime 4 g/day + metronidazole 1.5-2 g/day
4) Fluoroquinolones (ciprofloxacin 400-800 mg intravenously) + Metronidazole 1.5-2 g/day

Enzyme preparations
For concomitant chronic pancreatitis, prescribed enzyme preparations(festal, creon, panzinorm, mezim).
1) Creon orally, during or after meals. The average dose for adults is 150 thousand units/day; with complete insufficiency of exocrine pancreatic function - 400 thousand units/day. With long-term use, iron supplements are prescribed simultaneously.
2) panzinorm orally, 1 tablet with meals 3 times a day.
3) Festal orally, 1 tablet (enteric-coated tablet) 3 times a day during or immediately after meals.
4) mezim inside, during or after meals. The average dose for adults is 150 thousand units/day; with complete insufficiency of exocrine pancreatic function - 400 thousand units/day.

Hepatotropic therapy
1) Hepadif orally for adults is prescribed 2 capsules 2-3 times a day, regardless of meals, for children aged 7-14 years - 1-2 capsules 2-3 times a day. The course of treatment is at least 2 months. Depending on the severity of the disease, the course of treatment is repeated 2-3 times a year. Parenterally, the drug is administered intravenously. The daily dose for an adult is 1 bottle. Before administration, the contents of the bottle should be dissolved in 400-500 ml of a 5% dextrose (glucose) solution. If you are intolerant to glucose, you can dilute the contents of the bottle in 20 ml of water for injection and administer IV slowly in a stream.
2) Heptral orally, IM, IV. For intensive therapy, in the first 2-3 weeks of treatment, 400-800 mg/day is prescribed intravenously (very slowly) or intramuscularly; The powder is dissolved only in the special supplied solvent (L-lysine solution). For maintenance therapy - 800-1600 mg/day orally between meals.

Other types of treatment - no

Surgical intervention

Types of surgical interventions:
1) Laparoscopic cholecystectomy
2) Cholecystectomy from minilaparotomy access
3) Traditional cholecystectomy
4) Traditional cholecystectomy with intraoperative drainage of the common bile duct according to Pikovsky (for indurative pancreatitis); in the presence of cholangitis - according to Vishnevsky or Keru.
5) EPST as separate species operations or in combination with cholecystectomy and choledochotomy.
6) Dressings.

In case of acute calculous cholecystitis, after preparing the patient, cholecystectomy is performed in an emergency and delayed manner: in the first 2-3 days from the onset of the disease using the laparoscopic method, in case of technical difficulties - by the open method. Emergency surgery is indicated for symptoms of peritonitis, a tense enlarged gallbladder, and the presence of peripysical infiltrate. For chronic calculous cholecystitis, the operation begins with laparoscopy. If the hepatoduodenal zone is intact, the operation continues laparoscopically.

Indications for cholecystectomy using laparoscopic technique:
- Chronic calculous cholecystitis;
- Polyps and cholesterosis of the gallbladder;
- Acute calculous cholecystitis (in the first 2-3 days from the onset of the disease);
- Chronic acalculous cholecystitis;
- Asymptomatic cholecystolithiasis (large and small stones).

If the common bile duct is enlarged and there are stones in it, laparotomy, classic cholecystectomy and choledochotomy are performed with stone extraction, in some cases CDA. Indications for the application of CDA: choledocholithiasis or the presence of putty-like masses and sand in the bile ducts; cicatricial narrowing of the distal part of the common bile duct for several centimeters, combined with stenosis of the papilla of Vater; dilation of the hepatic and extrahepatic bile ducts with thickening of their walls; obstruction of the terminal part of the common bile duct due to chronic indurative pancreatitis. Contraindications to the application of CDA: duodenostasis; cicatricial ulcerative deformation of the duodenum; non-dilated, thin-walled or sclerotically changed common bile duct; obstruction of the common bile duct above the intended location of the anastomosis.
In the postoperative period, antibacterial, infusion, hepatotropic and symptomatic therapy is carried out.

Prevention

For prevention postoperative complications it is necessary to provide:
- full examination of patients, identification concomitant pathology and its correction in the preoperative period.
- hepatotropic therapy in the pre- and postoperative period
- adequate antibacterial therapy during and after surgery
- timely hospitalization of patients with complicated cholelithiasis
- timely surgical intervention for complicated cholelithiasis
- thorough sanitation of the abdominal cavity
- decompression of the biliary tract in breast cancer should be early and carried out according to urgent indications

Prevention of cholelithiasis. Primary - impact on risk factors for the development of cholelithiasis:
- gradual decrease in body weight;
- do not use fibrates and progestogens;
- avoid estrogen therapy;
- avoid long periods of fasting;
- limit foods rich in cholesterol in the diet (offal, egg yolks, caviar, etc.), increase the amount of dietary fiber;

Prevention of relapses of cholelithiasis (secondary prevention):
- continue treatment after the stones dissolve for another 3 months.
- impact on risk factors for the development of cholelithiasis

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013

Information

List of protocol developers
Rakhmatullin Yusupzhan Yakubovich Candidate of Medical Sciences, Associate Professor of the Department of General Surgery of KazNMU named after. S.D.Asfendiyarova

Conflict of interest
The protocol developer has no financial or other interests that could influence the conclusion, and is not related to the sale, production or distribution of drugs, equipment, etc., specified in the protocol.

Reviewers:
Ospanov O.B. - Doctor of Medical Sciences, President of the Kazakhstan Association of Endoscopic Surgeons.

Conditions for reviewing the protocol: after 5 years from the date of publication

Attached files

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1) Acute appendicitis. In acute appendicitis, the pain is not so intense, and, most importantly, does not radiate to the right shoulder, right scapula, etc. Also, acute appendicitis is characterized by migration of pain from the epigastrium to the right iliac region or throughout the abdomen; with cholecystitis, the pain is precisely localized in the right hypochondrium ; vomiting with appendicitis is one-time. Typically, palpation reveals a thickened consistency of the gallbladder and local tension in the muscles of the abdominal wall. Ortner's and Murphy's symptoms are often positive.

2) Acute pancreatitis. This disease is characterized by girdling pain and sharp pain in the epigastrium. A positive Mayo-Robson sign is noted. The patient's condition is characteristically grave; he assumes a forced position. The level of diastase in urine and blood serum is of decisive importance in diagnosis; figures above 512 units are conclusive. (in urine).

With stones in the pancreatic duct, the pain is usually localized in the left hypochondrium.

3) Acute intestinal obstruction. In acute intestinal obstruction, the pain is cramping and non-localized. There is no increase in temperature. Enhanced peristalsis, sound phenomena (“splashing noise”), and radiological signs of obstruction (Kloiber cups, arcades, symptom of pinnateness) are absent in acute cholecystitis.

4) Acute obstruction of the mesenteric arteries. With this pathology, severe pain of a constant nature occurs, but usually with distinct intensification, and is less diffuse in nature than with cholecystitis (more diffuse). A history of pathology of the cardiovascular system is required. The abdomen is easily accessible for palpation, without pronounced symptoms of peritoneal irritation. Fluoroscopy and angiography are decisive.

5) Perforated ulcer of the stomach and duodenum. Men are more likely to suffer from this, while cholecystitis most often affects women. Cholecystitis is characterized by intolerance to fatty foods, frequent nausea and malaise, which does not happen with a perforated ulcer of the stomach and duodenum; pain is localized in the right hypochondrium and radiates to the right scapula, etc., with an ulcer the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). The picture is clarified by the presence of a history of ulcers and tarry stools. X-ray reveals free gas in the abdominal cavity.

6) Renal colic. Pay attention to the urological history. The kidney area is carefully examined, Pasternatsky's symptom is positive, a urine test, excretory urography, and chromocystography are performed to clarify the diagnosis, since renal colic often provokes biliary colic.

Gallstone disease, chronic calculous cholecystitis.

Rationale for diagnosis:

The diagnosis was made based on:

The patient complains of discomfort and periodic dull pain of a girdle nature, appearing after eating any type of food, in the right hypochondrium, spreading to the epigastric region;

History of the disease: the appearance of similar pain about 1 year ago, in September 2015, after eating mainly fatty foods, which were not relieved by painkillers. As a result of inpatient treatment at the Central District Hospital in Ussuriysk for acute cholecystitis, she was admitted for planned surgical treatment;

Objective examination data:

1. the general condition of the patient is satisfactory, the skin and visible mucous membranes are pink, clean,

2.peripheral lymph nodes are not enlarged,

3.vesicular breathing is heard in the lungs, there are no wheezes,

4.heart sounds are clear, rhythmic, blood pressure 120/80 mmHg, pulse 76 beats per minute,

5. the tongue is moist, the abdomen is not swollen, soft, painless in all parts, the liver is not enlarged, stool and diuresis are regular (normal);

Instrumental studies: Ultrasound of the abdominal organs - the presence of stones up to 2-3 cm, enlargement and diffuse changes in the liver;

Laboratory research:; increase in the level of bilirubin in the blood, largely due to direct; the presence of leukocytosis, a sharp shift in the leukocyte formula to the left, and an increase in ESR.

All of the above is in favor of the diagnosis: cholelithiasis. Chronic calculous cholecystitis.

Differential diagnosis.

Differential diagnosis should be carried out with those nosological entities that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis.

Pain syndrome:

With cholelithiasis, chronic calculous cholecystitis - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall, painful symptoms of Murphy, Georgievsky-Mussi, Ortner-Grekov. Increased pain and deterioration of the condition are associated with errors in diet and intake of fatty foods.

With duodenal ulcers, the daily daily rhythm of pain, hunger - pain, eating - pain subsides, hunger - pain. On palpation there is pain in the right upper quadrant of the abdomen. The condition worsens significantly in the spring and autumn periods.

In chronic pancreatitis, pain is localized in the epigastric region, is dull in nature and radiates to the back. The pain intensifies after eating or drinking alcohol. Palpation of the abdomen usually reveals bloating, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation pain is noted at the Desjardins point or in the Choffard area. Often a painful point is detected in the left costovertebral angle (Mayo-Robson symptom). Sometimes a zone of skin hyperesthesia is determined corresponding to the zone of innervation of the 8-10 thoracic segment on the left (Kach's sign) and some atrophy of the subcutaneous fat layer in the area of ​​​​the projection of the pancreas onto the anterior abdominal wall (Groth's sign).

With choledocholithiasis - pain in the upper abdomen, more on the right, with radiation to the back.

Dyspeptic syndrome:

With cholelithiasis, chronic calculous cholecystitis - dryness, bitterness in the mouth, nausea, sometimes vomiting, stool disorders (usually diarrhea), there is a natural connection with the intake of fatty foods. Patients are usually adequately nourished.

In case of duodenal ulcer, the symptoms are similar. Vomiting brings relief, the condition worsens with fasting. Patients are often asthenic.

In chronic pancreatitis, there are characteristic symptoms; there is a natural relationship with the consumption of alcohol, spicy, fried foods. Stool disorders - diarrhea, steato-amylocreatorhea. The patients are asthenic.

With cholelithiasis and choledocholithiasis, the dyspeptic syndrome is similar to chronic cholecystitis.

Laboratory data:

In case of cholelithiasis, chronic calculous cholecystitis - normal blood and urine values, there may be slight leukocytosis, ESR increases. In blood biochemistry - transaminases, hepatic fraction of alkaline phosphatase, amylase increase slightly, total bilirubin may increase (due to direct bilirubin) - cholestatic syndrome is slightly expressed.

In case of duodenal ulcer - iron deficiency, normal urine values, with exacerbation of the disease, slight leukocytosis in the CBC is possible, transaminases are within normal limits, bilirubin is normal. Cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase, alkaline phosphatase are increased, transaminases may be increased, dysproteinemia, in urine - normal, feces - steatorrhea, creatorrhea, amilorrhea. Coagulogram without features.

With cholelithiasis, choledocholithiasis, slight leukocytosis is possible in the UAC, ESR increases, bilirubin is present in the urine, urobilin will be absent, and stercobilin will also be absent in feces. Feces like white clay. Biochemistry - transaminases increase sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Cholestatic syndrome is pronounced. In the coagulogram, changes include an increase in bleeding time, a decrease in the prothrombin index (lower limit of normal), and an increase in INR.

Instrumental methods: ultrasound, FGDS.

In case of cholelithiasis, chronic calculous cholecystitis, the gallbladder is enlarged, the wall of the bladder is compacted, and in the lumen there is hyperechoic bile (suspension) and stones. Diffuse changes in the parenchyma of the liver and pancreas are possible. On X-ray positive stones, with cholecystography - stones (filling defects), enlargement, dystopia of the gallbladder is possible. Duodenal intubation - inflammatory changes in bile (portion B).

In the case of duodenal ulcer, FGDS is used (ulcerative defect, cicatricial changes, stenosis), and pH-metry and urease test are also carried out in parallel. During duodenal intubation, inflammatory altered bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to perform FGDS - barium X-ray - a niche symptom is detected.

In chronic pancreatitis, ultrasound shows diffuse changes in the gland, calcification, fibrosis, cystic changes, reduction in size of the gland, decreased patency of the Wirsung duct (inflammatory change in the wall, possible calcifications in the duct).

With cholelithiasis, choledocholithiasis, ultrasound shows diffusely altered liver, dilation of the intrahepatic ducts, stones in the common bile duct. During duodenography under conditions of artificial controlled hypotension, pathology of the organs of the pancreaticoduodenal zone is revealed. RPCG - the ability to see the external and internal hepatic ducts, as well as the pancreatic ducts. CRCP - it is possible to determine both the nature and localization of obstruction in the hepatoduodenal zone.

Etiology and pathogenesis of the underlying disease.

Calculous cholecystitis- a disease caused by the presence of stones in the gallbladder and bile ducts. There are cholesterol, pigment and mixed stones (calculi).

Etiology The following main groups of etiological factors leading to the development of calculous cholecystitis are distinguished: 1. Inflammatory process in the wall of the gallbladder of bacterial, viral (hepatitis virus), toxic or allergic etiology. 2. Cholestasis. 3. Disorders of lipid, electrolyte or pigment metabolism in the body. 4. Dyskinesia of the gallbladder and biliary tract, which is often caused by disturbances in the neuroendocrine regulation of motility of the biliary tract and gallbladder, and physical inactivity. 5. Nutritional factor (unbalanced nutrition with a predominance of coarse animal fats in the diet to the detriment of plant fats). 6. Congenital anatomical features of the structure of the gallbladder and biliary tract, anomalies of their development. 7. Parenchymal liver diseases.

Pathogenesis There are two main concepts of the pathogenesis of calculous cholecystitis: 1) the concept of metabolic disorders; 2) inflammatory concept.

Today, these two concepts are considered as possible pathogenetic options (mechanisms) for the development of calculous cholecystitis - hepatic-metabolic (metabolic disorder concept) and vesical-inflammatory (inflammatory concept). According to the concept of metabolic disorders, the main mechanism of gallstone formation is associated with a decrease in the cholate-cholesterol ratio (bile acids / cholesterol), i.e. with a decrease in the content of bile acids in bile and an increase in cholesterol. A decrease in the cholate-cholesterol coefficient can be caused by lipid metabolism disorders (general obesity, hypercholesterolemia), nutritional factors (excess animal fats in food), and damage to the liver parenchyma of toxic and infectious origin. A decrease in the cholate-cholesterol ratio leads to a violation of the colloidal properties of bile and to the formation of cholesterol or mixed stones. According to the inflammatory concept, gallstones are formed under the influence of the inflammatory process in the gallbladder, leading to physicochemical changes in the composition of bile. A change in the pH of bile towards the acidic side, characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular the protein fractions of bile, and the transition of bilirubin micelles from a suspended to a crystalline state. In this case, a primary crystallization center is formed, on which desquamated epithelial cells, microorganisms, mucus, and other components of bile are layered. According to modern concepts, one of these mechanisms may dominate in the initial stage of development of calculous cholecystitis. However, in the later stages of the disease, both mechanisms function. The formation of stones initiates stagnation of bile, an inflammatory process, the stones serve as centers for crystallization of bile. Thus, the vicious circle closes and the disease progresses.