The pancreas plays an important role in our body, therefore, for its normal functioning, it is necessary to treat its needs with increased attention.

In the general case, with the body in full health, it is not so important to observe special sparing conditions, but if the pancreas fails, to ensure its normal existence, which it loves, becomes a paramount task for a sick person. It is especially important to constantly adhere to the appropriate list when choosing food for chronic forms of the disease.

This gland is located in the pancreas of our body, thanks to which it got its name. During normal functioning, it produces special enzymes that are actively involved in the digestive process. If a disease associated with inflammation develops in the pancreas, where this gland is located and its tissues gradually decompose, it cannot produce enough enzymes (a disease such as pancreatitis develops) necessary for the decomposition of food. In such a situation, you must strictly monitor your diet and include in the list only those foods that your pancreas loves and that do not provoke inflammation.

Chronic inflammation of the pancreas is called pancreatitis. This disease contributes to the decomposition and atrophy of some parts of the pancreas. In some periods, even with active treatment, lethal outcomes of the disease are not uncommon. After all, with an exacerbation of the chronic form of the disease of this gland, the process of inflammation often leads to its swelling and necrosis with suppuration, which is precisely what pancreatitis is dangerous for.

Therefore, with pancreatitis, especially its chronic form, it is so important to make a list of foods that the pancreas loves and strictly adhere to it. Firstly, with exacerbations of pancreatitis, hunger and cold are recommended. In no case should you use warm compresses and apply a hot heating pad to the pancreas during the inflammatory process associated with the course of the disease, and from products, it is recommended to limit yourself to only some liquids from this list:

• weak tea,
• mineral water,
• rosehip infusion,
• herbal tea, including acacia and sophora flowers, as well as elecampane root, burdock and chicory.

Acute pancreatitis requires not only a standard list of products from a strictly specified list, but also loves a certain frequency of nutrition. It is enough to ensure the intake of products 3-4 times a day, without additional snacks. The basis of the diet should be slightly dried bread (yesterday's) or crackers, as this disease is very fond of dishes with stewed vegetables, especially with zucchini. Moreover, dinner should be light enough and no later than a few hours before going to bed. A meal plan is just as important as a list of safe foods.

Hunger, cold and the standard list of foods that this disease and your gland loves will prevent the production of excess enzymes and help, thereby, relieve an attack of pancreatitis.

Pancreatitis is a very serious disease that requires a responsible attitude and strict adherence to a balanced diet due to a list of certain foods, and both the acute and chronic forms of this disease require strict dietary restrictions.

There is a certain list of foods that even the chronic form of such a disease does not like. Alcohol and its low-alcohol versions have a very negative effect on the body, and should definitely be excluded from the list. Also, pancreatitis does not like creams, fatty and smoked foods, rich broths, coffee and carbonated drinks, because they can provoke an inflammatory process and lead to a deterioration in well-being.

By constantly following certain rules, making a list of activities and excluding harmful products from the list, you can continue a full, healthy life even with chronic forms of the disease.

The diet for these diseases should contain proteins - 100-150 g (animals - 70%, vegetable - 30%), fats - 50-60 g, carbohydrates - 200 g. The duration of the diet for acute pancreatitis is 2-3 months, for chronic - 6-8 months.

Cholecystitis is inflammation of the gallbladder. The main factor in its development is malnutrition. Therefore, patients are advised to follow a specially formulated diet.

Allowed foods for cholecystitis and pancreatitis should include stale bread, non-meat soups, poultry, fish, lean meat, vegetables, egg white scrambled eggs, berries and fruits. It is necessary to avoid fatty, spicy, sour and salty foods, as well as drinking alcohol.

In the presence of acute calculous cholecystitis, a very strict diet is required, otherwise the patient's condition may worsen.

The basic rule of a therapeutic diet for these diseases is fractional nutrition. It involves regular intake of food in small portions every 2-3 hours. It is recommended to consume up to 2.5-3 kg of food and up to 2 liters of water per day.

It is important to remember that properly used products for cholecystitis and pancreatitis not only weaken the disease and put it into remission, but are also an effective measure to prevent its further development.

Food table for pancreatitis

acute cholecystitis

Etiology and pathogenesis

Classification

Complication

Prevention

chronic cholecystitis

Classification

Etiology

Pathogenesis

Flow

Complications

Prevention

Bibliography

Cholecystitis is an inflammation of the gallbladder. There are acute and chronic cholecystitis.

ACUTE CHOLECYSTITIS

Acute cholecystitis is one of the most common surgical diseases, and in frequency it ranks second after appendicitis.

The problem of acute cholecystitis over the past three decades has been relevant both due to the wide spread of the disease, and due to the presence of many controversial issues. At present, notable successes can be noted: the lethality in surgical treatment has decreased. There are especially many disagreements in the question of the choice of the time of intervention. In many ways, the answer to this question is determined by the setting formulated by B. A. Petrova: an emergency or urgent operation at the height of an attack is much more dangerous than a planned one, after the acute phenomena subside.

Etiology and pathogenesis

The occurrence of acute cholecystitis is associated with the action of not one, but several etiological factors, but the leading role in its occurrence belongs to infection. The infection enters the gallbladder in three ways: hematogenous, enterogenic and lymphogenous.

With the hematogenous route, the infection enters the gallbladder from the general circulation through the system of the common hepatic artery or from the intestinal tract through the portal vein further to the liver. Only with a decrease in the phagocytic activity of the liver, microbes pass through the cell membranes into the bile capillaries and then into the gallbladder.

The lymphogenic route of infection in the gallbladder is possible due to the extensive connection of the lymphatic system of the liver and gallbladder with the abdominal organs. Enterogenic (ascending) - the path of infection to the gallbladder is possible with a disease of the terminal section of the common section of the common bile duct, functional disorders of its sphincter apparatus, when the infected duodenal contents can be thrown into the bile ducts. This path is the least likely.

Inflammation in the gallbladder when an infection enters the gallbladder does not occur, unless its drainage function is impaired and there is no bile retention. In case of violation of the drainage function, the necessary conditions are created for the development of the inflammatory process.

Factors of violation of the outflow of bile from the bladder: stones, kinks of an elongated or tortuous cystic duct, its narrowing.

Acute cholecystitis arising on the basis of cholelithiasis is 85-90%. Also important is the chronic change of the gallbladder in the form of sclerosis and atrophy of the elements of the walls of the gallbladder.

The bacteriological basis of acute cholecystitis are different microbes and their associations. Among them, gram-negative bacteria of the Escherichia coli group and gram-positive bacteria of the genus Staphilococcus and Sterptococcus are of primary importance. Other microorganisms that cause inflammation of the gallbladder are extremely rare.

Due to the anatomical and physiological connection of the biliary tract with the excretory ducts of the pancreas, the development of enzymatic cholecystitis is possible. Their occurrence is not associated with the action of the microbial factor, but with the flow of pancreatic juice into the gallbladder and the damaging effect of pancreatic enzymes on the bladder tissue. As a rule, these forms are combined with the phenomena of acute pancreatitis. The combined forms of acute pancreatitis and cholecystitis are considered as an independent disease, called "cholecysto-pancreatitis".

It is well known that vascular changes in the wall of the gallbladder are important in the pathogenesis of acute cholecystitis. The rate of development of the inflammatory process and the severity of the disease depend on the circulatory disorder in the bladder due to thrombosis of the cystic artery. The consequence of vascular disorders are foci of necrosis and perforation of the bladder wall. In elderly patients, vascular disorders associated with age-related changes can cause the development of destructive forms of acute cholecystitis (primary gangrene of the gallbladder).

Classification

The question of the classification of acute cholecystitis, in addition to theoretical significance, is of great practical importance. A rationally compiled classification gives the surgeon the key to not only correctly classify one or another form of acute cholecystitis to a specific group, but also to choose the appropriate tactics in the preoperative period and during surgery.

One way or another, the classification of acute cholecystitis, as a rule, is based on the clinical and morphological principle - the dependence of the clinical manifestations of the disease on pathological changes in the gallbladder, abdominal cavity and on the nature of changes in the extrahepatic bile ducts. In this classification, two groups of acute cholecystitis are distinguished: complicated and uncomplicated.

All pathoanatomical forms of inflammation of the gallbladder that are daily encountered in clinical practice - catarrhal, phlegmonous and gangrenous cholecystitis - are classified as uncomplicated. Each of these forms should be considered as a natural development of the inflammatory process, a gradual transition from catarrhal inflammation to gangrene. An exception to this pattern is primary gangrenous cholecystitis, since the mechanism of its development is the primary thrombosis of the cystic artery.

Acute inflammation of the gallbladder can occur with and without stones in its lumen. The accepted division of acute cholecystitis into tubeless and calculous is conditional, since regardless of whether there are stones in the bladder or they are absent, the clinical picture of the disease and treatment tactics will be almost the same for each form of cholecystitis.

The group of complicated cholecystitis is made up of complications that are directly related to inflammation of the gallbladder and to the release of the infection beyond its limits. These complications include perivesical infiltrate and abscess, perforation of the gallbladder, peritonitis of varying prevalence, biliary fistulas, acute pancreatitis, and the most common complications are obstructive jaundice and cholangitis. Complicated forms occur in 15-20% of cases.

Complications

In some cases, the disease can become chronic, more often this is observed with purulent or phlegmous cholecystitis or with catarrh.

In case of an unfavorable course, the acute period of the disease is delayed, complications are possible: perforation of the gallbladder in the abdominal cavity with the development of peritonitis or the spread of infection to internal organs with the formation of biliary fistulas, ascending cholangitis, liver abscesses, etc.

Prevention

Compliance with a rational diet, physical education, prevention of lipid metabolism disorders, elimination of foci of infection.

CHRONIC CHOLECYSTITIS.

Inflammation of the gallbladder wall caused by prolonged irritation, either by a stone, or by repeated acute inflammatory processes, or by bacterial persistence.

Classification

1. Cholecystitis:

a) calculous

b) stoneless

Etiology:

Infection - often it is conditionally - pathogenic flora: E. coli, streptococcus, staphylococcus aureus, typhoid bacillus, protozoa (giardia).

Bile itself has a bactericidal effect, but when the composition of bile changes and especially when it stagnates, bacteria can rise through the bile duct into the gallbladder. Under the influence of infection, cholic acid is converted into lithocholic acid. Normally, this process occurs only in the intestines. If bacteria penetrate the gallbladder, then this process begins to go on in it. Lithocholic acid has a damaging effect and inflammation of the bladder wall begins, these changes can be superimposed by infection.

Dyskinesia can be in the form of spastic contraction of the gallbladder and in the form of its atony with bile stasis. Initially, there may be changes of a purely functional nature. Further, there is an inconsistency in the action of the bladder and sphincters, which is associated with impaired innervation and humoral regulation of the motor function of the gallbladder and biliary tract.

Normally, regulation is carried out as follows: contraction of the gallbladder and relaxation of the sphincters - vagus. Spasm of sphincters, overflow of the gallbladder - sympathetic nerve. Humoral mechanism: 2 hormones are produced in the duodenum - cholecystokinin and secretin, which act like the vagus and thus have a regulatory effect on the gallbladder and tracts. Violation of this mechanism occurs with vegetative neurosis, inflammatory diseases of the gastrointestinal tract, disturbances in the rhythm of nutrition, etc.

Dyscholia is a violation of the physicochemical properties of bile.

The concentration of bile in the bladder is 10 times greater than in the liver. Normal bile is made up of bilirubin, cholesterol (insoluble in water, so coats are needed to keep it dissolved as a colloid), phospholipids, bile acids, pigments, etc. Normally, bile acids and their salts (robes) are related to cholesterol as 7:1, if the amount of cholesterol increases, for example, to 10:1. then it precipitates, thereby contributing to the formation of stones.

Dyscholia is promoted by a high content of cholesterol (in diabetes mellitus, obesity, familial hypercholesterolemia), bilirubin (in hemolytic anemia, etc.), fatty, bile acids. At the same time, infection of bile is of great importance. In practice, the above factors are most often combined. The damaging effect of lithocholic acid, when it is formed in the gallbladder instead of the duodenum under the influence of infection, is associated with a change in pH, precipitation of calcium salts, etc.

Pathogenesis.

Chronic cholecystitis (XX) is caused by stagnation of bile and changes in its physicochemical properties. An infection can join such altered bile. The inflammatory process can be provoked by a stone, an anomaly in the development of the bladder, dyskinesia of the latter. Inflammation of the gallbladder can contribute to the further formation of stones. Inflammation causes secondary deformation, wrinkling of the bladder, the formation of various closed cavities from the folds of the mucous membrane. Inside these folds is infected bile, the distribution of the latter supports inflammation of the gallbladder wall.

It is possible for the infection to penetrate the bile ducts and passages with the development of cholangitis and damage to the liver tissue itself with the development of cholangiohepatitis. Calculous cholecystitis is fraught with obstruction of the bile duct and the development of dropsy, and with suppuration of the empyema of the gallbladder. The stone can cause perforation of the gallbladder wall.

The course of chronic cholecystitis:

recurrent; hidden latent course; bouts of hepatic colic. The course in most cases is long, characterized by alternating periods of remission and exacerbation; the latter often occur as a result of eating disorders, taking alcoholic beverages, hard physical work, the addition of acute intestinal infections, and hypothermia. The prognosis is favorable in most cases. Deterioration of the general condition of patients and temporary loss of their ability to work - only for periods of exacerbation of the disease. Depending on the characteristics of the course, latent (sluggish), the most common - recurrent, purulent-ulcerative forms of chronic cholecystitis are distinguished. Complications: accession of chronic cholangitis, hepatitis, pancreatitis. Often the inflammatory process is a "push" to the formation of stones in the gallbladder.

Complications

The transition of inflammation to the surrounding tissues: pericholecystitis, periduodenitis, etc. The transition of inflammation to the surrounding organs: gastritis, pancreatitis. Cholangitis with transition to biliary cirrhosis of the liver. There may be mechanical jaundice. If the stone is stuck in the cystic duct, then dropsy, empyema occurs, perforation is possible, followed by peritonitis; sclerosis of the bladder wall, and later cancer may occur.

Indications for surgery:

Obstructive jaundice for more than 8-12 days, frequent bouts of hepatic colic, non-functioning gallbladder - small, wrinkled, does not contrast. Hydrocele of the bladder and other prognostic adverse complications.

Prevention

Sanitation of foci of chronic infection, timely and rational treatment of cholecystitis, diet, prevention of helminthic invasions, acute intestinal diseases, sports, prevention of obesity.

Bibliography

1. Big medical encyclopedia

2. "Cholecystitis" Auth. Anna Kuchanskaya Ed. "All"

St. Petersburg 2001

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Department of Surgery

Course of surgical diseases

Abstract on the topic:

"Acute cholecystitis"

Introduction

1. Etiology and pathogenesis

2. Classification

3. Clinical symptoms

4. Additional research methods

6. Conservative treatment

7. Surgical treatment

Conclusion

List of used literature

Introduction

Cholecystitis is an inflammation of the gallbladder.

Acute cholecystitis is one of the most common surgical diseases, and in frequency it ranks second after appendicitis.

The problem of acute cholecystitis over the past three decades has been relevant both due to the wide spread of the disease, and due to the presence of many controversial issues. At present, notable successes can be noted: the lethality in surgical treatment has decreased. There are especially many disagreements in the question of the choice of the time of intervention. In many ways, the answer to this question is determined by the setting formulated by B. A. Petrova: an emergency or urgent operation at the height of an attack is much more dangerous than a planned one, after the acute phenomena subside.

Acute cholecystitis develops in 13-18% of patients with acute surgical diseases of the abdominal organs. Women get sick 3 times more often than men.

The reasons for the development of acute cholecystitis are diverse. These include hypertension in the biliary tract, cholelithiasis, infection in the biliary tract, dietary disorders, stomach diseases accompanied by dyscholia, a decrease in nonspecific resistance of the body, changes in the vessels of the biliary tract due to atherosclerosis.

Violation of the closing function of the sphincters located in the terminal section of the common bile duct and the major duodenal papilla leads to the development of spasm. This delays the release of bile into the duodenum and causes hypertension in the biliary tract. The causes of hypertension can also be morphological changes - stricture of the terminal section of the common bile duct, which occurs in the presence of long-term choledocholithiasis. This stricture causes permanent cholestasis. At patients the liver increases, the hyperbilirubinemia syndrome develops. Hypertension may also be due to the presence of single gallstones larger than 0.3-0.5 cm, which are displaced into the distal part of the common bile duct, which leads to the development of progressive obstructive jaundice and cholecystocholangitis.

It has been established that in 80-90% of cases acute cholecystitis is a complication of cholelithiasis. In this disease, stones that have been in the lumen of the gallbladder for a long time violate the integrity of the mucous membrane and the contractile function of the gallbladder. Often they obturate the mouth of the cystic duct, which contributes to the development of the inflammatory process.

The nutritional factor, as a rule, is a trigger in almost 100% of patients. Spicy and fatty foods, taken in excess, stimulate intense bile formation, which leads to hypertension in the ductal system due to spasm of the sphincter of Oddi. In addition, the possibility of the action of food allergens on the sensitized membrane of the gallbladder, which is also manifested by the development of spasm, is not excluded.

Among the diseases of the stomach that can lead to the development of acute cholecystitis, it should be noted chronic hypoacid and anacid gastritis, accompanied by a significant decrease in the secretion of gastric juice, especially hydrochloric acid. With achilia, pathogenic microflora from the upper parts of the digestive canal can enter the bile ducts from the lumen of the duodenum into the gallbladder.

The development of acute cholecystitis is promoted by local ischemia of the mucous membrane of the gallbladder and a violation of the rheological properties of the blood. Local ischemia is the background against which, in the presence of pathogenic microflora, acute destructive cholecystitis easily occurs.

1. Etiology and pathogenesis

The occurrence of acute cholecystitis is associated with the action of not one, but several etiological factors, but the leading role in its occurrence belongs to infection. The infection enters the gallbladder in three ways: hematogenous, enterogenic and lymphogenous.

With the hematogenous route, the infection enters the gallbladder from the general circulation through the system of the common hepatic artery or from the intestinal tract through the portal vein further to the liver. Only with a decrease in the phagocytic activity of the liver, microbes pass through the cell membranes into the bile capillaries and then into the gallbladder.

The lymphogenic route of infection in the gallbladder is possible due to the extensive connection of the lymphatic system of the liver and gallbladder with the abdominal organs. Enterogenic (ascending) - the path of infection to the gallbladder is possible with a disease of the terminal section of the common section of the common bile duct, functional disorders of its sphincter apparatus, when infected duodenal contents can be thrown into the bile ducts. This path is the least likely.

Inflammation in the gallbladder when an infection enters the gallbladder does not occur, unless its drainage function is impaired and there is no bile retention. In case of violation of the drainage function, the necessary conditions are created for the development of the inflammatory process.

Factors of violation of the outflow of bile from the bladder: stones, kinks of an elongated or tortuous cystic duct, its narrowing.

Acute cholecystitis arising on the basis of cholelithiasis is 85-90%. Also important is the chronic change of the gallbladder in the form of sclerosis and atrophy of the elements of the walls of the gallbladder.

The bacteriological basis of acute cholecystitis are different microbes and their associations. Among them, gram-negative bacteria of the Escherichia coli group and gram-positive bacteria of the genus Staphilococcus and Sterptococcus are of primary importance. Other microorganisms that cause inflammation of the gallbladder are extremely rare.

Due to the anatomical and physiological connection of the biliary tract with the excretory ducts of the pancreas, the development of enzymatic cholecystitis is possible. Their occurrence is not associated with the action of the microbial factor, but with the flow of pancreatic juice into the gallbladder and the damaging effect of pancreatic enzymes on the bladder tissue. As a rule, these forms are combined with the phenomena of acute pancreatitis. The combined forms of acute pancreatitis and cholecystitis are considered as an independent disease, called "cholecysto-pancreatitis".

It is well known that vascular changes in the wall of the gallbladder are important in the pathogenesis of acute cholecystitis. The rate of development of the inflammatory process and the severity of the disease depend on the circulatory disorder in the bladder due to thrombosis of the cystic artery. The consequence of vascular disorders are foci of necrosis and perforation of the bladder wall. In elderly patients, vascular disorders associated with age-related changes can cause the development of destructive forms of acute cholecystitis (primary gangrene of the gallbladder).

2. Classification

The question of the classification of acute cholecystitis, in addition to theoretical significance, is of great practical importance. A rationally compiled classification gives the surgeon the key to not only correctly classify one or another form of acute cholecystitis to a specific group, but also to choose the appropriate tactics in the preoperative period and during surgery.

One way or another, the classification of acute cholecystitis, as a rule, is based on the clinical and morphological principle - the dependence of the clinical manifestations of the disease on pathological changes in the gallbladder, abdominal cavity and on the nature of changes in the extrahepatic bile ducts. In this classification, two groups of acute cholecystitis are distinguished: complicated and uncomplicated.

Uncomplicated include all pathoanatomical forms of inflammation of the gallbladder that are daily encountered in clinical practice - catarrhal, phlegmonous and gangrenous cholecystitis. Each of these forms should be considered as a natural development of the inflammatory process, a gradual transition from catarrhal inflammation to gangrene. An exception to this pattern is primary gangrenous cholecystitis, since the mechanism of its development is the primary thrombosis of the cystic artery.

Acute inflammation of the gallbladder can occur with and without stones in its lumen. The accepted division of acute cholecystitis into acalculous and calculous is conditional, since regardless of whether there are stones in the bladder or they are absent, the clinical picture of the disease and treatment tactics will be almost the same for each form of cholecystitis.

The group of complicated cholecystitis is made up of complications that are directly related to inflammation of the gallbladder and to the release of the infection beyond its limits. These complications include perivesical infiltrate and abscess, perforation of the gallbladder, peritonitis of varying prevalence, biliary fistulas, acute pancreatitis, and the most common complications are obstructive jaundice and cholangitis. Complicated forms occur in 15-20% of cases.

Micrograph of the gallbladder with cholecystitis.

Diseases of the gallbladder, biliary tract and pancreas, in accordance with the ICD-10, are included in the headings K80 - K87, the heading K 80 belongs to cholelithiasis.

K 80 CHOLELITHIASIS

K 80.0 Calculosis of the gallbladder with acute cholecystitis.

K 80.1 Calculosis of the gallbladder with other cholecystitis.

K 80.2 Calculosis of the gallbladder without cholecystitis:

cholecystolithiasis,

Recurrent gallbladder colic,

Gallstones:

bile cystic duct,

Gallbladder

K80.3 Bile duct calculosis with cholangitis

K80.4 Bile duct calculosis with cholecystitis

K 80.5 Calculosis of the bile duct without cholangitis and cholecystitis:

Choledocholithiasis

Gallstones:

In ducts without further specification

Choledoch

hepatic duct

hepatic form:

Cholelithiasis

Recurrent colic

K80.6 Other forms of cholelithiasis

3. Clinical symptoms

Acute cholecystitis occurs in people of all ages, but more often they suffer from people over 50 years of age. Patients of elderly (60 - 74 years) and senile (75 - 89 years) age make up 40 - 50% of the total number of patients with acute cholecystitis.

The clinical picture of acute cholecystitis is diverse, depending on the pathological form of inflammation of the gallbladder, the prevalence of peritonitis and the presence of concomitant changes in the bile ducts. Due to the diversity of the clinical picture of the disease, diagnostic difficulties and errors in diagnosis arise.

Acute cholecystitis usually begins suddenly. The development of acute inflammation in the gallbladder is often preceded by an attack of biliary colic. An acute pain attack caused by blockage of the cystic duct with a stone is stopped on its own, or after taking antispasmodic drugs. However, after a few hours after the relief of an attack of colic, the whole clinical picture of acute cholecystitis appears.

The leading symptom of acute cholecystitis is severe and persistent abdominal pain, the intensity of which increases as the disease progresses. A distinctive feature of pain is its localization in the right hypochondrium with irradiation to the right subclavian region, shoulder, shoulder blade or lumbar region. Sometimes the pain radiates to the region of the heart, which can be regarded as an attack of angina pectoris (cholecystocoronary syndrome, according to S. P. Botkin).

Constant symptoms of acute cholecystitis are 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 largely depends on the depth of pathomorphological changes in the gallbladder.

The condition of the patient is different, depending on the severity of the disease. Skin of normal color. Moderate icterus of the sclera is observed with local hepatitis and with inflammatory infiltration of the extrahepatic bile ducts with stagnation of bile in them. The appearance of bright jaundice of the skin and sclera indicates a mechanical obstruction to the normal outflow of bile into the intestine, which may be associated with blockage of the bile duct by a stone or with a stricture of the terminal section of the common bile duct.

The pulse rate ranges from 80 to 120 beats per minute and above. A frequent pulse is a formidable symptom, indicating deep intoxication and severe morphological changes in the abdominal cavity.

The abdomen on palpation is significantly painful in the right hypochondrium and often in the epigastric region. With the transition of the process to the parietal peritoneum, tension of the abdominal muscles occurs - a symptom of Shchetkin-Blumberg. The gallbladder can be palpated in destructive forms of acute cholecystitis, when it increases in size and becomes dense. However, with significant muscle tension, it is not always possible to probe it.

Specific symptoms of acute cholecystitis are those of Ortner, Ker, Murphy and Georgievsky-Mussi (phrenicus symptom).

Ortner's symptom - pain when tingling the right costal arch with the edge of the palm;

Kera's symptom - increased pain with a deep breath, when the palpating hand touches the inflamed gallbladder;

Murphy's symptom - involuntary breath holding on inspiration with pressure on the area of ​​the right hypochondrium;

Georgievsky-Mussi symptom - pain on palpation between the heads of the sternocleidomastoid muscle.

Courvoisier's symptom may sometimes be positive - the gallbladder or perepiscal infiltrate is palpated (although this symptom is described in cancer of the pancreatic head and, strictly speaking, is not a symptom of cholecystitis.)

Jaundice - observed in 40-70% of patients, more often with calculous forms, when it is obstructive, mechanical. It can be a consequence of secondary hepatitis or concomitant pancreatitis, as well as cholangitis - then it can be parenchymal. Obstructive jaundice of calculous genesis is usually preceded by an attack of hepatic colic, it can be remittent in nature (unlike obstructive jaundice of tumor origin, which develops gradually and progressively increases). With complete obstruction of the choledochus, in addition to the intense color of urine (due to the presence of bilirubin) - "the color of beer", "strong tea", the feces become discolored - there is no stercobilin in it - "yellow man with white feces".

4. Additional research

The number of leukocytes in the blood and the amylase of blood and urine are urgently determined. If possible, from biochemical studies - blood for bilirubin and its fractions, cholesterol (normally up to 6.3 m / mol / liter), B-lipoproteins (up to 5.5 g / l), sugar, protein and its fractions, prothrombin index , transaminases and blood amylase. With jaundice, bilirubin and urobilin are examined in the urine, and stercobilin in the feces.

Ultrasound examination (ultrasound) is very valuable and, if possible, should be performed as an emergency. It allows you to identify the presence of stones in the biliary tract, the size of the gallbladder and signs of inflammation of its walls (thickening them, bypass).

Fibrogastroduodenoscopy (FGS) is indicated in the presence of jaundice - it makes it possible to see the secretion of bile or its absence from the Vater nipple, as well as the calculus wedged in it. In the presence of equipment, retrograde cholangio-pancreatography (RCPG) is possible.

Oral or intravenous contrast-enhanced cholangiography can be performed only after the disappearance of jaundice and subsidence of acute phenomena and is now rarely resorted to. In diagnostically unclear cases, laparoscopy is indicated. which gives a positive result in 95% of cases.

5. Differential diagnosis

Recognition of classical forms of acute cholecystitis, especially with timely hospitalization of patients, is not difficult. Difficulties in diagnosis arise in the atypical course of the disease, when there is no parallelism between pathomorphological changes in the gallbladder and clinical manifestations, as well as in the complication of acute cholecystitis with acute peritonitis, when, due to severe intoxication and diffuse nature of abdominal pain, it is impossible to identify the source of peritonitis.

Diagnostic errors in acute cholecystitis occur in 12-17% of cases. Erroneous diagnoses can be such diagnoses of acute diseases of the abdominal organs as acute appendicitis, perforated stomach 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 the diagnosis lead to the wrong choice of treatment method and belated surgical intervention.

When examining patients, it should be borne in mind that patients of the older age group most often suffer from acute cholecystitis. Patients with acute cholecystitis have a history of 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 shoulder blade. The general condition of patients with acute cholecystitis, other things being equal, is usually more severe. Vomiting in acute appendicitis - single, in acute cholecystitis - repeated. Palpation examination of the abdomen reveals the localization of soreness and muscle tension of the abdominal wall, characteristic of each of these diseases. 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 girdle pain, sharp pain in the epigastric region and much less pronounced pain in the right hypochondrium, absence of gallbladder enlargement, diastasuria, and the severity of the patient's general condition, which is especially characteristic of pancreatic necrosis.

Since repeated vomiting is observed in acute cholecystitis, and also often there are phenomena of intestinal paresis with bloating and stool retention, acute intestinal obstruction may be suspected. The latter is distinguished by the cramping nature of pain with localization uncharacteristic of acute cholecystitis, resonant peristalsis, "splash noise", Val's positive symptom and other specific signs of acute intestinal obstruction. Of decisive importance in the differential diagnosis is the survey fluoroscopy of the abdominal cavity, which allows to detect swelling of the intestinal loops and fluid levels (Kloiber's 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. An exception is covered perforation, especially if it is complicated by the formation of a subhepatic abscess. In such cases, one should take into account an ulcerative history, the most acute onset of the disease with a “dagger” pain in the epigastrium, and the absence of vomiting. Significant diagnostic assistance is provided by X-ray examination, which allows to detect the presence of free gas in the abdominal cavity.

Renal colic, as well as inflammatory diseases of the right kidney and perirenal tissue (pyelonephritis, paranephritis, etc.) may 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 imperative to pay attention to the urological history, carefully examine the kidney area, and in some cases it becomes necessary to use a targeted study of the urinary system (urinalysis, excretory urography, chromocystoscopy, etc.).

6. Conservative treatment

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

Conservative therapy based on pathogenetic principles includes a set of therapeutic measures aimed at improving the outflow of bile into the intestines, normalizing disturbed metabolic processes and restoring the normal functioning of other body systems. The complex of therapeutic measures should include: 1) hunger for 2-3 days; 2) application of a "bubble" with ice on the area of ​​the right hypochondrium; 3) gastric lavage while maintaining nausea and vomiting; 4) the appointment of injections of antispasmodics (atropine, platifillin, no-shpa, or papaverine) 3 times a day. The appointment of painkillers for acute cholecystitis is considered unacceptable, since pain relief often smoothes the picture of the disease and leads to viewing the moment of perforation of the gallbladder.

An important component of therapeutic measures for acute cholecystitis is the implementation of a right-sided pararenal blockade with a 0.5% novocaine solution in an amount of 80-100 ml. Pararenal novocaine blockade not only relieves pain, but also improves the outflow of infected bile from the gallbladder and bile ducts by increasing the contractility of the bladder and relieving spasm of the sphincter of Oddi (sphincter of the hepato-pancreatic ampulla). Restoration of the drainage function of the gallbladder and its emptying of purulent bile contribute to the rapid subsidence of the inflammatory process.

Taking into account the indications, glycosides, cocarboxylase, panangin, eufillin and antihypertensives are prescribed.

To the appointment of antibiotics in acute cholecystitis, many surgeons are negative, or at least recommend using them with great caution, arguing as follows. Antibiotics cannot stop and even significantly limit the destructive process in the gallbladder wall. At the same time, by reducing the temperature and leukocytosis, antibacterial drugs, as it were, "obscure" the coinic picture of the disease, interfere with an objective assessment of its symptoms, mask the development of complications, as a result of which the moment for timely surgical intervention may be missed.

In fairness, it should be noted that not only the use of antibiotics, but the entire complex of intensive care, improving the patient's condition, to a greater or lesser extent change the clinic of the disease. Therefore, the task of the doctor is to evaluate the symptoms, taking into account the influence of ongoing conservative measures. Based on this, we see no reason for such a restrained attitude towards antibiotics in acute cholecystitis. Moreover, taking into account the essence of the pathological process, which is based on a purulent infection, the use of antibiotics should be considered an effective therapeutic measure. The correct selection of antibacterial drugs is extremely important. In acute cholecystitis, the use of only those antibiotics that accumulate in sufficient concentration in gallbladder bile and to which the microbial flora that caused acute cholecystitis is sensitive is indicated.

7. Surgical treatment

acute cholecystitis pathogenesis treatment

Anesthesia. In modern conditions, the main type of anesthesia during operations for acute cholecystitis and its complications is endotracheal anesthesia with relaxants. Under conditions of general anesthesia, the duration of the operation is reduced, manipulations on the common bile duct are facilitated, and intraoperative complications are prevented. Local anesthesia can be used only when applying cholecystostomy.

Surgical accesses. For access to the gallbladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the Kocher, Fedorov, Czerny incisions and upper median laparotomy are the most widely used. Optimal are incisions in the right hypochondrium according to Kocher and Fedorov. They provide good access to the neck of the gallbladder and the main bile ducts, and are also convenient for surgical intervention on the major duodenal papilla.

The scope of the surgical intervention. In 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 biliodegistic anastomosis.

The final decision on the scope of surgical intervention is made only after a thorough revision of the extrahepatic bile ducts, which is carried out using simple and affordable research methods (examination, palpation, probing through the cystic duct stump or opened common bile duct), including intraoperative cholangiography. Conducting intraoperative cholangiography is a mandatory element of the operation for acute cholecystitis. Only according to cholangiography data can one reliably judge the state of the bile ducts, their location, width, the presence or absence of stones and strictures. On the basis of 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 operation for acute cholecystitis, leading to complete recovery of the patient. As is known, two methods of cholecystectomy are used - from the neck and from the bottom. The method of removal from the neck has undoubted advantages. With this method, the gallbladder is removed from the liver bed after the intersection and ligation of the cystic duct and cystic artery. The dissociation of the gallbladder from the bile ducts is a measure to prevent the migration of stones from the gallbladder to the ducts, and preliminary ligation of the artery ensures bloodless removal of the bladder. Removal of the gallbladder from the bottom is resorted to in the presence of a bladder neck and a hepatoduodenal ligament. Isolation of the gallbladder from the bottom allows you to navigate the location of the cystic duct and artery and establish a topographic relationship to their elements of the hepatoduodenal ligament.

Treatment of the stump of the cystic duct, the length of which should not exceed 1 cm, is not performed immediately after removal of the bladder, but after intraoperative cholangiography and probing of the bile ducts have been performed, using the duct stump for these purposes. You need to bandage it twice with silk, and 1 time with stitching.

The gallbladder bed in the liver is sutured with catgut, having previously achieved hemostasis in it by electrocoagulation of bleeding vessels. The bladder bed should be sutured in such a way that the edges of the entire wound surface of the liver adapt well and no cavities form.

Cholecystostomy. Despite the palliative nature of this operation, it has not lost its practical significance even today. As a low-traumatic operation, cholecystostomy is used in the most severe and debilitated patients, when the degree of operational risk is especially high.

Operations on the extrahepatic bile ducts. The combination of acute cholecystitis with lesions of the extrahepatic bile ducts requires an expansion of the scope of surgical intervention, including opening the common bile duct. Currently, the indications for choledochotomy are clearly defined, and they are:

1) obstructive jaundice on admission and at the time of surgery;

2) cholangitis;

3) expansion of extrahepatic bile ducts;

4) stones of the bile ducts, determined by palpation and on cholangiograms;

5) stricture of the terminal section of the common bile duct, confirmed by the results of intraoperative cholangiography, probing of the major duodenal papilla and manodebitometry.

An opening of the common bile duct is performed in the supraduodenal section of it closer to the duodenum. It is better to open a non-dilated bile duct with a transverse incision so that the subsequent suturing of the transverse incision does not result in narrowing of the duct. With an enlarged bile duct, both longitudinal and transverse incisions are made.

If there are stones in the bile ducts, it is necessary to remove them and rinse the ducts with a solution of novocaine, and then carefully revise the terminal section of the common bile duct, the large duodenal papilla, where the stones are most often seen. To detect stones in the major duodenal papilla (incarcerated, floating), the duodenum should be mobilized according to Kocher and the papilla should be palpated on a probe. To exclude stenosis of the major duodenal papilla, its patency is checked with a probe 3-4 mm in diameter. In the absence of stenosis, the probe passes freely into the intestinal lumen and is easily palpated through its wall.

An important step in the operation is the correct choice of the way to complete the choledochotomy. There are various ways to end choledochotomy: 1) suturing the wound of the bile duct tightly; 2) external drainage of the bile ducts; 3) creation of a biliary-intestinal fistula by forming a choledochoduodenoanastomosis or transduodenal papillosphincterotomy.

Sewing the wound of the common bile duct tightly in acute cholecystitis is considered by many to be unacceptable, firstly, because in conditions of inflammatory infiltration and concomitant bile hypertension, suture eruption and leakage of bile through the sutures of the duct is possible; secondly, also because with a blind suture of the common bile duct, the possibility of detecting left stones in the ducts and undiagnosed stenosis of the major duodenal papilla in the postoperative period is excluded, since it is impossible to perform control fistulocholangiography.

External drainage of the bile ducts. Each choledochotomy undertaken in acute cholecystitis for diagnostic or therapeutic purposes should end with external drainage of the bile ducts, provided that they are freely passable. External drainage of the bile ducts can be performed in the following ways: 1) according to Abbe - with a polyethylene catheter inserted through the stump of the cystic duct; 2) according to Ker - T-shaped latex drainage; 3) according to A.V. Vishnevsky - with a drainage-siphon. The choice of drainage method is suitable taking into account the pathology in the ducts and the nature of the surgical intervention.

With complications such as stricture and strangulated stone of the major duodenal papilla, internal drainage of the bile ducts by transduodenal papillosphincterotomy or choledochoduodenoanastomosis is possible. However, in the presence of an inflammatory process in the abdominal cavity, there is a risk of developing insufficiency of anastomotic sutures.

postoperative period. In the postoperative period, it is necessary to continue intensive therapy aimed at correcting disturbed metabolic processes and taking measures to prevent postoperative complications.

The basis of therapeutic measures of the postoperative period is infusion therapy, including the introduction of saline and protein solutions, 5 and 10% solutions of glucose, panangin, cocarboxylase, B vitamins and vitamin C. To improve the rheological state of blood and microcirculation in vital organs (liver, kidneys), prescribe the introduction of rheopolyglucin (400 ml) and complamin (300-600 mg), hemodez. With a tendency to oliguria, which is associated with functional kidney failure, it is necessary to stimulate diuresis in a timely manner with the introduction of lasix or mannitol. In order to improve liver function, sirepar or Essentiale is administered. Infusion therapy in the amount of 2-2.5 liters of fluid per day should be carried out for 3-4 days; as the patient's condition improves and intoxication disappears, the volume of parenteral fluid administered is reduced.

Prevention of suppurative processes in the abdominal cavity and surgical wound is carried out during the operation itself and in the postoperative period. The most important measures of this plan are washing the subhepatic space with antiseptic solutions (chlorhexidine) and prescribing broad-spectrum antibiotics (ampiox, kanamycin, tseporin, gentamicin, monomycin, etc.).

In the elderly, measures are taken to prevent venous thrombosis and thromboembolic complications, which are often the causes of death. For this purpose, it is important to activate the patient from the first day after the operation, to carry out therapeutic exercises, to bandage the lower limbs with elastic bandages. It is necessary to monitor the state of the hemostasis system; when a sharp hypercoagulable shift close to a thrombotic state is detected, anticoagulant therapy is prescribed (heparin 5000 IU 4 times a day intramuscularly under the control of thromboelastogram).

Carrying out in the pre- and postoperative periods a full correction of disturbed systems of homeostasis and suppression of the inflammatory process in the abdominal cavity with antibiotics play an important role in favorable outcomes of operations in acute cholecystitis.

Conclusion

Acute cholecystitis is one of the most common diseases of the gallbladder. Chronic cholecystitis usually occurs as a result of repeated attacks of acute. Primary chronic cholecystitis most often occurs against the background of cholelithiasis.

In the occurrence of acute cholecystitis, the main cause is infection. It can enter the gallbladder in three ways: through the blood, from the intestine through the bladder duct, through the lymphatic vessels. With blood and lymph, the infection enters the gallbladder only if the detoxifying function of the liver is impaired. If the motor function of the bile duct is impaired, bacteria can enter from the intestine. Inflammation in the gallbladder when an infection enters the gallbladder does not occur, unless its motor function is impaired and there is no bile retention.

Stones, bends of the elongated or tortuous cystic duct, its narrowing lead to stagnation of bile in the gallbladder. Acute cholecystitis, which occurs on the basis of cholelithiasis, is 85-90%. As a result of blockage of the gallbladder duct by a stone, the flow of bile into the intestine stops, and its pressure on the walls of the gallbladder increases. The walls are stretched, blood flow worsens in them, which contributes to the development of inflammation. The cause of chronic cholecystitis is most often cholelithiasis, when stones act on the walls of the gallbladder for a long time.

Acute cholecystitis is more common in people over 50 years of age. Patients of elderly and senile age make up 40-50% of the total number of patients with acute cholecystitis. Acute cholecystitis usually begins suddenly. The development of acute inflammation in the gallbladder is often preceded by an attack of biliary colic. An acute pain attack caused by blockage of the cystic duct with a stone is stopped on its own, or after taking painkillers. A few hours after the relief of an attack of colic, all signs of acute cholecystitis appear. The main manifestation is severe and persistent abdominal pain, which increases as the disease progresses. Constant symptoms of acute cholecystitis are 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. The appearance of bright jaundice of the skin and sclera indicates an obstruction to the normal outflow of bile into the intestine, which may be due to blockage of the bile duct by a stone. The pulse rate ranges from 80 to 120 beats per minute and above. A frequent pulse is a formidable symptom, indicating deep intoxication and severe changes in the abdomen. Chronic cholecystitis can be asymptomatic for years, turn into acute cholecystitis or manifest itself as complications.

Why is acute cholecystitis dangerous?

Complications occur in 15-20% of cases of acute cholecystitis. These include a purulent inflammatory process around the gallbladder, gangrene, perforation of the gallbladder with the development of inflammation in the abdomen and sepsis, biliary fistulas that communicate the gallbladder with the intestines, stomach and even the kidney, acute pancreatitis, obstructive jaundice.

Bibliography

1. Fedorov V.D., Danilov M.V., Glabai V.P. Cholecystitis and its complications. Bukhara, 1997, p. 28-29.

2. Pantsyrev Yu.M., Lagunchik B.P., Nozdrachev V.I. // Surgery. 1990. No. 1. S. 6-10.

3. Shulutko A.M., Lukomsky G.I., Surin Yu.V. etc. // Surgery. 1989. No. 1. S. 29-32.

4. Tagieva M.M. // Surgery. 1998. No. 1. S. 15-19.

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Federal Agency for Health and Social Development"

Department of Surgical Diseases of Pediatric faculty with a course of endoscopy and endosurgery

FOR THE TEACHER

TO THE PRACTICE

Topic "Acute cholecystitis"

Approved at the cathedral meeting

Protocol No. 10

«__ 19 ___ April 2007

Head Department of Surgical Diseases, Faculty of Pediatrics

with the course of endoscopy and endosurgery software

GOU VPO KrasGMA Roszdrav

Doctor of Medical Sciences, Prof.________________________________ E.V. Kasparov

assistant Boyakova N.V.

Krasnoyarsk

1. Topic of the lesson: "Acute cholecystitis"

2. Form of organization of the educational process: practical lesson

3. Meaning of the topic: Acute calculous cholecystitis is one of the severe manifestations of cholelithiasis. Mortality in acute cholecystitis remains quite high, especially in people over 60 years of age. Timely cholecystectomy for cholelithiasis avoids the development of acute cholecystitis.

4. Learning objectives:

4.1. General goal: to prepare a qualified doctor who is well versed in the diagnosis of cholecystitis.

4.2. Learning goal: be able to diagnose cholecystitis

4.3. Psychological and pedagogical goals: development of the doctor's responsibility for the diagnosis of acute cholecystitis, timely cholecystectomy in cholelithiasis will avoid the development of acute cholecystitis.

5. Location of the lesson: a practical lesson is held in the training room, curation of patients in the wards, in the admission and diagnostic department, dressing room, operating room. Control of the level of knowledge and holding the results of the lesson is carried out in the training room. The duration of the practical session is 180 minutes.

6.Equipment of the lesson: tables, slides, computer tutorial.

7. The structure of the content of the topic: Chronocard of the lesson (lesson plan)

8. Abstract

ACUTE CHOLECYSTITIS-nonspecific inflammation of the gallbladder. In 85-95% inflammation of the gallbladder is combined with stones. In more than 60% of cases of acute cholecystitis, microbial associations are sown from bile: more often E. coli, streptococci, salmonella, clostridia, etc. In some cases, acute cholecystitis occurs when pancreatic enzymes are thrown into the gallbladder (enzymatic cholecystitis).

Possible infection in the gallbladder with sepsis. Collagenoses, leading to narrowing and thrombosis of the cystic artery, can cause the development of gangrenous forms of acute cholecystitis. Finally, in about 1% of cases, the cause of acute cholecystitis is its tumor lesion, leading to obstruction of the cystic duct.

Thus, in the vast majority of cases, for the occurrence of acute cholecystitis, obstruction of the cystic duct or the gallbladder itself in the region of the Hartmann pocket is necessary. Stagnation of bile with the rapid development of infection causes a typical clinical picture of the disease. Violation of the barrier function of the mucous membrane of the gallbladder may be due to necrosis as a result of a significant increase in intraluminal pressure with obstruction of the cystic duct; in addition, direct pressure of the stone on the mucous membrane leads to ischemia, necrosis and ulceration. Violation of the barrier function of the mucous membrane leads to the rapid spread of inflammation to all layers of the bladder wall and the appearance of somatic pain.

Symptoms, course. It occurs more often in women over 40 years of age. Early symptoms of acute cholecystitis are very diverse. As long as the inflammation is limited to the mucosa, there is only visceral pain without a clear localization, often involving the epigastric region and the umbilical region. The pain is usually dull in nature. Muscle tension and local pain are not determined. Changes in the blood during this period may be absent.

The diagnosis is based primarily on the anamnesis (the appearance of pain after an error in the diet, unrest, bumpy driving), pain on palpation of the edge of the liver and the gallbladder area. However, when a complete obstruction of the cystic duct occurs and the infection quickly joins, the pain increases significantly, moves to the right hypochondrium, radiates to the supraclavicular region, interscapular space, and lumbar region. Nausea, vomiting, sometimes repeated (especially with cholecystopancreatitis). The skin can be icteric (in 7-15% acute cholecystitis is combined with choledocholithiasis). The temperature is subfebrile, but it can quickly rise and reach 39 degrees. FROM.

On examination: patients are more often malnourished, the tongue is lined. The abdomen is tense, lagging behind when breathing in the right hypochondrium, where a tense, painful gallbladder or inflammatory infiltrate can be palpated (depending on the duration of the disease). Locally positive symptoms of Ortner - Grekov, Murphy, Shchetkin - Blumberg.

In the blood - leukocytosis with a shift of the formula to the left, an increase in the level of serum amylase and urine diastasis (cholecystopancreatitis), hyperbilirubinemia (choledocholithiasis, edema of the major duodenal papilla, compression of the choledochus by infiltrate, cholecystohopatitis).

Significant assistance in the diagnosis is provided by ultrasound of the gallbladder and biliary tract (efficiency of about 90%). In typical cases of acute cholecystitis, the diagnosis is simple. Differential diagnosis is carried out with a perforated ulcer of the stomach and duodenum, acute appendicitis, acute pancreatitis, renal colic, myocardial infarction, basal right-sided pneumonia, pleurisy, herpes zoster with damage to the intercostal nerves.

Complications: diffuse peritonitis. Acute cholecystitis is one of the most common causes of diffuse peritonitis. Clinical picture: a typical onset of the disease, usually on the 3rd-4th day there is a significant increase in pain, muscle tension throughout the abdominal wall, diffuse soreness and positive symptoms of peritoneal irritation throughout the abdomen. The clinical picture is somewhat different in perforated cholecystitis: at the time of perforation of the gallbladder, there may be a short-term decrease in pain (imaginary well-being) followed by an increase in peritoneal symptoms and increased pain.

Subhepatic abscess occurs as a result of the delimitation of the inflammatory process in destructive cholecystitis due to the greater omentum, the hepatic angle of the colon and its mesentery. The duration of the disease is usually more than 5 days. Patients have a pain syndrome in the right half of the abdomen, high fever, sometimes of a hectic nature. On examination, the tongue is lined, the abdomen lags behind when breathing in the right half, sometimes a formation is determined by eye, which is limitedly displaced by aspiration. On palpation, muscle tension and a painful immobile infiltrate of various sizes. Plain x-ray examination of the abdominal and thoracic organs reveals paresis of the colon, limited mobility of the right dome of the diaphragm, and a small accumulation of fluid in the sinus is possible. Very rarely reveal the level of fluid in the cavity of the abscess. An ultrasound examination of the liver and biliary tract helps in the diagnosis.

Empyema of the gallbladder is caused by blockage of the cystic duct with the development of infection in the gallbladder while maintaining the barrier function of the mucous membrane. Under the influence of conservative therapy, the pain characteristic of acute cholecystitis decreases, but does not completely disappear, the feeling of heaviness in the right hypochondrium, a slight increase in temperature, there may be a slight leukocytosis in the blood. The abdomen is soft, in the right hypochondrium a moderately painful gallbladder is palpable, mobile, with clear contours. During an operative measure at a puncture of a bladder receive pus without admixture of bile.

Treatment of acute cholecystitis. Urgent hospitalization in a surgical hospital. In the presence of diffuse peritonitis, emergency surgery is indicated. Before surgery - premedication with antibiotics. The operation of choice is cholecystectomy with revision of the biliary tract, sanitation and drainage of the abdominal cavity. Mortality in emergency surgical interventions reaches 25-30%, it is especially high in septic shock.

In the absence of diffuse peritonitis, conservative therapy is indicated with simultaneous examination of the patient (respiratory organs, cardiovascular system, ultrasound examination to detect stones in the gallbladder). The complex of conservative therapy includes: local - cold, intravenous administration of antispasmodics, detoxification therapy, broad-spectrum antibiotics. If the calculous nature of cholecystitis is confirmed (by ultrasound) and there are no contraindications from the respiratory and circulatory organs, an early (not later than 3 days from the onset of the disease) operation is advisable: it is technically simpler, prevents the development of complications of acute cholecystitis, and gives minimal mortality. With severe concomitant pathology, especially in the elderly, for adequate preparation of the patient for surgery, laparoscopic puncture of the bladder with aspiration of the contents and washing of its cavity with antiseptics and antibiotics can be used. After 7-10 days, an operation is performed - cholecystectomy with revision of the biliary tract.

Prevention of acute cholecystitis is timely surgical treatment of cholelithiasis.

Chronic cholecystitis- chronic inflammation of the gallbladder. The disease is common, more common in women.

Etiology, pathogenesis. Bacterial flora (E. coli, streptococci, staphylococci, etc.), in rare cases - anaerobes, helminthic invasion (roundworm) and fungal infection (actinomycosis), hepatitis viruses; there are cholecystitis of toxic and allergic nature. The penetration of microbial flora into the gallbladder occurs by enterogenous, hematogenous or lymphogenous routes. A predisposing factor in the occurrence of cholecystitis is stagnation of bile in the gallbladder, which can be caused by gallstones, compression and kinks of the bile ducts, dyskinesia of the gallbladder and biliary tract, impaired tone and motor function of the biliary tract under the influence of various emotional stresses, endocrine and vegetative disorders , reflexes from pathologically altered organs of the digestive system. The stagnation of bile in the gallbladder is also facilitated by the prolapse of the viscera, pregnancy, a sedentary lifestyle, rare meals, etc.; the reflux of pancreatic juice into the biliary tract during their dyskinesia with its proteolytic effect on the mucous membrane of the bile ducts and gallbladder is also important.

Overeating, especially the intake of very fatty and spicy foods, the intake of alcoholic beverages, and an acute inflammatory process in another organ (tonsillitis, pneumonia, adnexitis, etc.) are often the immediate impetus for an outbreak of the inflammatory process in the gallbladder.

Chronic cholecystitis may occur after acute, but more often develops independently and gradually, against the background of cholelithiasis, gastritis with secretory insufficiency, chronic pancreatitis and other diseases of the digestive system, obesity.

Symptoms, course. Dull, aching pain in the area of ​​the right hypochondrium of a constant nature or occurring 1-3 hours after taking plentiful and especially fatty and fried foods is characteristic. The pain radiates up to the area of ​​the right shoulder and neck, right shoulder blade. Periodically, there may be a sharp pain resembling biliary colic. Dyspeptic symptoms are not uncommon: a feeling of bitterness and a metallic taste in the mouth, belching with air, nausea, flatulence, impaired defecation (often alternating constipation and diarrhea), as well as irritability, insomnia. Jaundice is not typical. On palpation of the abdomen, as a rule, sensitivity is determined, and sometimes severe pain in the projection of the gallbladder on the anterior abdominal wall and slight muscular resistance of the abdominal wall (resistance). Mussi-Georgievsky, Ortner, Obraztsov-Murphy symptoms are often positive. The liver is somewhat enlarged with a dense and painful edge on palpation in complications of chronic cholecystitis (chronic hepatitis, cholangitis). The gallbladder in most cases is not palpable, as it is usually wrinkled due to a chronic cicatricial sclerosing process. During exacerbations, neutrophilic leukocytosis, an increase in ESR and a temperature reaction are observed. With duodenal sounding, it is often not possible to obtain a cystic portion of bile B (due to a violation of the concentration ability of the gallbladder and a violation of the gallbladder reflex), or this portion of bile has only a slightly darker color than A and C, often cloudy. Microscopic examination in the duodenal contents reveals a large amount of mucus, cells of desquamated epithelium, "leukocytes", especially in portion B of bile (the detection of "leukocytes" in bile is not as important as before; as a rule, they turn out to be the nuclei of decaying cells of the duodenal epithelium) . Bacteriological examination of bile (especially repeated) allows you to determine the causative agent of cholecystitis.

With cholecystography, a change in the shape of the gallbladder is noted, often its image is fuzzy due to a violation of the concentration ability of the mucosa, sometimes stones are found in it. After taking the irritant - cholecystokinetics (usually two egg yolks) - there is an insufficient contraction of the gallbladder. Signs of chronic cholecystitis are also determined by echography (in the form of a thickening of the walls of the bladder, its deformation, etc.).

The course in most cases is long, characterized by alternating periods of remission and exacerbation; the latter often occur as a result of eating disorders, taking alcoholic beverages, hard physical work, the addition of acute intestinal infections, and hypothermia. The prognosis is favorable in most cases. Deterioration of the general condition of patients and temporary loss of their ability to work - only for periods of exacerbation of the disease. Depending on the characteristics of the course, latent (sluggish), the most common - recurrent, purulent-ulcerative forms of chronic cholecystitis are distinguished. Complications: accession of chronic cholangitis, hepatitis, pancreatitis. Often the inflammatory process is a "push" to the formation of stones in the gallbladder.

Chronic cholecystitis is differentiated from cholelithiasis (these two diseases are often combined), chronic cholangitis. Of primary importance are the data of cholecysto- and cholegraphy, especially repeated to exclude gallstones, as well as echography.

Treatment. With exacerbations of chronic cholecystitis, patients are hospitalized in surgical or therapeutic hospitals and treatment is carried out, as in acute cholecystitis. In mild cases, outpatient treatment is possible. Assign bed rest, dietary nutrition (diet No. 5a), with meals 4-6 times a day, antibiotics (oletethrin, erythromycin, levomycetin, ampicillin orally or glycocycline, monomycin, etc. parenterally). Assign also sulfanilamide preparations (sulfadimezin, sudfa-pyridazine, etc.). To eliminate biliary dyskinesia, spastic pain, improve bile flow, antispasmodic and anticholinergic drugs are prescribed (papaverine hydrochloride, no-shpa, atropine sulfate, platyfillin hydrotartrate, etc.), and with mild exacerbations and during the period of subsiding inflammation, duodenal soundings (after 1 -2 days, for a course of 8-12 procedures) or the so-called blind, or probeless, tubes with magnesium sulfate or warm mineral water (Essentuki No. 17, etc.). With severe inflammatory pain, amidopyrine or analgin is used intramuscularly, pararenal novocaine blockades, novocaine is injected - 30-50 ml of a 0.25-0.5% solution intradermally over the area of ​​\u200b\u200bmaximum pain, or electrophoresis with novocaine is prescribed for this area. During the period of subsiding of the inflammatory process, thermal physiotherapeutic procedures can be prescribed for the region of the right hypochondrium (diathermy, UHF, inductothermy, etc.).

To improve the outflow of bile from the gallbladder, both during the period of exacerbation and during remissions, choleretic agents are widely prescribed: allochol (2 tablets 3 times a day), cholenzym (1 tablet 3 times a day), decoction (10:250) of flowers immortelle sandy (1/2 cup 2-3 times a day before meals); decoction or infusion of corn stigmas (10:200, 1-3 tablespoons 3 times a day) or their liquid extract (30-40 drops 3 times a day); choleretic tea (one tablespoon brew 2 cups boiling water, strained infusion take 1/2 cup 3 times a day 30 minutes before meals); tsikvalon, nikodin, etc., as well as olimetin, rovachol, enatin (0.5-1 g in capsules 3-5 times a day) and cholagol (5 drops per sugar 30 minutes before meals 3 times a day). These drugs have antispasmodic, choleretic, nonspecific anti-inflammatory and diuretic effects. With a mild attack of biliary colic, cholagol is prescribed 20 drops per dose.

Chronic cholecystitis is treated with mineral water (Essentuki No. 4 and No. 17, Slavyanovskaya, Smirnovskaya, Mirgorodskaya, Naftusya, Novo-Izhevskaya, etc.), as well as magnesium sulfate (1 tablespoon of a 25% solution 2 times a day) or Karlovy Vary salt (1 teaspoon in a glass of warm water 3 times a day). After the exacerbation of cholecystitis subsides and for the prevention of subsequent exacerbations (preferably annually), sanatorium treatment is indicated (Essentuki, Zheleznovodsk, Truskavets, Morshyn and other sanatoriums, including local ones intended for the treatment of cholecystitis).

With the failure of conservative treatment and frequent exacerbations, surgical treatment of chronic cholecystitis (usually cholecystectomy) is performed.

Prevention of chronic cholecystitis consists in observing the diet, playing sports, physical education, preventing obesity, and treating focal infection.