Before talking about the development of the disease and surgery, it is important to understand anatomical features the most important bone connection, on the health of which, one might say, the fate of a person depends. After all, failure of the hip joint negatively affects the biomechanics of not only the legs, but also the entire locomotor system, which often leads to disability.

The joints are securely hidden behind the tendons, they are correctly called “ articular capsules».

Hip joint- the largest joint in the body. It is formed by two articulating bones - the femur and the acetabulum of the pelvis. Femoral head located in a cup-shaped depression pelvic bone, where she moves freely in various directions. Thanks to this interaction of two bone elements, the following is ensured:

• flexion and extension;
• adduction and abduction;
• hip rotation.

Rear part.

The surfaces of interacting bones are covered with a special elastic layer called hyaline cartilage. A special elastic coating allows the head to slide smoothly and unhindered, thanks to which a person moves freely and does not experience problems at the moment. physical activity. In addition, cartilage performs the functions of stabilizing the hip joint and cushioning every movement.

The joint structure is placed in a durable case - the joint capsule. Inside the capsule there is a synovial membrane that produces a specific fluid. It lubricates the cartilaginous covers of articular bones, moisturizes and enriches nutrients, which supports cartilage structures in excellent condition.

Outside the capsule lies the supra-articular group of the femoral and pelvic muscles, thanks to which, in fact, the joint is set in motion. In addition, the largest joint covers a fan of various ligaments that perform a regulatory function, preventing excessive movement of the hip, more than the physiological norm.

The hip joint bears the bulk of the loads, so it is easily injured and prone to rapid wear when unfavorable factors. This explains the high prevalence of the disease. Unfortunately, many patients turn to doctors for later arthrosis disorders, when functionality is irreversibly exhausted.

Under the influence of negative phenomena, synthesis is disrupted synovial fluid. It is produced in catastrophically low quantities, and its composition changes. Thus, cartilage tissue They are constantly undernourished and dehydrated. The cartilage gradually loses its former strength and elasticity, exfoliates and decreases in volume, which makes unhindered and smooth gliding impossible.

The extrahepatic bile ducts include: right and left hepatic, common hepatic, cystic and common bile. At the gate of the liver, the right and left hepatic ducts, ductus hepaticus dexter et sinister, emerge from its parenchyma. Left hepatic duct in the liver parenchyma it is formed by the fusion of the anterior and posterior branches. The anterior branches collect bile from the quadrate lobe and from the anterior part of the left lobe, and the posterior branches collect bile from the caudate lobe and from posterior section left lobe. The right hepatic duct is also formed from the anterior and posterior branches, which collect bile from the corresponding parts of the right lobe of the liver.

Common hepatic duct ductus hepaticus communis formed by the fusion of the right and left hepatic ducts. The length of the common hepatic duct ranges from 1.5 to 4 cm, diameter - from 0.5 to 1 cm.

Sometimes the common hepatic duct is formed from three or four bile ducts. In some cases, there is a high fusion of the cystic duct with the bile ducts in the absence of the common hepatic duct (Fig. 21). (V.I. Shkolnik, E.V. Yakubovich).

Fig.21. Gallbladder and bile ducts:

1 - ductus hepaticus sinister; 2 - ductus hepaticus dexter; 3 - ductus hepaticus communis;
4 - ductus cysticus; 5 - ductus choledochus; 6 - ductus pancreaticus; 7 - duodenum;
8 - collum vesicae felleae; 9- corpus vesicae felleae; 10- fundus vesicae felleae.

Sometimes both hepatic ducts or one of them open directly into the gallbladder in the area of ​​its bed.

Behind the common hepatic duct is the right branch of the hepatic artery; V in rare cases it passes anterior to the duct.

Cystic duct ductus cysticus has a length of 1-5 cm, on average 2-3 cm, diameter 0.3-0.5 cm. It passes in the free edge of the hepatoduodenal ligament and merges with the common hepatic duct, forming the common bile duct. The cystic and common hepatic ducts can connect at an acute, right or obtuse angle. Sometimes the cystic duct spirals around the common hepatic duct. The presented figure shows the main options for connecting the cystic and common hepatic ducts.

The common bile duct opens, as a rule, together with the pancreatic duct on the major duodenal papilla papilla duodeni major. At its confluence there is a ring-shaped pulp.

The ducts most often merge and form an ampulla 0.5-1 cm long. In rare cases, the ducts open into the duodenum separately (Fig. 22).

Fig.22. Options for connecting the cystic and common bile ducts.

The location of the major papilla is very variable, so it is sometimes difficult to detect when dissecting the duodenum, especially in cases where the intestine is deformed due to some pathological process(perioduodenitis, etc.) Most often, the major papilla is located at the level of the middle or lower third of the descending posteromedial part of the duodenum, rarely - in its upper third.

The hepatoduodenal ligament is more clearly defined if top part pull the duodenum downwards, and lift the liver and gall bladder upwards. In the ligament on the right, in its free edge, there is the common bile duct, on the left - the proper hepatic artery, and between them and somewhat deeper - the portal vein (Fig. 23).

Fig. 23. Topography of formations enclosed in the hepatoduodenal ligament:

1 - ductus hepaticus communis; 2 - ramus sinister a. hepaticae propriae; 3 - ramus dexter a. hepaticae propriae; 4 - a. hepatica propria; 5 - a. gastrica dextra; 6 - a. hepatica communis; 7- ventriculus; 8 - duodenum; 9 - a. gastroduodenalis; 10 - v. portae; 11 - ductus choledochus; 12-ductus cysticus; 13 - vesica fellea.

In rare cases, the cystic duct is absent and the gallbladder communicates directly with the right hepatic, common hepatic, or common bile ducts.

Common bile duct ductus choledochus has a length of 5-8 cm, diameter - 0.6-1 cm. There are four parts in it: pars supraduodenalis, pars retroduodenalis, pars pancreatica, pars intramuralis (Fig. 24).

Pars supraduodenalis

Pars retroduodenalis

Pars pancreatica

pars intramuralis

Rice. 24. Sections of the common bile duct

In addition to these main formations, the hepatoduodenal ligament contains smaller arterial and venous vessels(a. et v. gastrica dextra, a. et v. cystica, etc.), lymphatic vessels, The lymph nodes and hepatic plexuses. All these formations are surrounded by connective tissue fibers and fatty tissue.

Coming from the liver right and left hepatic ducts at the porta hepatis they unite to form the common hepatic duct, ductus hepaticus communis. Between the layers of the hepatoduodenal ligament, the duct descends 2-3 cm down to the junction with the cystic duct. Behind it pass the right branch of the proper hepatic artery (sometimes it passes in front of the duct) and the right branch of the portal vein.

Cystic duct, ductus cysticus, with a diameter of 3-4 mm and a length of 2.5 to 5 cm, emerging from the neck of the gallbladder, heading to the left, flows into the common hepatic duct. The angle of confluence and distance from the neck of the gallbladder can be very different. On the mucous membrane of the duct there is a spiral fold, plica spiralis, which plays a certain role in regulating the outflow of bile from the gallbladder.

Common bile duct, ductus choledochus, is formed as a result of the connection of the common hepatic and cystic ducts. It is located first in the free right edge of the hepatoduodenal ligament. To the left and somewhat posterior to it is the portal vein. The common bile duct drains bile into the duodenum. Its length is on average 6-8 cm. Along the common bile duct there are 4 parts:

1) supraduodenal part common bile duct goes to the duodenum in the right edge of lig. hepatoduodenale and has a length of 1-3 cm;
2) retroduodenal part common bile duct about 2 cm long, located behind the upper horizontal part of the duodenum, approximately 3-4 cm to the right of the pylorus of the stomach. Above and to the left of it passes the portal vein, below and to the right - a. gastroduodenalis;
3) pancreatic part common bile duct up to 3 cm long passes through the thickness of the head of the pancreas or behind it. In this case, the duct is adjacent to the right edge of the inferior vena cava. The portal vein lies deeper and crosses the pancreatic part of the common bile duct in an oblique direction to the left;
4) interstitial, terminal, part common bile duct has a length of up to 1.5 cm. The duct pierces the posteromedial wall of the middle third of the descending part of the duodenum in an oblique direction and opens at the top of the major (Vater) papilla of the duodenum, papilla duodeni major. The papilla is located in the region of the longitudinal fold of the intestinal mucosa. More often end part The ductus choledochus merges with the pancreatic duct, forming when entering the intestine hepatopancreatic ampulla, ampulla hepatopancreatica.

In the thickness of the wall of the large duodenal papilla, the ampulla is surrounded by smooth circular muscle fibers that form sphincter of hepatopancreatic ampulla, m. sphincter ampullae hepatopancreaticae.

Educational video of the anatomy of the gallbladder, bile ducts and Calot's triangle

Anatomy

What is the danger of blocked ducts?

Diagnosis of diseases

Features of treatment

Therapeutic diet

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Dear readers, bile ducts ( biliary tract) perform one important function- they conduct bile to the intestines, which plays a key role in digestion. If for some reason it periodically does not reach the duodenum, there is a direct threat to the pancreas. After all, bile in our body eliminates the properties of pepsin that are dangerous for this organ. It also emulsifies fats. Cholesterol and bilirubin are excreted through bile because they cannot be fully filtered by the kidneys.

If the gallbladder ducts are obstructed, the entire digestive tract. Acute blockage causes colic, which can result in peritonitis and urgent surgery; partial obstruction impairs the functionality of the liver, pancreas and other important organs.

Let's talk about what is special about the bile ducts of the liver and gallbladder, why they begin to conduct bile poorly and what needs to be done to avoid adverse consequences such a blockage.

The anatomy of the bile ducts is quite complex. But it is important to understand it in order to understand how the biliary tract functions. Bile ducts are intrahepatic and extrahepatic. On the inside, they have several epithelial layers, the glands of which secrete mucus. The bile duct has a biliary microbiota - a separate layer that forms a community of microbes that prevent the spread of infection in the organs of the biliary system.

The intrahepatic bile ducts have a tree-like structure. The capillaries pass into the segmental bile ducts, and they, in turn, flow into the lobar ducts, which form the common hepatic duct outside the liver. It enters the cystic duct, which drains bile from the gallbladder and forms the common bile duct (choledochus).

Before entering the duodenum, the common bile duct becomes excretory duct pancreas, where they unite into the hepatopancreatic ampulla, which is separated by the sphincter of Oddi from the duodenum.

Diseases that cause obstruction of the bile ducts

Diseases of the liver and gallbladder in one way or another affect the condition of the entire biliary system and cause blockage of the bile ducts or their pathological expansion as a result of a chronic inflammatory process and stagnation of bile. Obstruction is provoked by diseases such as cholelithiasis, cholecystitis, kinks in the gallbladder, the presence of structures and scars. In this condition, the patient needs urgent medical attention.

Blockage of the bile ducts is caused by the following diseases:

• bile duct cysts;
• cholangitis, cholecystitis;
• benign and malignant tumors pancreas and organs of the hepatobiliary system;
• scars and strictures of the ducts;
• cholelithiasis;
• pancreatitis;
• hepatitis and cirrhosis of the liver;
• helminthic infestations;
• enlarged lymph nodes of the hepatic hilum;
• surgical interventions on the bile ducts.

Most diseases of the biliary system cause chronic inflammation of the biliary tract. It leads to thickening of the mucosal walls and narrowing of the lumen of the ductal system. If, against the background of such changes, a stone enters the gallbladder duct, the stone partially or completely blocks the lumen.

Bile stagnates in the bile ducts, causing them to expand and aggravating the symptoms of the inflammatory process. This can lead to empyema or hydrocele of the gallbladder. For a long time the person tolerates minor symptoms of the blockage, but eventually irreversible changes in the bile duct lining will begin to occur.

Why is it dangerous?

If the bile ducts are clogged, you need to contact a specialist as soon as possible. Otherwise case will happen almost complete loss of the liver from participating in detoxification and digestive processes. If the patency of the extrahepatic or intrahepatic bile ducts is not restored in time, liver failure, which is accompanied by damage to the central nervous system, intoxication and goes into a severe coma.

Blockage of the bile ducts may occur immediately after an attack biliary colic https://site/zhelchnaya-kolika against the background of the movement of stones. Sometimes obstruction occurs without any preliminary symptoms. Chronic inflammatory process, which inevitably occurs with dyskinesia of the bile ducts, cholelithiasis, cholecystitis, leads to pathological changes in the structure and functionality of the entire biliary system.

In this case, the bile ducts are dilated and may contain small stones. Bile stops flowing into the duodenum right time and to the required extent.

Emulsification of fats slows down, metabolism is disrupted, the enzymatic activity of the pancreas decreases, food begins to rot and ferment. Stagnation of bile in the intrahepatic ducts causes the death of hepatocytes - liver cells. Bile acids and direct active bilirubin begin to enter the bloodstream, which provokes damage internal organs. Suction fat-soluble vitamins against the background of insufficient flow of bile into the intestines, it worsens, and this leads to hypovitaminosis and dysfunction of the blood coagulation system.

If a large stone gets stuck in the bile duct, it immediately closes its lumen. arise acute symptoms, which signal severe consequences obstruction of the biliary tract.

How does blocked duct manifest itself?

Many of you probably think that if the bile ducts are clogged, the symptoms will immediately be so acute that you will not be able to tolerate them. In fact clinical manifestations blockages may develop gradually. Many of us have experienced discomfort in the area of ​​the right hypochondrium, which sometimes even lasts for several days. But we do not rush to specialists with these symptoms. A similar one It's a dull pain may indicate that the bile ducts are inflamed or even clogged with stones.

As ductal patency worsens, additional symptoms appear:

• acute girdling pain in the right hypochondrium and abdomen;
• yellowing of the skin, the appearance of obstructive jaundice;
• discoloration of stool due to lack of bile acids in the intestines;
• itching of the skin;
• darkening of urine due to active excretion of direct bilirubin through the kidney filter;
• severe physical weakness, increased fatigue.

Pay attention to symptoms of obstruction of the bile ducts and diseases of the biliary system. If on initial stage undergo diagnostics, change your diet, you can avoid dangerous complications and preserve the functionality of the liver and pancreas.

Diseases of the biliary system are treated by gastroenterologists or hepatologists. You should contact these specialists if you have complaints of pain in the right hypochondrium and other characteristic symptoms. The main method for diagnosing bile duct diseases is ultrasonography. It is recommended to look at the pancreas, liver, gallbladder and ducts.

If a specialist detects strictures, tumors, dilatation of the common bile duct and ductal system, the following studies will be additionally prescribed:

• MRI of the bile ducts and the entire biliary system;
• biopsy of suspicious areas and tumors;
• feces for coprogram (detect low content bile acids);
• blood biochemistry (increased direct bilirubin, alkaline phosphatase, lipases, amylases and transaminases).

Blood and urine tests are prescribed in any case. Besides characteristic changes V biochemical research, with obstruction of the ducts, prothrombin time is prolonged, leukocytosis with a shift to the left is observed, and the number of platelets and red blood cells decreases.

Features of treatment

Treatment tactics for bile duct pathologies depend on concomitant diseases and the degree of blockage of the lumen of the ductal system. IN acute period antibiotics are prescribed and detoxification is carried out. In this condition, serious surgical interventions contraindicated. Experts try to limit themselves to minimally invasive treatment methods.

These include the following:

• choledocholithotomy - an operation for partial excision of the common bile duct in order to free it from stones;
• stenting of the bile ducts (installation of a metal stent that restores duct patency);
• drainage of the bile ducts by installing a catheter into the bile ducts under endoscopic control.

After restoration of patency of the ductal system, specialists can plan more serious surgical interventions. Sometimes blockage is caused by benign and malignant neoplasms which have to be removed, often together with the gallbladder (with calculous cholecystitis).

Total resection is performed using microsurgical instruments under endoscopic control. Doctors remove the gallbladder through small punctures, so the operation is not accompanied by heavy blood loss and a long rehabilitation period.

During cholecystectomy, the surgeon must assess the patency of the ductal system. If stones or strictures remain in the bile ducts after removal of the bladder, postoperative period may arise severe pain and emergency conditions.

Removing a bladder clogged with stones in a certain way saves other organs from destruction. And ducts too.

You should not refuse surgery if it is necessary and threatens the entire biliary system. The entire digestive tract and immune system suffer from stagnation of bile, inflammation, and the proliferation of infectious pathogens.

Often, against the background of ductal diseases, a person begins to lose weight sharply and feel unwell. He is forced to limit his activity and give up his favorite job, because constant pain attacks and health problems do not allow him to live a full life. And the operation in this case warns dangerous consequences chronic inflammation and bile stagnation, including malignant tumors.

Therapeutic diet

For any diseases of the bile ducts, diet No. 5 is prescribed. This involves eliminating fatty, fried foods, alcohol, carbonated drinks, and dishes that cause gas formation. The main goal of such nutrition is to reduce increased load on the biliary system and prevent the sharp flow of bile.

In the absence of severe pain, you can eat as usual, but only if you have not abused prohibited foods before. Try to completely avoid trans fats fried foods, pungency, smoked meats, semi-finished products. But at the same time, nutrition should be complete and varied. It is important to eat often, but in small portions.

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Resort to treatment folk remedies when the bile ducts are clogged, extreme caution is necessary. Many herbal recipes have a strong choleretic effect. Applying similar methods, you are risking your own health. How to clean the bile ducts herbal infusions It is impossible without the risk of developing colic; you should not experiment with herbs at home.

First, make sure there are no large stones that could cause blockage of the duct system. If you use choleretic herbs, give preference to those that have a mild effect: chamomile, rose hips, flax seeds, immortelle. Please consult your doctor first and perform an ultrasound. WITH choleretic compounds don't joke if you do high risk the occurrence of blockage of the bile ducts.

Articles you may find useful:

This video describes a method of gentle cleansing of the gallbladder and ducts that can be used at home.

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Brief anatomy of the biliary tract

Each liver cell participates in the formation of several bile canaliculi. At the periphery of the hepatic lobule, the bile canaliculi merge into the bile ducts themselves, covered with cuboidal epithelium - intralobular.

Coming out into the interlobular connective tissue, they pass into the interlobular tubules. Further, the interlobular ducts, merging, form interlobular ducts of the first and second order, lined with prismatic epithelium,

Alveolar-tubular mucous glands, connective tissue membrane, and elastic fibers appear in the walls of the ducts. The interlobular ducts form large intrahepatic ducts, which form the right and left hepatic ducts. The latter, merging, form the common hepatic duct, which has the Mirizzi sphincter. After the connection of the common hepatic duct and the cystic duct, the common bile duct (choledochus) begins, which is a direct continuation of the common hepatic duct. The width of the ducts varies: common bile ducts from 2 to 10 mm, hepatic ducts from 0.4 to 1.6 mm, cystic ducts from 1.5 to 3.2 mm. It should be noted that the diameter of the bile ducts when determining various methods may vary.

Thus, the diameter of the common bile duct, measured intraoperatively, ranges from 5-15 mm, with ERCP up to 10 mm, with ultrasound - 2-7 mm.

In the common bile duct, the length of which is 5-7 cm, there are supraduodenal, retroduodenal, retropancreatic, intrapancreatic and intramural sections. The common bile duct passes between the leaves of the lesser omentum anterior to the portal vein and to the right of the hepatic artery, and, as noted earlier, in most cases merges with the pancreatic duct in the thickness back wall The duodenum, opening into its lumen on the longitudinal fold of the mucous membrane with the major papilla of the duodenum. Options for connecting the common bile duct and the gastrointestinal tract in the area of ​​the nipple of Vater are shown in Fig. 1-6.

Rice. 1-6. Options for the fusion of the intrapancreatic section of the common bile and main pancreatic duct

The gallbladder is pear-shaped and is adjacent to the lower surface of the liver. It is always located above the transverse colon, adjacent to WDP bulb and is located in front of right kidney(the projection of the duodenum overlaps its shadow).

The capacity of the gallbladder is about 50-100 ml, but with hypotension or atony of the common bile duct, blockage with a stone, or compression by a tumor, the gallbladder can significantly increase in size. The gallbladder has a fundus, a body and a neck, which gradually narrows and becomes the cystic duct. At the junction of the neck of the gallbladder and the cystic duct, smooth muscle fibers form the sphincter of Mirizzi.

Saccular expansion of the neck of the gallbladder, often serving as a place formation of stones is called Hartmann's pouch. In the initial part of the cystic duct, its mucous membrane forms 3-5 transverse folds(valves or Heister dampers). The widest part of the gallbladder is its bottom, facing anteriorly: it is this that can be palpated when examining the abdomen.

The wall of the gallbladder consists of a network of muscle and elastic fibers with poorly defined layers. The muscle fibers of the neck and bottom of the gallbladder are especially well developed. The mucous membrane forms numerous delicate folds. There are no glands in it, but there are depressions that penetrate into the muscle layer. Submucosa and own muscle fibers not in the mucous membrane.

Brief anatomy of the duodenum

The duodenum (intestinum duodenak, duodenum) is located directly behind the pylorus of the stomach, representing its continuation. Its length is usually about 25-30 cm (“12 fingers”), the diameter is approximately 5 cm in the initial section and 2 cm in the distal section, and the volume ranges from 200 ml.

The duodenum is partially fixed to the surrounding organs, does not have a mesentery and is not completely covered by the peritoneum, mainly in the front, actually located retroperitoneally. The posterior surface of the duodenum is firmly connected through fiber to the posterior abdominal wall.

The size and shape of the duodenum are very variable; many variants of the anatomy of this organ have been described. The shape of the duodenum normally depends on gender, age, constitutional characteristics, characteristics physical development, body weight, condition of the abdominal muscles, degree of stomach filling. This is due to the existence of many classifications of its form. Most often (in 60% of cases), the duodenum has a horseshoe shape, bending around the head of the pancreas (Fig. 1-7). However, there are other forms of duodenum: ring-shaped, folded, angular and mixed forms, in the form of sharply curved loops located vertically or frontally, etc.

Rice. 1-7. Duodenum, normal anatomy

From above and in front the WPC is in contact with right lobe liver and gallbladder, sometimes with the left lobe of the liver. The front is covered with WPC transverse colon and its mesentery. It is closed with hinges at the front and bottom. small intestine. On the left, in its loop lies the head of the pancreas, and in the groove between the descending part of the intestine and the head of the pancreas there are vessels that feed neighboring organs. On the right, the duodenum is adjacent to the hepatic flexure of the colon, and at the back, its upper horizontal part is adjacent to the infundibular vein

Maev I.V., Kucheryavyi Yu.A.