HOLANGYT (cholangitis; Greek cho-1yo bile + angeion a vessel + - itis; synonym: the angiocholitis, holangiit) —
an inflammation of bilious channels (extrahepatic and intra hepatic). The isolated cholangitis meets seldom, more often it is combined with cholecystitis (holetsistokholangit, or an angiocholecystitis) and hepatitis (ge-patokholangit).
On character of a current cholangites subdivide on acute and chronic. A. Ya. Gubergrits (1966) among forms hron. a cholangitis allocates latent, recurrent and it is long flowing with a septic component. Carry also sclerosing cholangitis to chronic.
In most cases the cholangitis has a bacterial origin. The bacterial infection extends ascending (from intestines), hematogenous or ente-rogematogenny (on a portal vein or on a hepatic artery) and a lymphogenous way. The activator more often is colibacillus (see), is more rare — enterokokk (see), proteas (see Proteus), staphylococcus (see), a typroid stick (see the Typhoid), etc. In development of an acute cholangitis recently the great value is attached to a mephitic gangrene (see). Specific cholangites (at tuberculosis, syphilis, mycosis, a dignity, etc.) meet extremely seldom. An inflammation of bilious, preferential small interlobular ductules (cholangiolitis) perhaps also at a viral hepatitis (see a viral hepatitis). The cholangitis can develop also at nek-ry helminthic invasions — a clonorchosis (see), an opisthorchosis (see), a strongyloidosis (see), a fascioliasis (see). Traumatizing a mucous membrane hepatic and the general bilious channels a stone, and also damage by their pancreatic juice can be the cause of a cholangitis.
Development of inflammatory process in bilious channels is promoted the stagnation of bile which is observed at obstruction by a stone of the general bilious channel, strictures of a fa-terov of a nipple (a big nipple of a duodenum, T.), tumors of bilious channels and heads of a pancreas, and also a choledochal cyst, postoperative hems, a holedokhoyeyu-nalny anastomosis, perikholedokhe-alny lymphadenitis, ulcers and diverticulums of a duodenum, endoscopic manipulations on the general bilious channel, etc. The possibility of infection of bilious channels at diskineziya of bilious ways hypo - and atonic type is disputable. The inflammation of the general bilious channel — a choledochitis — most often arises at cholelithiasis (see), and also at vospa-
Fig. Mikropreparat of a liver at a pericholangitis: 1 — the destroyed walls swept
whom a bilious ductule; 2 — inflammatory infiltration of surrounding fabrics; 3 — hepatic segments; coloring hematoxylin-eosine; x 60.
litelny diseases of nearby bodies and fabrics.
The reason of a sclerosing cholangitis is not known. Assume that the leading role belongs to allergization, and also damage of bilious channels lipokholevy to - that (see. Bile acids).
On the nature of inflammatory changes allocate a cholangitis catarral, purulent, diphtheritic. At a catarral cholangitis the plethora of a mucous membrane, sites of desquamation of an epithelium, hypostasis of walls of bilious channels, impurity of slime and pus in their gleams are observed. At hron. the catarral cholangitis developing as a result of obstruction of bilious ways note expansion of gleams of bilious channels with an atrophy of their walls. Histologically growth of cicatricial fabric, an atrophy of muscular and mucous layers, sometimes sites of a hyperplasia in the form of polyps of a mucous membrane hepatic and the general bilious channels are defined.
The purulent cholangitis is, as a rule, combined with inflammatory changes of a gall bladder and liver. In a gleam of bilious channels find the putreform contents painted by bile. At an intra-hepatic purulent cholangitis and a cholangiolitis a liver flabby, bulked up, with the greased drawing. At a prelum of its parenchyma from a cut surface from bilious channels pus is emitted. Histologically reveal hypostasis and a plethora of a mucous membrane, places — desquamation of an epithelium.
The diphtheritic form is characterized by a necrosis, an ulceration and desquamation of an epithelium of a mucous membrane of bilious channels, in a gleam to-rykh find nolimor-fio-core leukocytes, adjournment of bilious pigments, about a shelled cover epithelium, a detritis, sometimes bacterial clumps.
Progressing of inflammatory process leads to development of a tseri-cholangitis, at Krom destruction of walls of bilious channels and plentiful inflammatory infiltration of surrounding fabrics (fig.) is observed. Distribution of purulent process on connecting tissue and a parenchyma of a liver comes to the end with their purulent fusion and formation of holangitichesky abscesses; microscopically they represent cavities of various sizes and the localizations filled with pus with impurity of bile. The Holangitichesky abscesses which are localized preferential under the capsule can be complicated by a fibrinopurulent perihepatitis (see) and peritonitis (see). The purulent cholangitis leads to growth of granulyatsionny fabric and further — to fibrosis and secondary biliary cirrhosis (see the Liver, diseases; Cirrhosis).
At a typhoid extent of changes of bilious channels can be various — from minimum to phlegmonous. Sometimes in walls of channels (preferential small) find the characteristic granulomas created from the large «typhus» cells surrounding the centers of a necrosis (holangiotif).
Morfol. the picture of specific cholangites depends on a type of the activator. So, existence in a mucous membrane of bilious channels of the granulomas containing mycobacteria of tuberculosis is characteristic of miliary tuberculosis. At inborn syphilis the fibrous growths and gummas on the course of bilious channels and vessels leading further to a stenosis and an obliteration of bilious channels can be observed. The actinomycosis is characterized by signs of a purulent destructive cholangitis, at a sapa the diphtheritic inflammation and a canker of hepatic channels is noted.
The cholangitis which developed as a result of damage of bilious channels by enzymes of a pancreas is characterized by a so-called necrotic inflammation, a cut usually is followed by dystrophic and focal necrotic changes of hepatocytes.
At a sclerosing cholangitis find a nonspecific inflammation and a fibrous thickening of walls of both extrahepatic, and vnut-ripechenochny bilious channels; process happens segmented or diffusion. The general bilious channel has an appearance of a dense cord (because of density of walls difficultly to open it), its outer diameter is not changed, walls are thickened, the gleam is sharply narrowed. Oddi's sphincter is, as a rule, not changed. Prigistol. a research the thickening of a wall, hron is noted. inflammatory infiltration and the fibrosis of a subserous and nodslizisty layer without transition to a mucous membrane of bilious channels leading to occlusion of bilious ways. In a liver find signs of a cholestasia (see), dystrophic changes of ge-latotsit, and also the picture characteristic of secondary biliary cirrhosis (see).
The acute cholangitis is shown by fever, oznoba and pouring sweats, jaundice (see). Jaundice usually accrues after each attack of fever, sometimes is followed by an itch of skin. Often patients complain of pains in the right upper quadrant of a stomach or a lower part of a thorax with irradiation to a shoulder girdle on the right. Pains happen different intensity, sometimes gain the nature of bilious colic (see Cholelithiasis). Vomiting, sometimes with impurity of bile is often observed. The described symptoms can once be observed or repeat daily. At a palpation increase and consolidation of a liver, morbidity in right hypochondrium, increase in a spleen is defined. The disturbances connected with intoxication from other bodies up to septic shock are observed (see).
Distinguish the recurrent acute cholangitis arising usually in the presence of a valve stone in a terminal part of the general bilious canal from acute cholangites. This form is characterized by the periodic oznoba and temperature increase caused by deterioration in outflow of bile and activation of an infection, rather long absence of pains and jaundices.
At persons of senile age in connection with frequent contamination of bile the purulent cholangitis quite often develops. At the same time poorly expressed wedge, a picture (lack of temperature reaction, insignificant local symptoms) can not correspond deep morfol. to changes of bilious channels.
The acute cholangitis occurs at children seldom, usually arises for the second time as display of other disease, is more often than a streptococcal etiology, proceeds hard, is distinguished hardly.
The acute cholangitis quite often is complicated by abscessing of a liver (see the Liver, abscesses of a liver), poddiaf-ragmaljny abscess (see), right-hand pleurisy (see), is more rare — abscess of a lung (see), a pericardis (see), pancreatitis (see); at break of abscess of a liver in an abdominal cavity — peritonitis (see), at generalization of process — sepsis (see). At inefficient treatment it can be also complicated by toxic dystrophy of a liver (see) and a hepato-renal syndrome (see).
The diagnosis of an acute cholangitis is made on the basis of expressed a wedge, pictures and data a lab. researches. The leukocytosis, acceleration of ROE, a hyperbilirubinemia (see), increase in activity of an alkaline phosphatase (see), sometimes — aminotransferases is noted moderate or high (more than 15 Ltd companies in 1 mkl) (see). Holangiografiya (see) in the acute period it is not informative.
Differential diagnosis is carried most often out with acute cholecystitis (see), at Krom .mestny symptoms are more expressed, and jaundice is less characteristic. The cholangitis is differentiated also with right-hand pneumonia (see), subphrenic abscess, abscess of a liver, appendicular abscess (see Appendicitis), acute pancreatitis (see), cancer of a liver (see the Liver), a paranephritis (see), sepsis, a lymphogranulomatosis
(see), collagenic diseases (see).
Treatment of an acute cholangitis complex. Conservative therapy is applied usually in initial stages. It includes antibacterial agents — antibiotics of a broad spectrum of activity, streptocides (Biseptolum, etc.); disintoxication therapy — an artificial diuresis (see Poisonings, the general principles of rendering acute management), hemosorption (see t. 10, additional materials), drainage of a chest lymphatic channel (see Catheterization of a chest channel) with a limfosorbtion (see). At inefficiency of conservative treatment, and also the urgent decompression of bilious channels is shown to patients with the increased operational risk (purulent intoxication, sepsis, pechenochno-io-chechny insufficiency, serious associated diseases). For this purpose apply temporary outside and constant internal drainage of bilious channels. Temporary outside drainage includes a transdermal transhepatic gepatokholangiostomiya (see the Liver, operations), a laparoscopic or operational cholecystostomy (see), endoscopic transpapillary drainage of the general bilious channel (see Holedokhoskopiya), constant internal drainage of bilious channels — an endoscopic or operational papillo-sphincterotomy (see Faterov of pacifiers), imposing of a biliodigestivny anastomosis (see Choledochoduodenostomy, the Cholecystogastrostomy, Hole-tsistoduodeiostomiya, the X oletsistoen-terostomiya). At treatment of the acute purulent cholangitis which is combined with obturatsionny jaundice the outside or internal drainage of bilious channels (see above) promoting elimination of stagnation of bile and the bilious hypertensia resulting from acute impassability of bilious channels and also reduction of intoxication and inflammatory changes in bilious channels pathogenetic is most justified. The decompression of bilious channels considerably increases efficiency of antibacterial therapy since does possible the intake of antibacterial agents in bile broken at a cholestasia. Besides, antibacterial agents (taking into account sensitivity of microflora to them) can be entered directly into bilious canals through the left drainage or through an umbilical vein.
Apply also hyposensibilizing means, drugs increasing nonspecific reactivity of an organism (retabolil, pentoxyl, methyluracil, etc.). Hyperbaric oxygenation (see) allows to korrigirovat air hunger, promotes improvement of microcirculation in parenchymatous bodies and increases sensitivity of microflora to antibacterial agents.
At an acute holangat, to-rogo impassability of bilious ways is the reason, the radical operation directed to elimination of the reasons of bilious impassability (a stone, a cicatricial stricture) and recovery of outflow of bile is necessary. It is reasonable to carry out it after subsiding of the acute inflammatory phenomena and elimination of jaundice. The failure from radical operation leads to a recurrence of a disease and a further aggravation of symptoms of the patient.
Forecast, as a rule, favorable. At timely carried out treatment the acute cholangitis comes to an end with recovery. Secondary biliary cirrhosis can be an outcome of a recurrent acute cholangitis. Persons of senile age have a forecast more serious.
Prevention of an acute cholangitis is directed to the prevention of disturbances of outflow of bile.
The chronic cholangitis can initially develop or to be an outcome of an acute cholangitis.
At a latent form hron. a cholangitis of pain and morbidity at a palpation in right hypochondrium are expressed unsharply or absolutely are absent, weakness, sometimes subfebrile temperature, chilling, occasionally skin itch, gradual increase in a liver is observed. Secondary biliary cirrhosis can be an outcome of a latent form.
At a recurrent form of a cholangitis of pain and local symptoms are also expressed poorly (at a choledocholithiasis of pain there can be SI flax-mi). The aggravation of process is followed by fever, a skin itch, sometimes jaundice. The liver is increased, condensed and painful. The thickening of distal phalanxes of fingers, change of nails in the form of clock glasses, a hyperemia of palms is noted. In some cases increase in a spleen is observed. Sometimes pancreatitis joins. Secondary biliary cirrhosis can be an outcome of the disease.
Rare form hron. a cholangitis is it is long the cholangitis flowing with a septic component, however existence of this form admits not all. The activator it most often consider the green streptococcus (see Streptococci). The disease proceeds hard, is followed by bacteremia (see), damage of kidneys and reminds a subacute bacterial endocarditis (see the Endocarditis bacterial under-ost ry).
Sclerosing (stenosing, primary sclerosing) the cholangitis is very rare disease. This form is often combined with ulcer nonspecific colitis (see), is more rare — with a disease Krone (see Krone a disease), Ridel's thyroiditis (see the Thyroiditis), a vasculitis (see) etc. At a sclerosing cholangitis in one cases preferential extrahepatic bilious channels, in others — intra hepatic, more often — that and others are surprised; sclerous process can have also segmented character. The disease meets aged up to 40 years more often, begins usually with an indisposition, a fever and fervescence. The main symptoms of a sclerosing cholangitis are jaundice and a skin itch, at a part of patients unpleasant feelings in right hypochondrium, nausea. Symptoms of a disease periodically appear and disappear. The liver increases. In late stages symptoms of biliary cirrhosis appear.
Diagnosis hron. a cholangitis put on the basis a wedge, pictures, data a lab., rentgenol. and tool researches. In blood the moderate leukocytosis, insignificant acceleration of ROE is noted. Apply to assessment of a condition of bilious channels intravenous x an olangiografiya (see), a retrograde pankreatokholangiografiya
(see Pankreatokholangiografiya retrograde), transdermal Cholanum-giografiyu, ultrasonic investigation (see. Ultrasonic diagnosis), a laparoscopy with a ho-langiografiya and a radio isotope research with HID A drugs. The last method allows to receive a sharp image of bilious channels even at jaundice (see Holegrafiya radio isotope). At diagnosis the holangiografiya, a holangiomanometriya (see) and a holedo-hoskopiya have crucial importance (see).
At a sclerosing cholangitis along with a small leukocytosis and slightly accelerated ROE increase in activity of an alkaline phosphatase is noted. Level bithe lirubina varies. At an endoscopic or transdermal holangio-grafiya the intra hepatic bilious channels in the form of beads which are often sharply narrowed with the reduced branchiness and also narrowing in nek-ry departments or throughout the general bilious channel are defined. Crucial importance at diagnosis of a sclerosing cholangitis has paws and Roth pya with the subsequent operational holangio-grafiya and gistol. research of material of a biopsy.
As hron. the cholangitis is followed by subfebrile temperature, symptoms of intoxication, the differential diagnosis should be carried out with the diseases which are followed by fever: tuberculosis (see), a thyrotoxicosis (see), rheumatism (see), a subacute bacterial endocarditis, etc.
For treatment hron. cholangites in a stage of an aggravation apply antibiotics courses on 2 — 3 weeks, between to-rymi reasonable to appoint other antibacterial agents (streptocides, Nevigramonum, drugs of a nitrofuran row), and also Nicodinum. Apply cholagogue, antispasmodics, vitamins, tyubazh (see). The physical therapy and sanatorium therapy are carried out only at cholangites with not expressed a wedge, a picture in a phase of remission. In case of obturation of bilious channels the operative measure directed to elimination of occlusion or creation of a bypass biliodigestivny anastomosis is shown. At a sclerosing cholangitis carry out bougieurage of the narrowed channels or drainage of bilious channels by means of the T-shaped or transhepatic drainage in combination with introduction of glucocorticosteroids parenterally and through a drainage. At a combination of a sclerosing cholangitis to ulcer nonspecific colitis in some cases hormonal therapy (see Hormonal therapy) and a colectomy is effective (see).
The forecast at a latent hron. cholangitis, as a rule, favorable; at recuring hron. a cholangitis — depends on timely recovery of outflow of bile. Forecast of a sclerosing cholangitis serious.
Prevention of a chronic cholangitis comes down to timely treatment of an acute cholangitis, and also the diseases leading to disturbance of outflow of bile.
Bibliography: A. S's logins. Between
national classification of chronic diffusion diseases of a liver, in book: Aktualn. vopr. gastroenterol., under the editorship of A.S. Loginov, page 3, M., 1977; Many
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