HOLETsISTYT (cholecystitis; Greek chole bile - f-kystis a bubble + - itis) — an inflammation of a gall bladder.
A story of the doctrine about cholecystitis is directly connected with the doctrine about cholelithiasis (see). At cholelithiasis for the first time drew J. Morganji's attention (1760) to change of a gall bladder. Gems-bakh (M. of Hemsbach, 1856), B. Naunin (1892) and Item S. Ikonnikov (1906) considered an inflammation of a gall bladder the reason of a lithogenesis. B. Rhee-del (1903) described cholecystitis without formation of stones. The big contribution to studying of cholecystitis and development of methods of its treatment were brought by domestic surgeons S. P. Fedorov,
A. V. Martynov, I. G. Rufanov,
A. D. Ochkin, and also is mute. researchers Kerr (N. Kehr) and to W. Korte.
On prevalence cholecystitis along with a peptic ulcer occupies one of the leading places among diseases of the digestive system. According to G. I. Rogachyov (1983), the annual average indicator of prevalence of cholecystitis in 16 districts of the Moscow Region in 1977 — 1979 made 3,9 for 1000 the population. Among acute diseases of abdominal organs acute cholecystitis takes the second place after appendicitis, making, according to different researchers, 10 — 12%. In Europe cholecystitis women (approximately by 4 times), in the countries of Asia incidence of cholecystitis of persons of men's have more often and female is approximately at the identical level. According to different researchers, stones at cholecystitis reveal in 60 — 96% of cases.
At children and persons of young age not calculous cholecystitis prevails. So, And. G. Rufanov noted that at the age of 13 — 20 years not calculous cholecystitis meets by 4 times more often calculous, and at patients at the age of 30 — 50 years calculous cholecystitis meets by 21/2 times more often of not calculous. Most of researchers note that not calculous cholecystitis in the subsequent, as a rule, becomes calculous.
The AETIOLOGY AND the PATHOGENY
In emergence and development of acute or chronic inflammatory process in a wall of a gall bladder matters several factors, the bacterial infection and stagnation of bile are conducting among to-rykh. The inflammation of a gall bladder is caused by various microflora. Microorganisms get into a gall bladder from a duodenum (the ascending way), and also a hematogenous or lymphogenous way from other centers hron. infections, napr, at caries of teeth, periodontosis, hron. tonsillitis, otitis, antritis, adnexitis, etc.
The factor promoting development of cholecystitis is stagnation of bile. Dyskinesia of bilious ways, inborn deformation of output department of a gall bladder, disturbance of neuroreflex regulation of the sphincteric device, inflammatory changes of area of a faterov of a nipple can be the cause of stagnation of bile in a gall bladder (a big duodenal nipple, T.), earlier formed stones, occlusive vesical and the general bilious channels, tumors of an abdominal cavity, pregnancy, a slow-moving way of life, etc. At an inflammation in a gall bladder disturbance physical is noted. - chemical properties of bile, change of its holatokholesterinovy index (the relation of bile acids to cholesterol), reduction of content of other ingredients of bile that leads to increase in its litogennost. The decrease in concentration which is observed at the same time bilious to - t in congestive bile reduces its bactericidal properties and promotes creating favorable conditions for further development of inflammatory process. At an inflammation pH of bile in the acid party in this connection its colloid structure is broken changes. It is one of the major factors promoting loss of ingredients of bile in a deposit and, respectively, to formation of gallstones. Therefore many domestic and foreign researchers consider not calculous cholecystitis an initial stage of calculous cholecystitis. Existence hron. hepatitis, pancreatitis, a duodenitis considerably increases possibility of cholecystitis because at these diseases motility of bilious ways and physical changes. - chemical properties of bile. Stagnation of bile and change of a holato-cholesteric index lead to build-up of pressure in a gall bladder, to its stretching and the expressed hypostasis of a wall, a prelum of vessels and disturbance of microcirculation (see) that aggravates inflammatory process and can lead to a heart attack and gangrene of the site of a wall of a gall bladder.
Vascular disorders can be also the prime cause of inflammatory changes of a wall of a gall bladder, napr, at a capillary toxicosis, a nodular periarteritis, torsion of a gall bladder, hypertensive crises, atherosclerotic defeat of vessels of abdominal organs, including and a gall bladder.
Existence in a gall bladder of concrements and their movement is followed by traumatizing his mucous membrane, promotes maintenance of inflammatory process and disturbance of evacuation of contents from a bubble. Large concrements can cause erosion and ulcerations of a mucous membrane of a gall bladder with the subsequent formation of perifocal commissural process, deformation of a gall bladder and disturbance of outflow of vesical bile. Besides, concrements are as if a tank hron. pnfektion.
Also hit in a gleam of a gall bladder of enzymes of a pancreas owing to a pankreatobiliar-ny reflux can be the cause of cholecystitis (see) — so-called enzymatic cholecystitis. Such cholecystitis proceeds with rough inflammatory reaction and is followed by development of bilious peritonitis without disturbance of an integrity of a wall of a gall bladder.
M. P. Konchalovsky (1936) and Ruble A. Luriya (1935) allowed a possibility of the allergic nature of nek-ry forms of cholecystitis. In developing of a disease the role of local allergization of a wall of a gall bladder (a kolibatsillyar-yy and autoimmune origin) and food allergy is established.
A certain role in emergence and development of cholecystitis is played by Heredity.
Damages of biliary tract at parasitic diseases, napr, a lambliasis (see), an amebiasis (see), an opisthorchosis (see), an ascaridosis (see), can promote developing of a disease or maintenance of inflammatory process in a gall bladder.
Experimental cholecystitis. The great value in studying of an etiology and pathogeny of cholecystitis had (along with a wedge, researches) creation of a pilot model of a disease. Experimental cholecystitis represents the inflammation of a gall bladder more or less similar to cholecystitis which is artificially caused in animals at the person. According to etiological and pathogenetic features of a disease it is possible to allocate three main ways of creation of model of experimental cholecystitis: artificial introduction of microbes to a cavity of a gall bladder (most often through specially created fistula) or creation of conditions for receipt in a gall bladder inf. agent; introduction to a cavity of a gall bladder of the foreign bodys, gallstones, the concentrated bile of the person injuring a mucous membrane of a gall bladder; creation of the special diet promoting formation of stones and development of an inflammation in experimental animals.
One of the first models of experimental cholecystitis was offered in 1915 by P. S. Ikonnikov. After preliminary bandaging of a vesical channel he entered into a cavity of a gall bladder of dogs and rabbits of culture of colibacillus, streptococci, stafilokokk and received a purulent inflammation of a bubble with further formation of stones. V. A. Galkin and A.S. Chechulin (1960) on the basis of this method developed model experimental bacterial nekalkulezno-go cholecystitis on dogs. The inflammation was received by imposing on a gall bladder of animals of a fistula according to Pavlov — to Dastry and introductions through it pure growth of colibacillus. This model allowed to make dynamic overseeing development of changes bio-chemical of composition of bile. The similar technique was applied also by I. K. Smirnov (1962). These models are rather simple, show a role inf. the agent in development of an inflammation is also allowed to give morfol. characteristic experimental hron. nekalkulez-ny cholecystitis. In 1938 H. N. Anichkov and M. A. Zakharyevska offered the following model of experimental cholecystitis: damage of a sphincter of Oddi at rabbits was resulted by the inflammation in a gall bladder caused by own colibacillus which got into a bubble in the ascending way. Researchers offered four ways of dysfunction of the trailer device of the general bilious channel: 1) imposing of a holedokhoduodeno-ostomy; 2) strengthening of a rubber tube in an opening of a faterov of a nipple; 3) administration of thread in an opening of a faterov of a nipple; 4) removal or destruction of a sphincter of Oddi. I. A. Ilyinsky, O. P. Hrabrova,
V. V. Rumyantseva (1966) who applied this model on cats gained more bystry and expressed development of cholecystitis. At gistol. a research on 3 — the 4th day thinning of a mucous membrane of a gall bladder, exfoliating of an epithelium, sometimes small infiltration was noted by neutrophilic leukocytes; in a gleam of a gall bladder between fibers the insignificant amount of purulent exudate, on 6 — — hypostasis, purulent infiltration of almost all layers of a wall of a gall bladder was found the 7th day. By 21st day in a wall of a gall bladder along with a purulent inflammation there were changes characteristic for hron. inflammations, growth of connecting fabric, a hypertrophy of a muscular coat and proliferation of cells of an epithelium was noted.
The first models of experimental cholecystitis with introduction to a cavity of a gall bladder of foreign bodys were executed by Barlow (Barlow, 1918). H. N. Petrov and LF of As of Krotkin (1928) received the expressed hyperplastic growths of an epithelium and weak inflammatory reaction in a wall of a gall bladder of animals at introduction to his cavity of gallstones of the person. Womack, Brikker (N. A. Womack, E. The m of Bricker, 1942) got acute cholecystitis at introduction to a gall bladder of the concentrated bile or gallstones. S.F. Yushkov (1957) in experiments on Guinea pigs caused acute, and further hron. an inflammation of a gall bladder, entering the small glass balls fastened with a copper wire into its gleam. The inflammation of a wall of a gall bladder was noted also at impact on his mucous membrane of various damaging agents (chemical or physical), including a gastric juice. To development of cholecystitis in an experiment at introduction to a cavity of a gall bladder of foreign bodys or inf. the agent artificially caused delay of evacuation of a disturbing factor from a cavity of a gall bladder promoted., Creation of models of experimental cholecystitis by selection of a diet is based on ratio distortion in it of cholesterol, bilious to - t and phospholipids therefore there is a formation of stones in a gall bladder to further development of an inflammation in its wall., X. Ladies, Christensen (F. Christensen, 1952) supported hamsters on the diet deprived of fats; for the 87th days at them stones in a gall bladder, Robins and Fazulo began to form (S. J. Robins, J. Fasulo, 1973) gained the same effect, having applied a diet with restriction irreplaceable fat to - t. Brenneman, Connor, Forker, Den-Besten (D. E. Brenneman, W. E. Connor, E. L. Forker, L. DenBesten, 1972) reached formation of gallstones at dogs by feeding by their food containing a large amount of cholesterol. Wasp of hectare, Portmen (T. Osuga, O. of W.Portman, 1971) showed a possibility of formation of stones in a gall bladder at the monkeys receiving the food rich with fats and cholesterol. Addition to food henodeoksikholi-new to - you or D-thyroxine accelerated a lithogenesis and led to increase in quantity of stones in a gall bladder * Krom of the above described three main ways of creation of models of experimental cholecystitis, there were also others * So, damage and inflammatory reaction to a wall of a gall bladder arose at primed animals after introduction of the allowing dose of serum by it in a gall bladder.
Development of pilot models of cholecystitis serves for studying of a pathogeny of a disease, and also searches of adequate methods of treatment.
Acute cholecystitis happens calculous and not calculous, however more often it arises against the background of cholelithiasis.
Pathological anatomy. The nonspecific inflammation is characteristic of acute cholecystitis. On character of an inflammation allocate catarral and destructive cholecystitis; the last is purulent, phlegmonous, phlegmonous and ulcer, diphtheritic and gangrenous. At acute catarral cholecystitis the gall bladder is increased, intense, filled with watery bile (in connection with impurity of serous exudate). The mucous membrane of a gall bladder is hyperemic, edematous, covered with muddy slime. Microscopically in a wall of a gall bladder against the background of a plethora and hypostasis in mucous and submucosal layers the infiltrates consisting of polymorphonuclear leukocytes, macrophages and layers of a deskvamirovan-ny epithelium are noted. Usually acute catarrh of a gall bladder comes to an end with a complete recovery of its structure.
Acute purulent cholecystitis most often develops in the presence in a gall bladder of stones. The gall bladder at the same time is increased, intense, its serous cover dim, is pruinose fibrin. The gleam of a gall bladder contains the purulent exudate painted by bile, sometimes with impurity of blood. Acute purulent cholecystitis proceeds as a phlegmonous inflammation more often. At phlegmonous cholecystitis in a reinforced wall of a gall bladder sites of a necrosis are noted (see) and fusions of fabric. A mucous membrane plethoric, bulked up, with hemorrhages, erosion or ulcerations. Diffusion infiltration of a wall of a gall bladder is microscopically noted by polymorphonuclear leukocytes. In case of massive hemorrhage in a wall of a gall bladder the inflammation accepts is purulent - hemorrhagic character. Quite often at purulent cholecystitis in a wall of a gall bladder abscesses are formed, to-rye in the subsequent can be opened in a gleam of a bubble with formation of ulcers or in an abdominal cavity that leads to peritonitis (see). Nekrotizirovan-ny sites of a mucous membrane become impregnated with fibrin (see) also take a form of dirty-green films that is characteristic of diphtheritic cholecystitis. At rejection of a detritis on site of a necrosis of a mucous membrane deep ulcers are formed. If necrotic process extends to all thickness of a gall bladder, gangrenous cholecystitis develops. At the same time the wall of a gall bladder gets dirty-brown coloring, becomes dim, flabby. Development of gangrenous cholecystitis is connected with disturbance of a hemodynamics as a result of inflammatory and necrotic changes in a wall of vessels at purulent cholecystitis and development of purulent vasculites and thrombovasculites, and also a fibrinoid necrosis. Gangrenous cholecystitis can develop also as a result of primary defeat of blood vessels, napr, at an idiopathic hypertensia, a nodular periarteritis.
Clinical picture. Acute cholecystitis, both calculous, and not calculous, begins as an aggravation hron more often. cholecystitis, sometimes suddenly against the background of the seeming wellbeing. The main symptom are pains, to-rye have character of hepatic (bilious) colic (see Cholelithiasis). Colic arises suddenly, is more often at night, the hypochondrium with irradiation in a waist on the right, the right shoulder and a shovel, the right half of a neck and the person is shown by sharp colicy pains in right. Pain is caused by the convulsive reductions of a bubble caused by obturation of a vesical channel a stone, inflammatory process, cicatricial changes, dyskinesia of a neck of a bubble. Pains are followed by nausea and vomiting, edge, as a rule, does not give relief, sometimes bradycardia and temperature increase. Bol is so strong that patients sometimes faint. Pains can irradiate in the left half of a thorax and be followed by arrhythmia (a so-called holetsistokardialny syndrome). Painful attack at cholecystitis long; it can last of several days to 1 — 2 week. Intensity of pains decreases a little over time; they become constant, stupid, periodically amplifying. In case of developing of acute cholecystitis against the background of chronic the attack of pains within several days can be preceded weight in epigastric area, nausea. The attack of cholecystitis is provoked, as a rule, by an error in a diet, physical or emotsionalny loading.
During the progressing in a gall bladder of inflammatory process there is a fever, temperature increases to 38 — 39 °, the general state worsens, weakness and other symptoms of intoxication appears (see). Acute cholecystitis can be followed by jaundice (see) owing to disturbance of passability of the general bilious channel (obstruction by a stone, hypostasis of a head of a pancreas at a holetsistopan-kreatita), development of a cholangitis (see) or exacerbations of hepatitis (see).
Depending on the nature of inflammatory process the course of acute cholecystitis has the features. So, acute catarral cholecystitis differs in rather high-quality current: quickly pain disappears, temperature is normalized; in some cases the catarrh can pass into purulent. The serious general condition, the expressed temperature reaction, a long pain syndrome are characteristic of purulent phlegmonous cholecystitis. The most severe form of acute cholecystitis is gangrenous cholecystitis. At gangrenous cholecystitis the local pain syndrome can be absent in connection with necrotic process in a wall of a gall bladder and death of its nervous device; at the same time into the forefront symptoms of the general intoxication with the peritoneal phenomena act (see Peritonitis).
Enzymatic cholecystitis begins with typical hepatic colic, after a cut symptoms of intoxication quickly accrue, pains amplify and symptoms of local irritation of a peritoneum — restriction of mobility of an abdominal wall in the field of an arrangement of a gall bladder, a protective muscle tension join. Pains and muscular tension extend then to other departments of an abdominal wall.
Duration of acute cholecystitis is from 2 — 3 weeks up to 2 — 3 months. Acute cholecystitis can be complicated by development of an empyema of a gall bladder (the hypochondrium, fever is shown by dull aches in right, in the field of a projection of a gall bladder tumorous education is palpated), and also bilious peritonitis (see), pancreatitis (see), a cholangitis (see).
At persons of advanced and senile age calculous cholecystitis prevails. The disease often proceeds atypically. The wedge, a picture is characterized by generally dispeptic frustration, pains are a little expressed, Nye's temperatures reaction and changes in blood in some cases do not correspond to intensity of inflammatory process that is connected with age changes of biliary tract (an atony, decrease in concentration and sokratitelny function of a gall bladder), decrease in reactivity of an organism. The originality of a course of cholecystitis at this age is defined by its frequent combination to pathology of other digestive organs and cardiovascular system that can shade symptoms of cholecystitis; in some cases even at development of bilious peritonitis the wedge, a picture happens erased.
Acute cholecystitis occurs at children quite often; in most cases he is not tracing-paper-leznym. The wedge, picture is characterized by increase in a liver, the phenomena of an acute abdomen — swelling, morbidity at a palpadiya, symptoms of irritation of a peritoneum, etc. (see. Acute abdomen). At children of early age the disease is shown by the general intoxication.
The diagnosis is made on the basis of the anamnesis, complaints of the patient, data of survey and laboratory researches. During the collecting the anamnesis reveal the working conditions contributing to a disease and life (hypodynamia), disturbance of food, associated diseases of digestive organs, hereditary burdeness.
At a palpation of a stomach morbidity in a point of a projection of a gall bladder to a front abdominal wall either more to the right or more to the left since approximately in 20% of cases the gall bladder is located atypically is noted. Come to light positive with it and they are
Fig. 1. Echogram at calculous cholecystitis: 1 — a wall of a gall bladder; 2 — a cavity of a bubble; 3 — the okhostruktura formed by a stone.,
we Kerr (strengthening of morbidity at a palpation during a breath), Murphy (the patient cannot deeply sigh because of the pain arising at immersion of fingers investigating in the right hypochondrium liver edges), Ortner (pain at easy effleurage on the right costal arch an edge of a palm), frenikus - simp - volume (morbidity during the pressing in the field of an attachment to a clavicle grudino - a clavicular and mastoidal muscle on the right) are lower, than Boas — Svirsky (morbidity during the pressing on acanthas of the IX—XII chest vertebrae or at effleurage by an edge of a brush in this area). Tension of muscles at a palpation of a stomach in the field of the right hypochondrium is noted. At development of an edema or empyema (see. The gall bladder) is observed significant increase in a gall bladder; its bottom quite clearly acts from under a liver edge, is available to a palpation. At destructive, enzymatic cholecystitis and perforation of a gall bladder symptoms of irritation of a peritoneum appear. In blood the moderated or expressed leukocytosis, a deviation to the left, the accelerated ROE is often noted.
From tool methods of a research at acute cholecystitis apply the ultrasound examination of a gall bladder, liver and pancreas (see. Ultrasonic diagnosis) allowing to reveal hypostasis, deformation of a gall bladder, existence of concrements (fig. 1), to define a condition of channels, a liver and a pancreas, and a computer tomography (see the Tomography computer). Use rentgenol. methods of a research (the cholecystography, a ho-langiografiya, retrograde ho to l an angiography) and duodenal sounding at acute cholecystitis it is contraindicated.
Differential d the news agency of ii about z at acute cholecystitis should be carried out with appendicitis (see), considering that perhaps atypical arrangement of a worm-shaped shoot (above an ileal bone), with a perforated ulcer of a duodenum (see. A peptic ulcer), right-hand pneumonia (see) and pleurisy (see), subphrenic abscess (see), vnutripe-chenochny abscess (see the Liver), and also with a myocardial infarction (see).
Always it is necessary to remember a myocardial infarction also because it is often combined with diseases of bilious ways.
Differential diagnosis is based taking into account the anamnesis and data of careful inspection of the patient. So, at an acute appendicitis of pain arise in epigastric area, but in the subsequent, as a rule, are localized and concentrate in the right half of a stomach, have no irradiation, characteristic of cholecystitis, to the area of a right shoulder-blade and supraclavicular area; strengthening of morbidity in the right half of a stomach at a palpation of the left ileal area (a symptom of Rovsinga) is noted.
The perforated ulcer of a duodenum is confirmed by the burdened anamnesis, absence at percussion of hepatic dullness, and also identification on the survey roentgenogram of an abdominal cavity of gas under the right dome of a diaphragm in vertical position of the patient.
Cough, the thorax pain connected, as a rule, with cough and the respiratory movements are characteristic of pneumonia and pleurisy. At diagnosis consider these percussions, auscultations, and also results rentgenol. researches of a thorax.
Differential diagnosis of cholecystitis with subphrenic and intra hepatic abscesses is based on data rentgenol. is-ledovaniye of a thorax, and also ultrasonic investigation.
The myocardial infarction is diagnosed on the basis of data of an electrocardiographic research.
In doubtful cases it is necessary to resort to a laparoscopy (see P eritoneoskopiya).
Treatment. Patients with acute cholecystitis shall be hospitalized in surgical department. At destructive forms of inflammatory process (phlegmonous, gangrenous), and also at development of peritonitis the emergency operative measure is shown.
At rather easy course of acute cholecystitis (a catarral form) carry out conservative treatment in the beginning. The patient appoint a bed rest, within 1 — 2 days — hunger, then fractional (4 — 6 times a day) food, a sparing diet (boiled meat and fish, boiled vegetables, a steam proteinaceous omelet, cottage cheese, porridge, broths of a dogrose, blackcurrant, fruit juice, baked apples), antibiotics of a broad spectrum of activity or (at their intolerance or nonsensitivity of the activator to them) — streptocides, spasmolytic, sedatives, at the expressed pain syndrome — perinephric novocainic blockade (see) or intradermal administration of novocaine in a painful zone. In case of inefficiency of conservative treatment and lack of improvement in a condition of the patient in 24 — 72 hours after receipt in a hospital make urgent operation. V. I. Struchkov and A. V. Grigoryan (1976) note that according to the emergency and urgent indications it is necessary to operate apprx. 26% of the patients who came to surgical department concerning acute cholecystitis. At the solution of a question of operation in an acute stage of a disease existence or lack of stones in a gall bladder, and also number of the previous attacks are not taken into account. Need of urgent operation is dictated by degree and prevalence of inflammatory process and existence of an obstacle for outflow of bile. Long waiting tactics at acute cholecystitis cannot be considered justified as often inflammatory process progresses that quite often is followed by destructive changes, formation of subhepatic abscess (see the Liver, pathology) and other purulent complications which are complicating operation, making heavier the postoperative period and increasing number of lethal outcomes in the postoperative period.
An operative measure
is preceded by the intense training of the patient (see. Preoperative period) including performing disintoxication and antibacterial therapy, purpose of anti-spastic means, correction of water and electrolytic balance, prevention of cholemic bleeding, etc. (see. Bilious channels; Gall bladder, operations).
Optimum method of anesthesia is the endotracheal anesthesia (see. Inhalation anesthesia) using muscular relaxants of short action. The section is made parallel to the right costal arch (subcostal), in diagnostically not clear cases use median or pararectal accesses (see the Laparotomy).
More often at cholecystitis make a cholecystectomia (see), the cut yavlya-
etsyatsya by one of indispensable conditions a complex research of bilious channels during operation, including a holangiografiya (see), and if necessary and tool methods — transillumination (see), sounding of channels (see. Bilious heat), a holedokhosko-piya (see) etc. Organ-preserving operations — a cholecystostomy (see), cholecystolithotomy (see Holetsisto-tom iya), a holetsistokholedokhostomiya
at cholecystitis, especially calculous, pathogenetic are unreasonable as they do not remove a cause of illness. However at critical condition of the patient or at impossibility to execute a cholecystectomia it is necessary to resort to a cholecystostomy or cholecystolithotomy in spite of the fact that after these operations, as a rule, recovery does not occur and on elimination of the acute phenomena it is necessary to resort to a repeated operative measure. At the cholecystitis complicated by a choledocholithiasis, a stricture of a faterov of a nipple, a cholangitis, perikholedokhealny lymphadenitis, bilious fistula, etc. along with removal of a gall bladder during operation eliminate an obstacle to outflow of bile or make correction of disturbances of extrahepatic bilious channels. For this purpose according to indications make a choledocholititomy (see the Choledochotomy) with sewing up tightly of an opening in a channel or drainage (see) the last by means of the T-shaped tube or through a stump of a vesical channel, and also choledochoduodenostomy (see) or enterostomy (imposing of an anastomosis between the general bilious channel and a jejunum) with switching off of a segment of a jejunum across Ru or Brown, a transduodenal papilloto-miya, a papillosfinkterotomiya or a papillosfinkteroplastika (see the Duodenum, the Veil ditch of pacifiers). The section of the stenosed site of a faterov of a nipple can be carried out endoscopic by means of a special fibroduo-denoskogkh that is especially shown to patients of advanced and senile age, the state to-rykh can be burdened by associated diseases of cardiovascular system, easy and other bodies. At such patients band operation (a transduodenal papillosfinkteroto-miya) is connected with big risk.
The complications which are found at a cholecystectomia in most cases arise at wrong bandaging instead of a vesical channel and an artery of other channels or vessels or elements of a pechenochnoduodenalny sheaf, and also at damages or crossing of a hepatic or general bilious channel, a hepatic artery, portal vein. Their damages during operation are usually connected with anomalies of development of bilious ways and vessels of this area; they are extremely dangerous since they can be the reason of bilious peritonitis, obturatsion-ache jaundices, a necrosis of a liver and therefore demand an urgent operative measure. Treat surgical mistakes also undetected during operation a choledocholithiasis, strictures of a faterov of a nipple, incomplete removal of a gall bladder, a long stump of a vesical channel with the concrements which remained in it.
After operation for cholecystitis of the patient it is necessary to place in intensive care unit or chamber of an intensive care. The main objectives of the early postoperative period are: full removal from an anesthesia, maintenance of cordial activity and blood circulation, function of external respiration, correction of disturbance of electrolytic balance, etc. (see. Postoperative period). At a favorable current postoperative for about 2 periods —
the 3rd days of the patient transfer to the general chamber, allow to rise and go; the control drainage in the absence of separated is deleted from an abdominal cavity on 2 — the 3rd days, seams are removed for the 7th days, patients are written out from a hospital on 9 — the 10th day. At the complicated cholecystitis (a choledocholithiasis, a cholangitis, strictures of bilious channels, etc.) or the complications arising in time or after operation carry out the corresponding treatment.
The postoperative lethality at uncomplicated cholecystitis, according to B. V. Petrovsky and O. B. Milonov (1982), makes 0,5%, and at complicated — 1,7%.
Patients of advanced and senile age, components, according to
V. S. Mayat and sotr. (1976), a half of all patients with acute cholecystitis, shall draw special attention of doctors. At this contingent of patients considerably the destructive forms of cholecystitis proceeding quite often without expressed a wedge, manifestations, and also the complications (a choledocholithiasis, a cholangitis, internal bilious fistulas, mechanical jaundice, hepatitis, pancreatitis, etc.) which are often caused long (for many years) the course of a disease meet more often. Most of patients of advanced and senile age have, besides, serious associated diseases of a cardiovascular sistekhma and lungs, a diabetes mellitus, etc. that considerably burdens the course of acute cholecystitis and increases risk of an operative measure. The postoperative lethality among persons of advanced and senile age is 8 — 10 times higher, than at other patients. Therefore before the immediate and urgent surgery by the patient of advanced and senile age especially thorough preoperative training including elimination of intoxication, correction of water-salt balance, and also the actions directed to normalization of cardiovascular activity, the prevention of tromboembolic episodes, hepatonephric insufficiency, disturbances of external respiration and treatment of associated diseases is necessary.
Due to the increased risk of operation at height of an attack at patients of advanced and senile age with associated diseases the transparietal decompressive puncture of a gall bladder which is carried out through tissue of a liver or an epiploon under control of a laparoskop can be in some cases undertaken (see Perito-neoskopiya). At the same time delete the liquid infected contents of a gall bladder and enter the mix consisting of antibiotics of a broad spectrum of activity and corticosteroids that leads to bystry subsiding of an acute inflammation into his cavity. In nek-ry cases in a cavity of a gall bladder temporarily leave a thin drainage (a micro cholecystostomy). At the same time carry out laparoscopic hole-tsistokhol the angiography (see Holan-giografiya) allowing to conduct the most informative research of bilious ways extremely important for definition of indications to the subsequent operative measure. At the choledocholithiasis (especially in the presence of the driven stone of a faterov of a nipple) complicated by obtu-ratsionny jaundice, method of the choice at the patients of advanced and senile age who are in a serious condition papillotom I promoting a decompression of biliary tract and release of the general bilious channel from stones am endoscopic. Sometimes for the purpose of a decompression carry out endoscopic nazobiliarny drainage (into the general bilious canal through fater of pacifiers by means of the endofiberscope enter a stylet, to-ry then move from an oral cavity to a nasal cavity).
In case of bystry subsiding of acute process against the background of conservative therapy by all patient with acute cholecystitis it is necessary to make clinical laboratory and rentgenol. research (holetsistokholangiografiya). At identification at patients of their calculous cholecystitis it is necessary to operate in 2 — 3 weeks, without writing out from a hospital (early planned operation), or in a condition of full remission, 4 — 6 months later after an attack. Operation in the «cold» period of a disease is preferable since it is followed by smaller number of complications during operation and in the postoperative period, and also lower (by 5 — 6 times) a lethality in comparison with the immediate and urgent surgeries.
Timely made operation allows to achieve an absolute recovery of patients and to avoid complications from other bodies went. - kish. path.
The forecast of acute cholecystitis depends on a form of a disease and timeliness of treatment. So, at catarral cholecystitis early the begun treatment can lead to recovery, however more often the disease accepts hron. character. At acute purulent cholecystitis (phlegmonous, gangrenous) in case of lack of complications from a liver, a pancreas and bilious channels after a timely operative measure the forecast is more often favorable.
The forecast of acute purulent cholecystitis at patients with associated diseases of cardiovascular system, hron. diseases of lungs, kidneys, etc., at elderly people, and also at accession of complications serious.
Prevention comes down to healthy nutrition and the mode, fight against an adynamia, obesity, locks, diseases of abdominal organs.
Hron. cholecystitis can independently arise or be an outcome of acute cholecystitis. He is calculous and not tracing-paper-leznym. Definition of a form of a disease has great practical value at the choice of tactics of treatment of the patient.
Pathological anatomy. Hron. cholecystitis can be catarral and purulent. At hron. catarral cholecystitis the wall of a gall bladder dense, sclerosed, is noted a mucosal atrophy and a hypertrophy of a muscular layer. Microscopically under an epithelium the numerous macrophages containing cholesterol, and also limfoplazmotsitarny infiltrates in the sclerosed stroma come to light. At a recurrence of a disease the plethora of vessels, hypostasis of a wall of a gall bladder and infiltration its polymorphic poison is observed by rny leukocytes. In some cases macroscopically reveal the thickening and polipovidny changes of folds of a mucous membrane with diffusion infiltration of walls lipids creating its characteristic mesh structure. Microscopically the epithelium on certain sites is absent, on others — expands with formation of small polyps. In a stroma and a submucosal layer a large number of ksantomny cells is noted (see the Xanthoma).
At hron. purulent cholecystitis process covers all layers of a wall of a gall bladder that leads to its sklerozirovaniye. In the thickness of a wall the pseudo-diverticulums and abscesses which are sources of repeated aggravations of process are formed of Rokitansky's sine — Ashoffa. The mucous membrane of an atrofichn, is thickened, under it among tyazhy fibrous fabric and hypertrophied muscle fibers inflammatory infiltrates are defined, on its surface ulcerations appear. A mucous membrane ulcers are filled with granulyatsionny fabric, cicatrize and in the subsequent are epithelized at the expense of the remained cells of the courses of Lushki. The last expand, branch, reach a subserous layer; part of them is kistozno expanded, filled with mucin. Adenomatous structures occur among granulyatsionny fabric. Places in the thickness of a wall lay salts of calcium, to-rye in rare instances can inlay all gall bladder. Gradually there is a deformation of a gall bladder, formation of commissures to the next bodies (pericholecystitis). The serous cover in places, free from commissures, has an appearance of glaze. As a result of these changes the gall bladder loses the functions, turns into the center hron. infections. In far come cases it represents the sclerosed deformed bag filled with concrements and pus. Microscopically in a wall of a gall bladder the expressed sclerous changes are noted, and also sites limfoplazmotsitar-ache infiltrations with impurity of macrophages and eosinophilic granulocytes. Sometimes lymphoid follicles meet the light centers of reproduction.
Macrodrugs of a gall bladder at chronic calculous cholecystitis — see tsvetn. tab., Art. 48, fig. 11, 12, 13.
Inflammatory process in a gall bladder at hron. cholecystitis can be followed by various complications both from a sakhmy gall bladder, and from surrounding bodies. At perforation of a wall of a gall bladder diffuse bilious peritonitis develops. Obturation of a vesical channel a stone, less often adenomatous growths at cervical not calculous cholecystitis can lead to an edema of a gall bladder, at a cut the bubble is intense and filled with «white bile». At activation of inflammatory process the empyema of a gall bladder can develop (its gleam contains bile with pus). Long finding of concrements in a gleam of a bubble can cause decubitus of its wall and development of internal bilious fistula (see. Bilious fistulas), at Krom there is a message of a gall bladder with other hollow bodies (a cross colon, a duodenum, a stomach). At an aggravation of process formation of paravezikulyar-ny subhepatic, subphrenic abscesses is possible, at break of abscess through a front abdominal wall outside bilious fistula can be formed.
Because the gall bladder is in anatomic and physiological communication with a liver, bilious channels and a pancreas, isolated hron. cholecystitis is observed seldom. Inflammatory process can extend to bilious canals with development of holetsistoangiokho-litas (angiocholecystitis), to a liver with development of reactive hepatitis, and in some cases and biliary cirrhosis. In a pancreas there can be toxic hypostasis, a focal necrosis, hron. intersticial pancreatitis with transition to fibrosis. It is caused by a pankre-atobiliarny reflux (see) as a result of a cholestasia, and also lymphogenous spread of an infection on tissue of a pancreas. At hit of the infected bile the acute hemorrhagic necrosis of a pancreas can develop in a pancreat duct (at lymphogenous spread of an infection inflammatory process in a pancreas carries hron. character).
Seldom the specific inflammation of a gall bladder develops. Tuberculosis of a gall bladder (see Tuberculosis extra pulmonary) is characterized by emergence in its wall of miliary hillocks and large nodes with the centers of a tyromatosis, on site to-rykh in the subsequent ulcers are formed. At tertiary syphilis (see) in a wall of a gall bladder gummas can be found.
Clinical picture. At hron. cholecystitis of the patient the long time feels bitterness in a mouth, moderate morbidity or feeling of weight in the field of the right hypochondrium. Intensity of pains depends on degree and duration of inflammatory process in a gall bladder (existence of a pericholecystitis) and the accompanying dyskinesia. At the accompanying dyskinesia on hypotonic type (see
Fig. 2. The survey roentgenogram of the right hypochondrium at calculous cholecystitis: are visible theine of X-ray contrast concrements.
Fig. 3. Obzorna?, the roentgenogram of the right hypochondrium at cholecystitis: the ring-shaped shadow formed by calciphied walls of a gall bladder (it is specified by an arrow).
Fig. 4. Holetsisto-gramma at calculous cholecystitis:
a shadow of a gall bladder with the defects of filling caused by stones (are specified arrows by us).
Fig. 5. Holetsisto-gramma at not calculous cholecystitis:
a shadow of the deformed gall bladder with the banners in his body and a neck caused by a pericholecystitis (are specified by shooters).
Gall bladder, pathology) pain insignificant, monotonous, constant; at the accompanying dyskinesia on hypertensive type — sharp, pristupoobrazny, reminding bilious colic. At a pericholecystitis pain differs in constancy and is connected with change of position of a body. Pains irradiate to the right lumbar area, the right shoulder and a shovel, irradiation of pains to the left, to the area of heart is sometimes noted. Patients complain of dispeptic frustration (an eructation, nausea, vomiting). Temperature can increase to subfebrile, is more rare — to higher figures.
Hron. cholecystitis proceeds with the periodic aggravations which are followed by strengthening of the symptoms described above. Aggravations more often happen are caused by errors in a diet, an excessive exercise stress, acute inflammatory diseases of other bodies. Hron. cholecystitis proceeds is good-quality more often. Depending on features of a current allocate the latent and recuring forms of a disease.
The diagnosis is established on the basis of the anamnesis, a wedge. pictures, data of laboratory, radiological and tool researches. At survey the same symptoms come to light, as at acute cholecystitis (see above Acute cholecystitis), but less expressed.
In blood there can be an insignificant leukocytosis, small acceleration of ROE, in some cases the unstable urobilinuria is noted (see). During the involvement in process of a pancreas find an amylorrhea, a creatorrhea (see Kal), a steatorrhea (see).
By rather informative and widely available method of laboratory diagnosis at nekalkulez-number hron. cholecystitis, to-ry it is possible to carry out both in a hospital, and in the conditions of policlinic, yavlya-
the research of bile by chromatic fractional duodenal sounding etsyatsya. Advantage of this method before usual (not chromatic) duodenal sounding (see) consists in coloring of a vesical portion of bile (a portion In) in blue color that allows to distinguish this portion from others. Chromatic fractional duodenal sounding allows to determine precisely time of allocation and amount of bile in different portions; it gives the chance more accurately to diagnose the accompanying hypotonic or hypertensive dyskinesia. So, if normal the gall bladder usually contains 30 — 50 ml of bile, then at hron. the cholecystitis which is combined with hypotonic dyskinesia in a gall bladder about 150 — 200 ml of bile and more accumulate, and it is allocated much more slowly, than normal. Chromatic fractional duodenal sounding is carried out according to the practical standard, but previously for 12 hours prior to a procedure of the patient takes in 0,15 — 0,3 g methylene blue in the gelatin or starched capsule. Often even at repeated sounding the portion In bile is not received that can be connected with an obliteration or wrinkling of a gall bladder and is a sign hron. cholecystitis. The portion In does not manage to be received also at a pericholecystitis in connection with disturbance of sokratitelny ability of a gall bladder. Microscopic examination of bile allows to find in it accumulation of cells of a cylindrical epithelium, slime, crystals of bilirubinate of calcium, cholesterol, and sometimes and parasites. At bacterial. a research for crops it is necessary to take bile separately from different portions. More often at hron. cholecystitis reveal the mixed collibacillary and coccal microflora. In process of development of inflammatory process in bile contents cholic to - you goes down, bilirubin, a lipoprotein complex, the holatokholesterinovy index changes.
Final diagnosis hron. cholecystitis establish after carrying out rentgenol. and tool inspections. By important method of a research at hron. ho-
to a letsistita is radiological. It is necessary to begin inspection with a survey X-ray analysis (see) areas of the right hypochondrium, at a cut it is possible to find shadows of X-ray contrast stones (fig. 2) or calcification of walls of a gall bladder (fig. 3). After that make the cholecystography (see) or the combined holetsistokholangiografiya, allowing to establish existence in a gall bladder of stones that is shown by defect of filling (fig. 4), and also to reveal deformation of a gall bladder (fig. 5) and disturbance of its function at not calculous cholecystitis. Define a condition of a wall of a bubble, existence in it of concrements, and also sokratitelny ability of a gall bladder by ultrasonic investigation. Gain ground a method of a radio isotope research of a gall bladder (see fig. 12 and 13 to St. Gall bladder, t. 8., p. 190 — 191), and also the computer tomography of a liver, gall bladder (fig. 6) and a pancreas, to-rye are applied first of all at patients with jaundice and at persons, the Crimea contraindicated (e.g., in connection with an allergy) usual rentgenol. research. At patients with jaundice and (or) at intolerance of a contrast agent (at its intravenous administration) it is possible to make a retrograde holangiografiya for specification of the diagnosis (see) during a fibroduodenoskopiya. It gives the chance to receive the direct contrasting of a gall bladder allowing to reveal its deformation (fig. 7) and disturbance of outflow of bile at not calculous cholecystitis at calculous cholecystitis — concrements in a gleam of a gall bladder, and sometimes in the general bilious channel.
Differential diagnosis. Chronic cholecystitis should be differentiated with a peptic ulcer, hron. inflammatory diseases of urinary tract and large intestine. Differential diagnosis between hron. carry out by cholecystitis and a peptic ulcer on the basis of features of a pain syndrome, seasonality of aggravations, data of radiological and endoscopic researches (see. Peptic ulcer).
At hron. diseases to urine of the removing ways of pain
irradiate to the inguinal area, the dysuric phenomena, changes in urine are noted. Hron. inflammatory diseases of intestines are excluded on the basis of data of a X-ray and endoscopic inspection (see Colitis).
Treatment. Hron. calculous cholecystitis and the complicated forms hron. not calculous cholecystitis are subject to operational treatment (see Cholelithiasis, the Cholecystectomia). Conservatively uncomplicated forms of not calculous cholecystitis and an aggravation of other forms hron treat. cholecystitis when the patient refuses flatly operational treatment or carrying out it is impossible because of the heavy accompanying zabolevayaiya.
Fig. 6. The computer tomogram of a trunk at the level I of a lumbar vertebra at not calculous cholecystitis: / — gall bladder; 2 — commissure of a gall bladder e an abdominal wall; 3 — a liver; 4 — a right kidney; 5 — a left kidney; 6 — a vertebra; 7 — longitudinal muscles of a back.
Conservative actions are directed to elimination of inflammatory process, fight against stagnation of bile and dyskinesia of bilious ways. The patient appoint bed or on the lupostelny mode, fractional food, a sparing diet (see above Acute cholecystitis), to-ruyu expand at improvement of health in 2 weeks, anti-inflammatory drugs (antibiotics or streptocides) during 2 — 3 weeks.
Use of cholagogue means depends on type of the accompanying dyskinesia. At dyskinesia on hypotonic type holetsis-tokinetik — magnesium sulfate, the Karlovy Vary salt, luccu oil, hypophysin, sorbite, xylitol, etc. are shown. At dyskinesia on hypertensive type it is reasonable to apply choleretics (Cholagolum, Cholosasum), and and also antispasmodics (atropine, drugs of a belladonna, Nospanum, Platyphyllinum, etc.). At difficulty in definition like dyskinesia, and also in cases of the mixed diskineziya recommend the cholagogue means of a plant origin (broth corn a rylets, a dogrose, etc.) possessing combined (more hole-retichesky) moderate effect.
Fig. 7. Retrograde holangiokholetsisto-gram at not calculous cholecystitis:
1 — the extended narrow gall bladder with the expressed deformation of his neck; 2 — the general hepatic channel; 3 — a vesical channel; 4 — the general bilious channel; 5 — a contrast agent in a duodenum; 6 — the distal end of a gastro-duodenoskop.
At a combination of cholecystitis to dyskinesia on hypertensive type recommend also sedatives (drugs of a valerian, motherwort, bromine, etc.). In case of involvement in patol. process of a pancreas in a complex to lay down. actions include fermental therapy (see Pancreatitis).
At hron. not calculous cholecystitis with a persistent current and existence at the patient of allergic reactions antihistamines (Dimedrol, Suprastinum, etc.), in case of immune insufficiency — levamisole are recommended.
Effective at hron. cholecystitis duodenal sounding or tubeless tyubazh (see), and also balneotherapy is. At dyskinesia on hypotonic type appoint alkaline waters with a high mineralization (Yessentuki No. 17, Arzni, Batalinskaya), at dyskinesia on hypertensive type — the warmed-up mineral water with smaller salt content and lower gas content (Yessentuki No. 4, No. 20, Slavyanovsky, Smirnovsky, Zheleznovodsk). At purpose of mineral water it is necessary to consider a condition of secretory function of a stomach.
Physiotherapeutic procedures are shown at hron. cholecystitis out of an aggravation. Are most effective: a diathermy (see), an inductothermy (see), UVCh (see UVCh-therapy), ultrasound (see. Ultrasonic therapy;), mud, ozokeritovy or paraffin applications on area of a gall bladder (see Mud cure, Ozokerite about treatment, the Paraffin therapy), radonic and hydrosulphuric bathtubs (see Bathtubs, Radon waters, Sulfide waters).
In a stage of remission by the patient it is reasonable to appoint a dignity. - hens. treatment in the resorts of Yessentuki, Borjomi, Zheleznovodsk, Truskavets, the Pestilence tires, Dorokhovo, etc.
Treatment hron. cholecystitis long. Patients shall be under dispensary observation. For the prevention of aggravations by it appoint a diet, the sparing mode of work, carry out sanitation of the centers hron. infections, and also 2 — 3 times a year preventive protivore-tsidivny treatment.
Forecast, as a rule, favorable.
Prevention consists in healthy nutrition and the mode, fight against an adynamia, obesity, diseases of abdominal organs, in timely and correct treatment of acute cholecystitis.
See also Cholelithiasis. Bibliography: Akopyan V. G. Surgical hepathology of children's age, page 230, M., 1982; And N and h to about in N. N. and 3 and x and r-evskaya M. A. Experimental and morphological researches about the ascending infection of zhelcheotvodyashchy system and a liver, Arkh. biol. sciences, t. 49, century 3, page 55, t. 50, century 2, page 37, 1938; Diseases of digestive organs, under the editorship of Ts. G. Masevich and
S. M. Ryss, page 529, JI., 1975;
Galkin V. A. Cholecystitis, M., 1973;
Galkin V. A., Lindenbratenl. And Loginov A. S. Recognition and treatment of cholecystitis, M., 1973; Gubergrits
A. Ya. Diseases of bilious ways, M., 1963; Davydovsky I. V. Pathological anatomy and pathogeny of diseases of the person, t. 2, page 319, M., 1958; D e d e r e r Yu. M., To r y l about in and N. P. and At with t and N about in G. G. Cholelithiasis, M., 1983; And to about N of N and to about in P. S. K to a question of inflammatory diseases of a gall bladder, a yew., SPb., 1906; L both d with to and y A. T. Symptomatic diagnosis of surgical diseases, page 83, M., 1973; The Urgent surgery, under the editorship of N. I. Blinova and B. M. Khromov, page 257, L., 1970; N of ides e r l e B., etc. Surgery of bilious ways, the lane from Czeches., Prague, 1982; Acute cholecystitis, under the editorship of G. D. Shushkov, L., 1966; P e t r about in N. N. and To a rotka on N. A. Experimental data about relationship of stones and cancer of a gall bladder, Vopr. onkol., t. 1, book 2, page 89, 1928; With to at I N. A. Diseases of a holangio-duo-deno-pancreatic zone, Riga, 1981; Strukova. And. and Serov V. V. Pathological anatomy, page 317, M., 1979; Sh and and to T. V. Enzymatic cholecystitises, L., 1974; Diseases of the liver, ed. by L. Schiff a. E. R. Schiff, Philadelphia, 1982; SherlockSh. Diseases of the liver and biliary system, Oxford a. o., 1975.,
V. A. Galkin, A. D. Timoshin;
O. B. Milonov (operational treatment), N. K. Permyakov, G. M. Mogilevsky
(stalemate. An.), N. N. Petrovichev (experimental cholecystitis).,