CHOLELITHIASIS

From Big Medical Encyclopedia

CHOLELITHIASIS (cholelithiasis; synonym: kalkulez, calculous cholecystitis) — the disease caused by education and existence of concrements in a gall bladder and in bilious channels.

For the first time gallstones (see) at the person Gentile da Foligno described in 14 century. The detailed description of gallstones and wedge, pictures of the disease caused by them were submitted in 1760 by J. Morganyi. In 1814 Mr. Shevrel (M. of E. Chevreul) investigated and called cholesterol substance, from to-rogo gallstones consist. Bouchard (Ch. Bouchard) in 1882 found influence of the slowed-down metabolism and constitutional factor on development. 10 years later B. Naunin put forward the infectious theory of an origin of gallstones though in 1856 Gemsbakh (Meckel v. Hemsbach) connected process of a lithogenesis with an inflammation of a gall bladder. According to the existing theories products of an inflammation — slime, layers of an epithelium, etc. are a basis for aggregation of components of bile and formation of gallstones. In 1885

B. V. Pashutin explained formation of gallstones with high content in bile of almost insoluble cholesterol and trace amount of the substances holding it in solution. L. Ashoff and A. Bacmeister in 1909 established a role of stagnation of bile in the course of a lithogenesis. Researches of Russian surgeons of C. P. Fedorova and A. V. Martynov, therapists M. P. Konchalovsky and A. L. Myasnikov made the significant contribution to development of representations about

. is a widespread disease though the characteristic of true incidence is extremely difficult because at considerable number of people the disease proceeds latentno. Pathoanatomical data are reliable: stones in bilious ways, on the researches I. Magyar, find in 10 — 20% of all openings in Europe. After 40-year age this indicator reaches 25%, and after 70 years — 50%. According to the majority of statistical reviews. occurs at women more often than at men. Aged up to 20 years gallstones are formed seldom.

== Etiology and pathogeny ==. — polyetiological disease. Interaction of such factors as genetic predisposition, irrational food, disbolism, infection, staz bile, etc., is premises for change physical. - chemical properties of bile — a diskholiya, at a cut bile (see) becomes litogenny, i.e. capable to formation of stones.

Normal hepatic bile can get a litogennost in a gall bladder (a cholecystogenic diskholiya) or becomes temporary regular hepatoenteric circulation of the main components of bile, litogenny owing to disturbance. At the same time the so-called holato-cholesteric index — a ratio between the content in bile decreases bile acids (see) and cholesterol (see). Cholesterol is water-insoluble and in bile keeps only thanks to the bile acids having big superficial activity and lecithin. At a shortcoming bilious to - t cholesterol drops out in a deposit, giving rise to formation of stones. There is an opinion that at. the liver produces litogenny bile (a hepatic diskholiya). According to many authors, electrophoretic definition of a macromolecular (lipidic) complex of bile in comparison with norm revealed decrease in indicators both in hepatic, and in vesical bile at. Besides, it is revealed that at. activity of hydroxy-3-methylglutaryl-CoA-reductase — the enzyme participating in synthesis of cholesterol in a liver is increased, and activity 7 - the alpha hydroxylase participating in synthesis bilious to - t, reduced. At a part of patients existence of cholesteric stones is caused by diseases of a gall bladder, went. - kish. path. Pavel (I. Pavel, 1962) early stage. considers disorder of allocation and absorption of substances a wall of a gall bladder. N. A. Skuya in 1966, 1972 established a role of local allergization of a wall of a gall bladder (a collibacillary and autoimmune origin) in development of a dyscrinism, cholecystogenic diskholiya and lithogenesis. The last is promoted also by an infection of a gall bladder, stagnation of bile and disorder of exchange of cholesterol. In formation of gallstones factors of food are important: irregular food, high caloric content of food, use of products rich with cholesterol. In 10 — 27% of cases. in a gall bladder the pigmental stones consisting generally of bilirubinate of calcium are found. In bile and to its sedimentation leads the strengthened hemolysis at a hemolitic disease, repeated hemotransfusions to increase in amount of bilirubin, etc. The enzyme beta glucuronidase (a bacterial, hepatic origin) which is emitted with a mucous membrane of a gall bladder hydrolyzes a glucuronide of bilirubin. The bilirubinate of calcium serving as the center of an apresation and formation of stones that is promoted also staz to bile and by an infection (see is formed of free bilirubin and calcium of bile. Gallstones ).

One of the first pilot models of calculous cholecystitis was created by P. S. Ikonnikov in 1915; as a result of bandaging of a vesical channel at dogs with introduction to a cavity of a bubble of colibacillus and other microbes purulent cholecystitis developed, and in 3 — 4 months gallstones were formed. Other researchers used various methods: using the infectious agent (V. A. Galkin, A.S. Chechulin, 1960; V. V. Silakova, R. K. Marchenko, 1962); with dysfunction of a sphincter of the general bilious channel (Oddi's sphincter) (H. H. Anichkov, M. A. Zakharyevskaya, 1938); with creation of aseptic stagnation of bile (D. A. Brusilovskaya, 1948); with introduction to a cavity of a gall bladder of a foreign body [P. Rous and soavt., 1924]; with disturbance of an innervation of a gall bladder (V. A. Ivanov, M. N. Molodenkov, 1964); with feeding (hamsters) cholesterol [Teppermen (1965)]; using defective food etc. All developed models Zh. it is impossible to consider satisfactory because modeling of diseases with slow development and a various origin is extremely difficult.

Pathological anatomy

Fig. 1. Microdrug of a wall of a gall bladder at cholelithiasis: deep epithelial intussusceptums — the «Lushki's courses» (1) reaching a muscular layer (2), below a fragment of the same drug at bigger increase.

Pathoanatomical changes at. are connected with the processes leading to education gallstones (see), existence them in a gall bladder and bilious channels, and also with migration of stones on system of bile-excreting channels and their obstruction (see. Bilious channels , Gall bladder , Cholecystitis ).

Fig. 2. Microdrug of a muscular layer of a wall of a gall bladder at cholelithiasis: and — crystal structures of cholesterol (are specified by shooters) in the thickness of a muscular layer; — multinucleate colossal cells (are specified by shooters) in the thickness of a muscular layer.

I. V. Davydovsky considered characteristic for. emergence of the so-called courses of Lushki — growth of unstriated muscles and mucous glands of a gall bladder (fig. 1). The courses are covered by a prismatic epithelium, reach a muscular coat and a subserous basis of a bubble, promote penetration of an infection and are, according to some authors, the reason of a lithogenesis. Another morfol, sign. existence of intraparietal cholesteric granulomas is. They arise owing to ulcer and necrotic defeats of walls of a gall bladder and penetration into a muscular coat of bile, cover components in process reparations (see) are immured by fibrous fabric in the thickness of a muscular layer. Cholesterol of bile crystallizes and rezorbirutsya by multinucleate colossal cells (fig. 2) found in large numbers in granulomas. Granulomas are localized, as a rule, in a body and a neck of a gall bladder.

Clinical picture

by fig. 4 — the Opened gall bladder filled with stones: a single cholesteric and pigmental stone in the narrowed cavity of a gall bladder — the wall of a bubble is thickened, on an inner surface — decubituses (are specified by shooters)
fig. 5 — the Opened gall bladder filled with stones: small fasetirovanny cholesteric and pigmental stones
fig. 6 — the Opened gall bladder filled with stones: the large mixed stones.

Wedge, manifestations. are extremely various in this connection conditionally distinguish the following a wedge, forms Zh.: painful chronic; dispeptic chronic; bilious (hepatic) colic; other wedge, forms, including latent, so-called anginal, and Seynt's triad.

Painful hron, form Zh. can proceed in the presence of so-called small signs among which dispeptic frustration, an indisposition are usually observed. The dispeptic phenomena (feeling of weight in an anticardium in 1 — 3 hour after food, the abdominal distention, ponosa arising after meal, especially fat) arise periodically. Sometimes there are aching pains in the pit of the stomach and in the field of the right hypochondrium also in connection with food, extending in a back and a right shoulder-blade. In this period at a deep palpation some pain in right hypochondrium is found, painful points are defined (in an anticardium, in a gall bladder, in a pancreatic and bilious and vesical point, in a point of a phrenic nerve, etc.). The diagnosis is specified rentgenol, a research (see. Gall bladder, radiodiagnosis ).

Dispeptic hron, form Zh. in the absence of pains of characteristic localization is followed by the complaints indicating functional disorders of activity went. - kish. a path — heartburn, feeling of weight in the pit of the stomach, an unstable chair, a steatorrhea, a meteorism.

The most typical symptom. — attack of bilious (hepatic) colic. The provocative role in emergence of an attack belongs to negative emotions, consumption of fats, spices, hot spices, sharp physical. to the movements, and also work in inclined situation. At women colic quite often matches periods or comes after the delivery. Pain at., as a rule, arises suddenly, often at night, the hypochondrium is localized in right, is more rare under a xiphoidal shoot or to the right of it with characteristic irradiation in a right shoulder-blade and infrascapular area, a shoulder, a neck, a jaw, frontal area, the right eye. More rare pains irradiate to the left, to the area of heart, provoking an attack of stenocardia. Pain, as a rule, strong, the pricking, tearing apart, cutting character, development of shock is possible. The attack of bilious colic sometimes is followed by repeated vomiting.

During a painful attack the stomach is blown up, the abdominal wall is strained, is sharper in the field of a projection of a gall bladder. At old men and the weakened patients tension can be absent. Sharp morbidity at a palpation is characteristic in right hypochondrium. After subsiding of pain it is possible to probe the increased painful liver, and sometimes and a gall bladder. Skin over area of a gall bladder is painful. Find typical symptoms in many patients: Myuss (morbidity during the pressing between legs right grudino - a clavicular and mastoidal muscle), Ortnera (sharp pain at effleurage by a finger in the right subcostal area or directly on a costal arch). Quite often morbidity in a vesical point (crossing of the right direct muscle of a stomach with a costal arch) comes to light, and also during the pressing under a bottom corner of a right shoulder-blade and on the right at acanthas of the VIII—XI chest vertebrae.

At a research of the patient tachycardia, a priglushennost of cordial tones are quite often noted; more rare — bradycardia, premature ventricular contraction, a cantering rhythm.

Often, even at not complicated infection., bilious colic is followed by bystry and considerable rise in temperature; fever lasts not for long.

Duration of a painful attack at uncomplicated. it is various — of several minutes till several o'clock, and at some patients to 2 days. In most cases after the termination of an attack at a research of a gall bladder and liver it is not possible to establish any deviations and patients feel healthy. Sometimes a nek-swarm time there are a weakness and weakness. In rare instances bilious colic comes to an end with an exit in intestines of a stone (to dia, no more than 1 cm) which can be found in Calais in 1 — 2 days. The termination of an attack can be followed by allocation of plentiful amount of light urine.

Obturation of bile-excreting channels, at a cut bilious colic is the leading symptom, has a number of accessory signs: the gall bladder is filled with bile and becomes available to a palpation. At duodenal sounding (see), carried out out of the period of the expressed pains, it is not possible to receive vesical bile. Obstruction of the general bilious channel is characterized by development jaundices (see), hypercholesterolemia, giperfosfatazemiya. In the presence of a valve stone there is an alternating jaundice with strengthening and weakening of coloring of integuments. It is found hyperbilirubinemia (see), there is a skin itch, and at a long current — the phenomena hemorrhagic diathesis (see).

At obstruction of hepatic channels a wedge, a picture is less characteristic, laboratory and tool researches are small and informative. At accession of an infection temperature increases; in blood — a leukocytosis, ROE accelerates.

The so-called anginal form is observed at elderly people with coronary heart disease and disappears after a cholecystectomia. Seynt's triad — a combination. with phrenic hernia and a divertuculosis of a large intestine (see. Seynta syndrome ).

Current. variously on weight and frequency of attacks., not complicated by an infection and obturation, having shown time by an attack of bilious colic, can never disturb the patient any more though usually attacks repeat: in one cases they follow one by one with small intervals, in others — arise 1 — 2 time a year, sometimes more rare. The wrong way of life and food of the patient, unfavorable conditions of work, existence of negative emotions and other factors can become their reasons. A number of patients can have a spontaneous recovery. after an exit of a small stone in intestines.

Complications

Fig. 3. Scheme of biliary tract: 1 — a gall bladder; 2 — a neck of a gall bladder, 3 — vesical to a channel 4 — the right hepatic channel; 5 — the left hepatic channel; 6 — the general hepatic channel; 7 — the general bilious channel; 8 — a pancreas; 9 — a pancreat duct; 10 — a duodenum of Fig. 3 (norm) it is given for comparison.
Fig. 4. Diagrammatic representation of some complications of cholelithiasis: and — stones in a gall bladder, one stone got stuck in a neck of a gall bladder, the bubble is increased — an edema; — the gall bladder is filled with stones, as a result of an inflammation is wrinkled, does not function as the vesical channel is closed; in — stones in a gall bladder, one stone got stuck in the mouth of the general bilious channel, channels are expanded; — stones in a gall bladder, owing to repeated otkhozhdeniye of stones the output department of the general bilious channel is struck and narrowed, bilious channels are expanded above.

At the big stones located at the bottom of a gall bladder and at infringement of a stone in output department of a bubble decubituses can develop (tsvetn. fig. 4-6) and gangrene of its wall with perforation, bilious peritonitis (see) or subhepatic abscess, internal fistulas. At long obstruction of a neck of a gall bladder there is his edema, and at suppuration of contents — an empyema. Obstruction by a stone of the general bilious channel leads to development of mechanical jaundice. Jaundice arises also after rather rare process — a hepatolithiasis, at Krom stones are formed in hepatic channels and cork them. Repeated or long finding of stones in the general bilious channel involves an inflammation it — a choledochitis. The diagrammatic representation of some options of the complications connected with advance of stones on bilious channels and their obstruction is submitted in the figure 4. Long mechanical jaundice often is followed by a cholangitis and, at last, conducts to secondary biliary to cirrhosis (see). At its long current and especially in the presence of complications. always is followed patol, changes in a liver — reactive hepatitis, more rare by a fatty hepatosis, involvement in patol, process of a pancreas. Against the background of long existence. there can be cancer of a gall bladder.

Diagnosis

Fig. 5. The roentgenogram of area of the right hypochondrium in a direct projection: in a gall bladder shadows of the stones containing lime are visible (are specified by an arrow).
Fig. 6. The roentgenogram of a gall bladder in a direct projection: the large mixed stones (1) in a gall bladder; the slit-like cavities (2) filled with gas in stones.
Fig. 7. Holetsistogramma: multiple stones in the bottom of the contrasted gall bladder.
Fig. 8. Holetsistogramma: multiple «floating» stones in a gall bladder (are specified by an arrow).

Data of the anamnesis, heredity (existence in a family of exchange diseases), outward of the patient (obesity) are of the known diagnostic value.

Laboratory and tool researches include duodenal sounding (see), rentgenol. research of bilious ways, duodenoskopiya (see), biochemical, research of blood serum (definition of bilirubin and its fractions, cholesterol, activity of an alkaline phosphatase etc.), bile and urine.

Rentgenol, the research is directed to identification of gallstones, and also definition of a functional condition of a gall bladder by means of various methods — X-ray analysis (see), tomographies (see), cholecystographies (see), holegrafiya (see), holangiografiya (see), including and during operation.

Gallstones in usual pictures are found only at content of lime in them St. 0,3%. The majority of the mixed stones on the roentgenogram give a shadow in the form of a ring or a polygon, is more rare than the wrong configuration (fig. 5). Sometimes in the center of the mixed stone it is possible to distinguish the slit-like cavity containing gas (fig. 6). Limy (cretaceous) stones give the clear image or in the form of accumulation of a light body in a bubble («limy bile»), or in the form of the heavy body which is partially filling a gall bladder. Cholesteric and pigmental stones poorly absorb x-ray emission, and against the background of limy weight defects of filling can be visible. Multiple small uglekaltsiyevy stones are found in the form of an intensive and heterogeneous shadow. The stones invisible at a usual X-ray analysis come to light during the contrasting of a gall bladder as defects of filling (fig. 7). Cholesteric small Kam at vertical position of the patient form the chain of enlightenments crossing a gall bladder in transverse direction («floating stones» — fig. 8).

If the stone corked a vesical channel, then the shadow of a gall bladder at a holegrafiya does not come to light; in this case it is necessary to make a tomography.

The differential diagnosis

At diskineziya of bilious ways communication of emergence of a pain syndrome with negative emotions is considerably expressed, the abdominal wall during an attack is not strained, results of duodenal sounding without pathology, contrast cholecystography (see) does not reveal concrements.

Irradiation of pains is essential to the differential diagnosis with right-hand renal colic: up — at bilious colic, down (in a leg, in a groin, in generative organs) — at renal; the dysuric phenomena and a hamaturia are characteristic of renal colic (see. Nephrolithiasis ).

Atypical pains at peptic ulcer (see), in particular at an ulcer of a duodenum, differ from. the previous characteristic anamnesis, data rentgenol, researches.

In cases of differentiation with pancreatitis (see) diagnosis facilitate not inherent. a peculiar localization of pains in the left epigastric area, to the left of a navel, with irradiation in a back, in the left part of a backbone, a left shoulder-blade and a shoulder and so-called girdle pains; high content of a diastase in urine is characteristic of acute pancreatitis.

The differential diagnosis with acute appendicitis (see) in most cases does not cause difficulties; in unsoluble cases, at the available signs of a so-called acute abdomen, it is necessary to resort to operation.

Mechanical jaundice at. differs from mechanical jaundice at a bile duct carcinoma and a pancreas in bystry development, communication with a pain syndrome and existence in the anamnesis of bilious colic. Rather slow development of jaundice allows to suspect a tumor. The diagnosis is helped and rentgenol, by a research.

Treatment

Conservative treatment. Rendering the acute therapeutic management at bilious colic is begun with introduction of anti-spastic means (1 ml of 0,1% of solution of sulfate atropine, 1 ml of 0,2% of solution of Platyphyllinum subcutaneously, etc.), according to indications — drugs (2 ml of 1% of solution of Promedolum, etc.). Carry out right-hand or bilateral perinephric blockade (80 — 120 ml of 0,25% or 0,5% of solution of novocaine). Drugs of nitroglycerine are sometimes effective. It is useful warmly: the hot bathtubs, hot-water bottles warming compresses, etc.

In the mezhpristupny period appoint a course of anti-spastic means — atropine, a benzatsin, etc., cholagogue means, mineral waters, thermal physiotherapeutic procedures. At persistent pains carrying out 3 — 5 perinephric novocainic blockade is rational. In early phases Zh. and in the absence of an exacerbation of a disease the resort therapy in local profile sanatoria or in resorts is shown (Borjomi, Dzhermuk, Yessentuki, Zheleznovodsk, Truskavets, etc.).

In the presence of an infection first of all enter antibiotics, as well as at treatment of inflammatory processes of bilious ways, and then hold all complex of events.

Operational treatment is the radical method allowing to achieve recovery of patients. An operative measure is shown at frequent long painful attacks and development of complications (obturatsionny jaundice, an empyema of a gall bladder, a cholangitis, etc.). Contraindications — the expressed cardiovascular and pulmonary insufficiency, heavy changes of internals. The most frequent type of operations at. — cholecystectomia (see), much less often (and according to limited indications) are applied cholecystostomy (see) and a so-called ideal cystifellotomy — removal of a single stone with the subsequent sewing up of a wall of a gall bladder (see. Cystifellotomy ). The cholecystectomia can be combined with removal of gallstones from bilious channels (see. Bilious channels , Gall bladder ) and their drainage on Kerr's way, Vishnevsky, etc. (see. Drainage ). For this purpose usually use choledochotomy (see).

Forecast at uncomplicated forms Zh. and timely treatment favorable. It is less favorable at accession of complications and is defined in each case.

Prevention

For prevention. are important the general gigabyte. mode, systematic physical. work, sports activities, healthy nutrition (the use of vegetables, low-fat, poor in cholesterol and products rich with protein, regular meal), fight against obesity, infections and disturbances of functions went. - kish. path, timely elimination of stagnation of bile, mental retension.



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H. A. Skuya; O. B. Milonov (hir.).

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