GALL BLADDER

From Big Medical Encyclopedia

GALL BLADDER (vesica fellea, PNA, JNA, BNA) — hollow body of the alimentary system, in Krom occurs accumulation of bile, increase in its concentration and from to-rogo intake of bile to the general bilious canal and a duodenum is periodically carried out. Besides. the item regulates and supports on a fixed level pressure of bile in bilious ways.

== Comparative anatomy

==. the item appears at the lowest vertebrata (cyclostomous fishes) at whom division of a liver into two shares and formation of hepatic channels is for the first time noted. At cartilaginous fishes. the item is located in the left hepatic lobe. At higher vertebrata, starting with bony fishes. the item in process of increase in mass of a parenchyma of a liver is displaced knaruzh to portal fissures. At some fishes, birds and mammals (large hoofed animals). the item is reduced and disappears that is compensated by expansion of a hepatic channel. Occasionally (at some predatory, napr, at a lion). the item can be double or divided into two cavities.

Embryology

Fig. 1. The diagrammatic representation of options of the direction of a neck of a gall bladder (it is specified by shooters): 1 — the neck of a bubble is directed up and to the left; 2 — the neck of a bubble is directed up and to the right.

At an embryo of the person bookmark Zh. the item happens on the 4th week of development in the form of an outgrowth epithelial tyazhy, going in the anteroinferior direction from laying of a liver. By the end of the 4th week of development these tyazh merge and form a small sack — primary gall bladder (primordium vesicae felleae). Later in connection with the strengthened growth of epithelial cells there is a reduction, and then and full closing of a cavity of primary. item. On the 5th week of development primary. the item is surrounded with a layer of a mesenchyma from all directions, from a cut its muscular and connective tissue covers, and tissue of a liver form. From the middle of the 6th week of development in primary. items are formed the multiple cavities (a stage of vacuolation) further connecting in a uniform cavity (fig. 1). In the subsequent primary. the item moves to the visceral surface of a liver and on the 7th week of development lies on this surface in a deep furrow. Disturbances of developments. items cause various anomalies of its structure: formation of two. item, underdevelopment and disturbance of a form and situation Zh. item, development of two-chamber. item, etc.

Anatomy

Fig. 1. Gall bladder and its situation on the visceral surface of a liver: 1 — a bottom of a gall bladder; 2 — a vesical channel; 3 — own hepatic artery; 4 — a portal vein; 5 — a gastrohepatic sheaf; 6 — the left hepatic lobe; 7 — a hepatic lobe having a tail; 8 — the lower vena cava; 9 — a shoot having a tail; 10 — a neck of a gall bladder; 11 — the right hepatic lobe; 12 — a body of the gallbladder.
Fig. 2. The diagrammatic representation of options of an arrangement of a gall bladder (the liver and a gall bladder are given in a section): 1 — usual situation in a pole of a gall bladder; 2 — an intra hepatic arrangement; 3 — an extrahepatic arrangement with formation of a mesentery (it is specified by an arrow).
Fig. 3. Diagrammatic representation of ligaments of gall bladder: 1 — a duodenum; 2 — a vesical and colonic sheaf; 3 — a cross colon; 4 — a vesical and duodenal sheaf; 5 — a mesentery of a gall bladder.

. the item is located on the visceral surface of a liver between square and right its shares in a pole. item (fossa vesicae felleae). Usually it has pear-shaped, is more rare conical shape (tsvetn. fig. 1). At patol, states a form Zh. the item can change (a form of hourglasses, a fishing hook, etc.). Length. the item fluctuates within 5 — 14 cm, averaging 6 — 10 cm, width reaches 2,5 — 4 cm, the volume of 30 — 70 ml. Wall. the item easily of a rastyazhim, it can contain up to 200 ml of liquid. Both sizes, and capacity. items considerably change at patol, processes. Anatomically in. the item is distinguished: a bottom (fundus) — its widest part turned kpered, reaching a first line of a liver and sometimes supporting it; a body (corpus vesicae felleae) — its middle part located between a bottom and a neck; and a neck (collum) — the waist. the item, located in the tail of a hepatic pole and passing into the vesical canal. Sometimes the neck forms divertikulopodobny protrusion (Gartman's «pocket»), seldom there are two protrusions. Transition of a body. the item in a neck happens under acute or at an obtuse angle. Usually (87%) the neck of a bubble is directed up and to the left, and the initial part of the vesical canal goes kpered, kzad or up. More rare (13%) neck. by the item it is sent (fig. 1) up and to the right. Allocate two walls. and.: upper, adjacent to a lower surface of a liver and separated from it by a layer of not properly executed friable connecting fabric, and lower, free, turned into an abdominal cavity and adjacent to peloric department of a stomach, an upper part of a duodenum and a cross colon. Bottom. the item prilezhit to a cross colon, and in cases of a vystoyaniye for bottom edge of a liver — to a front abdominal wall. The specified sintopichesky relations define possibility of soustiya. the item with these bodies at formation of decubituses in it from pressure a stone. the item is fixed to a liver by the visceral peritoneum passing from it on. the item, and also by means of the small blood vessels connecting vessels. item and liver. In rare instances. the item is in a liver. Also seldom. the item completely lies out of a liver, is covered with a peritoneum from all directions and has «mesentery» (fig. 2). In this case at mobile. the item covered with a visceral peritoneum from all directions there can be peritoneal sheaves: vesical and colonic (lig. cysticocolicum), going from. the item to a cross colon, and puzyrnoduodenalny (lig. cysticoduodenale), connecting a neck of a bubble and an upper part of a duodenum (fig. 3). Depth. the item it is individual that matters at operative measures on it.

The deep arrangement is characteristic of newborns and children. item. At elderly people. the item lies more superficially. Sometimes. the item happens dihundred-pyrobathing to different places: between leaves of a pechenochnoduodenalny sheaf (a rotirovanny bubble), a crescent sheaf, on a visceral surface of the left hepatic lobe. It is projected. the item usually on a front abdominal wall in the place of crossing of the right parasternal line with the line connecting the ends of the X edges. In relation to a backbone. the item is projected usually at the L1 level — L2, more rare, at a high position of a liver, at the level of Th11, and at low — at the L4 level. Depending on character of a constitution situation Zh. the item can change from horizontal to vertical.

Innervation. the item is carried out from hepatic neuroplex (plexus hepaticus) formed by branches of a celiac texture, the front wandering trunk, phrenic nerves and gastric neuroplex. Hepatic neuroplex sends branches to a bubble on the course of a cholecystis artery and a vesical channel. Sensitive innervation. the item is carried out by the nerve fibrils going from the V—XII chest and I—II lumbar segments of a spinal cord. Presence of the sensitive nerve fibrils going from the lower node of a vagus nerve is possible. The sympathetic nerve fibrils innervating. items, come from side horns of the VII—XI chest segments of a spinal cord, parasympathetic — from a vagus nerve. Suitable to. items nerves create three neuroplexes in its wall: submucosal (plexus submucosus), intermuscular (plexus intermuscularis) and subserosal (plexus subserosus). At hron, long inflammatory processes. items happen profound degenerative changes of its intramural nervous device that causes considerable disturbances of motility. item.

Fig. 2. Blood supply of a gall bladder: 1 — a gall bladder; 2 — the right hepatic lobe; 3 — a square hepatic lobe; 4 — the left branch of own hepatic artery; 5 — the right branch of own hepatic artery; 6 — Calot triangle; 7 — own hepatic artery; 8 — the right gastric artery; 9 — the general hepatic artery; 10 — a gastroduodenal artery; 11 — the general bilious channel; 12 — the general hepatic channel; 13 — a vesical channel; 14 — a vesical artery; 15 — arteries of a gall bladder.

Blood supply. the item comes from a cholecystis artery (a. cystica), edge usually (85% of observations) departs from the right branch of own hepatic artery to the right of the general hepatic channel (61%) or to the left of it (24%); in the latter case it crosses the general hepatic channel more often (22%) in front, is more rare (2%) behind. Sometimes the cholecystis artery originates from the general hepatic artery (10%), from the left branch of own hepatic artery (1%), from the place of division of own hepatic artery into branches (1%), from a zheludochnoduodenalny artery (3%). As a rule, the cholecystis artery passes a single trunk, rare two trunks. It goes to left or, more rare, to a front surface of a neck. the item, making at the same time the upper party of a triangle of Khalo formed vesical and the general hepatic by channels and a vesical artery (tsvetn. fig. 2). The specified features of an arrangement of an artery and its relation to channels require special attention from the surgeon at operations on the bilious ways and. item. At the level of a neck. the item a cholecystis artery is divided into two branches; one of them goes on an upper (hepatic) surface. the item, another, usually larger — on lower, covered with a peritoneum. From 4 to 8 couples of lateral branches which are widely anastomosing among themselves depart from each of these branches. Veins. item (vv. cysticae), as a rule, multiple (3 — 4), form from intramural veniplexes and are located on the parties. item; they fall through a parenchyma of a liver into intra hepatic branches of a portal vein, and sometimes and extrahepatically in right or (seldom) in left branches of this vein.

Lymph drainage. V Zh. the item is available three networks limf, capillaries: in a mucous membrane under an epithelium, in muscular and serous covers. Forming from them limf, vessels go to a subserosal limf, a texture, a cut widely anastomoses with limf, vessels of a liver. Outflow of a lymph is made in hepatic limf, nodes (nodi lymphatici hepatici) located at a neck. the item in portal fissures, along the general bilious channel, and also in limf, a bed of a liver. See also Bilious channels , Liver .

Histology

Fig. 3. Microdrug of a wall of a gall bladder: 1 — folds of a mucous membrane; 2 — an epithelium; 3 — the microvillis forming the soaking-up border; 4 — own layer of a mucous membrane; 5 — a submucosal layer; 6 — a muscular coat; 7 — a fibrous cover; 8 — a serous cover

Wall. the item consists of three covers: mucous (tunica mucosa), muscular (tunica muscularis) and connective tissue (tunica fibrosa); lower wall. the item it is covered with a serous cover (tunica serosa). Wall thickness. the item makes 1,5 — 2 mm. Mucous membrane. the item has numerous folds. One of them going spiralno in a neck is called Geyster's valve and together with bunches of smooth muscle fibers forms a so-called sphincter of Lyutkens. Multiple protrusions of a mucous membrane between muscle bundles are called crypts or Rokitansky's sine — Ashoffa. Between bunches of muscle fibers and in a connective tissue cover. items lie the tubular aberrant channels which are not reported with a cavity. items which ends are kolboobrazno expanded and are sometimes branched out: Lushki's courses. Crypts and aberrant channels are places of a delay of an infection owing to what formation of abscesses in a wall is possible. item, and also formation of intraparietal stones. Mucous membrane. the item it is covered with high prismatic epithelial cells on which apical surface there is a set of the microvillis (length apprx. 1 micron) having ability of absorption (tsvetn. fig. 3). Allocate three types of epithelial cells of a mucous membrane. item. The most part is made by prismatic cells. In a small amount the cells which are characterized by more dark coloring of kernels and cytoplasms meet. The third type of cells — «pencil cells» — appears only at an inflammation. item. Cells have the kernel supplied with one or several kernels and various organellas [mitochondrions, a lamellar complex (Golgi's complex)], a cytoplasmic reticulum and cytoplasmic inclusions. Electronic and microscopic and gistokhy, researches show that epithelial cells of a mucous membrane. items possess secretory function. In a supranuklearny zone of cells there are two types of granules: light secretory, synthesized by a lamellar complex and a granular cytoplasmic reticulum and containing neutral mucin, and dark — the lysosomes rich with hydrolases. Believe that contents of secretory granules are released from cells by means of the return pinocytic. Under an epithelium own layer of a mucous membrane (a subepithelial layer) formed by network of elastic fibers with inclusion of cellular elements is located. In a neck. items in this layer lie the tubular or alveolar and tubular glands emitting slime. Under a mucous membrane there is a submucosa (tela submucosa) from friable not properly executed connecting fabric. Muscular coat. the item develops of bunches of the smooth muscle and elastic fibers oriented in various directions. In a neck. items bunches of muscle fibers lie preferential tsirkulyarno, participating in formation of a sphincter of Lyutkens. The connective tissue cover is presented by the dense fibrous fabric consisting of bunches of elastic and collagenic fibers. On the lower wall. the item between a connective tissue cover and a peritoneal cover is available a subserosal basis (tela subserosa).

Physiology

Studying of physiology. by the item it is connected with development of methods of a research of bilious ways. For studying of biliary secretion (see. Bile production ) and receipts it in. items impose a fistula. item. The priority in clarification of the mechanism of an exit of bile in intestines belongs to pupils. I. P. Pavlova of G. G. Bruno (1898) and H. To N. Klodnitsky (1902). Imposing a constant fistula of the general bilious channel, they established that ejection of bile in a gut is connected with receipt of food weight in went. - kish. a path and partly with a hungry peristaltics of intestines. For the combined overseeing by bile secretion and an exit of bile in a gut (see. Zhelchevydeleniye ) G. V. Folbort (1917) suggested to create fistulas at the same time. item and bilious channel. These classic methods were improved and modified by many authors (S. M. Gorshkova, I. T. Kurtsin, 1967). Sequence of data about functions Zh. the item was received by means of duodenal sounding and studying of electric activity of muscles. item.

An important role in studying of physiology. the item played rentgenol, the method developed in an experiment by P. K. Klimov and in clinic L. D. Lindenbraten and also a radio isotope research.

Movement of bile in. the item and in bilious ways happens under the influence of the secretory pressure of a liver, a cut reaches 300 mm w.g. Without sufficient pressure in bilious ways of filling. the item does not happen. But movement of bile depends also on other factors — a tone of bilious channels, a tone and motility. item and conditions of the locking mechanism of his neck and vesical channel, concentration ability. item and functions of a sphincter of Oddi.

Fig. 4. A series holetsistogramm men of 20 years after reception of 60 ml of egg yolk: 1 — before reception of a yolk; 2 — 4 — stage of latency (pictures are made in 5, 10 and 15 minutes after reception of a yolk); 5 — 11 — priming reaction and the period of emptying; 12 — 16 — the period of filling (the picture 5 is made in 30 minutes after reception of a yolk, the subsequent pictures are executed at an interval of 15 minutes).

According to the standard classification there are three types of the movements Zh. item: 1) the rhythmic reductions arising 3 — 6 times in 1 min. in a hungry condition of the person or an animal; 2) peristaltic waves of different force and duration; rhythmic reductions always accumulate on them; 3) the tonic contractions causing long, strong increase in intravesical pressure. X-ray cinema observations showed that after meal reductions begin. the item in the field of a bottom and a body at simultaneous expansion of a neck. Then there occurs reduction of all bubble, pressure in it increases to 200 — 300 mm w.g., and the portion of bile is thrown out the general bilious canal. Activity. by the item of the healthy person it is strictly adapted to different operating conditions of the alimentary system. In view of frequency in meal work. the item differs in recurrence. Each cycle of a physical activity. the item can be divided into four periods conditionally: 1) latent; 2) priming reaction; 3) emptyings; 4) fillings (fig. 4). During emptying and filling the periods of reduction and relaxation alternate. item. Only in the first period of reduction are long and strong, and relaxations are short-term, and in the period of filling — on the contrary. Locking mechanism of a neck. the item and a vesical channel all the time functions.

It that opens access of hepatic bile in. the item or vesical bile to the general bilious canal, stops it. Change of the direction of current of bile in a vesical channel is made each 1 — 2 min. Duration of stage of latency of meal to motor reaction. the item depends on structure and the volume of food. After reception of 300 ml of milk it is equal to 2,3±0,7 min., 60 ml of a yolk — 4,8±1,5 min., 50 g of oil — 8,1±1,5 min. Priming (initial) reaction is caused by reflex influences from an oral cavity, a gullet and a stomach and is expressed in change of a form and small increase. item.

During emptying. the item decreases in sizes and its contents are removed to bilious canals. Ejection of bile in a duodenum matches time of passing of a peristaltic wave through a pyloric part of a stomach. Duration of the period of reduction. the item depends on amount of fat in food. In the presence of a large amount of fat reduction. the item proceeds to an exit in a duodenum of the last portions of gastric contents. At trace amount of fat in food of reduction. items last not for long and come to an end even before full gastric emptying.

Fig. 5. Kimogramma of a gall bladder of the person after reception: 1 — three egg yolks; 2 — 100 g of fried meat; 3 — 250 g of bread.

Emptying. the item at men goes quicker, than at women, and at people 50 years quicker, than at young people are more senior. At elderly and old people lengthening of stage of latency is noted. After the end of the period of emptying in. the item always remains a nek-swarm amount of bile (residual bile). Its volume is defined by duration and intensity of the ended period of emptying, i.e. eventually character and volume of the eaten food. To each type of food at the person there correspond certain terms of stage of latency, quantity and rate of biliation from. item (tab. 1 and fig. 5).

Table 1. EMPTYING of the GALL BLADDER AFTER RECEPTION of SOME FOODSTUFF (according to L. D. Lindenbraten)



Period of emptying. the item is replaced by the period of its filling. At the person change of the periods of emptying and filling is during the day observed. the item, connected with meals. At night bile collects in. the item, and it becomes «shop of bile» for digestion (I. P. Pavlov). Role. the item as supplier of bile it is especially important in the morning. During the day, if intervals between meals do not exceed 4 — 5 hours. the item has the small sizes and contains a little concentrated bile.

Mechanism of action various pharmakol. drugs and hormones on. the item is difficult and not up to the end studied.

Introduction of acetylcholine, prozerin, thyroxine strengthens effect of food, accelerating reduction. item. Aminazine, serotonin, adrenaline detain sokratitelny activity. item. Atropine possesses the weakening action on. item. Administration of morphine stops the begun reduction. item. Polyatomic alcohol (sorbite, xylitol, a mannitol, glycerin) have clear holetsistokinetichesky influence. During digestion and out of it in. the item happens continuous movement of portions of bile, a cut is caused by hl. obr. concentration ability. item. The bile arriving from a liver at vertical position of the person accumulates in a neck in the beginning. the item, and then extends along its walls and gradually mixes up with the concentrated vesical bile.

Fig. 6. Kimogramma of a gall bladder of a dog, characterizing: 1 — spontaneous reductions of a gall bladder; 2 — reflex changes of its tone during the passing of food on a gullet and a stomach.
Fig. 7. Kimogramma of a gall bladder of a dog characterizing the stimulating influence of cholecystokinin on motility of a gall bladder (the moment of administration of cholecystokinin is designated by an arrow).

Regulation of functions Zh. the item is carried out in the neurohumoral way. At natural meal nerve centers of a brain «start» biliary secretion and motility. items which then more and more amplify reflex influences from receptor fields of an oral cavity, a stomach and upper part of intestines. The act of food, passing of food on a gullet and a stomach cause reflex changes of a tone. the item (fig. 6), At receipt of food weight in a peloric part of a stomach, duodenal and a jejunum is connected to the complex-reflex mechanism of regulation the powerful regulator of function Zh. the item in the form of the specific hormones emitted by a mucous membrane of duodenal and lean guts. In 1928 Ivy and Oldberg (A. S. Ivy, E. Oldberg) was open cholecystokinin (see) — the hormone which is produced in a mucous membrane of a duodenum, proximal departments of a jejunum and causing reduction. item. Its education is connected with receipt of food in a duodenum (especially strong stimulators of formation of cholecystokinin are salt to - that, yolks, proteins, polyatomic alcohol, vegetable juice). After short stage of latency cholecystokinin causes strong tonic contraction. item (fig. 7).

J. Caroli and it sotr. in 1960 found the anti-hormone which is slowing down effect of cholecystokinin. Apparently, of cholecystokinin it is formed and urokholetsistokinin, found in urine of people Svatosh (And. Svatos, 1959) and increasing motility. and. Believe also that in regulation of a bile production and zhelchevydeleniye a part is played secretin, AKTG, corticosteroids, thyroxine, adrenaline. Hormones affect secretory elements of a liver and muscles. the item and sphincters not directly, and through a vegetative innervation.

In all layers of a wall. items of willows of area of sphincters of channels are nervous cells which provide function Zh. the item even at section of the nerves suitable it. Efferent impulses go preferential through vagus nerves, and braking — on sympathetic ways. Interaction of the centers of a brain and both departments of V. of N of page is depending on the interoceptive alarm system and provides optimum performance. the item

See also Bile .

Methods of a research

At inspection of persons with diseases. the item character of complaints of the patient and the detailed anamnesis is of great importance. Careful studying of so-called structure of pain allows not only to differentiate defeat. the item from diseases of other bodies, but also quite often to reveal character of suffering (cholelithiasis, parasitic cholecystitis, dyskinesia of a gall bladder, etc.).

An essential role in diagnosis of diseases. items play methods laboratory, tool and X-ray radio-gramophones. researches. Duodenal sounding (see) allows to reveal a tone and motor evakuatornuyu function Zh. the item, character of the available microflora or a parasitic invasion, extent of change of chemical structure and physical. properties of bile, in a nek-swarm gives to a measure the chance to judge existence of inflammatory process. Sounding is used in various modifications: by a classical technique, multimoment continuous, hromatografichesky, with the double probe, etc.

X-ray inspection is based on identification morfol, and funkts, changes in most. the item and bodies surrounding it by means of a number of methods: X-ray analysis (see) and roentgenoscopies (see) without use of contrast agents and using them — cholecystographies (see), holegrafiya (see), holangiografiya (see); researches went. - kish. path; tseliako-and gepatografiya. The choice rentgenol, methods and the sequence of their use is defined taking into account the anamnesis, a wedge, by pictures of a disease and the estimated diagnosis.

Fig. 8. Holetsistogramma is normal — is given for comparison (the shadow of a gall bladder is specified by an arrow).
Fig. 9. A series holetsistogramm after a cholagogue breakfast at multiple inborn banners of a gall bladder: the shape of a gall bladder in the course of its reduction does not change (banners are specified by shooters).

Rentgenol, a research gives the chance of presurgical recognition of numerous options and malformations. the item — its doubling, unusual situation, excesses and banners (fig. 8 and 9). The metal foreign bodys which got in are accurately visible on roentgenograms. item. Low-contrast foreign bodys can be found at the cholecystography because they cause defects of filling in a shadow of a bubble.

At stones. the item if they contain lime, rentgenol, a research (usual and contrast) allows to define their quantity (single and multiple), a form (ring-shaped, polygonal, etc.), an arrangement. Stones, not detaining beams of X-ray, can be found only after introduction of contrast means (Cholevidum, Bilignostum, Biligrafinum, etc.). Others rentgenol, methods, napr, the tomography, a transdermal holangiografiya, etc., are also of great importance in diagnosis of stones. the item (see. Cholelithiasis ).

At inspection of patients with cholecystitis there is an opportunity to distinguish a look it — calculous and acalculous and to give an assessment to concentration and motive ability. the item, in particular to allocate group of patients with so-called disconnected. item (blockade of a gall bladder). At acute cholecystitis the weak shadow of increased is observed. item and paresis of a duodenum. At a holegrafiya a shadow. the item in case of its blockade does not appear, and it can be used for differential diagnosis with other acute diseases of abdominal organs. Tseliakografiya (see) allows to find expansion of a vesical artery and its branches and a thickening of walls of a bubble.

At hron, cholecystitis. the item quite often gives a shadow in usual pictures. An indirect sign of defeat of a bubble is existence of gallstones in it. But the leading role in radiodiagnosis hron, cholecystitises is played by artificial contrasting. item. At a holegrafiya and the cholecystography the main find the following rentgenomorfol. and funkts, symptoms: stones in. item and bilious channels, deformation, increase or reduction of the sizes Zh. the item, restriction of a smeshchayemost or change of its normal situation (because of commissures), expansion of bilious channels, lack of a shadow. item, disturbance of process of filling and concentration ability of a bubble, disorder of its motive function.

Lack of a shadow. the item at a holegrafiya is, as a rule, observed at the impassability of a vesical channel caused by a stone, hems, hypostasis of a mucous membrane. As for concentration function Zh. the item, in an initial stage of cholecystitis is observed its strengthening, and further easing that is determined by intensity of a shadow. and. at a holegrafiya. In the expressed cases of cholecystitis at a holegrafiya lamination and pristenochny regional strips of the iodated bile are not defined. In the period of an exacerbation of cholecystitis at a number of patients noticeable increase in duration of the period of emptying is observed. the item with easing of speed and force of its reductions and increase by 1,5 — 2 times of amount of residual bile.

Fig. 1. Edema of a gall bladder
Fig. 10. The roentgenogram at an edema of a gall bladder: sharp increase and omission of a shadow of a bubble against the background of gas in intestines (it is specified by shooters).

At patients with an edema. the item quite often is possible to see the increased bubble already at raying or on roentgenograms (fig. 10). After reception of sorbite shadow. the item does not decrease, and at a holegrafiya a contrast agent does not come to a bubble. Diagnosis of an edema. the item is facilitated if in a projection of a vesical channel the shadow of a gallstone appears. At increased. items are visible impressions on walls duodenal and cross colonic guts.

Existence of internal bilious fistula is followed by emergence of a row rentgenol, signs among which the main are: availability of gas in. item and channels; identification of a large gallstone in a stomach or a gut; transition of contrast weight from went. - kish. a path to bilious canals or. item.

At a focal and diffusion form of a cholesterosis at the cholecystography only increase in intensity of a shadow is noted. the item and its accelerated emptying. At a polypostural form the small and accurately outlined defects of filling in a shadow are defined. item. They are located pristenochno (sometimes it is possible to reveal a leg of «polyp») and, unlike stones, do not move in a bubble. At patients with an adenomyomatosis on holetsistogramma parallel to a contour of a shadow. the item is planned a continuous or discontinuous shadow strip — x-ray display filled with the iodated bile of sine of Rokitansky — Ashoffa. The segmented form of an adenomyomatosis, besides, leads to a wide circular banner. item. The single adenomioma in a typical case causes roundish defect of filling at the bottom of a bubble with accumulation of a contrast agent in the center of defect. Gialinokaltsinoz Zh. is distinguished by the item without effort since the calciphied bubble clearly appears on roentgenograms.

Cancer. the item in an initial stage can be found on a symptom of defect of filling in a shadow of a bubble at the cholecystography. In later stage. the item at the cholecystography and a holegrafiya does not come to light. At a tseliakografiya or a gepatikografiya it is possible to find additional, so-called tumoral vessels, coming from a vesical artery. Sometimes expansion of a vesical artery or amputation of one of its branches is defined. In the started stage during the contrasting went. - kish. a path note symptoms of shift, a prelum or germination by a tumor of a wall of a duodenum and hepatic curvature of a large intestine.

Fig. 11. A series holetsistogramm the patient with hypokinetic dyskinesia of bilious ways after reception of a cholagogue breakfast: in an upper row — before treatment, difficulty and delay of transition of bile from a bubble to canals is noted; in the lower row — after treatment, normal emptying of a gall bladder is noted (pictures are made respectively in identical terms after an equivalent cholagogue breakfast).

Rentgenol, a research matters also in detection of dysfunctions. items of Diskholiya are expressed by disorder of its concentration function. At the same time on holegramma define lack of a dvukhsloynost or trekhsloynost of bile, lack of pristenochny strips of the iodated bile, change of terms of contrasting. the item (see. Cholecystography ). Dyskinesia are shown in change of normal filling and emptying. item: in the increased its motility — the Hyperkinetic form (fig. 11), in weakened — a hypokinetic form, in discrepancy between

tension. the item and the complicated and slowed down transition of the iodated bile to channels (a hypertensive form).

After operations on. item rentgenol. the research can be useful first of all for diagnosis of early postoperative complications. In case of development of outside bilious fistula resort to a fistulokholangiografiya that allows to define the direction and a source of fistula and a condition of bilious channels. Not less important rentgenol, a research for assessment of results of surgical intervention, including for definition of morphology and function Zh. the item after a cystifellotomy, for studying of a condition of a biliodigestivny anastomosis, for diagnosis patol, changes in bilious ways or the next bodies at so-called. postcholecystectomy syndrome (see). In the latter case it is necessary to make holegrafiya (see) to exclude the stones left in bilious canals, to establish caliber of bilious channels, to determine the sizes of a stump of a vesical channel, to investigate function of a sphincter of the general bilious channel.

At children's age rentgenol, researches Zh. items shall be made only according to strict indications. Doses of contrast agents for the cholecystography and a holegrafiya reduce according to age and weight of the child.

Gallstones occur at children very seldom therefore object of radiodiagnosis are hl. obr. anomalies of development. item and hron, cholecystitises. Quite often at the cholecystography single and multiple excesses and banners are found in children. item. Much less often diverticulums or anomalies of situation Zh are defined. item. It can be on a lower surface of the left hepatic lobe, in a cross furrow of a liver, on site a round sheaf or even in a parenchyma of a liver (intra hepatic. item). By means of the cholecystography and a holegrafiya it is possible to distinguish cases of doubling before operation. item. Two can meet. the item with independent vesical channels or the bubble having two cavities divided by a longitudinal partition, but connecting to the general vesical canal. At all malformations. it is important to item to estimate function of this body to define a wedge, value of anomaly.

At children of younger age at hron, cholecystitises a shadow. the item on holegramma can be absent in general because of insufficiency of a sphincter of a hepatopancreatic ampoule. At more adult children disturbance of concentration ability is noted. item. Between weight of cholecystitis and extent of disorder of concentration function there is a direct dependence. At diskineziya. the item its concentration ability remains, but motive function is broken. The slowed-down emptying is usually observed. item and increase in volume of residual bile. Children at the age of 1 — 5 years have a reduction. the item happens twice more slowly, than at the senior children.

The radio isotope research allows to determine the sizes, situation and a form Zh. the item by method of scanning, gives the chance to judge disturbance of its function. It is justified at inflammatory diseases. item, lithogenesis, tumors, diskineziya and some other diseases. In some cases, when to use of X-ray contrast methods of a research there are contraindications (e.g., the expressed jaundice), tracer techniques of a research get special value.

Radio isotope research Zh. the item can be carried out by methods of the radio cholecystography, scannings (see) and dynamic stsintigrafiya (see). The radio isotope cholecystography (radio cholecystography) — studying of function Zh. the item, consisting in repeated outside measurement of a radiation intensity over it after introduction to an organism of radioactive drug which is caught from blood by a liver, is allocated with bile and collects in. item. The research can be carried out by means of marked 131I Bilitrastum, Bilignostum, the Bengalese pink. Bengalese pink activity 0,3 mkkyur on 1 kg of body weight enter on an empty stomach intravenously. One sensor is installed over heart, the second — over the right hepatic lobe, the third — over. the item, the fourth — is 3 cm more left than a navel (over intestines). Normal curve of radioactivity. the item is characterized by short peak on the 1st min. (vascular peak), long increase of activity in. the item to a maximum in 199+12 min. (and it crosses a curve of activity of a liver, rising over it) and the subsequent slow decrease. For studying of motility. items give a cholagogue breakfast and repeatedly register a radiation intensity over. item and intestines.

At impassability of a vesical channel lack of radioactive drug is noted in. item. At patients hron, cholecystitis and cholelithiasis accumulation of radioactive connection in. by the item it is slowed down and does not reach datum level. Curve of radioactivity. the item is not crossed from the curve radioactivity of a liver. Emptying. by the item after a cholagogue breakfast it is slowed also down. All specified signs well are correlated with data rentgenol. researches — cholecystographies (see) and holegrafiya (see).

Fig. 12. A series skanogramm a gall bladder in 2 (1 and 2), 3 (3 and 4), 4 (5 and 6) hour after administration of radioactive drug (norm): 1, 3, 5 — skanogramma in a direct projection; 2,4, 6 — in the right side projection; the gall bladder (it is surrounded with a dashed line) is located at a liver edge (it is designated by a solid line), intensively accumulates radioactive drug By the 4th o'clock concentration of drug in a gall bladder decreases.

For scanning marked Bilitrastum, Bilignostum or the Bengalese pink enter on an empty stomach intravenously. Necessary condition for a konturirovaniye. the item is passability of a vesical channel and sufficient accumulation of radioactive drug in. item. Usually in 60 — 120 min. after an injection of drug on skanogramma there is a sharp image. item (fig. 12). On the basis of the analysis of this image it is possible to judge topography, a form and size Zh. the item and to a certain extent about amount of the radioactive drug which collected in it. A better understanding about dynamics of accumulation and removal of radioactive drugs from. the item can be received, making in different terms the account of radioactivity of all body before shielding of area Zh. item (holetsistometriya). The dynamic stsintigrafiya by means of high-speed scanners or gamma cameras allows to receive a series of the images characterizing all process of receipt and removal of radioactive connection from. item.

Fig. 13. A series skanogramm a gall bladder in 2 (1 and 2), 3 (3 and 4), 4 (5 and 6) hour after administration of radioactive drug at chronic cholecystitis: 13,5 skanogramma in a direct projection; 2, 4, in — in the right side projection - the gall bladder (it is designated by a dashed line) is located at a liver edge (it is designated by a solid line), accumulates radioactive drug less, than normal. In a side projection the sizes of a bubble it is slightly more, than normal, irregularity of shading because of existence of stones in it is visible. By the 4th o'clock concentration of drug in a gall bladder decreases.

At impassability of a vesical channel image. the item is absent. The same is observed at the numerous stones filling all Zh.P. At sufficient accumulation of radioactive drug in. items stones cause irregularity or roundish defects of shading on skanogramma in the area Zh. item. At hron, cholecystitis increase of radioactivity is slowed down and does not reach normal amounts (fig. 13). Accumulation of radioactive drug is sharply reduced in. the item at patients with parenchymatous jaundice.

Ultrasonic diagnosis of diseases. the item gains ground. The image revealed on echograms. the item allows to determine the sizes of body, its shift, deformation, reduction or increase in a cavity. the item to study motor function at use of food or medicamentous irritants. Ekhografiya by means of ultrasonic waves well reveals a state and function Zh. the item even when it radiological does not come to light. By means of ultrasonic inspection (see. Ultrasonic diagnosis ) it is possible to diagnose gallstones, expansion Zh accurately. the item at mechanical jaundice because of cancer of a holedokhopankreatichesky zone or obturation of the general bilious channel a stone, reduction of a cavity. the item at parenchymatous jaundice, change of a form, consistence and density at its cancer.

A laparoscopy (see. Peritoneoskopiya ), in addition to a possibility of visual examination and assessment of a state. the item, allows to make at the same time transhepatic or transcystic holangiografiya (see), and also aim biopsy. Besides, at a laparoscopy it is possible to find metastasises of a tumor and to avoid unreasonable operation.

Thermovision, electro dermatometriya. The Teplovizorny method based on registration of a caloradiance over area of the right hypochondrium and a method of an elektrodermatometriya (see. Galvanopalpation ), allowing to register objectively expressiveness of zones of Zakharyin — Geda on extent of increase in electric conductance of skin, also matter in diagnosis of diseases. item.

All existing methods of a research Zh. it is reasonable to item to apply not in all cases of his disease. Depending on the nature of defeat. items are shown these or that, the most informative in this specific case, methods of inspection. So, for identification of diskineziya. the item and bilious ways multimoment and chromatic duodenal sounding, the X-ray cholecystography and X-ray television cinematography, the radio cholecystography have the greatest value. For diagnosis of cholecystitises, in addition to rentgenol., bacterial, a research of bile, immunol, inspection is shown (skin tests with microbic antigens, definition of antibodies to microbes, to fabric Zh. item), scanning. item, termografiya and elektrodermatometriya. Rentgenol, inspection in various modifications can be useful to identification of a pericholecystitis, defeat of bilious channels and differentiation with dyskinesia, cholelithiasis and tumoral defeats. For diagnosis of cholelithiasis the research of chemical composition of bile, the cholecystography and a holegrafiya, a laparoscopy and a laparoscopic holetsistokholangiografiya, a fibroduodenopankreatokholangiografiya, scanning and an ekhografiya have preferential value. For detection of tumors. the leading value the laparoscopy, the laparoscopic and intravenous cholecystography, and also scanning and an ekhografiya have the item. The parasitic nature of a disease comes to light preferential at microscopic examination of duodenal contents and a calla.

Pathological anatomy

Dystrophic changes of walls. items are observed seldom. In an epithelium of his mucous membrane deposits of neutral lipids and cholesterol are noted. At a cardiovascular form of an amyloidosis deposits of amyloid in intraparietal vessels are described. item. At frustration pigmental and a lipometabolism in walls. items are observed deposits of iron and cholesterol. Occasionally inflammatory processes are resulted by petrification of walls. the item owing to deposits of lime. On this background in a wall. the item the osteogenesis is possible.

Fig. 14. Microdrug of a wall of a gall bladder at a cholesterosis: polipovidny protrusion mucous on two thin legs (1), the stroma of a polyp (2) is filled with lipids; coloring hematoxylin-eosine; X 36.

Cholesterosis (synonym: speckled, or strawberry. item, scaly. item, honey. the item, lipoid cholecystitis, a cholesteatosis, cholesteric polyposes) — a peculiar form of a lipoidosis of a mucous membrane. item. According to the generalized data, it is observed in 10 — 12% of cases for sections and in 16 — 32% of cases for operations. Macroscopic changes. items at a cholesterosis are quite characteristic: the bubble is slightly more than normal, is stretched, intense, a wall its thin, bile tar-like. The most expressed changes at a cholesterosis are observed on a mucous membrane of a gall bladder. On a brownish-greenish background of a mucous membrane the thin, yellowish strips going in lengthwise direction intertwining among themselves and forming small - or a krupnopetlisty net are noted. In places of crossing of lines of a grid it is possible to find small or larger polyps on a thin leg (fig. 14) of bright yellow color (see. Cholesterosis ).

Primary isolated circulatory disturbances in walls. items are observed seldom. The ischemic necrosis is described. the item at the person at fibrinferment of a hepatic artery. The ischemic necrosis of a mucous membrane and subjects of muscular layers owing to pressure is most often observed by a stone. The defect which is formed owing to decubitus, as a rule, happens superficial, but perforation of a wall sometimes develops. the item with development of diffuse bilious peritonitis or arises an anastomosis between. the item and adjacent hollow body (the stomach, a duodenum, is more rare a cross colon).

Extensive necrosis of walls. the item is observed at his gangrene arising owing to secondary circulatory disturbances at acute cholecystitis (see. Cholecystitis ). Necrosis of walls. and. can develop at a pelting in its gleam of a secret of a pancreas. The activated pancreatic proteases and hydrolases cause a diffusion or local autolysis of walls. item.

Ulcerations, necrosis and perforation of walls. items are observed occasionally at a nodular periarteritis and a fibrinoid necrosis of vessels, at a malignant form of an idiopathic hypertensia. At asphyxia and at acute and hron, heart failure hypostasis of walls sometimes develops. item. In this case walls. items are sharply thickened, sometimes as if steklovidna. Histologically at the same time find sharp hypostasis of preferential subserous basis consisting of friable fibroadipose fabric *

it is the Most frequent in. items are observed acute and hron, inflammatory diseases (see. Cholecystitis ). Acute inflammatory changes in a wall. items can have various character from catarral to destructive forms. Hron, inflammatory processes are presented by inertly current inflammation in a wall. item. Reason of inflammatory diseases. items are stagnation of bile, ascending (on bilious channels from a duodenum) and descending (from intra hepatic bilious ways), and also a hematogenous and lymphogenous infection. Inflammatory diseases. items, as a rule, are followed by formation of stones in it. The result of acute inflammatory process in. the item can be formation of his edema, edges develops at obturation of a neck of a bubble or a vesical channel a stone. the item is increased in sizes, its wall is stretched, folds of a mucous membrane are absent, in a wall. items are available growths of connecting fabric with the centers of small-celled infiltration. V Zh. the item contains the muciform liquid produced by glands of a mucous membrane. At infection of contents of a bubble the empyema can develop hron. item.

Tuberculosis. the item is observed extremely seldom. At the general miliary tuberculosis in walls of a bubble and channels hillocks or ochazhka of a miliary necrosis meet. Even less often krupnouzlovaty forms of tuberculosis meet. the items which are usually combined with the same damage of a liver.

At inborn syphilis gummas in walls are described. the items which are followed by an ulceration and fibrosis of walls with a stenozirovaniye and an obliteration of a vesical channel.

Defeats. items in the form of catarral cholecystitis with a bacteriocholia are observed at many acute infectious diseases (a typhoid, a paratyphoid, cholera, salmonellosises) as bile is the favorable environment for development of many bacteria. At a typhoid in walls. the item and channels find the typroid granulomas constructed of large light «typhus» cells. At cholera the bubble is often stretched by rather turbid or light watery bile, in a cut quite often find cholera vibrioes. In other cases contents dense, black color. The mucous membrane of a bubble is full-blooded, sometimes with hemorrhages. Defeats. items at an intestinal (toxic) form of a salmonellosis are characterized by a plethora of capillaries, diapedetic hemorrhages, micronecroses. At septic (septicopyemic) and typroid forms of a salmonellosis in. the item is observed a reactive hyperplasia of a reticuloendothelium and the centers of a purulent inflammation. Infiltrates consist of polymorphonuclear leukocytes, lymphocytes and plasmocytes.

From helminths ascarids who can creep to the general bilious canal and intra hepatic channels have the greatest value. Thereof acute pancreatitis, a purulent cholangitis, cholecystitis, jaundice, abscess and biliary cirrhosis can develop. From trematodes in. items parasitize various types of flukes and an opistorkhisa.

At infection with cercariae of flukes (Distomata) in. items quite often contain hundreds of parasites and their eggs. The disease can proceed asymptomatically with very little changes of walls. item. In other cases the disease gets a form hron, cholecystitis and a cholangitis with the greatest defeats of intra hepatic bilious channels. Fibrosis of walls is noted. the item, growth of surrounding connecting fabric with infiltration by its kruglokletochny elements. At an opisthorchosis, except signs hron, cholecystitis and a cholangitis, proliferation of an epithelium of bilious channels, hl is observed. obr. intra hepatic.

From the elementary zooparasites (Protozoa) in. items most often settle a lyambliya (Lamblia intestina lis), getting from a duodenum. The lambliasis of bilious ways can be followed by catarral cholecystitis and a cholangitis, but latent parasitism is more often observed.

Pathology

the Symptomatology

For diseases. the item localization of pain in right hypochondrium is characteristic, is more rare in epigastric area, with irradiation in a right shoulder-blade, a clavicle, a shoulder joint, is frequent in the left hypochondrium, to the area of heart and for a breast that sometimes simulates clinic of a myocardial infarction. Pain arises or the fault, beer, acute snack amplifies after reception of fat or fried dishes, eggs, cold or carbonated drinks, at physical. loading, carrying weights, especially in the right hand, jolting, cooling, under the influence of psychological tension. At cholelithiasis pain quite often arises at night, unjustly. Constant persistent pains can be observed at tumoral defeat. item. The temperature increase and a fever accompanying a painful attack usually demonstrate development of cholecystitis, and development of symptoms of peritonitis, undoubtedly, confirms existence of destructive processes in. item. Emergence during an attack of pain or soon after it more likely tells jaundices about existence of gallstones. Feeling of sharp weakness in the period of a painful attack, blanching, cold sweat, numbness of extremities, heartaches, headaches, i.e. the expressed clinic of vegetative crisis, testify to the increased neurovascular lability and are quite often observed at dyskinesia. item. At diseases. items are often observed the dispeptic phenomena: nausea, an eructation, bitterness in a mouth, a loss of appetite, etc.

Survey of patients is directed to identification of disturbance of food (at obesity gallstones meet more often, at exhaustion it is necessary to think of tumoral process), jaundices, protrusions in an abdominal wall (increase. item, hernia), participations of a stomach in the act of breath. The superficial palpation allows to reveal increase in resistance or morbidity of an abdominal wall in right hypochondrium. Hron, inflammatory disease. the item naturally is followed by emergence of zones of a skin hyperesthesia of Zakharyin — Geda in right hypochondrium, under a right shoulder-blade, in hard cases — on the left side. At a deep palpation normal. the item is not probed. Defined at a palpation, and sometimes and seen approximately. the item (a positive symptom of Courvoisier) confirms the available organic changes interfering outflow of bile (existence of a stone in vesical or generally bilious channels, the stenosis or cancer of a big nipple of a duodenum, swelled or, more often, cancer of a head of a pancreas). Dense education in the right hypochondrium is suspicious on a tumor. item. A characteristic symptom at inflammatory defeat. the item is its morbidity at a palpation, especially at a breath — Kerr's symptom. Also morbidity at effleurage in the right subcostal area (Lepene's sign) is often observed. Quite often morbidity at a palpation of area Zh. the item comes to light more in a sitting position of the patient (Murphy's symptom). Morbidity at effleurage on the right costal arch of the patient is sometimes observed (Grekov's symptom — Ortnera), during the pressing on a phrenic nerve between legs grudino - a clavicular and mastoidal muscle on the right (a symptom of Myussi). A large number and other painful points inherent to cholecystitis which are found less often is described.

Malformations

Fig. 15. Diagrammatic representation of some types of malformations of a gall bladder: 1 — lack of a gall bladder; 2 — a shnurovidny atresia of a gall bladder; 3 — a hymenoid atresia of a gall bladder (it is given in a section; the white arrow specified a crossing point in a bubble); 4 — a hypoplasia of a gall bladder (it is given in a section); 5 — doubling of a gall bladder (two gall bladders with the general vesical channel); 6 — doubling of a gall bladder (two gall bladders with certain vesical canals); 7 — incomplete doubling of a gall bladder (a two-chamber gall bladder; it is given in a section); 8 — a gall bladder with a diverticulum; 9 — an allotopia of a gall bladder (the gall bladder in drawings is specified by black shooters).

To malformations. items (fig. 15) refer the inborn changes of its size, a form and situation leading to sharply expressed dysfunctions. They would make — the person has 8% of all anomalies.

An aplasia (agenesia) — total absence. the item — it is caused by lack of a rudiment of a bubble or its death in the embryonal period. Frequency of this defect, according to openings, 1: 7500.

A hypoplasia — sharp reduction of the sizes Zh. item. At the same time extremely rare defect. the item has an appearance of small expansion of initial department of a vesical channel; at gistol, a research in it find complex tubular glands that confirms the diagnosis.

An atresia — lack of a cavity. the item — arises at disturbance of an embryogenesis of bilious ways at a stage of vacuolation. the item at this type of a malformation has an appearance of a fibrous tyazh. The isolated atresia. the item meets extremely seldom, usually it is accompanied by an atresia of bilious channels.

Doubling of a gall bladder comes owing to formation of two cellular laying of body from one general. One of two. the item is located in the typical place, another can be displaced in a furrow of a round sheaf, in a parenchyma of a liver, in a wall of a stomach, etc. Vesical channels during the doubling. items merge in one or go separately. Incomplete doubling. the item is shown by formation of a longitudinal partition in its gleam.

Diverticulums (single observations are described) arise owing to a banner. the item embryonal tyazha or in the presence in it defects of a muscular layer.

Anomalies of an arrangement (allotopia). items meet more often and are found in 3% of all openings. At an allotopia. the item can be located in the field of the left share, a round sheaf and a back surface of a liver. A number of authors refers intra hepatic localization to anomalies. the item and wandering. the item having a mesentery.

Malformations. items can proceed without wedge, manifestations or to be complicated by cholecystitis, cholelithiasis, torsion of a bubble with the corresponding symptomatology. Diagnosis of malformations is possible at use rentgenol, and tracer techniques of a research, a laparoscopy. In the presence the wedge, manifestations is required operational treatment.

Damages

the Isolated damages. items meet seldom since he deeply lies down, is protected by a costal arch and a liver. Damages. items, as well as damages of other hollow bodies of a stomach, share on closed and opened. Open damages — the knife and gunshot wounds closed — gaps and separations. item.

The mechanism of the closed injury can be various: direct stroke in the right hypochondrium a blunt object, falling, a sharp prelum of this area or an upper half of a stomach. In these cases there is a sudden strong prelum. item; the bile which is in it cannot quickly come out through a vesical channel, hydraulic pressure in it sharply increases, and the wall is broken off. Existence of inflammatory changes (acute cholecystitis, cholelithiasis) promotes damage. item. Pathoanatomical changes at the closed injury. the item — the slit-like rupture of its wall which is localized usually in the field of a bottom or a neck. Separations of a bubble from a liver are described.

After subsiding of the acute pains arising at the time of blow (shock is observed seldom), patients feel quite often well. Further, usually several hours, pains later appear or amplify again, lokalizuyas at first in right hypochondrium where the limited muscle tension of a front abdominal wall and shchazheny areas of the right hypochondrium at breath can be noted. Protrusion in this zone is sometimes observed. At a palpation during the first hours after an injury the stomach soft, but is painful in right hypochondrium, Ortner and Shchetkin's symptoms — Blyumberg are positive. Later at percussion obtusion in the right half of a stomach comes to light. Further the characteristic picture of diffuse develops peritonitis (see).

During the opening of an abdominal cavity a significant amount of bile is allocated (to 2 — 2,5 l). Often peritonitis at these patients develops inertly, and sometimes there is an otgranicheniye (encystment) of inflammatory process in this connection indications to an operative measure are defined late. Often closed damages. items mask symptoms of damage of other bodies: liver, gut, stomach. Presurgical diagnosis of the closed damage. for the item it is difficult. Usually operation is undertaken concerning an estimated rupture of a gut, injury of a liver, etc., and the final diagnosis is established only during operation.

Because characteristic symptoms of the closed isolated damages. items are absent that interferes with their early identification and timely elimination of dangerous complications, it is necessary to apply more widely a laparocentesis with use of the «rummaging» catheter and a laparoscopy (see. Peritoneoskopiya ).

Diagnosis of the isolated knife or fire (open) damages. for the item it is difficult, however localization of a wound, the expiration of bile from it sometimes facilitate the diagnosis.

The volume of an operative measure at the isolated damages. the item depends on character and extent of these damages, and also on changes of the walls of body which were available to an injury. At a small rupture, a small linear wound and lack of signs patol, changes of a wall of a bubble it is possible to be limited to sewing up of a wound. Stitches should be put in two ranks: the first — continuous through all layers, the second nodal, serous and muscular; it is recommended to use synthetic thread on an atraumatic needle.

At the considerable sizes of a wound. the item, existence patol, changes of its wall, at full separations. the item from the surface of a liver should execute typical cholecystectomia (see). At incomplete separations. in some cases it can be hemmed by the item from a liver to area of a bed. The abdominal cavity in all cases needs to be drained and drained carefully.

Diseases

increase in number of patients with pathology Is noted. the item, especially at children's and advanced age. It is promoted a long low-active infection in an organism, by disturbances of food with relative reduction of consumption of dairy and vegetable products in a diet, the psychogenic and neurogenic factors contributing to stagnation of bile, increase in allergogenny and toxic influences. Subjective and objective symptoms of defeat. items considerably vary depending on character and weight patol, process, a phase of a disease. Among diseases. it is reasonable to item to allocate: functional — dyskinesia, exchange — a cholesterosis, inflammatory — cholecystitis, parasitic and tumoral diseases, and also the diseases caused by a combination of a set of disturbances, i.e. having polyetiological character — cholelithiasis. In a wedge, practice the combination funkts, and organic disturbances is often observed. So, dyskinesia meet not in pure form more often, and in a combination with cholecystitis, cholelithiasis or a lambliasis. At patients with a parasitic invasion and cholelithiasis secondary inflammatory changes are quite often observed in. item. Nevertheless from the practical point of view and allocation of the forms mentioned above is very convenient for performing the differentiated treatment.

Functional disturbances

Dyskinesia — funkts, disturbance motor evakuatornoy functions Zh. item. Often it is combined with dyskinesia of bilious channels (see. Bilious channels ) and with disturbance of a tone of a sphincter of a pechenochnopodzheludochny ampoule. Distinguish primary and secondary dyskinesia. item. Diseases which cornerstone are funkts, disturbances of zhelchevydelitelny system because of frustration of neurohumoral regulatory mechanisms belong to primary diskineziya. Secondary dyskinesia arise reflex at various diseases of abdominal organs. Dyskinesia. the item quite often is a consequence and one of local a wedge, displays of the general neurosis, diencephalic vegetative crisis, the postponed viral hepatitis and other infections and intoxications. For a wedge, pictures of dyskinesia. the item emergence of pains in right hypochondrium of the aching, pricking or skhvatkoobrazny character with typical irradiation in a right shoulder-blade, a shoulder, a clavicle or without irradiation is characteristic. Heavy painful attacks give sometimes the grounds to assume existence at patients of cholecystitis and can be the cause for a wrong cholecystectomia. Distinguish hypotonic, hypokinetic, hypertensive and hyperkinetic forms of dyskinesia. item. Are more often limited to differentiation of diskineziya on two groups — with decrease in a tone and motility. item and their increase. At hypotonia and a hypokinesia. items of pain have stupid character more often and happen long; at a hypertension and its hyperkinesia short-term colicy pains prevail. Characteristic feature of diskineziya. the item is communication of pains with disorders and psychological loading.

At survey of patients out of the period of an aggravation insignificant morbidity in the area Zh is usually noted. the item and in an anticardium. Painful points and zones of a skin hyperesthesia inherent to an inflammation. items, are expressed unsharply or are even absent. In duodenal contents there are no inflammatory elements or it is a little of them, a vesical reflex often labile. Diagnosis of dyskinesia. the item is based on characteristic a wedge, a picture, results of duodenal sounding, a holetsistokholangiografiya, radio isotope and ultrasonic researches. Lack of symptoms of an organic disease (concrements, stenosis of a hepatopancreatic ampoule, perivisceritis, etc.) in the presence of disturbance motor evakuatornoy functions of a bubble allows to assume dyskinesia with a high probability. item. To funkts, to disturbances. the item should refer also development of congestive. item. Usually in emergence of congestive. items matter purely functional moments — dyskinesia, disturbance of motor function of a duodenum — duodenostaz. To development of congestive. the item are promoted also by the mechanical factors complicating outflow of bile — anomaly of development of bilious channels, existence of commissural process etc.

Clinically congestive. the item is shown by the dull, constant aching aches in right hypochondrium, amplifying during the jolting, bystry walking, carrying weight in the right hand.

Exchange diseases: a cholesterosis — rather often found defeat. the item, being in adjournment of ethers of cholesterol in his mucous membrane that is promoted by stagnation of bile in a bubble. Meets at corpulent women of 35 — 65 years with the expressed disturbances of a lipometabolism, with the increased content of cholesterol in blood more often. A wedge, manifestations of a cholesterosis in the presence of stones in. items usually differ in nothing from symptoms of calculous cholecystitis. Diagnosis of an acalculous cholesterosis is difficult, usually patients note constant dull aches in right hypochondrium, sometimes replaced by the acute, pricking pains more often arising at an inclination of the case forward. At duodenal sounding in portion In bile crystals of cholesterol sometimes are found. Treatment of a cholesterosis. the item at expressed a wedge, manifestations operational — a cholecystectomia.

Inflammatory diseases

it is the Most frequent in. items are observed acute and hron, inflammatory processes (see. Cholecystitis ), most often caused by conditionally pathogenic microflora (colibacillus, staphylococcus, a streptococcus, etc.). Matters as well a viral infection. The infection can get in. the item from went along the general bilious and vesical canals. - kish. a path (the ascending infection) or from the intra hepatic bilious courses (the descending infection), and also a lymphogenous and hematogenous way. To development of inflammatory process in. the item is promoted by stagnation of bile in it. Inflammatory diseases. items often are followed by formation of stones in it.

Acute inflammatory changes in a wall. items can have various character — from catarral to destructive forms. Hron, inflammatory changes are presented by inertly current inflammation in a wall. item. The result of inflammatory process in. the item can be development of his edema. Edema. the item can not cause explicit a wedge, symptoms also usually are not complicated by perforation, but existence of the constant center of an infection dictates need of a cholecystectomia at patients with an edema. item

Hron, inflammatory diseases. items often are followed by involvement in patol, process of other digestive organs (a liver, a stomach, a pancreas, intestines), dysfunctions of female generative organs, nervous and cardiovascular disturbances.

Parasitic diseases. An invasion of parasites in. the item, especially at children's age, often brings to it funkts, and to inflammatory diseases. Except lambliasis (see), opisthorchosis (see) and fascioliasis (see), defeat meets. the item as a result of implementation of an intestinal ugritsa (strongyloidosis), ascarids, the Chinese fluke (clonorchosis) and other parasites. A symptomatology of a malospetsifichn — pain in right hypochondrium, dispeptic frustration, dysfunction of intestines, sometimes fever, a fever, weight loss, a skin itch, an eosinophilia of blood. The diagnosis is established during the finding of parasites in duodenal contents or Calais. Inflammatory and parasitic diseases. and. lead to diverse complications — to a cholangitis (cm), to a cholangiolitis, to hepatitis (see), to pancreatitis (see), to a holetsistopankreatit, biliary cirrhosis (see). Parasitic diseases. items usually treat conservatively, but existence at the same time in. and. inflammatory process sometimes forces to resort to operational treatment.

To diseases. the item having a difficult etiology cholelithiasis belongs, edges it is characterized by formation of concrements in. item. In some cases existence of concrements in. the item does not give any a wedge, manifestations and comes to light as a find at surgical interventions in other occasion or on openings. But formation of concrements is more often in. the item is combined with the expressed inflammatory changes in it — development of calculous cholecystitis (see. Cholelithiasis ). Treatment funkts, disturbances. the item consists in elimination of the reasons causing them however unsuccessfulness of conservative treatment at expressed a wedge, displays of dyskinesia. the item sometimes causes the necessity of removal of the last. Congestive. the item in the presence of mechanical obstacles to outflow of bile can also be the indication to operational treatment. Cholelithiasis, especially in combination with inflammatory diseases. the item, as a rule, is subject to operational treatment.

Tumors

Fig. 3. The opened gall bladders — multiple papillomas.

Benign tumors — papillomas (tsvetn. fig. 3), adenomas, adenomioma, fibroadenomas, tsistoadenoma, myomas, myxomas, etc. — meet seldom. So, in clinic of Mayo (USA) on 17 000 cholecystectomias they made 8,5%. Among them papillomas which happen multiple are more often observed, the diffusion papillomatosis sometimes meets. item. Tumors usually are located in the field of a bottom and can be combined with concrements. Clinically benign tumors. items prove or are observed by nothing the complaints characteristic for hron, cholecystitis. At the cholecystography small tumors. items usually do not come to light, larger often take for a concrement. Therefore benign tumors. items are diagnosed in most cases during operation or are an accidental find on section.

Treatment of benign tumors. items operational, in most cases make typical cholecystectomia (see) since it is not always possible to exclude a malignancy of a tumor. At a combination of a tumor. the item with concrements or hron, cholecystitis needs removal. item.

Malignant tumors — cancer and sarcoma. Sarcomas meet very seldom in the form of myosarcomas, a miksokhondrosarok, melanosarcomas, lymphosarcomas and angiosarcomas. Histologically they treat spindle-shaped and cellular and polymorphocellular forms with colossal cells.

Primary cancer. the item makes from 2 to 8% of all malignant tumors of the person and takes the fifth place among malignant tumors went. - kish. path. Usually cancer. items are surprised persons 40 years are more senior, at young people and children only separate observations are described. According to most of authors, women have cancer. the item by 4 — 5 times more often than men that is explained by his frequent combination to the cholelithiasis more inherent to women. Frequency of a combination of primary cancer. the item with gallstones it is also long the proceeding calculous cholecystitis from 62 to 94% hesitate. P. Carnot entered even the new term «kalkulokantser». Nevertheless to direct dependence between these two diseases it is not established.

Fig. 2. The opened gall bladders — diffusion infiltriruyushchaya a form of cancer

Cancer. the item is localized more often in the field of its bottom, the neck and a surface turned to a liver, etc. (tsvetn. fig. 2). On gistol, to a structure the adenocarcinoma, then a scirrhus, the mucous, solid, planocellular and low-differentiated cancer meet more often. The tumor has high degree of a zlokachestvennost, early metastasizes, usually on limf, to ways. First of all the liver and limf, nodes of portal fissures is surprised that it leads to development of obturatsionny jaundice; the prelum of a portal vein is followed by ascites.

In an initial stage cancer. the item proceeds asymptomatically. If it develops against the background of cholelithiasis, then a wedge, manifestations of the last usually mask symptoms of cancer. Such symptoms as intensive constant pains and the palpated hilly tumor in right the hypochondrium, jaundice, a lose of weight, the increasing weakness, anemia, ascites, allow to suspect cancer only. items, but in most cases are manifestations of already far come defeat at germination or a prelum a tumor or its metastasises of nearby bodies and fabrics (a liver, extrahepatic bilious channels, a stomach, duodenal, small or large intestine and so forth).

Pristupoobrazny pains, substantial increase of temperature, an oznoba, pouring sweats are not characteristic of cancer. items, but can take place at accession of consecutive infection and development cholangitis (see) or at a combination of cancer to acute cholecystitis. In this regard allocate the following a wedge, forms of primary cancer. item: icteric, «tumoral», dispeptic, septic and mute.

Hypochromia anemia, a small leukocytosis, the accelerated ROE, a bilirubinemia, an achlorhydria not yav lyatsya by characteristic signs for primary cancer. items also develop usually in a late stage of a disease.

At duodenal sounding the vesical reflex usually is absent, in rare instances of receiving a portion In in it there is a large number of leukocytes and slime, and in the smears painted across Romanovsky — to Gimza, cancer cells can be found. Due to the long asymptomatic course of cancer. the item diagnosis, especially early, presents great difficulties. Absence characteristic a wedge, manifestations and insufficient basic data during the carrying out laboratory, rentgenol, and tool methods of a research aggravate these difficulties. Rentgenol, a research went. - kish. a path allows to reveal the shift or a prelum, and also deformation of nearby bodies that usually does not give specific instructions on defeat by a cancer tumor. item. At cholecystographies (see) defect of filling in some cases can decide on uneven contours or deformation. item; at considerable defeat of a wall and vesical channel a shadow. the item is not contrasted that is observed also at calculous cholecystitis. Diagnostic opportunities of secretory holegrafiya (see) in most cases low, and in the presence of jaundice it is not shown. Scanning and ultrasonic echolocation. items in view of lack of specific characters of malignant process cannot be considered as reliable.

Germination or innidiation of cancer. the item in a liver manages to be revealed by means of a gepatoskanirovaniye, ultrasonic diagnosis (see), and also tseliakografiya (see) and the selection angiography (see. Gepatografiya ). Important diagnostic value has peritoneoskopiya (see).

Treatment only operational. During operation the diagnosis of cancer usually comes easy, except for cases of widespread ekstravezikalny defeat when it is difficult to establish primary localization of a tumor, and also at crayfish. the item, indiscernible it is macroscopic during operation and the operating surgeons revealed unexpectedly for at patomorfol, a research of a remote bubble. In this regard it is reasonable to make urgent gistol, a research Zh. the item after a cholecystectomia at all persons of advanced and senile age. Radical operations manage to be executed only in the early stage of a disease diagnosed seldom. Operability at cancer. the item makes apprx. 30%.


At localization of cancer process in the field of a bottom or a neck. the item intervention can be limited to a cholecystectomia, at defeat of a wall, adjacent to a liver, the resection of the site of a liver is necessary.

At germination of a tumor. items in a liver or in the presence of a solitary metastasis make a segmented resection of a liver or a hemihepatectomy; during the involvement in blastomatous process of extrahepatic bilious channels or surrounding bodies — their resection. However expediency of so radical operations by many surgeons is disputed. In case of multiple metastasises in a liver or in people around and furthermore intervention it is necessary to graduate from the remote bodies a trial chrevosecheniye. At hron, empyemas. the items which complicated cancer it make cholecystostomy (see), at obturatsionny jaundice because of metastasises in portal fissures — a rekanalization of bilious channels or transhepatic outside drainage of share or segmented hepatic channels (see. Bilious channels, operations ).

Forecast of cancer. the item in most cases even after radical operations bad. In addition to a high direct lethality (35,5%), five-year survival, according to aggregated data, does not exceed 1%.

Improvement of results of operational treatment should be expected during the performance of operations in earlier terms that it is connected with development of more perfect methods of diagnosing of cancer. item. In this problem timely operative measures are of great importance at hron. calculous cholecystitises.

Clinicodiagnostic characteristic of the main malformations, damages and diseases. the item is provided in table 2.

Operations

Operative measures on. items are usually made concerning his inflammatory diseases, damages and tumors, but is the most frequent at acute and hron, cholecystitis.

Operations on. items at inflammatory diseases depending on terms of their performance subdivide on emergency — during the first hours after receipt, urgent — in the first 24 — 72 hours, early — 7 — the 14th days after receipt and the operations which are carried out in the period of remission in several months after a bad attack. In the first case operation is undertaken according to vital indications when the delay can lead to heavy complications or a lethal outcome. If the condition of patients does not demand an immediate surgery, then begin to carry out by him the treatment directed to subsiding of inflammatory process and recovery of outflow of bile (antibiotics, spasmolysants, etc.). If conservative treatment after 2 — 3 days is inefficient or there occurs deterioration, patients it is necessary to operate. At bystry subsiding of the inflammatory phenomena after the general and special a wedge. inspections, preoperative training of patients operate later 2 — 3 weeks, without writing out from a hospital. Such tactics is applicable hl. obr. at uncomplicated cholecystitises. An operative measure in earlier terms can be followed by great technical difficulties in connection with existence of considerable inflammatory changes (a pericholecystitis, inflammatory infiltration of a neck of a bubble and hepatoduodenal sheaf).

At elderly patients destructive forms of an inflammation are often observed. the item, and a wedge, a picture of a disease usually does not correspond to heavy destructive changes in a wall. the item therefore at this category of patients it is necessary to expand indications for an operative measure.

Preoperative preparation consists in holding the actions improving lung ventilation (respiratory gymnastics, expectorants, banks, mustard plasters), cordial activity (drugs of a digitalis, strychnine) normalizing activity of c. and. pages (sedatives), and also in treatment of associated diseases. At the phenomena of a liver failure purpose of a diet, protein-rich, correction of a hypoproteinemia is reasonable (plasma transfusion, administration of proteinaceous drugs, mixes of amino acids, parenteral administration of glucose, purpose of vitamins — C, B2 and B12). Prevention of the cholemic bleedings which are quite often developing at obturatsionny jaundice requires intramuscular or intravenous administration of Vikasolum; in some cases for improvement of processes of a blood coagulation hemotransfusion is shown. Also correction of water and electrolytic balance, especially in the presence of jaundice is necessary. Duration of preoperative preparation fluctuates of 1 — 2 hour (in need of the emergency operative measure) up to several days (in the absence of the emergency or urgent indications to operation), but shall not take more than 7 — 10 days, especially in the presence of obturatsionny jaundice or a cholangitis since operation, removing a cause of illness and its complications, in itself is the best means of elimination of intoxication in these cases and promotes removal of the patient from serious condition.

Anesthesia at operations on. shall provide with the item to the surgeon freedom of manipulations in the field of portal fissures, a pechenochnoduodenalny sheaf, in a pankreatoduodenalny zone therefore the endotracheal anesthesia with the managed breath and use of muscle relaxants is optimum. Abnormal liver functions and jaundice shall be considered in anesthesiology practice as sources of the increased risk. In these conditions it is necessary to care also for prevention of development of hepatonephric insufficiency. At the choice of drugs for premedication and anesthetics for an introduction and main anesthesia it is necessary to proceed from complexity, injury and duration of operation. In cases of deep damage of a liver use of nitrous oxide, especially in combination with a neyroleptanalgeziya is reasonable. In usual a wedge, practice for an introduction anesthesia can recommend to 0,5 — 1% solution of a barbiturate of short action (hexenal, thiopental), and for the basic — nitrous oxide against the background of small doses of ether.

Technology of operation. An operative measure is made in position of the patient on spin with the roller at the level of XII of a chest vertebra that facilitates access to a neck of a bubble. Slanting cuts in right hypochondrium, sometimes straight lines (on the centerline, a trance are most often applied - or pararectal) cuts, to the Crimea if necessary add a section at an angle (see. Laparotomy ). The choice of a section depends on constitutional features of the patient and alleged changes in an abdominal cavity. Operation of removal is most often made. the item — cholecystectomia (see). Sometimes. items use for creation of a biliodigestivny anastomosis for recovery of normal outflow of bile in the presence of unremovable obstacles in the general bilious channel or in the field of a big nipple of a duodenum. Most often impose an anastomosis between. the item and a duodenum (see. Cholecystoduodenostomy ). the item and a small bowel (holetsistoenterostomiya), is more rare between. the item and a stomach — holetsistogastroanastomoz (see. Cholecystogastrostomy ).

The cholecystostomy is made seldom, usually at destructive changes. the item at the elderly patients who are in a serious condition when the cholecystectomia is technically impracticable or life-threatening. Imposing of outside fistula exempts a gall bladder from the infected bile and concrements, eliminates intoxication. In the subsequent fistula can independently be closed; if it does not occur, 1,5 — 2 months later it is possible to undertake repeated intervention for elimination of the main pathology and elimination of bilious fistula. The removal of a single stone recommended by nek-ry surgeons from not changed. the item (a so-called ideal cystifellotomy) should not be carried out since the conditions promoting repeated formation of concrements at this intervention are not liquidated, and the cicatricial deformation which is inevitably developing in the subsequent. the item even more worsens its function.

The postoperative current depends on the general condition of the patient before operation, on duration, complexity and the nature of the made surgery. The special attention after operation is deserved by corpulent patients of advanced and senile age with disturbances of cardiovascular system and a respiratory organs inherent in the last. Actions which need to be held from the first hours after operation shall be aimed at providing normal function of external respiration and the prevention of pulmonary complications, maintenance of activity of cardiovascular system, correction of water and electrolytic balance, elimination of the painful and reflex factors connected with an operational injury, fight against intoxication. For this purpose patients are given in a bed a semi-sitting position, carry out respiratory and remedial gymnastics, appoint the early movements and a rising. At emergence of pulmonary complications (bronchitis, pneumonia) — streptocides, antibiotics, expectorants, banks, inhalations. At hepatonephric insufficiency (see. Hepato-renal syndrome ) appoint intravenous administration of 40% of solution of glucose, vitamins of group B, K, C, intravenously enter 4% hydrosodium carbonate, 1% glutaminic to - that, Sireparum, Polyglucinum, appoint plentiful soda drink (borzhy), lipocainum, methionine. At severe forms of hepatonephric insufficiency the good effect is rendered by catheterization chest channel (see) on a neck during 4 — 5 days. Special attention in the postoperative period should be paid to prevention of cholemic bleedings, prevention and treatment of paresis of intestines.

To early postoperative complications at the patients operated concerning diseases. items, belong the bleedings from a bed of a bubble or a vesical artery which are followed by outside bleeding or formation of subhepatic hematomas and also a zhelcheistecheniye from a bed. the item, vesical or extrahepatic bilious channels with formation of subhepatic abscess or development of diffuse bilious peritonitis. Hematomas and suppuration of a postoperative wound, alloyed fistulas, outside belong to late postoperative complications bilious fistulas (see), postoperative hernias.


Table 2. Clinicodiagnostic characteristic of the main malformations, damages and diseases of a gall bladder

Bibliography:

Anatomy, embryology — Vereshchagina L. N. Individual anatomic distinctions of a gall bladder and extrahepatic bilious channels at newborns, Vestn, hir., t. 94, No. 6, page 53, 1965, bibliogr.; r and-goryev N. G. O to the nature of the nervous device of a gall bladder, Arkh. annate., gistol, and embriol., t. 54, century 5, page 50, 1968, bibliogr.; Filimonov G. P., Savchenko A. P. and Sexton E. E. X-ray anatomy of arteries of a gall bladder (according to an intravital angiography), in the same place, t. 68, century 3, page 60, 1975, bibliogr.; Surgical anatomy of a stomach, under the editorship of A. N. Maksimenkov, page 297, L., 1972; Chapman G. Century and. lake of The fine structure of mucosal epithelial cells of a pathological human gall bladder, Anat. Rec., v. 154, p. 579, 1966; Luciano L., Reale E. u. WolpersC. Die Fein-struktur der Gallenblase und der Gallen-gange, Histochemistry, Bd 38, S. 57, 1974.

Physiology — Gorshkova G. M and Kurtsin I. T. Mechanisms of zhelche-allocation, L., 1967, bibliogr.; To l to them about in P. K. Mechanisms of regulation of functions of zhelchevydelitelny system, L., 1969, bibliogr.; Physiology and pathology of a bile production and a zhelchevydele-niya, under the editorship of I. T. Kurnin, L., 1965, bibliogr.; With and about 1 i J., P 1 e s s i e of J. a. Plessier B. L’hormone inhibitrice de la cholecystokinine, son role en patho-genese biliaire et pancreatique, Arch. Mal. Appar. dig., t. 49, p. 1585, 1960; I v y A. G. a. OldbergE. Hormone mechanism for gall-bladder contraction and evacuation, Amer. J. Physiol., v. 86, p. 599, 1928; Svatos A. Cholecystoki-nin activity of urine, Science, v. 129, p. 567, 1959, bibliogr.

Radio isotope research and radiodiagnosis of diseases — Galkin V. A., Lindenbraten L. D. and L about and N about in A. S. Recognition and treatment of cholecystitis, M., 1972, bibliogr.; Galperin E. I. and Ostrava I. M. A contrast research in surgery of bilious ways, M., 1964, bibliogr.; Zubovsky G. A., Ryazan G. V. and Nemes V. V. Radio isotope gepatokholetsistografiya, Medical radio-gramophones., t. 19, No. 6, page 53, 1974, bibliogr.; Lindenbraten L. D. Radiological and radio isotope differential diagnosis of jaundices, Owls. medical, No. 8, page 34, 1972, bibliogr.; Petrova I. S. and Pole E. 3. X-ray radiological researches of bile-excreting channels, Kiev, 1972, bibliogr.; R ab to ying I. X., etc. X-ray functional studying of a gall bladder and biliary tract, Klin, medical, t. 48, No. I, page 95, 1970, bibliogr.; From V. N lavn. Radio isotope diagnosis of diseases of a gall bladder, Medical radio-gramophones., t. 15, No. 4, page 20, 1970, bibliogr.; Spesivtseva V. G., etc. Use of radioisotopes for a skennirovaniye of a gall bladder, Owls. medical, No. 10, page 26, 1969; J and-t of a s J. A. Hyperplastic cholecystoses, Amer. J. Roentgenol., v. 83, p. 795, 1960; Rosch J., G rollman J. H. a. S t e with k e 1 R. J. Arteriography in the diagnosis of gallbladder disease, Radiology, v. 92, p. 1485, 1969; W i s e R. E. Intravenous cholangiography, Springfield, 1962, bibliogr.

Pathology — Bairov G. A., Pugachev A. And Sh and p to and N of an A. P. Hirurgiya of a liver and bilious channels at children, L., 1970; In both l I in and G. D. and Panchenko's N K. P. Rak of a gall bladder, Surgery, No. 2, page 97, 1975, bibliogr.; Vinogradov V. V., P. I. and Kochiashvilya V. I. Neprokhodimost's Winter of bilious ways, M., 1977, bibliogr.; Gloutsal L. Diseases of a gall bladder and bilious ways, the lane from Czeches., Prague, 1967; Ishchenko I. N. Operations on the bilious ways and a liver, Kiev, 1966, bibliogr.; To about-renev H. N, Shumanov and T. I. and Ustimenko E. M. The hypodermic and getting injuries of a gall bladder, Surgery, No. 3, page 49, 1974, bibliogr.; Littmann I. Belly surgery, the lane with it., Budapest, 1970; Milonov O. B. and M about in the h at A. A N. Surgical aspects of treatment of chronic hepatitis, Surgery, No. 9, page 67, 1974; The Multivolume guide to internal diseases, under the editorship of E. M. Tareeva, t. 5, M., 1965, bibliogr.; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 8, M., 1962; H about and l-l of A. M of ER. Diseases of a gall bladder and bilious ways, M., 1969, bibliogr.; Residents of Perm N. K. and Podolski y A. E. Holesteroz of a gall bladder, M., 1969; Petrov B. A. and Galperin E. I. Hirurgiya of extrahepatic bilious channels, M., 1971, bibliogr.; Rarenkoa.S. The closed isolated injuries of a gall bladder, Vestn, hir., t. 111, No. 11, page 92, 1973, bibliogr.; B. S. rose trees and P e-N and N V. A. Holesteroz of a gall bladder, M., 1973; Sitenko V. M. and Not - h and y A. I. A postcholecystectomy syndrome and repeated operations on the bilious ways, L., 1972, bibliogr.; Quietly in E. V. Mistakes, dangers and complications at operations on the bilious ways, L., 1976, bibliogr.; Fedorov S. P. Gallstones and surgery of bilious ways, M. — L., 1934; Tskhakaya Z. And., Vinogradov V. V. and M and m and m of t and in r and sh in and l and D. G. Hirurgiya of a choledocholithiasis, Tbilisi, 1976, bibliogr.; Shalimov A. A. and d river. Hirurgiya of a liver and bilious channels, page 221, Kiev, 1975, bibliogr.; A d s about n M. A. Carcinoma of the gallbladder, Surg. Clin. N. Amer., v. 53, p. 1203, 1973; Bothra R. Torsion of the gallbladder in the aged, Brit. J. Surg., v. 60, p. 359, 1973; Gastroenterology, ed. by H. L. Bockus, v. 1 — 4, Philadelphia, 1974 — 1976; HenningsenB.u.Jung-h a n n s K. Aplasie der Gallenblase, Chir. Prax., S.45, 1974, Bibliogr.; Meyer-Burg J. u. a. Die Kranke Gallenblase, Lpz., 1974; Sherlock S. Diseases of the liver and biliary system, Oxford, 1975.


L. D. Lindenbraten (physical., rents., I am glad.), O. B. Milonov (pathology, hir.), S. S. Mikhaylov (An., gist., embr.), A. M. Nogaller (mt. issl., pathology), N. K. Permyakov (stalemate. An.), A. P. Shapkina (malformations), authors of the tab. of D. E. Malakhovka, A. M. Nogaller.

Яндекс.Метрика