Choledocholithiasis is the term for the presence of stones in the bile ducts. As a rule, such obstructions are formed in gallbladder. Ducts are small tubes that carry bile from the gallbladder to the intestines. The organ is a pear-shaped formation located under the liver, in the right upper corner abdominal cavity. As a rule, stones remain in the bladder or freely pass through the common bile duct.

However, according to the results of statistical studies, it was found that about 15% of patients with gallstones also have stones in the bile ducts.

Symptoms

Choledocholithiasis is a sluggish disease that may not express itself in any way for many months and even years. However, in cases where the stone gets stuck in the duct and turns into an obstruction, there are the following signs violations:

• pain in the abdominal cavity, localized at the top in the right side or in the middle;
• increase in body temperature;
• jaundice (yellowing of the skin and eyes);
• loss of appetite;
• nausea and vomiting;
• earthen chair.

B stone can cause both irregular and permanent pain. At times, the pain seems to calm down, in order to sharply increase after a while. Acute pain syndrome may lead to the need for urgent treatment for medical care. Most severe manifestations disorders are often confused with signs of cardiac pathology - for example, a heart attack.

Complications

A stone in the bile duct (the symptoms of which the patient ignores for a long time) can lead to infection. Bacteria that multiply rapidly in the area of ​​​​the lesion can move inside the liver. The consequences of such an infection pose a direct threat to human life. In addition to bacterial damage, complications such as cholangiolytic cirrhosis of the liver or pancreatitis can also occur.

Causes

There are two types of stones: cholesterol and pigment.

Cholesterol formations have yellowish color and are the most common. Scientists believe that stones of this type gradually build up from bile, which contains:

• too much cholesterol;
• excess bilirubin;
• not enough salt bile acids.

Cholesterol deposits also occur in the case of incomplete or too rare emptying of the gallbladder.

It is still not known exactly why pigment stones form in the bile ducts. According to the observations of doctors, they are found in patients suffering from:

• cirrhosis of the liver;
• infectious diseases of the biliary tract;
• hereditary blood diseases leading to excessive production of bilirubin by the liver.

Risk factors

The risk group primarily includes people with a history of cholelithiasis and other pathologies associated with the functioning of the bile-producing organ and its associated pathways. Moreover, it is not uncommon for these patients to develop bile duct stones after bladder removal. A gallstone is sometimes enough to cause significant discomfort and severe pain.

The following factors increase the risk of deposition of cholesterol and pigment formations in the excretory tract:

• obesity;
• high-calorie, high-fat diet low level saturation with fiber;
• pregnancy;
• long post;
• rapid weight loss;
• lack of physical activity.

Some of these factors are fairly easy to correct by making appropriate lifestyle changes.

Circumstances that cannot be changed include:

• age: stones are more often found in older people;
• gender: women suffer from this disease more often;
• nationality: Asians, Mexicans and American Indians are diagnosed with choledocholithiasis more often than representatives of other nations;
• family history: according to some scientists, genetic characteristics may play a significant role in the development of predisposition to choledocholithiasis.

Diagnostics

If there are appropriate symptoms, the doctor will need to verify the presence of stones in the common bile duct. For diagnostic purposes, one of the following imaging studies is performed:

• transabdominal ultrasound is a procedure that uses high-frequency sound waves, allowing to study the state of the liver, gallbladder, spleen, kidneys and pancreas;
• computed tomography of the abdominal cavity (cross-sectional x-ray);
• endoscopic ultrasound (ultrasound probe is placed in a flexible endoscopic tube and passed through oral cavity v digestive tract);
• - a procedure that allows you to localize not only stones in the bile ducts, but also other pathological phenomena (tumors, areas of narrowing);
• magnetic resonance cholangiopancreatography - and pancreatic duct;
• percutaneous transhepatic cholangiogram - X-ray of the bile ducts.

Your doctor may also order one or more blood tests to make sure you have or don't have an infection and at the same time check that your liver and pancreas are functioning properly. The most commonly prescribed tests are:

• general blood analysis;
• bilirubin test;
• analysis of pancreatic enzymes;
• analysis of the liver.

Treatment

Stones from the bile duct must be removed to ensure normal patency and the disappearance of pain. Doctors may recommend one of the following procedures to relieve the obstruction:

• extraction of stones;
• breaking cholesterol and pigment formations into fragments (lithotripsy, crushing);
• surgery for the purpose and obstruction of the ducts (cholecystectomy);
• a surgical operation consisting in dissection of the common bile duct to remove stones or facilitate their passage (sphincterotomy);
• biliary stenting.

Procedures

Endoscopic biliary sphincterotomy remains the most common treatment for choledocholithiasis. During this procedure, a special device in the form of a balloon or basket. With its help, the obstruction of the paths is eliminated. This method has been proven effective in 85% of cases.

If the stone does not pass on its own and the doctor suspects that endoscopic biliary sphincterotomy will not be enough, lithotripsy is prescribed. In this procedure, stones are crushed into small fragments to facilitate their extraction or independent passage.

A stone in the gallbladder duct may be adjacent to a similar formation in the organ itself. In such cases, the most effective method treatment is the removal of the gallbladder. During surgical operation the doctor will examine the duct to make sure it is normal.

If stones cannot be completely removed for any reason surgical method(and also if you have been suffering from pain caused by stones in a blocked duct for a long time, but do not want to remove your gallbladder), your doctor will recommend biliary stenting. The procedure consists of inserting tiny tubes that widen the passage and thereby eliminate obstruction and stones in the bile duct. The operation is gentle and provides effective prevention cases of choledocholithiasis in the future. In addition, stents can protect against infectious diseases.

Prevention

If once you have already experienced pain associated with choledocholithiasis, most likely, the pain syndrome will recur - and more than once. Even removal of the gallbladder is not the best treatment: stones from the bile duct must be eliminated purposefully, otherwise there will be a risk of typical symptoms of the pathological condition.

However, in many cases choledocholithiasis can be prevented. All you need to do is make small changes to your lifestyle. The risk of the disease is significantly reduced by moderate exercise and slight changes in diet. Doctors advise to do it as often as possible hiking and make sure your diet is high in vegetable fiber. It is desirable to reduce the consumption of saturated fats.

Long term forecast

In 2008, several well-known medical clinics A Canadian and US study found that approximately 14% of patients re-experience symptoms of bile duct stones within fifteen years of first onset of typical pain syndrome and appropriate treatment. Obviously, the removal of stones from the bile ducts is not always done with sufficient care, since there is reason to believe that the recurrent disease is associated with an increase in residual cholesterol formations in size.

Folk remedies

Alternative medicine is not considered a highly effective means of combating choledocholithiasis, however, according to some experts, simple folk medicines, cooked at home, can increase the flow of bile or prevent excessive production and accumulation of cholesterol.

Are you experiencing pain and suspect that it is caused by a stone in the bile duct? What to do if you can not see a doctor yet? Try one of the following folk methods.

natural preparations

• Pour in a tablespoon apple cider vinegar in a glass of apple juice and stir. Drink every time you feel pain in the gallbladder and ducts. The tool has an analgesic effect after 5-15 minutes.
• Add four tablespoons lemon juice into a glass of water. Drink the mixture on an empty stomach every morning. The therapy lasts for several weeks - until the stones are completely eliminated from the body.
• Boil a glass of water, add a teaspoon of crushed dried leaves peppermint, remove from heat, cover with a lid and infuse for five minutes. Strain and add a teaspoon of honey. Drink Mint tea warm, twice a day for 4-6 weeks, better between meals.
• Prepare vegetable mixture. To do this, squeeze the juice from one beetroot, one cucumber and four medium-sized carrots. Mix and drink twice a day. Follow these instructions for two weeks and you will notice how quickly your condition returns to normal.

Medicinal herbs

• Place a teaspoon of dried dandelion root powder into a glass. Pour hot water, cover and leave for five minutes. Strain, add some honey to improve the taste. Drink this two to three times a day for 1-2 weeks to dissolve duct stones after gallbladder removal.
• Healing tea can also be prepared from other beneficial plants. Add two teaspoons of marshmallow root and one teaspoon of holly mahonia to four glasses of water. Boil the mixture for 15 minutes, then remove from heat. Add two teaspoons of dried and one teaspoon of dried peppermint leaves, then infuse the tea for 15 minutes. Strain and drink throughout the day.

In addition, the tender green dandelion leaves can be eaten directly - for example, steamed or added fresh to vegetable salads.

Dandelion is contraindicated in patients with diagnosed diabetes.

Gallstone disease (GSD) is a very common pathology throughout the world, today the removal of stones from the gallbladder can be done in several ways.

GSD is most common in developed industrial regions, where people eat more protein and fatty foods.

In addition, the disease is 3 to 8 times more likely to affect women than men. How to treat pathology medically, surgically and folk remedies- in this article.

Features of the disease

The gallbladder is located near the liver. Its role is to store the bile that comes there from the liver.

Bile is a complex fluid containing bilirubin and cholesterol that helps the digestive tract to digest food.

The main reason for the occurrence of stones in the bladder is called excessive cholesterol in the bile, its stagnation and improper outflow, infection of the organ.

If bile stagnates in the bladder for a long time, cholesterol settles and turns into “sand”, grains of sand grow over time and calculi form.

The volumes of stones can be very different - from two to three millimeters to several centimeters. In some cases, the calculus extends to the entire organ and stretches it.

Small formations 1-2 mm in diameter move freely along the ducts, but larger ones cause a clinic of the disease.

Most often, the disease occurs without any symptoms. If suddenly there are clinical symptoms then urgent action needs to be taken.

Typical manifestations of cholelithiasis are sudden colic, in which a person feels pain under the ribs on the right, heartburn, nausea, fever, bloating, and jaundice are present.

If the disease has been going on for a long time, then over time bile ducts narrow, the bladder becomes infected, chronic inflammation occurs.

If stones in the gallbladder were found in a patient, then the doctor first of all studies their composition and determines the type of calculus - cholesterol, calcareous, pigment or mixed.

Modern medicine offers several ways to remove gallstones - this is dissolution with the help of special preparations, crushing with a laser or ultrasound, and dissolving residues with acids. But the main method of removing formations is cholecystectomy.

In recent years, abdominal operations have faded into the background, and endoscopic removal is increasingly being used.

dissolving stones

Crushing and dissolution of stones are methods that allow you to get rid of formations in the bladder with the least loss while preserving the organ itself and its ducts.

Indications for the dissolution of calculi are cholesterol formations up to 2 cm. Pigment and calcareous stones cannot be dissolved in this way.

To dissolve calculi, doctors use the drugs Ursosan, Henohol, Ursofalk.

At the same time, they can stimulate organ contractions and bile secretion, for which Allochol, Holosas, Zixorin are used.

This method of treatment has some contraindications. This:

• various pathologies of the digestive tract;
• reception oral contraceptives with estrogen;
• pregnancy;
• obesity;

In addition, the method has many disadvantages, so it is not used so often.

So, after the dissolution of stones in 10 - 70% of cases, relapses may occur, because after the end of the medication, the cholesterol in the patient's body begins to grow again.

The course can last from 6 months to several years and be accompanied by diarrhea, impaired liver function tests. In addition, the cost of drugs is quite high.

crushing stones

In some situations, doctors offer the patient other ways to grind stones. For example, crushing formations with ultrasound grinds them with the help of a shock wave.

This effect allows you to grind stones up to 3 mm, after which they calmly move along the ducts and exit into the intestines.

This method is prescribed in cases where the patient has up to 4 large stones (up to 3 cm) that do not have lime in their composition.

Grinding stones with ultrasound is contraindicated in case of poor blood clotting, pathologies of the gastrointestinal tract chronic type, pregnancy.

In addition, the method has its drawbacks - after the procedure, duct blockage may occur due to vibration, and the sharp edges of stone fragments can damage the walls of the bladder.

Another way to crush stones while preserving the bile and ducts is a laser beam.

For the procedure, the doctor makes a puncture in the anterior wall of the peritoneum and the laser beam acts directly on the stones and splits them. Crushing stones with a laser lasts about 20 minutes.

This technology cannot be used by people over 60 years old, people who weigh more than 120 kg, as well as patients in serious condition.

Laser fragmentation has some disadvantages. So, during the procedure, there is a high probability of burning the organ, as a result of which an ulcer may form.

The sharp edges of stone fragments can damage the bladder and clog the ducts. In addition, this procedure is not carried out in every clinic.

Surgical treatment

Laparoscopy is an operation performed under general anesthesia using special metal conductors for this.

The peritoneum is filled with gas, a chamber is inserted inside, and stones are removed from the organ using the picture on the screen. The laparoscopy operation takes about an hour. The patient is in the hospital for about a week.

Laparoscopy is usually prescribed for calculous cholecystitis. Has laparoscopy and contraindications.

So, it is impossible to perform an operation for obesity, with large calculi, with adhesions after other operations, suppuration of the bile, problems with the heart and breathing.

Cholecystectomy is a treatment in which the stones are removed along with the bladder itself.

Indications for surgery - big sizes stones, regular recurrence of the disease with severe attacks pain, fever and other complications.

Doctors use both laparoscopy and abdominal surgery to remove the gallbladder.

With laparoscopy, the doctor makes several incisions in the abdomen: through one, the laparoscope is inserted, and through another small incision, the organ is removed.

After such an operation, the patient recovers quite quickly, in addition, it is relatively inexpensive.

As for the open abdominal surgery, the indications for its implementation are very large stones, various complications and inflammation in the organs.

With this method of treatment, the doctor makes an incision of 15 - 30 cm, which is located from the hypochondrium to the navel.

Such an operation has some disadvantages - it is a high invasiveness, the risk of infection or internal bleeding after treatment, the likelihood of death in emergency treatment.

Another minimally invasive, but at the same time rather painful method of treatment is the removal of stones through the mouth.

Unlike laser or ultrasound, the removal of stones through the mouth brings a lot unpleasant sensations sick.

People with a strong gag reflex are especially affected, since a special tube must be inserted into the mouth for the operation.

Before removing the stones through the mouth, the patient is given anesthesia, then a special tube is inserted into the mouth and advanced to the place where the stones accumulate.

It should be noted that before the advent of laser therapy, the removal of stones through the mouth was used quite often.

Treatment with folk methods

Many people suffering from gallstone disease prefer to use folk remedies to remove stones. You need to understand that folk methods treatment can be carried out only after the permission of the doctor.

For the treatment of gallstone disease, you need to use only fresh juices vegetables, as pasteurized or canned juices already lose all their useful properties.

For treatment with folk remedies, you can take the juice of one lemon, dilute it in a glass of water and drink 1 glass several times a day for about a month.

The following mixture helps to fight stones: 7 - 10 parts of carrot juice, 3 parts of cucumber and beet juice.

GSD can be treated with herbal infusions. For example, take 5 parts of celandine, wormwood, sweet clover and 3 parts of chicory, valerian, gentian and dandelion.

Everything is mixed, pour a spoonful of the mixture with a cup of boiling water. Infusion drink ¼ cup twice a day.

Although in some cases folk recipes and help get rid of gallstones, but doctors recommend using other treatments for this problem.

One of the most common pathologies is gallstone disease. Removal of stones from the gallbladder today is carried out in several ways.

general information

This pathology is found not only in people who have crossed the sixty-year threshold. The presence of gallstones is detected even in young people. In women, this disease occurs 5 times more often than in men.

The main causes of pathology

Next to the liver is the gallbladder. Its main duties are the accumulation and preservation of the bile that this organ produces.

Bile plays an important role in the process of digestion of food. It contains bilirubin and cholesterol. Their combination allows the body to "work" with fatty and protein foods.

When an infection enters the gallbladder, the outflow of bile is disrupted. This contributes to its further stagnation. Against this background, precipitation of cholesterol is observed. Sand is formed first. Then it turns into stones.

Sometimes stagnation of bile is provoked by the stones themselves. This happens when they, having reached an impressive size, block the bile ducts. The sizes of the stones vary. Small specimens move freely through the bile ducts. Formations of impressive size over time provoke the development cholelithiasis.

How pathology manifests itself

The following signs indicate that a person has stones in the gallbladder:

1. Rapid increase in body temperature.
2. Nausea.
3. Strong pain in the abdomen on the right.

Having found these signs in yourself, you should not hesitate to visit a doctor.. Otherwise, serious complications may arise.

Establishing an accurate diagnosis

It is possible to determine the method of correct removal of stones from the gallbladder only after diagnostic study. It allows you to specify:

• parameters of stones;
• the number of stones;
• location of stones;
• injury to the walls of the organ.

The patient is assigned to undergo ultrasound, X-ray, tomography, MRI or CT, as well as ENDO ultrasound.

The doctor tries to remove stones in the gallbladder in the most gentle way. But in some cases, surgery is the only treatment.

How can you help the sick

Starting treatment, the specialist specifies the type of stones in the gallbladder. Education can be:

• pigmented;
• lime;
• cholesterol;
• mixed.

The main way to remove stones from the gallbladder is cholecystectomy. Doctors also resort to dissolving stones and crushing them using ultrasound or a laser. Abdominal operations are less common today.

Dissolution of stones

If the doctor has identified cholesterol stones, the size of which does not exceed 20 mm, then surgery can be avoided. They are easily removed by dissolution.

To remove stones from the gallbladder, the following drugs are used:

1. Henohol.
2. Urofalk.
3. Ursosan.

These funds are combined with Holosas and Allochol, which provide natural bile production. This contributes to strengthening contractile function organ. Stones quickly dissolve, and their remains are painlessly removed from the body.

This treatment is not for everyone. The main contraindications are renal pathologies and gastrointestinal problems. Dissolution is not prescribed for overweight people, as well as for those who take contraceptives containing estrogens. If the dissolution was successful, then the operation is not assigned to the patient.

This manipulation has serious disadvantages. The main disadvantage is the duration of the therapeutic course.

Sometimes a person is forced to be treated for three years. Another disadvantage is the risk of relapse. Side effects of this method of therapy include upset stool.

Laser application

One of the most modern ways to remove stones from the gallbladder is laser crushing. This operation is carried out by highly qualified specialists, using powerful equipment.

A laser device is placed in the patient's body. Next, the specialist makes several punctures. After that, laser beams are released. Stones from the organ are removed after 4-6 procedures.

During this operation, particles with sharp corners are often formed that can injure the internal mucosa. Therefore, the entire course of the intervention is controlled by an ultrasound machine.

Having crushed the stones, the doctor prescribes a stimulant medicines. The main advantage of this therapeutic method is that the skin is almost not injured.

The disadvantages include the impossibility of removing stones larger than 30 mm. Doctors also identify the following shortcomings:

• receiving a laser burn;
• exacerbation of pathologies of the gastrointestinal tract;
• exacerbation of other chronic diseases.

Application of ultrasound

Another in the most efficient way, allowing to remove stones from the gallbladder, is crushing using ultrasound.

To carry out this operation, specific equipment is used. With its help, wave shocks are created, which are directed to stones. Stones crack or crumble. The crushing procedure is carried out until the formations break up into small particles, the size of which is 3 mm. This allows them to leave the gallbladder on their own.

This manipulation is also controlled by ultrasound equipment.. This eliminates injury to the inner shell of the organ by sharp corners of the particles. Exposure to ultrasound has its pros and cons. The advantages of this manipulation include:

• no mechanical damage;
• minimal harm to the body;
• fast recovery.

The main disadvantage is the risk of side effects. In addition, manipulation can provoke an exacerbation of cholecystitis and pancreatitis. The procedure is strictly contraindicated when carrying a fetus.

Surgery

Gallbladder stones can be removed with an endoscope. This operation is called laparoscopy. This manipulation involves the introduction of general anesthesia. On average, it takes no more than 60 minutes.

Carrying out laparoscopy

Trocars are inserted at the same time. These are specific conductors made of metal. They make the process easier.

The introduction of trocars is carried out through pre-made incisions. Then in abdominal cavity carbon dioxide is introduced. A device is inserted into one of the cuts, providing a display of everything that happens on the screen.

Such interference implies the presence of constant monitoring. The specialist looks for stones, grabs them and takes them out. One of the last "strokes" of the intervention is the imposition of staples on the vessels and ducts of the organ.

This procedure is not indicated for all patients. If the patient has excess weight, then laparoscopy should be abandoned. Other contraindications include respiratory pathologies, cardiac and vascular diseases. If the stones are very large, then laparoscopy is also not performed. If the doctor detects adhesions or purulent inflammation, then this therapeutic method also has to be abandoned.

In the most advanced case, not only formations are removed. The gallbladder is also removed. If the pathology recurs, or a large number of huge stones are detected in the patient, then he is prescribed a cholecystectomy.

Disadvantages of the procedure

Such a surgical intervention involves the implementation of a sufficiently large incision. Its size varies from 15 to 30 cm. An incision is located in the area between the navel and hypochondrium.

The main disadvantages of the operation include:

• risk of internal bleeding;
• the risk of infection;
• high invasiveness.

If treatment is carried out urgently, then the risk of death of the patient increases.

Removal through the mouth

Another minimally invasive way to treat the gallbladder is to remove the stones through the mouth. This is a rather painful operation, prescribed only in extreme cases. Patients who have a strong vomiting reflex. For intervention, a special tube is inserted into the patient's mouth.

Before the operation, the specialist injects anesthesia. The inserted tube moves to where the formations were found. After that, the specialist opens the probe. Having acquired the shape of an umbrella, he collects calculi and extracts through his mouth. Before the advent of the laser method, this type of operation was used quite often.

After removing the stones, the patient is prescribed a special diet. It is based on fractional nutrition. This is necessary to open the sphincter.

This helps the bile to leave the ducts freely. Human pressure remains normal, and the formation of new stones is excluded. For breakfast, it is desirable to eat porridge.

From cereals, preference should be given to rice, oatmeal and buckwheat are also useful. Porridge can be alternated with a protein omelet.

For lunch, it is recommended to cook soups. Meat should be temporarily abandoned. It should be replaced with chicken or turkey fillet. The food is steamed. Dinner should be light. Before lights out, you are allowed to drink a little low-fat kefir. Must refrain from alcohol and tobacco products. It is desirable to drink herbal decoctions, non-acidic juices, compotes and fruit drinks. From physical activity should also be temporarily discontinued.

Biliary interventions are minimally invasive procedures that are performed to treat a blockage or narrowing of the bile ducts. In addition, these techniques are used in the treatment of inflammatory or infectious lesions of the gallbladder.

Bile is biological fluid, which is involved in the processes of digestion. It is produced by liver cells, and then, through the system of bile ducts and passages, it is stored in the gallbladder. When needed, the gallbladder contracts and bile is released into the small intestine.

Blockage of the biliary tract disrupts the flow of bile into duodenum, which leads to the development of jaundice, in which the content of bile acids in the blood increases. With severe jaundice, there is a change in the color of the skin and sclera ( albuginea eyes) that acquire a yellow tint.

When blockage of the final sections of the bile ducts (for example, the common bile duct), which is possible with cholelithiasis, inflammation or infection of the gallbladder occurs, that is, cholecystitis. treatment given state is an surgical removal gallbladder: using a sparing laparoscopic technique or traditional open operation. However, in some cases, the severe condition of the patient does not allow for surgical cholecystectomy. In such situations, percutaneous cholecystostomy is possible, which is performed by a specialist. interventional radiology.

Interventions on the biliary tract include:

• Percutaneous transhepatic cholangiography (PTCHG): x-ray procedure, which involves the injection of contrast material directly into the bile ducts inside the liver, which allows them to be clearly imaged. The examination is usually performed by an interventional radiologist. If a blockage or narrowing of the ducts is detected, additional procedures may be performed:
• Endoscopic retrograde cholangiopancreatography (ERCP): a diagnostic procedure that combines the possibilities endoscopic examination using optical instruments to study the condition internal organs and x-ray examination. As a rule, ERCP is performed by a gastroenterologist. If a blockage or narrowing of the ducts is detected, additional procedures may be performed:
  • Insertion of a catheter to remove excess bile.
  • Removal of gallstones that may form in the gallbladder or bile ducts.
  • Sphincterotomy: a small incision in the area of ​​the external opening of the common bile duct, which ensures the normal outflow of bile and the exit of small gallstones.
  • Placement of a stent in the lumen of the bile duct: a small plastic or metal tube that restores the patency of the duct or forms a bypass for the normal outflow of bile.
• Laparoscopic cholecystectomy, or removal of the gallbladder. The operation is performed by a surgeon.
• Percutaneous cholecystostomy: A minimally invasive procedure in which a drain tube is inserted under image guidance into a distended, inflamed, or infected gallbladder to relieve pressure within the gallbladder. Usually this procedure indicated in a serious condition of the patient, which does not allow for cholecystectomy. Typically, treatment is performed by an interventional radiology specialist.

An interventional radiologist is a specialist who performs minimally invasive surgical procedures under imaging control. The physician has sufficient skills and experience in the use of fluoroscopy/fluoroscopy, CT and ultrasound which allows him to perform percutaneous procedures such as biopsies, the insertion of catheters and drainage tubes to remove excess fluid or drain abscesses, and the placement of stents for vasoconstriction or any ducts.

In what areas are interventions on the biliary tract used?

Blockage or narrowing of the biliary tract occurs in a number of diseases, which include:

• Inflammatory conditions: pancreatitis (inflammation of the pancreas), sclerosing cholangitis (inflammation of the bile ducts), cholecystitis (inflammation of the gallbladder)
• Tumors: cancer of the pancreas, gallbladder, liver, bile ducts, and enlargement lymph nodes against the background of various oncological and other diseases
• Gallstone disease involving the gallbladder and/or bile ducts
• Bile duct injury during surgery
• infections

In general, PTCG and ERCP can be used for all of the above conditions that are accompanied by narrowing or blockage of the biliary tract. An exception is the need to remove the gallbladder (cholecystectomy), which is performed surgically.

How should you prepare for the procedure?

Before the procedure, the doctor prescribes a short course of antibiotics to the patient. Usually, before treatment, a series of blood tests are also performed, which allow you to evaluate the function of the liver and kidneys, as well as the work of the blood clotting system.

It is very important to tell the doctor about all medications the patient is taking, including plant origin, as well as the presence of allergies, especially to local anesthetics, drugs for anesthesia or iodine-containing contrast materials. Some time before the procedure, you should stop taking aspirin or other drugs that thin the blood, as well as non-steroidal anti-inflammatory drugs.

You should also tell your doctor if you have recently previous diseases or other conditions.

Women should always inform their physician and radiologist of any possibility of pregnancy. As a rule, X-ray examinations are not performed during pregnancy in order to avoid negative impact to the fruit. If necessary x-ray examination everything should be done possible measures to minimize the effect of radiation on the developing child.

The physician must provide the patient detailed instructions on preparation for the procedure, including any necessary changes to the usual drug regimen.

In addition, a few hours before the procedure, you should stop eating and drinking.

For the duration of the procedure, it is necessary to remove some or all of the clothes and put on a special hospital gown. In addition, remove all jewelry, eyeglasses, and any metal or clothing items that may interfere with the x-ray image.

It is advisable to come to the hospital with a relative or friend who will help the patient get home.

Some interventions on the biliary tract require short-term hospitalization.

What does the equipment for the procedure look like?

For interventions on the biliary tract, X-ray or ultrasound equipment, as well as a CT scanner, can be used. In addition, the physician may require devices such as endoscopes, laparoscopes, catheters, and/or stents.

X-ray equipment:

For this type of procedure, an X-ray tube, a patient table and a monitor located in the radiologist's office are usually used. To monitor the process and to control the doctor's actions, a fluoroscope is used, which converts x-rays into a video image. To improve the quality of images, a special amplifier is used, suspended above the patient table.

Ultrasonic equipment:

The ultrasound scanner consists of a console that includes a computer and electronic equipment, a video display and an ultrasound sensor used to scan internal organs and blood vessels. The sensor is a small handheld device that resembles a microphone and is connected to the scanner with an electrical cord. The ultrasound transducer sends high-frequency sound signals and picks up the echo reflected from the internal structures of the body. The principle of operation of the device is similar to sonars, which are used on submarines.

At the same time, an image instantly appears on a monitor resembling a television or computer screen. His appearance depends on the amplitude (strength), frequency and time it takes for the sound signal to return from the patient's body to the transducer.

CT Scanner:

A CT scanner is a massive rectangular machine with a hole, or tunnel, in the middle. During the procedure, the patient is placed on a narrow table that slides inside a tunnel. The X-ray tube and electronic X-ray detectors are located opposite each other inside a ring-shaped structure called a gantry. In a separate office there is a computer workstation, where the processing of the received image is carried out.

There is also a doctor or technologist who controls the operation of the tomograph and the course of the examination. The CT scanner produces x-ray images or "sections" of tissues and organs with a thickness of 0.1 to 1 cm.

Optional equipment:

• Catheter: a long thin plastic tube of extremely small diameter
• Balloon catheter: a long thin plastic tube with a small balloon at the end
• Stent: a small plastic tube or mesh frame design
• Endoscope: an optical instrument with a light that is used to examine the internal organs
• Laparoscope: a thin, tube-shaped instrument with a light and a lens that allows you to view the inside of the abdomen

What is the procedure based on?

At percutaneous transhepatic cholangiography(ChCHG) contrast material is injected into the bile ducts under imaging control, which makes it possible to obtain an x-ray image of the bile ducts and gallbladder.

Endoscopic retrograde cholangiopancreatography(ERCP) combines endoscopic and x-ray examination of the bile ducts, gallbladder and pancreatic ducts and allows you to get their x-ray image.

At percutaneous cholecystostomy imaging control is used to place a drain tube into an infected or inflamed gallbladder. This ensures the normal outflow of bile from the gallbladder.

Laparoscopic cholecystectomy This is a procedure during which a laparoscope is inserted into the abdominal cavity through a small incision in the navel, which is a thin instrument in the form of a tube with a light bulb and a lens at the end. This allows you to see the state of the abdominal cavity from the inside on the monitor screen. After that, the surgeon under imaging control highlights the gallbladder and removes it through a small incision in the anterior abdominal wall. If it is impossible to perform a laparoscopic operation, the doctor uses the traditional removal of the gallbladder by open access.

How is the procedure carried out?

In some cases, the procedures are performed on an outpatient basis, while other situations require a short-term hospitalization of the patient. About the features of the treatment should be consulted with your doctor.

Before the procedure, the doctor prescribes an examination: ultrasound, computed tomography(CT) and/or magnetic resonance imaging (MRI).

Antibiotics are used to prevent infection; nausea and pain syndrome can be controlled by special drugs.

The doctor helps the patient to sit on the operating table. To control the heartbeat, pulse and blood pressure during the procedure, devices are used that are connected to the patient's body.

The nurse sets up an intravenous infusion system, with which the patient will be sedated. In other cases, general anesthesia is possible.

Endoscopic retrograde cholangiopancreatography (ERCP):

The endoscope is inserted into the initial sections of the small intestine through the mouth, esophagus and stomach, after which a thin catheter is passed through it, and the contrast material enters directly into the bile ducts. Then an x-ray is taken.

Percutaneous transhepatic cholangiography (PTCHG):

The skin at the injection site of the needle or laparoscope is thoroughly cleaned of hair, disinfected and covered with a surgical sheet.

A pinpoint skin incision or a small puncture is performed.

Under x-ray control, a thin needle is inserted into the liver through the skin in the area below the ribs, through which a contrast material enters the liver tissue and bile ducts. After that, there are x-rays. If a blockage of the bile ducts is detected in the patient's body, a special catheter may be temporarily left, which ensures the outflow of bile into the small intestine or an external reservoir.

The stent is placed under imaging control. A stent is placed in the narrowing of the bile duct to keep it open. A special balloon catheter can be used to widen the narrowed duct.

During the procedures, self-expanding stents are used, which expand on their own after placement. There are also stents that require a balloon to deploy. Such stents are usually combined with a balloon catheter, so after the expansion of the balloon, the stent expands and is located along the inner surface bile duct. After the balloon is collapsed and removed, the stent remains in place and helps keep the duct open. Removal of gallstones: If the x-ray shows the presence of a stone in the common bile duct, the doctor makes a small incision in its wall and removes the foreign object.

Laparoscopic cholecystectomy:

A laparoscope, which is a thin tube-shaped instrument with a light and a lens at the end, is inserted into the abdominal cavity through a small incision near the navel. For best view in the area of ​​​​the proposed surgical intervention, carbon dioxide is pumped into the abdominal cavity. Near the insertion site of the laparoscope, the surgeon makes three additional incisions through which special surgical instruments are inserted.

The gallbladder is removed under the control of images that are projected onto the monitor screen from the lens at the end of the laparoscope.

After the end of the operation nurse removes an intravenous catheter for infusion of drugs.

What should I expect during and after the procedure?

Devices are connected to the patient's body to monitor heartbeats and blood pressure.

When setting up the system for intravenous infusion, as well as with the introduction of a local anesthetic, you can feel a slight prick.

When using general anesthesia during the procedure, the patient is unconscious, and his condition is monitored by an anesthesiologist.

If the procedure is carried out under local anesthesia, then sedative (sedative) drugs are administered intravenously, which is accompanied by drowsiness and a feeling of relaxation. Depending on the degree of sedation, the patient's consciousness may or may not be preserved.

The introduction of a contrast material is often accompanied by a feeling of warmth or heat.

Until full recovery of consciousness after the completion of the procedure, the patient remains in the intensive care unit.

In general, after all the described procedures, a complete return to normal life is possible within a few next days. In some cases, the doctor leaves a drainage tube in the patient's body, through which the bile flows into a special external reservoir. The duration of the drainage tube stay depends on each specific case of the disease. More detailed information can be obtained from your physician.

Who studies the results of the procedure and where can they be obtained?

The analysis of the results of the procedure is carried out by an interventional radiology specialist, who prepares and signs a report for the attending physician.

After completion of the procedure or other treatment, the specialist may recommend to the patient a follow-up dynamic examination, during which an objective examination, blood tests or other tests are performed and instrumental examination. During this examination, the patient can discuss with the doctor any changes or side effects that appeared after the treatment.

Benefits and risks of interventions on the biliary tract

Advantages:

• PTCG and similar procedures do not require surgical incisions: the doctor makes only a small puncture of the skin, which does not even need to be closed with sutures. Surgical incisions are also not required for ERCP and similar procedures. Very small incisions are only necessary for laparoscopic interventions.
• The described procedures avoid the risks of open access surgery.
• The duration of hospitalization is reduced.
• The rehabilitation period is significantly reduced compared to open surgery.

Risks:

• Any procedure that involves breaking the integrity of the skin carries the risk of infection. However, in this case the chance of developing an infection that requires antibiotic therapy is less than 1 in 1000 cases.
• There is a very small risk of developing allergic reaction on contrast material.
• In rare cases, the procedure is accompanied by bleeding, which, however, almost always stops on its own. If necessary, treatment is carried out arterial embolization, which is a low-traumatic procedure.
• There is a very small risk of damage to internal organs, such as perforation of the intestinal wall.

Restrictions during interventions on the biliary tract

Minimally invasive procedures such as biliary interventions are not suitable for all patients. Therefore, the decision on the possibility of using a particular technique in a particular case of the disease is made jointly by the attending physician and a specialist in interventional radiology.

In general, minimally invasive techniques are preferred over open ones. surgical interventions, however, in some situations they cannot be used. In such cases, the doctor chooses open access surgery.

Sometimes there is a recurrence of the disease, such as blockage of the installed stent or the development of cholecystitis. In such situations, repeated intervention on the biliary tract is required. If the doctor does not consider it possible, then an open surgical operation is performed.

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Gallstone disease (GSD), cholelithiasis is the formation of stones (calculi) in the gallbladder, bile ducts. Stones in the gallbladder

maintain inflammation in it and lead to the development of cholecystitis.

These stones can enter the choledochus (bile duct) from the gallbladder through the cystic duct or form directly in the common

bile duct, even in patients after a previous cholecystectomy (removal of the gallbladder).

Gallstones periodically cause blockage of the bile ducts, which, depending on its level and extent, may manifest

bile colic, jaundice, cholangitis or pancreatitis.

Asymptomatic choledocholithiasis is usually detected during cholangiography (magnetic resonance imaging, computed tomography)

approximately 15% of patients undergoing cholecystectomy.

Blockage of the bile ducts is the starting link in a chain of disorders that begin with an increase in pressure in the ducts. Sometimes when

a significant increase in the stone that causes blockage of the ducts can move and independently pass into the duodenum. If

uh If this does not happen, then the bile ducts above the site of blockage expand and complications may develop.

Pain that occurs in patients with choledocholithiasis is similar to pain in acute cholecystitis. Pain is localized, usually in the epigastric

area or right hypochondrium and in some cases radiate to the back.

In those cases when there is a "jamming" of the stone at the level of the ampulla of the major duodenal papilla, the pains are girdle,

since in the process involves the pancreatic duct.

Patients with obstructive jaundice, which develops due to prolonged blockage of the bile ducts, note darkening of the urine and lightening of the feces

(up to completely white - the so-called acholic). Often there is nausea and vomiting, complaints of back pain.

In asymptomatic choledocholithiasis, laboratory values ​​may be within normal limits, although screening tests for functional

liver tests sometimes show elevated levels of alkaline phosphatase or total bilirubin.

Patients with symptomatic choledocholithiasis may experience jaundice (both clinically and biochemically) with

an increase in the level of alkaline phosphatase and transaminases. An increase in the content of only alkaline phosphatase does not play a big role in the formulation

the diagnosis of choledocholithiasis, but in combination with the expansion of the bile ducts or an increase in the level of total bilirubin, the value of this enzyme

rises.

In addition, the degree of increase in the level of liver enzymes does not always correspond to the degree of obstruction. biliary tract. Increase

decrease) is hallmark choledocholithiasis and helps to differentiate between benign and malignant disorders

patency of the bile ducts. Although all these symptoms cannot give an accurate picture and mask under the suspicion of choledocholithiasis, for example, cancer

bile ducts.

Diagnostic manipulations to make a diagnosis of choledocholithiasis include ultrasound scanning, magnetic resonance

tomography (MRI), spiral computed tomography (SCT), endoscopic ultrasonography (EndoUzi).

Endoscopic cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography for diagnostic purposes is currently not

apply.

Ultrasound scanning can detect either a stone in the common bile duct (quite rare) or an enlarged bile duct.

A more accurate diagnostic method is MRI and EndoUzi.

Causes.

One of the main reasons is the violation of the diet. People who often eat fatty, fried foods suffer from this disease much more often.

Excessive body weight, hypovitaminosis, physical inactivity also lead to the occurrence of stones in the gallbladder and bile ducts. In people who

suffer from chronic pain for a long time calculous cholecystitis(gallstones) and who do not undergo surgery to remove the gallbladder for a long time

bladder (cholecystectomy) cholelithiasis is more common. Women get sick 3-4 times more often than men.

The main manifestations (clinic) of the disease.

The main manifestations include pain in the right hypochondrium, which often occurs after eating fatty foods. Pain may radiate to the right

hand, right scapula, lumbar, subscapular or subclavian region. Also, some time after the pain attack may appear

yellowness of the sclera and skin. Other manifestations include nausea, vomiting, and sometimes fever.

Major complications and course of the disease.

The appearance or formation of calculi (stones) in the bile ducts is already a complication of cholelithiasis. Only in rare cases

The primary site where gallstones form is not the gallbladder, but the bile duct itself. In cases where

an infection joins, inflammation of the bile ducts develops - cholangitis, often purulent cholangitis.

A formidable complication is obstructive jaundice, which occurs when a stone clogs both the common bile duct and

pancreatic duct. In such cases, the bile that is produced in the liver is not able to flow into the duodenum.

gut. Typically, in such cases, severe inflammation pancreas, pancreatitis, and sometimes pancreatic necrosis (death and

self-digestion of the pancreas), which poses an immediate threat to the life of the patient.

Diagnostics.

To date, the gold standard in the diagnosis of gallstone disease is an ultrasound examination (ultrasound) of the abdominal cavity. V

in the vast majority of cases, this is enough, but sometimes to clarify the diagnosis, and especially in the event of complications, they use

computed tomography (CT), magnetic resonance imaging (MRI), spiral computed tomography (SCT), endoscopic

ultrasonography (EndoUzi). These studies are confirmed by a biochemical blood test, in which, with the development of obstructive jaundice,

the level of such a bile pigment as bilirubin rises.

Disease treatment.

gold standard is the performance of therapeutic endoscopic cholangiopancreatography (ERCP), in which it is possible to perform

papilotomy and removal of stones from the bile ducts.

Numerous attempts to treat such a disease conservatively, such as drug therapy, a variety of folk methods, attempts to crush

stones (lithotripsy) with their subsequent withdrawal have proven to be ineffective, and in many cases even life-threatening. And if in some

cases positive effect still attacked, then after a while the stones still formed, which forced the patients to turn to

surgeons. At the same time, at the time of treatment, patients, as a rule, are already ill long time, often the disease is already with complications, and therefore the operation

much harder to do. It is very dangerous to prescribe choleretic drugs or folk methods that cause choleretic

the effect. In the overwhelming majority of cases, such patients come to the surgeon already with terrible complications, since the stones clog

bile ducts, causing jaundice, pancreatitis, pancreatic necrosis and others.

Since in this pathology, calculi are more often present both in the gallbladder and in the bile ducts, the main task of treatment is

is the removal of the gallbladder and the removal of stones from the bile ducts. After removal of stones from the bile duct, it is advisable

removal of the gallbladder (cholecystectomy).

To date, this is the only way to eliminate the cause of the disease and return the patient to normal life. Before the operation

surgeon must know for sure whether or not there are stones in the bile ducts, which are possible only

as a result of detailed preoperative about the survey.

The common bile duct (choledoch) flows into the duodenum. At the confluence there is a so-called major duodenal papilla

intestines (Vater's nipple). Therefore, treatment begins with expanding the place where the duct flows into the intestine, i.e. cut its mouth, thereby

increasing the diameter of the duct, which allows calculi, which are often relatively small, but in some

cases can reach a significant size (up to 4-5 cm), go out on their own with a current of bile. This technology is called endoscopic

retrograde cholangiopancreatography (ERCPG), which is supplemented by dissection of the papilla (papilosphincterotomy).

Often, those stones that are close can be pulled out using special tools directly during the procedure (lithoextraction).

This procedure, in fact, made a revolution in the treatment of such patients, because for its implementation it is not necessary to make any abdominal incisions at all.

A thin endoscope is inserted through the mouth and passed into the duodenum. With its help, the endoscopy surgeon sees the image

on the monitor. The endoscope contains narrow channels through which special ultra-precise instruments are inserted, which is used to make

operation - contrast is introduced,the duct is cut, stones are pulled out. This operation is performed under intravenous anesthesia and is performed

only in specialized s centers by experienced specialists, since the procedure is very technically complex, and its incorrect implementation

can lead to very seriousconsequences. In the case when the procedure was successful, after it, the removal of the gallbladder is already performed.

bladder - cholecystectomy.

Worldwide, the "gold standard" in the treatment of gallstone disease is laparoscopic cholecystectomy. It consists of removing the gallbladder

bubbles along with stones using special equipment.

So, instead of a large traditional incision in the abdominal cavity, 3-4 incisions up to 1 cm are performed. Through these incisions (punctures), a camera is inserted into the abdomen,

which transmits the image to the monitor, and thin ultra-precise instruments with which the operation is performed. Such operations

performed under general anesthesia, the duration of the operation is on average no more than an hour.

This technique, in fact, made a revolution in surgery, because thanks to its implementation, overwhelming advantages appeared in comparison with

with traditional methods.

So, for example, a patient after surgery can be discharged already on the 3rd-4th day, there is no large postoperative scar, instead there is

3-4 small scars, which are sewn up with one cosmetic seam - an impeccable cosmetic effect. With this method, in fact

there is no possibility of infection in the abdominal cavity and in the wound. Due to small incisions, there are virtually no

complications such as postoperative hernia. Pain syndrome so small that the vast majority are not even assigned strong

narcotic painkillers, however, conventional analgesics are sufficient. Another advantage is the much smaller

psychologicaltrauma and a very short time of social and labor rehabilitation sick. All these advantages have resulted in

what this technique everywhereworldwide recognized as the "Gold Standard" in the treatment of gallstone disease.

True, there are situations when it is not possible to get into the bile ducts endoscopically, laparoscopic or traditional

operation to extract stones from the ducts. This happens quite rarely, in professional hands, due to anatomical features,

the impossibility of passing instruments into the bile duct due to tumor damage, for example, the head of the pancreas.

Postoperative rehabilitation.

Patients who have undergone surgery for a year adhere to a diet that limits the consumption of fatty, fried foods.

meals and foods that are rich in cholesterol. Strong physical activity is also limited for the first few months. After graduation

rehabilitation period, a person is considered healthy.