SMOLENSK STATE MEDICAL ACADEMY

MEDICAL FACULTY

DEPARTMENT OF HOSPITAL SURGERY

Discussed at the methodical meeting

(Protocol #3)

METHODOLOGICAL DEVELOPMENT
TO THE PRACTICE

Topic: “Complicated cholecystitis.

Postcholecystectomy syndrome”

methodological development
compiled by: assistant Nekrasov A.Yu.

METHODOLOGICAL DEVELOPMENT

(for students)

to a practical lesson at the Department of Hospital Surgery

Topic: » Complicated cholecystitis.

postcholecystectomy syndrome

Lesson duration - 5 hours

I. Lesson Plan

	Stage	Location
	Participation in the morning conference of doctors of the hospital surgery clinic	Conference hall of the department
	Organizational events	study room
	Checking background knowledge on a topic
	curation of patients	Chambers, dressing room
	Analysis of supervised patients
	Discussion of the topic of the lesson	study chamber
	Control of assimilation of material
	Test control of knowledge
	Solution of situational problems
	Determining the task for the next lesson

II. Motivation.

1. Objectives of the study.

The student must be able to:

a) assess the patient's complaints, identifying early signs of the disease (pain, symptoms of cholecystitis);

b) collect a detailed history of the disease, paying special attention to the duration of the manifestations of diseases; possible connection with lifestyle, nutrition, bad habits; previous treatment;

c) identify past diseases in anamnesis, assess lifestyle and working conditions, collect dietary and family history;

d) during physical examination, pay attention to the condition of the skin, peripheral lymph nodes, the presence of signs of jaundice, peritonitis, intoxication;

e) evaluate the data of laboratory and instrumental (OAC, OAM, B\C, ultrasound, cholangiography) research methods;

f) independently determine the patient's blood group, perform the necessary tests for the compatibility of transfused blood products;

g) prepare the patient for examination methods (ultrasound).

The student must know:

n the disease in the early stages is manifested only by nausea, vomiting, pain;

n the disease at an early stage of the disease can be determined by careful collection of anamnesis and complaints

n already at the first treatment with complaints of pain in the right hypochondrium, it is necessary to conduct an ultrasound scan

n the difficulties of timely diagnosis are due to the late treatment of patients;

n conservative methods of treatment are indicated only for uncomplicated forms;

n patients with destructive forms are subject to surgical treatment;

n Mandatory treatment is antispasmodics, analgesics;

n unfavorable prognostic factors are patients with complicated forms.

IV-A. Basic knowledge.

Anatomy of the liver.

Lectures on normal anatomy.

Surgical anatomy of the liver.

Lectures on topographic anatomy.

Functions of the liver.

Lectures on physiology, propaedeutics of internal diseases.

Liver dysfunction.

Lectures on pathological physiology.

Innervation of the liver.

Blood supply to the liver.

Lectures on normal anatomy, topographic anatomy.

IV-B. Literature on the new topic.

Main:

Surgical diseases / Ed. M.I. Kuzina (MMA). MZ textbook. - Publishing house "Medicine", 2000.
Surgical diseases / Textbook of the Ministry of Health. - Publishing house "Medicine", 2002.
Surgery / Ed. Yu.M. Lopukhina, V.S. Saveliev (RSMU). Textbook UMO MZ. - Publishing house "GEOTARMED", 1997.
Surgical diseases / Ed. Yu.L. Shevchenko. MZ textbook. - 2 volumes. - Publishing house "Medicine", 2001.
Lectures on the course of hospital surgery.

Additional:

Methodological development of the department on the topic “Complicated cholecystitis.

Postcholecystectomy syndrome.

1. Questions for self-preparation:

a) on basic knowledge;

Anatomy of the liver.
Distinctive anatomical features of the liver.
Liver functions and their disorders.
Blood supply to the liver.
Innervation of the liver.
Physiology of the act of digestion.

b) on a new topic:

1. The incidence of the disease

2. Classification

3. Diagnosis of acute cholecystitis.

4. Special symptoms of cholecystitis

5. Complications of acute cholecystitis

6. Additional research methods

7. Differential diagnosis

8. Treatment of patients with acute cholecystitis

9. Surgical interventions

10. Indications for choledochotomy

11. Mortality in acute cholecystitis

12. Postcholecystectomy syndrome

2. Lesson content.

Acute cholecystitis, often combined and complicating cholelithiasis (GSD), among all acute diseases of the abdominal organs takes the 2nd place, and according to some recent statistics, even the 1st place, accounting for 20-25% of them. GSD affects 10 to 20% of the world's population, 40% of people over 60 and 50% over 70 years of age. In recent years, there has been an increase in diseases of the biliary tract, which is associated: a) with an irrational, high-fat diet, b) with an increase in life expectancy.

Pathologically, there are:

Among acute cholecystitis
1) simple (catarrhal) cholecystitis,
2) destructive - phlegmonous, gangrenous, perforative.
Among chronic cholecystitis
1) hypertrophic,
2) atrophic,
3) dropsy of the gallbladder.

The latter is an absolute indication for surgery.

Diagnosis of acute cholecystitis in cases of a typical course of the disease is not difficult. Characterized by pain in the right hypochondrium and epigastrium with irradiation to the right shoulder, shoulder blade, supraclavicular region (along the phrenic nerve). Sometimes pain is accompanied by reflex angina pectoris, which was also noted by D.S. Botkin.

The pains are either in the nature of hepatic colic - very sharp, in which patients are restless, rush about, changing the position of the body, most often with cholelithiasis, with blockage of the cystic duct or common bile duct with a stone, less often with mucus or pus. In other cases, the pains increase gradually, the patients lie down, afraid to move, “to move”, which is observed when the inflammatory process prevails, the bladder is stretched by inflammatory exudate and the peritoneum is involved in the process.

Pain is preceded by errors in the diet (fatty, spicy, food), physical overstrain, sometimes a nervous shock. Accompanying - vomiting - repeated, scanty, painful, not bringing relief. The pulse in the presence of an inflammatory component is quickened, sometimes arrhythmic, in the presence of jaundice it can be slowed down. Body temperature - with colic is normal, in the presence of inflammation it rises, sometimes to high numbers, with complications of cholangitis, chills may occur. In old people, even with destructive forms, the temperature can remain normal.

The abdomen is limitedly involved in breathing in the upper section, painful and tense in the right hypochondrium, here, with destructive forms, protective muscle tension is noted, a positive symptom of Shchetkin-Blumberg and Mendel.

Special symptoms of cholecystitis:

Symptom Zakharyin - soreness with pressure in the projection of the gallbladder.
Symptom Obraztsov - increased pain with pressure in the right hypochondrium on inspiration.
Symptom Ortner-Grekov - pain when tapping the edge of the palm on the right costal arch.
Symptom Georgievsky-Mussi (symptom of the phrenic nerve) - pain when pressed between the legs of the sternocleidomastoid muscle.
Sometimes Courvoisier's symptom may be positive - the gallbladder or perepiscal infiltrate is palpated (although this symptom is described in cancer of the pancreatic head and, strictly speaking, is not a symptom of cholecystitis.
Jaundice - observed in 40-70% of patients, more often with calculous forms, when it has the character of obstructive, mechanical. It can be a consequence of secondary hepatitis or concomitant pancreatitis, as well as cholangitis - then it can be parenchymal. Obstructive jaundice of calculous genesis is usually preceded by an attack of hepatic colic, it can be remittent in nature (unlike obstructive jaundice of tumor origin, which develops gradually and progressively increases). With complete obstruction of the choledochus, in addition to the intense color of urine (due to the presence of bilirubin) - “the color of beer”, “strong tea”, feces become discolored - there is no stercobilin in it - “yellow man with white feces”.

The liver is enlarged, there is no splenomegaly (unlike hemolytic jaundice). With prolonged jaundice, the death of liver cells occurs, "white bile" is secreted, liver failure develops with a transition to a coma. Enzymatic and vascular cholecystitis quickly progress and pass into a destructive form.

Perforation with local delimitation of the process: a) infiltration; b) abscess.
Diffuse bile peritonitis without delimitation.
Subhepatic, subdiaphragmatic and other localization abscesses,
Cholangitis, angiocholitis followed by liver abscess and biliary cirrhosis.
Pancreatitis.

Additional Research

The number of leukocytes in the blood and the amylase of blood and urine are urgently determined. If possible, from biochemical studies - blood for bilirubin and its fractions, cholesterol (normally up to 6.3 m / mol / liter), B-lipoproteins (up to 5.5 g / l), sugar, protein and its fractions, prothrombin index , transaminases and blood amylase. With jaundice - bilirubin and urobilin are examined in the urine, stercobilin - in the feces.

Ultrasound examination (ultrasound) is very valuable and, if possible, should be performed as an emergency. It allows you to identify the presence of stones in the biliary tract, the size of the gallbladder and signs of inflammation of its walls (thickening them, bypass).

Fibrogastroduodenoscopy (FGS) is indicated in the presence of jaundice - it makes it possible to see the secretion of bile or its absence from the Vater nipple, as well as the calculus wedged in it. In the presence of equipment, retrograde cholangio-pancreatography (RCPG) is possible.

Oral or intravenous contrast-enhanced cholangiography can be performed only after the disappearance of jaundice and subsidence of acute phenomena and is now rarely resorted to. In diagnostically unclear cases, laparoscopy is indicated. which gives a positive result in 95% of cases.

Differential diagnostic difficulties usually arise in cases of atypical course of acute cholecystitis.

With acute appendicitis
a) with a high location of the appendix - subhepatic or with volvulus of the large intestine during embryonic development, when the caecum along with the appendix is in the right hypochondrium.
b) With a low location of the gallbladder, with enteroptosis, most often in the elderly.
With a perforated ulcer, usually duodenal or pyloric, with a small diameter perforated hole, with covered perforation.
In the presence of jaundice, when it becomes necessary to differentiate obstructive jaundice of calculous nature from tumor (cancer of the head of the pancreas or Vater's nipple), and sometimes from parenchymal and even hemolytic.
With acute pancreatitis, which often accompanies diseases of the biliary tract and it is necessary to decide what is primary, cholecystopancreatitis or pancreatocholecystitis prevails in the clinical picture.
With right-sided renal colic, sometimes in the absence of typical irradiation and symptoms.
With high small bowel obstruction, especially when the duodenum is obstructed by a gallstone as a result of a decubitus ulcer of the gallbladder wall and duodenum by a stone.
With angina pectoris and myocardial infarction, given that an attack of hepatic colic can provoke and be accompanied by angina pectoris.
With lower lobe right-sided pneumonia, especially when the diaphragmatic pleura is involved in the process.

In cases of diagnostic difficulties, an anamnesis should be collected in particular detail, a thorough examination of the abdomen with a check of the symptoms of all the listed diseases, additional research data should be conducted and analyzed.

Treatment of patients with acute cholecystitis from the first hour of admission to the clinic should begin with intensive complex pathogenetic therapy aimed both at the underlying disease and at a possible reduction in the severity of the patient's condition associated with the presence of age-related or concomitant diseases (which need to be identified during this period) . It includes:

rest (bed rest in a surgical hospital),
diet (table 5a, in the presence of pancreatitis - hunger),
cold in the presence of inflammation.
atropine, with colic with promedol,
novocaine blockade according to Vishnevsky - pararenal on the right, round ligament of the liver (Vinogradov),
broad-spectrum antibiotics, the desirable tetracycline series, which creates a high concentration in the biliary tract,
infusion detoxification therapy,
symptomatic treatment of concomitant diseases. Indications for surgery are perforation of the bladder with peritonitis, the threat of perforation, i.e. destructive cholecystitis, especially with its enzymatic or atherosclerotic (vascular) form, complicated forms - abscesses, obstructive jaundice, cholangitis.

According to the terms of surgical intervention, there are:

a) An emergency operation, in the first hours after the patient's admission, is indicated in the presence of perforation, peritonitis. Preoperative preparation is carried out on the operating table. In other cases, patients are prescribed complex intensive therapy, which is also a preoperative preparation, an examination is carried out, including ultrasound.

b) If conservative treatment during the day does not give an effect, an urgent operation is indicated, which is usually performed on the 2-3rd day from the onset of the disease.

c) If conservative therapy leads to the relief of an acute process, it is better to perform the operation in a delayed period (after 8-14 days), without discharging the patient, after preliminary preparation and examination.

Such is the tactics of the country's leading surgeons (Petrovsky, Vinogradov, Vishnevsky, and others). In these cases (in the absence of a history of jaundice), it can be performed laparoscopically. An emergency operation is accompanied by mortality - 37.2%, urgent - 2.6%, delayed - 1.1% (Kuzin). With the failure of conservative treatment, the recurrence of attacks and the absence of signs of intoxication, it is necessary to exclude biliary dyskinesia. An absolute indication for surgery is dropsy of the gallbladder - surgical treatment is indicated.

Anesthesia - intubation anesthesia, epidural anesthesia. Accesses: more often Fedorovsky, parallel to the costal arch, less often pararectal or median. The latter is used in combination with umbilical hernias and diastasis of the rectus muscles or, if necessary, simultaneous intervention on the stomach.

The operation on the biliary tract must necessarily begin:

a) from the revision of the hepato-pancreatoduodenal zone,

b) examination of the gallbladder, its size, the condition of its walls. Determination of the presence of stones in it, which is sometimes possible only when its contents are suctioned,

c) examination of the hepatoduodenal ligament and the common bile duct passing through it with the determination of its diameter (more than 1.2 cm indicates a violation of the outflow).

d) transillumination of the duct in order to identify stones,

e) cholangiography by introducing contrast by puncturing the choledochus or cannulating the cystic duct according to Halsted-Pikovsky,

f) in the presence of signs of hypertension - manometry,

g) examination and palpation of the pancreas, especially its head and nipple of Vater,

h) after opening the duct - choledochotomy - the nature of the bile is determined - putty-like, with a stone, transparent, cloudy, probing and bougienage of the duct in order to detect patency in the duodenum,

i) with an enlarged duct and suspicion of the presence of a stone - choledochoscopy,

The main surgical intervention for cholecystitis is cholecystectomy - removal of the gallbladder: (from the bottom to the neck or from the neck with isolated ligation of the cystic artery and cystic duct).

In rare cases, in extremely severe, elderly patients, with technical difficulties in removal and insufficient qualification of the surgeon, cholecystostomy with drainage of the bladder is performed. This operation is purely palliative, it is impossible with gangrenous forms, and subsequently, a significant proportion of patients require a second operation - cholecystectomy. In recent years, in elderly patients with a high degree of surgical risk, especially in the presence of jaundice, cholecystostomy by laparoscopy is recommended as the first stage for decompression and sanitation of the biliary tract.

Choledochotomy - opening of the choledochus is indicated when the choledochus expands more than 1.2 cm, blockage of the duct by a stone, multiple stones, cholangitis, insufficient patency of the terminal section of the choledochus or sphincter, and symptoms of biliary hypertension. It is accompanied by the extraction of stones, bougienage and probing, and sometimes cholangioscopy. It can end with a) a blind suture, b) external drainage (according to Vishnevsky, according to Pikovsky-Holstead through the cystic duct with its sufficient diameter, T-shaped). c) internal drainage - the imposition of bypass, biliodigestive anastomoses - choledocho-duodenal or choledocho-jejunal.

External drainage is indicated in case of good patency in the duodenum 12: a) with cholangitis (cloudy bile, history of chills), b) with choledochus enlargement (1.2-1.5 cm, c) biliary hypertension, e) after prolonged obturation with a stone, e) concomitant pancreatitis, subject to the patency of Vater's nipple. With it, antegrade (through drainage) cholangiography is possible in the future.

Internal drainage is indicated: a) with a pronounced extended structure of the distal choledochus, b) with a tightly wedged, non-extractable stone in the region of the Vater nipple, c) with multiple stones or putty-like bile. In the last two cases, as well as with stenosing papillitis, transduodenal papillosphincterotomy and papillosphincteroplasty are now more often performed. In the presence of special equipment, papillotomy can be performed endoscopically.

All operations on the biliary tract end with obligatory drainage of the subhepatic space.

The postoperative period - according to the scheme, as in the preoperative period. Enzyme inhibitors, detoxification agents, transfusion of blood components, protein substitutes, desensitizers are added; anticoagulants (as indicated). Early movements, lung ventilation /oxygenation/. The drainage usually changes on the 4th day and is removed individually. Drainage from the common bile duct is removed no earlier than 10-12 days.

Mortality varies widely depending on the timing of the operation (this has already been said), the age of patients, complications. On average, it ranges from 4 to 10%, in the elderly - 10-26%. In our clinic, the overall mortality rate is 4.5%, in people older than 60 years, 18.6%.

Postcholecystectomy syndrome

Often this diagnosis is made in the presence of pain, dyspepsia in patients who have undergone cholecystectomy. According to the clinic of academician Petrovsky, only in 23.3% of patients these phenomena were associated with an error during the operation or the operation itself. In 53.3% of patients, they were due to the long-term existence of cholecystitis before surgery, the presence of associated chronic pancreatitis, hepatitis, or concomitant diseases of the abdominal organs. It is necessary to operate patients earlier, before the occurrence of complications of cholecystitis. “Surgeons must prove the need for timely surgical intervention for cholecystitis to both patients and their attending physicians” (A.D. Ochkin).

VII.Scheme of examination of the patient.

When identifying complaints, pay special attention to pain in the right hypochondrium.

Collecting an anamnesis of the disease, pay special attention to the time of the first signs of the disease.

In the long-term history, identify past diseases, collect dietary and family history.

During a physical examination, pay attention to the condition of the skin, peripheral lymph nodes, the presence of signs of jaundice, peritonitis, intoxication.

When identifying signs of acute cholecystitis, one should resort to additional laboratory and instrumental diagnostic methods (OAC, OAM, B\C, ultrasound, cholangiography).

VIII.situational tasks.

1. A 47-year-old patient was admitted to the clinic with complaints of pain in the right hypochondrium, nausea, general malaise, fever. For two days he noted the appearance of pain, after an error in the diet, he was treated independently. During the examination, the pulse was 82 beats per minute, body temperature was 37.9 degrees. On palpation in the right hypochondrium, pain in the right hypochondrium is determined. Symptoms of peritoneal irritation are not detected.

Sample response. Taking into account the history of the disease, the presence of a clinic of the inflammatory process, acute cholecystitis can be suspected in the patient. It should be differentiated from pancreatitis, peptic ulcer of the 12th section of the intestine. For specification of the diagnosis it is necessary to make urgently US, FGDS. With the diagnosis of “Acute cholecystitis”, conservative therapy is indicated, with the ineffectiveness of the last operation.

2. A 42-year-old patient was admitted to the clinic with complaints of pain in the right hypochondrium, nausea, general malaise, fever, jaundice. For 4 days she noted the appearance of pain, jaundice after an error in the diet, was treated independently. During the examination, the pulse was 72 beats per minute, body temperature was 37.6 degrees. The yellowness of the skin is revealed. On palpation in the right hypochondrium, pain in the right hypochondrium is determined. Symptoms of peritoneal irritation are not detected.

What is your presumptive diagnosis? With what diseases should a differential diagnosis be made? How it is possible to specify the diagnosis?

Sample response. Taking into account the history of the disease, the presence of an inflammatory process clinic can be suspected in a patient with acute cholecystitis complicated by jaundice. It should be differentiated from pancreatitis. To clarify the diagnosis, B/X, ultrasound, FGDS should be performed urgently. With the diagnosis of “Acute cholecystitis”, an operation is indicated - cholecystectomy with revision of the choledochus.

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Acute cholecystitis

Acute cholecystitis is an inflammation of the gallbladder.

The following classification of acute cholecystitis is most acceptable:

I. Uncomplicated cholecystitis:

1. Catarrhal (simple) cholecystitis (calculous or acalculous), primary or exacerbation of chronic recurrent.

2. Destructive (calculous or acalculous), primary or exacerbation of chronic recurrent:

a) phlegmonous, phlegmonous-ulcerative;

b) gangrenous;

II. Complicated cholecystitis:

1. Occlusive (obstructive) cholecystitis (infected dropsy, phlegmon, empyema, gangrene of the gallbladder).

2. Perforated with symptoms of local or diffuse peritonitis.

3. Acute, complicated by lesions of the bile ducts:

a) choledocholithiasis, cholangitis;

b) stricture of the common bile duct, papillitis, stenosis of the papilla of Vater.

4. Acute cholecystopancreatitis.

5. Acute cholecystitis complicated by perforated bile peritonitis.

The main symptom in acute cholecystitis is pain, which occurs, as a rule, suddenly in full health, often after eating, at night during sleep. The pain is localized in the right hypochondrium, but can also spread to the epigastric region, with irradiation to the right shoulder, scapula, supraclavicular region. In some cases, before its appearance, patients for several days, even weeks, feel heaviness in the epigastric region, bitterness in the mouth, and nausea. Severe pain is associated with the reaction of the gallbladder wall to an increase in its contents as a result of a violation of the outflow during inflammatory edema, an inflection of the cystic duct, or when the latter is blocked by a stone.

Often there is irradiation of pain in the region of the heart, then an attack of cholecystitis can proceed as an attack of angina pectoris (Botkin's cholecystocoronary syndrome). The pain is aggravated by the slightest physical exertion - talking, breathing, coughing.

There is vomiting (sometimes multiple) of a reflex nature, which does not bring relief to the patient.

On palpation, a sharp pain and muscle tension in the right upper square of the abdomen is determined, especially a sharp pain in the area of the gallbladder.

Objective symptoms are not equally expressed in all forms of acute cholecystitis. Increased heart rate up to 100 - 120 beats per minute, intoxication phenomena (dry, furred tongue) are characteristic of destructive cholecystitis. With complicated cholecystitis, the temperature reaches 38 ° C and above.

When analyzing blood, leukocytosis, neutrophilia, lymphopenia, and an increased erythrocyte sedimentation rate are observed.

Specific symptoms of acute cholecystitis include:

1) a symptom of Grekov - Ortner - percussion pain that appears in the gallbladder area with a slight tapping of the edge of the palm along the right costal arch;

2) Murphy's symptom - increased pain that occurs at the time of palpation of the gallbladder with a deep breath of the patient. The doctor places the thumb of the left hand below the costal arch, at the location of the gallbladder, and the remaining fingers along the edge of the costal arch. If the patient's deep breath is interrupted before reaching the height, due to acute pain in the right hypochondrium under the thumb, then Murphy's symptom is positive;

3) symptom of Courvoisier - an increase in the gallbladder is determined by palpation of the elongated part of its bottom, which protrudes quite clearly from under the edge of the liver;

4) Pekarsky's symptom - pain when pressing on the xiphoid process. It is observed in chronic cholecystitis, its exacerbation and is associated with irritation of the solar plexus during the development of an inflammatory process in the gallbladder;

5) Mussi-Georgievsky symptom (phrenicus symptom) - pain on palpation in the supraclavicular region at a point located between the legs of the sternocleidomastoid muscle on the right;

6) Boas' symptom - pain on palpation of the paravertebral zone at the level of IX-XI thoracic vertebrae and 3 cm to the right of the spine. The presence of pain in this place with cholecystitis is associated with zones of Zakharyin-Ged hyperesthesia.

uncomplicated cholecystitis. Catarrhal (simple) cholecystitis can be calculous or acalculous, primary or as an exacerbation of chronic recurrent. Clinically, it proceeds calmly in most cases. The pain is usually dull, appears gradually in the upper abdomen; amplifying, localized in the right hypochondrium.

On palpation, there is pain in the gallbladder area, there are also positive symptoms of Grekov - Ortner, Murphy. There are no peritoneal symptoms, the number of leukocytes is in the range of 8.0 - 10.0 - 109 / l, the temperature is 37.6 ° C, rarely up to 38 ° C, there are no chills.

Attacks of pain last for several days, but after conservative treatment they disappear.

Acute destructive cholecystitis can be calculous or acalculous, primary or exacerbation of chronic recurrent.

Destruction can be phlegmonous, phlegmonous-ulcerative or gangrenous in nature.

With phlegmonous cholecystitis, the pain is constant, intense. Dry tongue, repeated vomiting. There may be a slight yellowness of the sclera, soft palate, which is due to infiltration of the hepatoduodenal ligament and inflammatory edema of the mucous membrane of the bile ducts. Urine dark brown. Patients lie on their back or on their right side, afraid to change their position in the back, because in this case severe pain occurs. On palpation of the abdomen, there is a sharp tension in the muscles of the anterior abdominal wall in the region of the right hypochondrium, there are also positive symptoms of Grekov-Ortner, Murphy, Shchetkin-Blumberg. The temperature reaches 38 ° C and above, leukocytosis 12.0 - 16.0 - 109 / l with a shift of the leukocyte formula to the left. With the spread of the inflammatory process to the entire gallbladder and the accumulation of pus in it, an empyema of the gallbladder is formed.

Sometimes phlegmonous cholecystitis can turn into dropsy of the gallbladder.

Gangrenous cholecystitis in most cases is a transitional form of phlegmonous cholecystitis, but it can also occur as an independent disease in the form of primary gangrenous cholecystitis of vascular origin.

Clinic at first it corresponds to phlegmonous inflammation, then the so-called imaginary well-being may occur: pain decreases, symptoms of peritoneal irritation are less pronounced, temperature decreases. However, at the same time, the phenomena of general intoxication increase: frequent pulse, dry tongue, repeated vomiting, pointed facial features.

Primary gangrenous cholecystitis from the very beginning proceeds violently with the phenomena of intoxication and peritonitis.

Complicated cholecystitis. Occlusive (obstructive) cholecystitis develops when the cystic duct is blocked by a calculus and initially manifests itself as a typical picture of biliary colic, which is the most characteristic sign of cholelithiasis. A sharp pain occurs suddenly in the right hypochondrium with irradiation to the right shoulder, scapula, to the region of the heart and behind the sternum. Patients behave uneasily, vomiting appears at the height of the attack, sometimes multiple. The abdomen may be soft, while a sharply painful, enlarged and tense gallbladder is palpated.

An attack of biliary colic can last several hours or 1 - 2 days, and when the stone returns to the gallbladder, it suddenly ends. With prolonged blockage of the cystic duct and infection, destructive cholecystitis develops.

Perforated cholecystitis proceeds with the phenomena of local or diffuse peritonitis. The moment of perforation of the gallbladder may go unnoticed by the patient. If adjacent organs are soldered to the gallbladder - the greater omentum, the hepatoduodenal ligament, the transverse colon and its mesentery, i.e., the process is limited, then complications such as subhepatic abscess, local limited peritonitis develop.

Acute cholecystitis, complicated by lesions of the bile ducts, can occur with clinical manifestations of choledocholithiasis, cholangitis, choledochal stricture, papillitis, stenosis of the Vater nipple. The main symptom of this form is obstructive jaundice, the most common cause of which is the calculi of the common bile duct, which obstruct its lumen.

When the common bile duct is blocked by a stone, the disease begins with acute pain, characteristic of acute calculous cholecystitis, with typical irradiation. Then, after a few hours or the next day, obstructive jaundice appears, which becomes persistent, accompanied by severe skin itching, dark urine and discolored (acholic) putty-like feces.

Due to the accession of the infection and its spread to the bile ducts, symptoms of acute cholangitis develop. Acute purulent cholangitis is characterized by severe intoxication - general weakness, lack of appetite, icteric coloration of the skin and mucous membranes. Constant dull pain in the right hypochondrium radiating to the right half of the back, heaviness in the right hypochondrium, with tapping on the right costal arch - a sharp pain. The body temperature rises in a remitting type, with profuse sweating and chills. Tongue dry, lined. The liver on palpation is enlarged, painful, soft consistency. Leukocytosis is noted with a shift of the leukocyte formula to the left. In a biochemical study of blood, an increase in the content of direct bilirubin and a decrease in the content of prothrombin in the blood plasma are observed. The disease can be complicated by life-threatening cholemic bleeding and liver failure.

Differential diagnosis. Acute cholecystitis must be differentiated from perforated gastric and duodenal ulcers, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, nephrolithiasis with localization of the calculus in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia.

Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Dyskinesia of the biliary tract is a violation of their physiological functions, leading to stagnation of bile in them, and later to the disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the trailing apparatus of the lower end of the common bile duct.

TO dyskinesia include:

1) atonic and hypotonic gallbladders;

2) hypertonic gall bladders;

3) hypertension and spasm of the sphincter of Oddi;

4) atony and insufficiency of the sphincter of Oddi.

The use of cholangiography before surgery makes it possible to recognize the main varieties of these disorders in patients.

Duodenal sounding makes it possible to establish the diagnosis of an atonic gallbladder if there is an abnormally abundant outflow of intensely colored bile that occurs immediately or only after the second or third administration of magnesium sulfate.

With cholecystography in the position of the patient on the stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile is collected.

When the diagnosis of "acute cholecystitis" is established, the patient should be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out according to vital indications in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent operations - with the failure of vigorous conservative treatment during the first 24-48 hours from the onset of the disease.

Operations are performed in a period of 5 to 14 days and later with a subsiding attack of acute cholecystitis and an observed improvement in the patient's condition, i.e., in the phase of reducing the severity of the inflammatory process.

The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.

Indications for choledochotomy - obstructive jaundice, cholangitis, impaired patency in the distal sections of the common bile duct, stones in the ducts.

A blind suture of the common bile duct is possible with full confidence in the patency of the duct and, as a rule, with single large stones. External drainage of the common bile and hepatic ducts is indicated in cases of cholangitis with patency of the distal duct.

Indications for the imposition of a biliodigistic anastomosis are the lack of confidence in the patency of the Vater nipple, indurated pancreatitis, the presence of multiple small stones in the ducts in patients. Biliodigestive anastomosis can be performed in the absence of pronounced inflammatory changes in the anastomosed organs by a highly qualified surgeon. In other conditions, it should be limited to external drainage of the biliary tract.

The management of patients in the postoperative period must be strictly individualized. They are allowed to get up in a day, they are discharged and the stitches are removed after about 10-12 days.

The human body is a reasonable and fairly balanced mechanism.

Among all infectious diseases known to science, infectious mononucleosis has a special place ...

The disease, which official medicine calls "angina pectoris", has been known to the world for quite a long time.

Mumps (scientific name - mumps) is an infectious disease ...

Hepatic colic is a typical manifestation of cholelithiasis.

Cerebral edema is the result of excessive stress on the body.

There are no people in the world who have never had ARVI (acute respiratory viral diseases) ...

A healthy human body is able to absorb so many salts obtained from water and food ...

Bursitis of the knee joint is a widespread disease among athletes...

Surgery for acute cholecystitis

Acute cholecystitis

Acute cholecystitis, or inflammation of the gallbladder, remains one of the most common ailments faced by a general surgeon.

In most cases (>90%), obstruction of the cystic duct by a stone occurs. In contrast to biliary colic, constant (rather than intermittent) pain in the hypochondrium, fever, leukocytosis, and there is also a change in the level of liver enzymes in the blood test are noted. After obstruction of the cystic duct, the bladder expands, resulting in subserous edema, venous and lymphatic stasis, cellular infiltration, and limited areas of ischemia. In 50-75% of cases, bacteria play a certain role in the development of acute cholecystitis. Among them: Escherichia coli, Klebsiella aerogenes, Streptococcus fecalis, Clostridium spp., Enterobacter spp. and Proteus spp. Antibacterial drugs used in treatment should have a sufficient spectrum of action. If left untreated, acute gangrenous cholecystitis (most common in patients with diabetes) may develop gallbladder perforation or sepsis, and mortality increases. Another possible complication of cholecystitis is perforation of the gallbladder into the wall of adjacent hollow organs (duodenum, jejunum, or large intestine). In this case, a vesico-intestinal fistula is formed. If the stone migrates into the intestinal lumen, gallstone intestinal obstruction may develop. In the case of untreated acute cholecystitis, gangrenous cholecystitis can develop (most often in diabetic patients), leading to gallbladder perforation or sepsis, thus increasing morbidity and mortality.

Symptoms of acute cholecystitis

Most patients with acute cholecystitis will have a history of abdominal symptoms that can be correlated with bile ducts, although in some cases acute cholecystitis is the first manifestation of cholelithiasis. In all observations of acute cholecystitis, the most characteristic symptom is constant pain in the right hypochondrium, symptoms of peritoneal irritation (Blumberg's symptom, Murphy's symptom). At first, pain develops due to obstruction of the cystic duct and expansion of the gallbladder, although with the development of inflammation, edema and ischemia, pain is caused by irritation of the peritoneum. As with biliary colic, pain is usually localized in the right hypochondrium, but can also develop in the epigastrium, and sometimes radiate to the shoulder and back. Unlike the pain of biliary colic, which usually lasts only a few hours, the pain of acute cholecystitis can last for several days. However, it is worth noting that patients with both acute cholecystitis and biliary colic experience nausea, vomiting, and anorexia.

An objective examination in acute cholecystitis usually reveals an elevated temperature. Often, an inflamed bladder can be palpated as a tender swollen mass, but this is not always the case. Patients with diabetes, in particular, may have severe cholecystitis with minimal findings on objective examination. Murphy's symptom is considered positive with a sudden increase in pain during palpation in the right hypochondrium during inspiration, which is due to the contact of the inflamed gallbladder with the anterior abdominal wall, which is deflected by the palpating hand. Patients often hold their breath mid-inhalation. A similar phenomenon during an ultrasound of the right upper quadrant is called Murphy's ultrasonic symptom (the role of the palpating hand is performed by the sensor).

Diagnosis of acute cholecystitis

Data from a laboratory study in acute cholecystitis reveal leukocytosis, an increase in AsAT and ALT, alkaline phosphatase. Usually, the level of total bilirubin increases slightly (by 1-2 times), although a significant increase (> 2 times) may indicate concomitant choledochal obstruction. Surprisingly, in patients with the detection of the disease, even at a very late stage, a biochemical blood test can remain completely normal.

The two most common imaging modalities used in the diagnosis of acute cholecystitis are abdominal ultrasonography and biliocintigraphy. Plain x-rays are of limited use because only about 15% of gallstones are radiopaque and the gallbladder is not visible at all. The first step is usually an ultrasound. It provides answers to the following questions: "Are gallstones present?" "Is the gallbladder enlarged?" and “Are the intrahepatic or extrahepatic ducts dilated?”. The main criterion for establishing the diagnosis of cholecystitis is often considered a thickening of the bladder wall. As a result of such an examination, many false positive and false negative results occur. For example, in patients with low serum albumin and a normal gallbladder, perivesical fluid can be detected as a result of anasarca in the absence of inflammation. In addition, patients with severe cholecystitis may have normal gallbladder wall thickness on ultrasound. The most reliable symptoms of the disease that can be detected by ultrasound are stones, gallbladder enlargement, and Murphy's ultrasound sign. It is also necessary to always determine the diameter of the extrahepatic ducts in order to rule out choledocholithiasis.

For patients in whom the diagnosis of acute cholecystitis is doubtful, a radioisotope study is performed. If there is no cystic duct obstruction, extrahepatic bile ducts and bladder are identified.) If there is an obstruction, then the gallbladder will not be visible. The method is very sensitive in patients who have recently eaten, but has a 10-15% false positive rate when fasted for several days. Therefore, its use in the intensive care unit is somewhat limited. In patients with a typical clinic of acute cholecystitis, confirmed by ultrasound, this diagnostic method is not used.

Differential Diagnosis

Acute cholecystitis can mimic a number of other acute abdominal conditions such as appendicitis, perforated gastric ulcer, small bowel obstruction, hepatitis, and acute pancreatitis. In addition, differential diagnosis is carried out with pneumonia, coronary artery disease and herpes zoster (shingles). Usually, a careful history and examination can confirm the diagnosis. An increase in serum amylase, which sometimes occurs with acute cholecystitis, can make it difficult to differentiate from pancreatitis. In this case, it is necessary to perform a CT scan of the abdominal cavity.

Patients with suspected acute cholecystitis should be hospitalized. They are prescribed hunger and infusion therapy. If the diagnosis is confirmed, intravenous administration of broad-spectrum antibiotics is necessary.

In the absence of contraindications (IHD, pancreatitis, cholangitis), cholecystectomy is performed within 24-36 hours. If the patient asked for help late (after 4-5 days), treatment with antibiotics should be started and laparoscopic surgery should be delayed for 6 weeks. Since the inflammatory process is most pronounced between 72 hours and 1 week from the onset of the disease, the success of laparoscopic cholecystectomy is called into question, and they tend to opt for open surgery. Except in very low-risk patients, removal of the gallbladder is always necessary. Such patients can be performed percutaneous cholecystostomy under ultrasound guidance and local anesthesia.

crushing stones

Extracorporeal extracorporeal shock wave lithotripsy has been used in the past for the treatment of gallstone disease. The essence of the method is the action of a shock wave on a stone. The aim was to crush the stones into pieces (approximately 5 mm) capable of passing through the cystic duct and the sphincter of Oddi. Unfortunately, the success rate was low and the complication rate was high, so the method was discontinued.

Treatment of acute cholecystitis complicated by biliary pancreatitis

The timing of cholecystectomy depends entirely on the clinical course of the disease. Patients with a mild or moderate course are usually examined first. If symptoms subside within the first 48 hours of gallstone pancreatitis, laparoscopic cholecystectomy is usually performed. If jaundice accompanies pancreatitis, then ERCP is performed to rule out choledochal stones. In addition, if the patient's condition worsens within 48 hours, ERCP is also performed to look for a stone in the ampulla of Vater's papilla. The procedure is carried out carefully because of the risk of aggravating the course of pancreatitis. As soon as the obstruction (if it was) is eliminated, treatment begins according to generally accepted principles. When the pancreatitis is resolved (which may take several weeks), the patient is discharged from the hospital and prepared for a planned cholecystectomy in a few months to prevent future exacerbation of the disease.

Laparoscopic cholecystectomy for acute cholecystitis

In 1992, at the NIH Consensus conference, scientists concluded that laparoscopic cholecystectomy provides a safe and effective treatment for patients with gallstone disease and is the treatment of choice for these patients. This operation is widespread today, although the radical method in surgery of the biliary system has been used for more than a century. Previously, the procedure was very traumatic. Access was through a median or long incision in the right hypochondrium, which required a very long recovery period. Now minimally invasive methods are used. This allows patients to return to normal activities much earlier. With the exception of a few relative contraindications (portal hypertension, previous right hypochondrium surgery, cirrhosis), laparoscopic gallbladder removal can be performed in most patients. The advent of laparoscopic methods has made surgery of the biliary system less traumatic. However, not all patients are able to perform laparoscopic surgery. Sometimes during the operation it is necessary to additionally perform a standard laparotomy. While the percentage of transition to laparotomy in elective cholecystectomy is 1-2%, in patients with acute cholecystitis it varies from 5 to 10%. This number is even higher in concomitant diabetes mellitus.

Technical aspects of laparoscopic cholecystectomy

If elective laparoscopic cholecystectomy proceeds without complications, then one-day surgery can be used. No special bowel preparation is required before surgery. After the introduction into anesthesia, the patient is placed on the operating table in the supine position. The gastric tube must be inserted by the anesthesiologist for decompression and removed at the end of the operation. Bladder catheterization is not required if an open trocar insertion method is used. The abdomen is treated and lined in the usual way. A small incision is made under the navel to the fascia. Next, the fascia is grasped with Kocher clamps, lifted and dissected. A trocar (usually 10 mm) is inserted and secured. Carbon dioxide is injected under low pressure (15 mm Hg). Then three trocars are inserted in the right hypochondrium. Use instruments designed exclusively for laparoscopic surgery. The gallbladder is removed from the edge of the liver, and manipulations begin in the Kahlo triangle. After careful isolation, revision, and clipping of the cystic duct and cystic artery, the bladder is dissected and removed from the abdominal cavity. Careful hemostasis is performed, and all trocars are removed under eye control. Drainage of the abdominal cavity is not carried out if there is no likelihood of postoperative bile leakage (from the bed of the bladder or unsuccessfully clipped cystic duct). Then the trocar insertion sites are sutured. The patient is taken to the recovery room where he is allowed to resume normal feeding once he is fully conscious to prevent aspiration. After discharge, most patients can resume normal activities 5 days after surgery.

The use of intraoperative cholangiography for laparoscopic cholecystectomy is controversial. Most surgeons use it for suspected choledochal stones if ERCP was not performed before surgery, others in all cases. Its continued use increases the cost of surgery and is not indicated to prevent biliary damage. If, however, the anatomy is unclear, cholangiography can help identify extrahepatic bile ducts. If performed, the cholangiogram must be correctly interpreted by both the surgeon and the radiologist.

The technical aspects of identifying structures in open cholecystectomy correspond to those of the laparoscopic approach. The use of laparoscopic instrumentation and small trocar incisions is preferable to the traditional surgical instrumentation used in open cholecystectomy and an incision in the right upper quadrant of the abdomen or a midline approach.

surgeryzone.net

Surgery (Acute cholecystitis)

RUSSIAN STATE

MEDICAL UNIVERSITY

Department of Hospital Surgery

Topic: "Acute cholecystitis".

Completed by a 5th year student

medical faculty

511a gr. Krat V.B.

Clinic of acute cholecystitis:

The temperature rises to 38-39°C, sometimes with chills. In elderly and senile people, severe destructive cholecystitis can occur with a slight increase in temperature and moderate leukocytosis. The pulse with simple cholecystitis increases according to temperature, with destructive and, especially, perforated cholecystitis with the development of peritonitis, tachycardia up to 100-120 beats per minute is noted.

When examining blood, neutrophilic leukocytosis (10 - 20 x 109 / l) is noted, with jaundice hyperbilirubinemia.

Differential Diagnosis:

Accesses: 1) according to Kocher;

2) according to Fedorov;

From the second day, they begin to eat liquid food through the mouth. On the 5th day, a narrow tampon facing the bladder bed is removed and replaced with others, leaving a wide delimiting tampon in place, which is pulled up and removed on the 5-6th day with a smooth flow on the 8-10th day. By day 14, the discharge from the wound usually stops and the wound closes on its own. After removal of the gallbladder, patients are advised to follow a diet.

Literature:

1. Avdey L. V. “Clinic and treatment of cholecystitis”, Minsk, Gosizdat, 1963;

2. Galkin V.A., Lindenbraten L.A., Loginov A.S. “Recognition and treatment of cholecystitis”, M., Medicine, 1983;

3. Savelyev V. S. "Guidelines for emergency surgery of the abdominal organs", M., 1986;

4. Smirnov E.V. “Surgical operations on the biliary tract”, L., Medicine, 1974

5. Skripnichenko D.F. "Emergency abdominal surgery", Kiev, "Health", 1974;

6. Hegglin R. "Differential diagnosis of internal diseases", M., 1991.

7. "Surgical diseases", edited by Iuzin M.I., Medicine, 1986

www.mirznanii.com

Acute cholecystitis

Acute cholecystitis is an acute inflammation of the gallbladder of a bacterial nature.

ICD-10 CODE

K81.0. Acute cholecystitis. Acute cholecystitis is one of the most common diseases of the abdominal organs and ranks second after acute appendicitis. High incidence is associated with an increase in the incidence of gallstone disease (GSD) and an increase in life expectancy. More often the disease occurs in people over 50 years of age; elderly and senile patients account for more than 50%; the ratio of men and women among patients is approximately 1:5. The classification of acute cholecystitis is of practical importance for making the right tactical decision, adequate to a specific clinical situation. The classification is based on the clinical and morphological principle of the dependence of the clinical manifestations of the disease on pathomorphological changes in the gallbladder, extrahepatic bile ducts and abdominal cavity. In this classification, two groups of acute cholecystitis are distinguished - uncomplicated and complicated.

Clinical and morphological classification of acute cholecystitis

Form of cholecystitis:

catarrhal;
phlegmonous;
gangrenous.

Complications:

perivesical infiltrate;
perivesical abscess;
perforation of the gallbladder;
peritonitis;
mechanical jaundice;
cholangitis;
external or internal biliary fistula.

Uncomplicated acute cholecystitis includes all pathomorphological forms of inflammation of the gallbladder that occur daily in clinical practice. This is catarrhal, phlegmonous and gangrenous inflammation. Each of these forms should be considered as a natural development of the inflammatory process: a gradual transition from the catarrhal process of inflammation to gangrene. With this mechanism of development of the pathological process, foci of necrosis of various sizes occur against the background of phlegmonous changes in the gallbladder as a result of vascular disorders. An exception to this pattern is primary gangrenous cholecystitis, since its origin is based on circulatory disorders in the wall of the gallbladder (atherothrombosis). In primary gangrenous cholecystitis, the entire gallbladder undergoes necrosis at once, its walls are thinned, parchment-like and black in color. Relatively rare is enzymatic cholecystitis, which develops as a result of the reflux of pancreatic secretions into the gallbladder, which can occur in the presence of a common ampulla of the bile duct and pancreatic duct. With enzymatic cholecystitis, the mucous membrane of the gallbladder is primarily damaged, and the infection is secondary. The occurrence of acute cholecystitis is associated with two main factors: infection of the bile or gallbladder wall and bile stasis (biliary hypertension). Only when they are combined, conditions are created for the development of the inflammatory process. Infection in the gallbladder enters in three ways - hematogenous, lymphogenous and enterogenous. In most cases, infection occurs by the hematogenous route: from the general circulation through the system of the common hepatic artery or from the gastrointestinal tract through the portal vein. With a decrease in the phagocytic activity of the reticuloendothelial system of the liver, microorganisms through the cell membranes enter the bile capillaries and with the flow of bile into the gallbladder. Usually they are located in the wall of the gallbladder, in the passages of Lushka, so often the microbial flora can not be detected in the gallbladder bile. The main importance is attached to gram-negative bacteria - enterobacteria (E. coli, Klebsiella) and Pseudomonas. In the overall structure of the microbial flora that causes acute cholecystitis, gram-positive microorganisms (non-spore-forming anaerobes - bacteroides and anaerobic cocci) make up a third, and almost always in association with gram-negative aerobic bacteria. The second decisive factor in the development of acute cholecystitis is bile stasis, which occurs most often as a result of obstruction of the neck of the gallbladder or cystic duct by a stone. The stones, being in the cavity of the gallbladder, do not create an obstacle to the outflow of bile. However, if the diet is violated, the contractility of the gallbladder increases and obstruction of the neck or cystic duct may occur. Less often, biliary stasis is caused by blockage of the cystic duct with lumps of mucus, putty-like detritus, and stagnation can also occur when the gallbladder is narrowed and kinked. Following the blockade, intravesical biliary hypertension causes the development of an inflammatory process in the gallbladder. In 70% of patients, it is stone obturation that leads to stagnation of bile and biliary hypertension, which allows us to consider cholelithiasis as the main factor predisposing to the development of acute "obstructive" cholecystitis.

Lysolecithin is of great importance in the pathogenesis of the inflammatory process, high concentrations of which are formed in bile during blockade of the gallbladder, accompanied by damage to its mucosa and the release of phospholipase A2. This tissue enzyme converts bile lecithin into lysolecithin, together with bile salts, it damages the mucous membrane of the gallbladder, causes a violation of the permeability of cell membranes and a change in the colloidal state of bile. As a result of these processes, aseptic inflammation of the gallbladder wall occurs.

In conditions of biliary hypertension, when the gallbladder is stretched, mechanical compression of the vessels occurs, microcirculation disorders occur, blood flow slows down and stasis in capillaries, venules, and arterioles occurs. The degree of vascular disorders in the wall of the gallbladder is directly dependent on the severity of biliary hypertension. If elevated pressure persists, then due to ischemia of the gallbladder wall and changes in the qualitative composition of bile, the endogenous infection becomes virulent. The exudation that occurs during inflammation into the lumen of the gallbladder contributes to the progression of intravesical hypertension and even more damage to the mucosa. In this case, we can talk about the formation of a pathophysiological vicious circle, the primary link in the development of the inflammatory process in which acute biliary hypertension is considered, and the secondary one is infection. The timing and severity of the inflammatory process in the gallbladder largely depend on vascular disorders in its wall. They lead to the appearance of foci of necrosis, most often occurring in the bottom or neck, followed by perforation of the bladder wall. In elderly patients, circulatory disorders in the gallbladder against the background of atherosclerosis and hypertension often cause the development of destructive forms of acute cholecystitis. With atherothrombosis or cystic artery embolism, these patients may develop primary gangrene of the gallbladder. The clinical symptoms of acute cholecystitis depend on the pathological changes in the gallbladder, the presence and extent of peritonitis, and the nature of the concomitant pathology of the bile ducts. The diversity of the clinical picture of the disease can create diagnostic difficulties and cause errors.

Acute cholecystitis occurs suddenly and manifests as severe persistent abdominal pain, the intensity of pain increases as the disease progresses. The development of acute inflammation in the gallbladder is often preceded by an attack of biliary colic. Localization of pain in the right hypochondrium and epigastric region is characteristic. Often there is irradiation to the right shoulder, supraclavicular region, interscapular space or to the region of the heart. The latter localization can be regarded as an attack of angina pectoris (cholecystocoronary symptom of S.P. Botkin), as well as provoke its occurrence.

Constant symptoms of acute cholecystitis are nausea and repeated vomiting, which does not bring relief to the patient. An increase in body temperature is noted from the first days of the disease, its nature depends on pathomorphological changes in the gallbladder. Chills are characteristic of destructive forms of acute cholecystitis. The general condition of the patient upon admission to the hospital depends on the form of the disease. The skin is usually of normal color. Moderate scleral icterus may be due to the transition of the inflammatory process from the gallbladder to the liver and the development of local toxic hepatitis. The appearance of icterus of the sclera and skin is a sign of the mechanical nature of extrahepatic cholestasis (choledocholithiasis, stenosis of the major duodenal papilla). This must be taken into account when determining treatment tactics. The pulse rate ranges from 80 to 120 per minute and above. A frequent pulse is a symptom indicating developing intoxication and inflammatory changes in the gallbladder and abdominal cavity. In acute cholecystitis, you can identify:

Ortner's symptom - a sharp pain in the projection of the gallbladder with a slight tapping of the edge of the palm along the right costal arch;
Murphy's symptom - involuntary holding of breath on inspiration when pressing on the area of the right hypochondrium;
Kera's symptom - increased pain on inspiration with deep palpation of the right hypochondrium;
Georgievsky-Mussi symptom (phrenicus symptom) - soreness on the right when pressed between the legs of the sternocleidomastoid muscle;
symptom of Shchetkin-Blumberg - becomes positive in case of involvement in the inflammatory process of the peritoneum.

The frequency of detection of the above symptoms depends on the severity of the inflammatory process in the gallbladder (a form of acute cholecystitis) and the involvement of the peritoneum. With the progression of the inflammatory process in the gallbladder, structural changes occur in the liver, which is associated with toxic damage to hepatocytes. Depending on the severity of damage to hepatocytes and liver parenchyma, an increase in the level of enzyme activity (ACT, alkaline phosphatase, lactate dehydrogenase, etc.) is detected in the blood. Determination of the activity of liver enzymes, the level of bilirubin and its fractions is of particular importance in the detection of jaundice, which may be hepatocellular or obstructive in nature. In acute cholecystitis, significant changes in the rheological state of the blood and the hemostasis system occur: an increase in blood viscosity, the aggregation ability of erythrocytes and platelets, and the coagulation activity of the blood. These violations can lead to disorders of microcirculation and metabolism in the liver and kidneys, create prerequisites for the development of acute liver failure and the occurrence of thromboembolic complications.

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Abstract: Surgery (Acute cholecystitis)

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RUSSIAN STATE

MEDICAL UNIVERSITY

Department of Hospital Surgery

Head Department Professor Nesterenko Yu. P.

Teacher Andreitseva O.I.

Completed by a 5th year student

medical faculty

511a gr. Krat V.B.

Acute cholecystitis is an inflammatory process in the extrahepatic tract with a predominant lesion of the gallbladder, in which there is a violation of the nervous regulation of the activity of the liver and biliary tract for production, as well as changes in the biliary tract itself due to inflammation, bile stasis and cholesterolemia.

Depending on pathological changes, catarrhal, phlegmonous, gangrenous and perforative cholecystitis are distinguished.

The most frequent complications of acute cholecystitis are encysted and diffuse purulent peritonitis, cholangitis, pancreatitis, liver abscesses. In acute calculous cholecystitis, partial or complete obstruction of the common bile duct with the development of obstructive jaundice can be observed.

There are acute cholecystitis that developed for the first time (primary acute cholecystitis) or on the basis of chronic cholecystitis (acute recurrent cholecystitis). For practical application, the following classification of acute cholecystitis can be recommended:

I Acute primary cholecystitis (calculous, acalculous): a) simple; b) phlegmonous; c) gangrenous; d) perforative; e) complicated cholecystitis (peritonitis, cholangitis, bile duct obstruction, liver abscess, etc.).

II Acute secondary cholecystitis (calculous and acalculous): a) simple; b) phlegmonous; c) gangrenous; d) perforative; e) complicated (peritonitis, cholangitis, pancreatitis, bile duct obstruction, liver abscess, etc.).

Etiology and pathogenesis of acute cholecystitis:

The inflammatory process in the wall of the gallbladder can be caused not only by a microorganism, but also by a certain composition of food, allergological and autoimmune processes. At the same time, the integumentary epithelium is rebuilt into goblet and mucous membranes, which produce a large amount of mucus, the cylindrical epithelium flattens, microvilli are lost, and absorption processes are disrupted. In the niches of the mucosa, water and electrolytes are absorbed, and colloidal solutions of mucus turn into a gel. Lumps of the gel, when the bladder contracts, slip out of the niches and stick together, forming the beginnings of gallstones. Then the stones grow and impregnate the center with pigment.

The main reasons for the development of the inflammatory process in the wall of the gallbladder is the presence of microflora in the cavity of the gallbladder and a violation of the outflow of bile. The focus is on infection. Pathogenic microorganisms can enter the bladder in three ways: hematogenous, lymphogenous, enterogenic. More often, the following organisms are found in the gallbladder: E. coli, Staphilococcus, Streptococcus.

The second reason for the development of the inflammatory process in the gallbladder is a violation of the outflow of bile and its stagnation. In this case, mechanical factors play a role - stones in the gallbladder or its ducts, kinks of the elongated and tortuous cystic duct, its narrowing. Against the background of cholelithiasis, according to statistics, up to 85-90% of cases of acute cholecystitis occur. If sclerosis or atrophy develops in the wall of the bladder, the contractile and drainage functions of the gallbladder suffer, which leads to a more severe course of cholecystitis with deep morphological disorders.

Vascular changes in the wall of the bladder play an unconditional role in the development of cholecystitis. The rate of development of inflammation, as well as morphological disorders in the wall, depend on the degree of circulatory disorders.

Clinic of acute cholecystitis:

The clinic of acute cholecystitis depends on the pathoanatomical changes in the gallbladder, the duration and course of the disease, the presence of complications and the reactivity of the body. The disease usually begins with an attack of pain in the gallbladder. Pain radiates to the area of the right shoulder, right supraclavicular space and right shoulder blade, to the right subclavian area. The pain attack is accompanied by nausea and vomiting with an admixture of bile. As a rule, vomiting does not bring relief.

In patients, during examination, icterus of the sclera is noted; severe jaundice occurs when the patency of the common bile duct is impaired due to obstruction by a stone or inflammatory changes.

The abdomen is painful on palpation in the region of the right hypochondrium. In the same area, muscle tension and symptoms of peritoneal irritation are determined, especially pronounced in destructive cholecystitis and the development of peritonitis.

There is pain when tapping along the right costal arch (Grekov-Ortner symptom), pain with pressure or tapping in the gallbladder area (Zakharyin symptom) and with deep palpation while inhaling the patient (Obraztsov symptom). The patient cannot take a deep breath with deep palpation in the right hypochondrium. Soreness on palpation in the right supraclavicular region (Georgievsky's symptom) is characteristic.

In the initial stages of the disease, with careful palpation, an enlarged, tense and painful gallbladder can be determined. The latter is especially well contoured in the development of acute cholecystitis due to dropsy of the gallbladder. With gangrenous, perforative cholecystitis, due to the pronounced tension of the muscles of the anterior abdominal wall, as well as with exacerbation of sclerosing cholecystitis, it is not possible to palpate the gallbladder. In severe destructive cholecystitis, there is a sharp pain during superficial palpation in the right hypochondrium, light tapping and pressure on the right costal arch.

When examining blood, neutrophilic leukocytosis (10 - 20 x 109 / l) is noted, with jaundice hyperbilirubinemia.

The course of acute simple primary acalculous cholecystitis in 30-50% of cases ends with recovery within 5-10 days after the onset of the disease. Although acute cholecystitis can be very difficult with the rapid development of gangrene and perforation of the bladder, especially in the elderly and senile age. With exacerbation of chronic calculous cholecystitis, stones can contribute to more rapid destruction of the bladder wall due to stagnation and the formation of bedsores.

However, much more often inflammatory changes increase gradually, within 2-3 days the nature of the clinical course is determined with the progression or subsidence of inflammatory changes. Therefore, there is usually enough time to assess the course of the inflammatory process, the patient's condition and the reasonable method of treatment.

Differential Diagnosis:

Acute cholecystitis is differentiated with the following diseases:

1) Acute appendicitis. In acute appendicitis, the pain is not so intense, and, most importantly, it does not radiate to the right shoulder, right shoulder blade, etc. Also, acute appendicitis is characterized by migration of pain from the epigastrium to the right iliac region or throughout the abdomen, with cholecystitis, pain is precisely localized in the right hypochondrium ; vomiting with appendicitis single. Usually, palpation reveals thickening of the gallbladder and local muscle tension of the abdominal wall. Ortner's and Murphy's signs are often positive.

2) Acute pancreatitis. This disease is characterized by girdle pain, sharp pain in the epigastrium. Mayo-Robson's sign is positive. Characteristically, the patient's condition is grave, he takes a forced position. Of decisive importance in the diagnosis is the level of diastase in the urine and blood serum, the evidence is more than 512 units. (in urine).

With stones in the pancreatic duct, pain is usually localized in the left hypochondrium.

3) Acute intestinal obstruction. In acute intestinal obstruction, pain is cramping, non-localized. There is no rise in temperature. Increased peristalsis, sound phenomena (“splashing noise”), radiographic signs of obstruction (Kloiber bowls, arcades, pinnate symptom) are absent in acute cholecystitis.

4) Acute obstruction of the arteries of the mesentery. With this pathology, severe pains of a constant nature occur, but usually with distinct amplifications, they are less diffuse than with cholecystitis (more diffuse). Be sure to have a history of pathology from the cardiovascular system. The abdomen is well accessible for palpation, without severe symptoms of peritoneal irritation. Radioscopy and angiography are decisive.

5) Perforated ulcer of the stomach and duodenum. Men are more likely to suffer from this, while women are more likely to suffer from cholecystitis. With cholecystitis, intolerance to fatty foods is characteristic, nausea and malaise are frequent, which does not happen with a perforated ulcer of the stomach and duodenum; pains are localized in the right hypochondrium and radiate to the right shoulder blade, etc., with an ulcer, the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). The presence of an ulcerative anamnesis and tarry stools clarify the picture. X-ray in the abdominal cavity we find free gas.

6) Renal colic. Pay attention to the urological history. The kidney area is carefully examined, Pasternatsky's symptom is positive, urinalysis, excretory urography, chromocystography are performed to clarify the diagnosis, since renal colic often provokes biliary colic.

A correct assessment of the patient's condition and the course of the disease in acute cholecystitis requires clinical experience and careful monitoring of the patient's condition, repeated studies of the number of leukocytes and the leukocyte formula, taking into account the dynamics of local and general symptoms.

In patients with a primary attack of acute cholecystitis, surgery is indicated only in case of an extremely severe course of the disease, the rapid development of destructive processes in the gallbladder. With a rapid subsidence of the inflammatory process, with catarrhal cholecystitis, the operation is not indicated.

Conservative treatment of patients consists in the use of broad-spectrum antibiotics, detoxification therapy. To stop the pain syndrome, it is advisable to conduct a course of therapy with atropine, no-shpa, papaverine, as well as to block the round ligament of the liver or pararenal novocaine blockade according to Vishnevsky.

Surgical treatment of cholecystitis is one of the most difficult sections of abdominal surgery, which is explained by the complexity of pathological processes, involvement of the biliary tract in the inflammatory process, the development of angiocholitis, pancreatitis, perivesical and intrahepatic abscesses, peritonitis and the frequent combination of cholecystitis with choledocholithiasis, obstructive jaundice.

During the first 24-72 hours after admission, emergency surgery is indicated for those patients with acute cholecystitis who have worsening disease despite vigorous antibiotic treatment. Early surgery is indicated after the inflammatory process subsides after 7-10 days from the onset of the attack, for patients suffering from acute calculous cholecystitis, exacerbation of chronic cholecystitis with severe and often recurring attacks of the disease. Early surgery contributes to the fastest recovery of patients and the prevention of possible complications in conservative treatment.

In acute cholecystitis, cholecystectomy is indicated, in the presence of obstruction of the bile ducts - cholecystectomy in combination with choledochotomy. In a very serious condition of patients, cholecystotomy is performed. Operations can be performed both by laparoscopic method and by standard methods with laparotomy.

Laparoscopic surgeries are performed under local anesthesia. An incision 4-6 cm long is made above the bottom of the gallbladder, parallel to the costal arch. The tissues of the abdominal wall are layered and pushed apart. The wall of the gallbladder is brought into the wound, the contents are punctured. The gallbladder is removed. Conduct an audit of the cavity of the bladder. At the same time, after the end of X-ray and endoscopic studies, plastic drains are inserted, purse-string sutures are applied. The wound is sutured.

Operations requiring standard laparotomy: cholecystotomy, cholecystostomy, choledochotomy, choledochoduodenostomy.

Accesses: 1) according to Kocher;

2) according to Fedorov;

3) transrectal mini-access 4 cm long.

Cholecystotomy - the imposition of an external fistula on the gallbladder. During this operation, the bottom of the gallbladder is sewn into the wound so that it is isolated from the abdominal cavity, and opened immediately or the next day, when adhesions of the bladder walls with the edges of the incision are formed.

This operation is carried out as the first moment of operation in the elderly for acute cholecystitis. Subsequently, cholecystectomy is required to eliminate the biliary fistula.

Cholecystostomy - opening the gallbladder, removing the gallbladder and sewing it tightly. This operation is performed in debilitated patients with impaired cardiac and respiratory activity, for whom a more complex operation may be life threatening. This operation can give subsequent relapses, since a pathologically altered gallbladder remains, which serves as a site for the development of infection and the formation of new stones. To prevent complications after the operation, it is more advantageous to insert and seal tightly in the bladder a thin rubber drainage.

Cholecystectomy - removal of the gallbladder, the operation is most often performed in typical cases in two ways: 1) from the neck; 2) from the bottom.

Cholecystectomy from the bottom is technically simpler, but less commonly used due to the possibility of purulent contents leaking into the choledochus. When released from the bottom, the bubble is captured with a terminal clamp, its peritoneum is incised on the sides, and the bubble is separated from the liver in a blunt or sharp way, capturing and ligating individual branches a. cystica. After separation of the bladder from the liver bed, the main branch of the cystic artery and the cystic duct are tied. In the presence of powerful adhesions, the method of isolation from the bottom is simpler, but bleeding from the branches of the cystic artery somewhat complicates the operation, since when the bleeding vessels are captured in the depth of the wound, the right hepatic duct passing near the cystic artery can be tied.

Cholecystectomy from the cervix is more difficult. First, the cystic duct and cystic artery are ligated in the Kahlo triangle. Then they begin to separate the bottom of the gallbladder, trying to save the peritoneum of the hepatic surface of the bladder, in order to later peritonize its bed. It is acceptable to leave parts of the bladder mucosa in its bed.

In cases of detection during the operation of a sclerosed and surrounded by powerful adhesions of the gallbladder, when finding the neck and duct encounters insurmountable difficulties, the bladder is opened throughout its entire length and the mucosa is burned by electrocoagulation. After burning the mucosa, the remaining wall of the bladder is screwed inside and sewn with catgut sutures over the scab. Burning of the mucosa is in severe cases an advantage over the removal of the bladder in an acute way. This operation is called mucoclasis (according to Primbau).

Choledochotomy is an operation used to examine, drain, remove stones from the duct. The duct is drained in case of cholangitis to divert the infected contents of the ducts to the outside. There are three types of choledochotomy: supraduodenal, retroduodenal and transduodenal.

After removal of the stone, the duct is carefully sutured with thin catgut sutures and closed with a second row of sutures placed on the peritoneum. A tampon is brought to the site of the opening of the duct, since with the most careful suturing, bile can seep between the sutures and cause bile peritonitis.

Choledochoduodenostomy - the formation of an anastomosis between the bile duct and the duodenum. This operation is performed with narrowing or obstructed strictures of the bile duct. As a disadvantage of choledochoduodenostomy, the possibility of duodenal contents entering the duct should be noted. However, experience shows that with a normal outflow of bile, this is not accompanied by dangerous consequences. Short-term outbreaks of biliary tract infection are treated with antibiotics.

In the postoperative period, acute cholecystitis is prevented, the coagulation and fibrinolytic systems, water-salt and protein metabolism are corrected, and thromboembolic and cardiopulmonary complications are prevented.

From the second day, they begin to eat liquid food through the mouth. On the 5th day, the narrow tampon facing the

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I lay the bladder bed, leaving a wide delimiting tampon in place, which is pulled up on the 5-6th day and removed with a smooth flow on the 8-10th day. By day 14, the discharge from the wound usually stops and the wound closes on its own. After removal of the gallbladder, patients are advised to follow a diet.

Improving the results of treatment of patients with acute cholecystitis depends on more active surgical treatment. Cholecystectomy, performed in a timely manner according to sufficient indications, saves patients from severe complications and prolonged suffering.

Gallbladder symptoms of the disease and treatment with folk remedies

MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN

ANDIJAN STATE MEDICAL INSTITUTE

DEPARTMENT OF SURGICAL DISEASES 6-7 COURSES WITH THE COURSE OF ANESTHESIOLOGY-RESUSISTANT AND UROLOGY

HEAD OF THE DEPARTMENT, PROFESSOR F.N. NISHANOV

LECTURE TOPIC:

ACUTE CHOLECYSTITIS

LECTURER: d.m.s. professor NISHANOV F.N.

REVIEWER: Head of the Department of Surgery, FUV ASMI, Professor

Khojimatov G.M.

Andijan 2005

PLAN AND CHRONOLOGY OF THE LECTURE:

Introduction - 5 min.
Etiology and pathogenesis - 10 min.
Classification -5 min.
Clinical semiotics-10 min.
Laboratory and instrumental diagnostics-15 min.

Break 5 min.

Therapeutic tactics - 10 min.
Surgical treatment - 10 min.
Operations on extrahepatic bile ducts - 10 min.
Postoperative period - 10 min.
Questions and answers to consolidate the topic of the lecture - 5 min

Lecture No. X

ACUTE CHOLECYSTITIS

Acute cholecystitis is one of the most common diseases of the abdominal organs. In the last two decades, significant progress has been made in the diagnosis and improvement of its treatment methods, which has reduced mortality to 2.5%. At the same time, it remains high among elderly and senile patients, which makes this problem not only medical, but also socially significant.

Etiology and pathogenesis

The occurrence of acute cholecystitis is associated with the action of several etiological factors. The leading role in its development is played by infection and stagnation of bile (biliary hypertension). Only if they are present, the necessary conditions are created for the development of the inflammatory process in the gallbladder.

It is believed that the infection enters the gallbladder in three ways - hematogenous, lymphogenous and enterogenous. In most cases, infection of the gallbladder occurs by the hematogenous route - from the general circulation through the system of the common hepatic artery or from the gastrointestinal tract through the portal vein. With a decrease in the phagocytic activity of the reticuloendothelial system of the liver, microbes pass through the cell membranes into the bile capillaries and enter the gallbladder with bile flow. Usually they "nest" in the wall of the gallbladder, in the passages of Lushka, so the microbial flora can not be found in the gallbladder bile.

The bacteriological basis of acute cholecystitis is various microorganisms and their associations. Among them, the main importance belongs to gram-negative bacteria - these are enterobacteria (E. coli, Klebsiella) and Pseudomonas. In the overall structure of the microbial flora that causes acute cholecystitis, gram-positive microorganisms (non-spore-forming anaerobes - bacteroides and anaerobic cocci) make up about one third, and almost always in association with gram-negative aerobic bacteria.

The second decisive factor in the development of acute cholecystitis is an increase in intravesical pressure. Most often, the cause of its occurrence is obturation with a stone of the neck of the bladder or cystic duct. Less commonly, a sudden increase in pressure in the gallbladder leads to blockage of the duct by a lump of mucus, its narrowing and kinks, as well as dysfunction of the biliary tract - spasm of the sphincter of Oddi. Only from the moment of occurrence of intravesical biliary hypertension, favorable conditions appear for the development of infection and destructive changes in the wall of the gallbladder. In about 70% of patients with acute cholecystitis, gallstones are the cause of bile stasis in the gallbladder. Based on this fact, some authors call such cholecystitis "obstructive".

In the pathogenesis of the inflammatory process in the wall of the gallbladder, lysolycetin. High concentrations of lysolycetin in bile appear when the gallbladder is blocked, which is accompanied by trauma to its mucosa and the release of phospholipase A 2. This tissue enzyme converts bile lecithin into lysolicetin, which the together with bile salts, it has a damaging effect on the mucous membrane of the gallbladder, causes a violation of the permeability of cell membranes and a change in the colloidal state of bile. The consequence of these tissue damage is aseptic inflammation of the gallbladder wall. Under conditions of biliary hypertension and stretching of the gallbladder, mechanical compression of the vessels occurs, and microcirculation disorders occur. This is manifested by a slowing of blood flow and stasis both in capillaries and in venules and arterioles. It has been established that the degree of vascular disorders in the wall of the gallbladder is directly dependent on the magnitude of biliary hypertension. If the increase in pressure persists for a long time, then due to a decrease in hemoperfusion and ischemia of the gallbladder wall, as well as a change in the qualitative composition of bile, the endogenous infection becomes virulent. The exudation that occurs during inflammation into the lumen of the gallbladder leads to a further increase in intravesical hypertension, to increased damage to the mucosa. In this case, we can talk about the formation of a pathophysiological vicious circle, in which the primary link in the development of the inflammatory process in the gallbladder wall is acute biliary hypertension, and the secondary is infection.

It is well known that the timing and severity of the development of the inflammatory process in the gallbladder largely depend on vascular changes in its wall. Their consequence is foci of necrosis and perforation of the bladder wall, which most often occur in the area of the bottom or neck. In elderly patients, vascular disorders associated with atherosclerosis and hypertension often cause the development of destructive forms of acute cholecystitis. As a consequence of atherothrombosis or cystic artery embolism, they may have primary gangrene of the gallbladder.

Classification

The question of the classification of acute cholecystitis is not only theoretical, but also of great practical importance. A rationally compiled classification gives the surgeon the key to the choice of treatment tactics, which should be adequate to the clinical situation.

The existing many classifications of acute cholecystitis, created by various authors, suggests that there is still no unity in the interpretation of various aspects of this disease. In everyday practice, we use the classification, which, from our point of view, corresponds to the modern diagnostic algorithm and the choice of treatment. It is extremely simple and convenient for clinical use.

It is based on the clinical and morphological principle - the dependence of the clinical manifestations of the disease on pathomorphological changes in the gallbladder, extrahepatic bile ducts and abdominal cavity. In this classification, two groups of acute cholecystitis are distinguished: uncomplicated and complicated.

Clinical and morphological classification of acute cholecystitis

Uncomplicated acute cholecystitis includes all pathomorphological forms of inflammation of the gallbladder that occur daily in clinical practice. Each of these forms should be considered as a natural development of the inflammatory process: a gradual transition from catarrhal inflammation to gangrene. An exception to this pattern is primary gangrenous cholecystitis, since its development is based on primary thrombosis (embolism) of the cystic artery.

Acute inflammation of the gallbladder can occur with and without stones in its lumen. The accepted division of acute cholecystitis into acalculous and calculous is rather arbitrary, since regardless of the presence or absence of stones, the clinical picture of the disease and treatment tactics in an urgent situation will be almost the same. We do not consider it appropriate to isolate the so-called acute "obstructive" cholecystitis, since in most cases the development of acute cholecystitis is based on obturation of the neck or duct of the gallbladder with a stone.

The group of complications consists of pathological processes directly related to inflammation of the gallbladder and the spread of infection beyond its limits, as well as those caused by cholelithiasis and its consequences.

Clinical semiotics

Acute cholecystitis occurs in people of all ages, but is more common in people over 50 years of age. Patients of elderly (60-74 years) and senile (75-89 years) age account for 50% of the total number of cases. The ratio among them of men and women is 1:5.

Clinical manifestations of acute cholecystitis depend on the pathomorphological picture of inflammation of the gallbladder, the presence and extent of peritonitis, as well as concomitant changes in the bile ducts. Due to the diversity of the clinical picture of the disease, diagnostic difficulties and errors are possible.

Acute cholecystitis usually begins suddenly. The development of acute inflammation in the gallbladder is often preceded by an attack of biliary colic caused by blockage of the neck of the gallbladder or cystic duct by a stone. An acute pain attack stops on its own or after the introduction of antispasmodic drugs. A few hours after the colic attack subsides, clinical signs of acute cholecystitis appear.

The leading symptom of acute cholecystitis is a strong and persistent abdominal pain, the intensity of which increases with the progression of the disease. Its distinctive feature is localization in the right hypochondrium with irradiation to the right supraclavicular region, shoulder or shoulder blade. Sometimes the pain radiates to the region of the heart, which can be regarded as an attack of angina pectoris (cholecystocoronary syndrome of S.P. Botkin).

Persistent symptoms of acute cholecystitis - nausea and repeated vomiting, which does not bring relief to the patient. Increase in body temperature observed from the first days of the disease. Its nature largely depends on the depth of pathomorphological changes in the gallbladder.

The condition of the patient may be different, depending on the form of the disease. The skin is usually of normal color. Moderate jaundice of the sclera can manifest itself in cases of local hepatitis and with pericholedochal lymphadenitis, which occurs with stagnation of bile in hepaticocholedochus. The appearance of bright jaundice of the skin and sclera indicates the mechanical nature of extrahepatic cholestasis, which may be associated with bile duct lithiasis or stricture of the major duodenal papilla (MPD). The pulse rate ranges from 80 to 120 beats per minute and above. A frequent pulse is a formidable symptom, indicating severe inflammatory changes in the gallbladder and abdominal cavity.

The specific signs of acute cholecystitis are described: Orthner's symptom - pain when tapping the right costal arch with the edge of the hand; Kera's symptom pain in the projection of the gallbladder on the anterior abdominal wall during palpation at the height of inspiration; Murphy's sign involuntary breath holding on inspiration during palpation of this area; Mussi-Georgievsky(phrenicus-symptom) - soreness when pressing with a finger of the right supraclavicular fossa between the legs of the sternocleidomastoid muscle. The frequency of detection of these symptoms is not the same, which depends on the nature of morphological changes in the gallbladder and the possible transition of inflammation to the parietal peritoneum.

In acute cholecystitis and its complications, there are significant structural changes in the liver. They are the result of involvement in the inflammatory process of the segment of the liver adjacent to the gallbladder, and toxic damage to hepatocytes. The degree of these changes is closely related to the duration of the disease and the severity of the inflammatory process. Depending on their depth in the patient's blood, one can detect increased content of enzymes: aminotransferase, aldolase, alkaline phosphatase, lactate dehydrolase, γ-glutamyl transferase. Determining the activity of liver enzymes, as well as bilirubin and its fractions, is important when a patient has jaundice, which can be hepatocellular or obstructive in nature.

Significant changes in acute cholecystitis occur in the rheological state of the blood and the hemostasis system: an increase in blood viscosity, the aggregation ability of erythrocytes and platelets, and blood coagulation activity. Violations of hemorheology and hemostasis can lead to disorders of microcirculation and tissue metabolism in the liver and kidneys, create prerequisites for the development of acute hepatic-renal failure, as well as for the occurrence of thromboembolic complications.

catarrhal cholecystitis - the mildest form of the disease, characterized by moderate pain in the right hypochondrium, nausea and vomiting once or twice.

The general condition of the patient suffers little. The pulse can increase up to 90 beats per minute. The tongue is wet. On palpation of the abdomen, there is local pain in the right hypochondrium. The hallmark signs of acute inflammation of the gallbladder - the symptoms of Ortner, Ker, Murphy and Myus-si-Georgievsky - are mild or absent; the Shchetkin-Blumberg symptom is not determined. The gallbladder is not palpable, but the area of its projection is slightly painful. The number of leukocytes in the blood increases to 9-11∙10 9 /l. A mildly pronounced clinical picture of catarrhal cholecystitis is often mistakenly regarded as a stopped attack of biliary colic.

With catarrhal inflammation, the disease can end in complete clinical recovery. With active drug treatment, inflammation in the gallbladder stops by 6-8 days from the onset of the disease. If, after the inflammatory process subsides, obturation of the cystic duct with a stone persists, a dropsy of the gallbladder. In this case, the bubble reaches a large size due to the accumulation in the lumen of its colorless, mucus-like sterile liquid (“white bile”). It is palpated as an elastic and painless mass. Dropsy of the gallbladder can exist for a long time and not cause any suffering. However, it can be complicated by the development empyema of the gallbladder. That is why such patients are shown surgery in a planned manner.

Phlegmonous cholecystitis characterized by constant intense pain in the abdomen with typical irradiation to the right shoulder or right supraclavicular region. Patients are concerned about nausea, repeated vomiting, which does not bring relief. Weakness and malaise are pronounced, there may be chills. Body temperature rises to 37.8-38.0°C and above, lasts for several days.

The patient's condition is usually moderate. The pulse quickens to 90-100 beats per minute. Dry tongue. The abdomen is swollen, significantly painful in the right hypochondrium and, often, in the epigastric region. Almost always there are phenomena of local peritonitis: the tension of the abdominal muscles and the Shchetkin-Blumberg symptom are determined in the right hypochondrium. With mildly pronounced tension of the abdominal wall, it is possible to palpate an enlarged and painful gallbladder. As a rule, there are positive "sign" symptoms of acute cholecystitis. The number of leukocytes in the blood reaches 12-15∙10 9 /l, in the leukocyte blood formula - a neutrophilic shift.

With phlegmonous inflammation of the gallbladder, different outcomes of the disease are possible. Clinical recovery is observed with timely hospitalization of the patient and active conservative therapy. Relief of the inflammatory process in the wall of the gallbladder and abdominal cavity may result in the formation of empyema of the gallbladder. In this pathological condition, the gallbladder is palpable in the form of a dense and moderately painful formation, symptoms of peritoneal irritation are not determined. As a result of the accumulation of purulent exudate in the "disconnected" gallbladder, the patient periodically has chills and high fever. In the blood taken during a fever, a high leukocytosis with a stab shift is determined.

With phlegmonous cholecystitis, the inflammatory process goes beyond the gallbladder and spreads to the parietal peritoneum and neighboring organs, including the hepatoduodenal ligament. The transition of the inflammatory process to the organs and tissues surrounding the gallbladder leads to their tight adhesion and the formation of an inflammatory infiltrate. Peripesical infiltrate is detected on the 4th-6th day of the disease. Clinically, it is characterized by the presence of a dense, painful and immobile formation in the right hypochondrium. With a tendency for the inflammatory process to subside and the inflammatory infiltrate to resolve, abdominal pain decreases, peritoneal symptoms disappear, leukocytosis decreases, and temperature normalizes. With drug therapy, the infiltrate ceases to be palpable after 1.5-2 weeks, however, it takes at least 1.5-2 months to completely subside the inflammatory process.

In the absence of a reliable limitation of the inflammatory process due to tight adhesions between the gallbladder and surrounding organs (transverse colon, greater omentum, stomach), the infection outside this focus leads to the development of peritonitis. In acute cholecystitis, the spread of the inflammatory process occurs mainly along the right lateral canal and other parts of the right half of the abdominal cavity. It should be noted that widespread peritonitis with a destructive lesion of the gallbladder is not often observed. This is due to the typical reaction of the restriction of the inflammatory focus by the surrounding organs, their adhesion to the gallbladder.

Gangrenous cholecystitis. Depending on the mechanism of development of this form of cholecystitis, its clinical manifestations appear gradually or suddenly. The gradual appearance of clinical symptoms of the disease is observed during the transition of the phlegmonous form of cholecystitis to gangrenous (secondary gangrenous cholecystitis).

With the development of necrosis of the gallbladder wall in the clinical picture of the disease, the phenomena of intoxication come to the fore, while the pain syndrome can be mildly pronounced. Patients are inhibited, adynamic, or, conversely, excited. The pulse quickens to 110-120 beats per minute. Dry tongue. The abdomen becomes swollen, intestinal paresis increases. On palpation, one can note a slight decrease in pain in the right hypochondrium and the degree of tension in the abdominal muscles. Body temperature drops and may be normal. At the same time, the number of leukocytes and a shift to the left of the leukocyte blood formula increase. Severe intoxication, the appearance of tachycardia at normal temperature (a symptom of "toxic scissors") and leukocytosis with an increase in the number of stab neutrophils indicate deep morphological changes in the gallbladder with the development of areas of necrosis or its total gangrene.

For primary gangrenous cholecystitis, arising as a result of thrombosis of the cystic artery, a rapid course is characteristic from the first hours of the disease. It is manifested by severe intoxication and rapidly progressive peritonitis.

Perforated cholecystitis develops in patients with a gangrenous form of the disease in case of failure to provide them with surgical care or due to a decubitus ulcer of the bladder wall with a gallstone. In the first case, perforation occurs most often in the region of the bottom of the gallbladder, in the second - in the region of the neck. A vivid clinical picture of the disease is observed when the gallbladder perforates into the free abdominal cavity, which leads to the spillage of purulent gallbladder bile in all its departments. Clinically, the moment of perforation is manifested by the sharpest pains in the abdomen and repeated vomiting. The patient is covered with cold sweat, the skin turns pale. In the first minutes, there is a slowing of the pulse and hypotension. Subsequently, blood pressure stabilizes, the pulse increases sharply as peritonitis develops. Examination of the abdomen reveals a pattern of widespread peritonitis. Perforation of the gallbladder into the free abdominal cavity develops in 1-3% of cases of acute cholecystitis.

A less pronounced clinical picture is observed with perforation of the gallbladder, delimited by an inflammatory infiltrate. At the time of perforation, purulent bile enters the subhepatic space, which is accompanied by increased pain in the right hypochondrium and a gradual increase in symptoms of purulent intoxication (dry tongue, tachycardia, leukocytosis with a shift of the leukocyte formula to the left). Symptoms of peritoneal irritation may be absent. Perforation of the gallbladder with accumulation of infected bile in the inflammatory infiltrate delimiting it leads to the formation subhepatic abscess with the development of systemic inflammatory response syndrome.

Purulent cholangitis, complicating the course of acute cholecystitis, may develop as a result of a direct transition of the inflammatory process from the gallbladder to the extrahepatic bile ducts. This is accompanied by a thickening of their walls and a narrowing of the lumen, which, in turn, leads to a violation of the outflow of bile into the intestine. However, in most cases, purulent cholangitis occurs in the presence of stones in the bile ducts and stricture of the major duodenal papilla. Obstructive cholangitis is most severe due to persistent biliary stasis and rapid spread of infection into the intrahepatic bile ducts. Purulent obstructive cholangitis can lead to cholangiogenic liver abscesses and biliary sepsis. Clinical signs of purulent cholangitis do not appear immediately, but 3-4 days after the onset of the attack, and sometimes later. It is characterized by three clinical signs (Charcot's triad): increasing icteric staining of the skin and sclera, high temperature up to 38-39 ° C, accompanied by chills and pain in the right hypochondrium. The patient's condition is severe, consciousness may be confused; attention is drawn to tachycardia and a tendency to hypotension. Palpation of the abdomen, along with symptoms of acute cholecystitis, can reveal an increase in the size of the liver and spleen. The blood test reveals high leukocytosis with a shift of the leukocyte formula to the left, a sharp increase in ESR, hyperbilirubinemia, as well as an increase in the level of transaminase, alkaline phosphatase, gamma-glutamyltransferase. With the progressive course of purulent cholangitis, signs of hepatic-renal failure and DIC appear. Purulent obstructive cholangitis, which complicates the course of acute cholecystitis, is accompanied by high (up to 40%) mortality.

Laboratory and instrumental diagnostics

Correct and timely diagnosis of acute cholecystitis and its complications is the key to improving treatment outcomes. In connection with an emergency, it involves the use of an optimal set of laboratory and instrumental methods (Fig. 10.1), which must be carried out within 24 hours from the moment the patient is hospitalized.

Rice. 10.1. Diagnostic algorithm for acute cholecystitis and its complications.

This approach allows us to have an accurate diagnosis and develop adequate treatment tactics.

The figure shows a list of laboratory and instrumental studies, which, from our point of view, are the standard for diagnosing acute cholecystitis and its complications. In the study of the composition of peripheral blood in patients with various forms of acute cholecystitis, significant changes are detected in the white blood. An increase in the number of leukocytes with a shift in the formula to the left (due to stab neutrophils) indicates a destructive process in the bladder wall. The more severe the inflammatory process in the gallbladder and abdominal cavity, the more pronounced these changes. However, in debilitated patients and senile patients, a clear pattern between the severity of changes in the gallbladder and the number of leukocytes in the blood may not be observed.

Determining the level of bilirubin in the blood in patients with acute cholecystitis is a mandatory study, which allows to detect cholestasis already in the early stages of the disease. A moderate increase in the content of bilirubin in the blood (25-40 µmol / l) is often found in patients with acute cholecystitis. Slight hyperbilirubinemia is explained by the development of concomitant toxic hepatitis with intrahepatic cholestasis. But even such a level of hyperbilirubinemia should be considered as an alarming moment, indicating pronounced destructive changes in the gallbladder, or extrahepatic cholestasis due to lithiasis or the structure of OBD. To determine the cause of hyperbilirubinemia, it is necessary to perform a detailed biochemical blood test, and in the case of an emergency operation, apply intraoperative cholangiography to assess the condition of the bile ducts.

The standard diagnostic examination of a patient with acute cholecystitis includes the study of amylase in the urine. Moderate increase in amylase in the urine up to 128-256 units. according to Wolgemut, acute cholecystitis is often noted, which is probably associated with a violation of the function of the gastrointestinal tract and the evasion of the enzyme into the blood. Its higher level (512 units and above) requires clarification of the cause of amylasuria, since this is not typical for acute cholecystitis. Therefore, in such cases, it is necessary to conduct additional studies (determination of blood amylase, ultrasound, laparoscopy) to exclude or confirm the presence of acute pancreatitis, which can occur under the guise of acute cholecystitis and cause a diagnostic error. Experience shows that acute cholecystitis is most often misdiagnosed in acute pancreatitis. The list of mandatory studies in a patient with acute cholecystitis should include ECG and chest x-ray. The results of these studies are extremely important for a comprehensive assessment of the patient's physical condition, exclusion of acute myocardial infarction and right-sided pleuropneumonia, which can mimic the symptoms of an acute abdomen and cause diagnostic errors.

Ultrasonography occupies a central place among special instrumental methods for diagnosing acute cholecystitis. The significance of ultrasound is determined by the high information content of the method in diseases of the pancreatohepatobiliary system, its non-invasive nature, the possibility of repeating the study and performing medical procedures under its control. The availability of the ultrasound method for many medical institutions and high diagnostic accuracy (98%) allow us to consider this study standard for acute cholecystitis. To avoid unforgivable diagnostic errors, ultrasound should be performed in all patients with suspected this disease, regardless of the severity of clinical symptoms. According to ultrasound signs, it is necessary to determine the morphological form of acute cholecystitis, since the choice of treatment tactics depends on this.

Ultrasound signs catarrhal cholecystitis are an increase in the size of the gallbladder, a thickening of its walls up to 4-5 mm, which have even, clear contours throughout. In addition, there are no structural changes in the tissues adjacent to the gallbladder. credible signs of destructive cholecystitis serve as an increase in the size of the gallbladder (more than 90.0 x 30.0 mm), a significant thickening of the walls (6 mm or more), doubling (stratification) of the wall, uneven contours and the presence of suspended small hyperstructures without an acoustic shadow (Fig. 10.2) in the cavity gallbladder (pus). In addition, liquid is detected in the subhepatic space and areas of increased echogenicity of surrounding tissues - signs of inflammatory infiltration. The detection of a symptom of an echo-negative band (rim) of various shapes and widths adjacent to the gallbladder may indicate the formation of a perivesical abscess. Most often, in acute cholecystitis, calculi are located in the bladder cavity: hyperechoic structures that give an echo shadow. Identification of a fixed echostructure with an acoustic shadow in the area of the gallbladder neck is a sign of an impacted stone. An additional symptom of acute cholecystitis is a positive Murphy ultrasound sign - increased pain in the gallbladder area on inspiration under an ultrasound probe. When assessing the results of ultrasound, attention is paid to the state of the extrahepatic bile ducts: normally, the width of the hepaticoledochus does not exceed 8 mm. An increase in the diameter of the hepaticoledochus to 9 mm or more may indicate biliary hypertension due to a stone or stricture. Unfortunately, bile duct stones are rarely detected by ultrasound, as they are usually located in the retroduodenal choledochal cavity, which is not accessible for ultrasound evaluation.

Rice. 10.2. Ultrasound echogram of the gallbladder.

If it is impossible to obtain information about the state of the gallbladder and bile ducts during primary ultrasound due to severe flatulence, it must be repeated the next day after appropriate preparation of the patient (taking activated charcoal or espumizan, cleansing enema). A re-examination (after 24-48 hours) is also necessary if the patient has signs of catarrhal inflammation of the gallbladder and is undergoing conservative treatment. Ultrasound control when monitoring a patient allows us to evaluate the effectiveness of ongoing conservative therapy, to identify signs of progressive inflammation of the gallbladder wall and its destruction.

The high diagnostic accuracy of ultrasound, the simplicity and harmlessness of the study, the possibility of conducting it at any time of the day, allow us to consider ultrasound as the primary method in the diagnosis of acute cholecystitis.

Laparoscopy - accurate and informative method for diagnosing acute cholecystitis. Previously, it was widely used to diagnose this disease, which made it possible to avoid diagnostic errors. Currently, due to the introduction of ultrasound into everyday practice, the indications for the use of laparoscopy in cases of suspected acute cholecystitis are significantly limited. From our point of view, it is indicated when the diagnosis is unclear due to the inconclusive clinical picture of acute cholecystitis and the inability to establish the cause of the acute abdomen by other (non-invasive) diagnostic methods.

Endoscopic retrograde cholangiopancreatography (ERCP) used in acute cholecystitis in cases of obstructive jaundice and obstructive cholangitis. In such situations it is very important before surgery have accurate information about the nature and level of obstruction of the bile ducts. With the successful completion of an X-ray contrast study, the doctor is able to identify bile duct stones,

To determine their localization and the level of blockage of the duct, as well as to establish the presence of stenosis and its extent. Determining the nature of the pathology in the bile ducts using the X-ray endoscopic method allows you to correctly resolve the issues of therapeutic tactics.

ERCP should be performed in each case of acute cholecystitis occurring with severe extrahepatic cholestasis, if the severity of the inflammatory process in the abdominal cavity does not require urgent surgical intervention, and endoscopic examination can be completed by performing endoscopic papillotomy and nasobiliary drainage to eliminate biliary stasis. It is necessary to refrain from performing ERCP in the group of patients who, due to the severity of the inflammatory process in the abdominal cavity, the operation should be performed in the next 12-24 hours, and also if it is impossible to complete the diagnostic stage of the endoscopic examination by performing therapeutic measures. In these cases, to assess the state of the bile ducts and identify the nature of the pathology, intraoperative cholangiography.

Medical tactics

Despite the constant discussion on the issue of therapeutic tactics in acute cholecystitis, which takes place on the pages of the medical press, there is still no single view on this issue. Some surgeons advocate a purely conservative method of treatment, while others are in the position of active-expectant tactics. The failure of these positions affects the immediate results of treatment, which, unfortunately, cannot be considered favorable.

Modern achievements in anesthesiology and the development of new medical technologies make it possible to radically revise the existing treatment tactics both in uncomplicated acute cholecystitis and in its complicated forms. The tactics of the surgeon in acute cholecystitis should be active. The main principles are as follows:

Destructive cholecystitis with various variants of its course
serves as an indication for surgical intervention - ho-
lecystectomy or cholecystostomy, which should be performed in
within 24-48 hours from the moment of hospitalization of the patient.
Only catarrhal is subject to purely conservative treatment.
cholecystitis, in which it is usually successful, allowing
to stop the inflammatory process. Surgical intervention in
these patients are performed in a planned manner after a comprehensive examination
which makes it possible to assess the degree of operational anesthesia
biological risk. In case of progressive inflammation and development

destructive changes in the gallbladder (which is detected during dynamic clinical observation and control ultrasound), active surgical tactics are used.

With this approach, the question of the need for surgery is resolved immediately when the final diagnosis of acute destructive cholecystitis occurs, both with and without peritonitis. A distinctive feature of this treatment tactic is the timing of the operation. Depending on this, the operation can be emergency or urgent.

An emergency operation is performed within the next 4-6 hours from the moment the patient enters the hospital. Indications for it are all forms of destructive cholecystitis - phlegmonous, gangrenous or perforated, occurring with a systemic inflammatory reaction syndrome, local or diffuse peritonitis. Indications for an urgent operation, which is performed within the first 12-48 hours from the moment of hospitalization of the patient, is phlegmonous cholecystitis, which occurs both with and without local peritonitis.

The timing of the operation is not determined by the need to monitor the patient to make a decision: to operate or not to operate. They are dictated by the patient's condition, the need for preoperative preparation and a minimum set of studies to assess the severity of his physical condition. Preoperative preparation should be aimed at correcting metabolic disorders and disorders of the cardiovascular and pulmonary systems, which are often found in patients with acute cholecystitis. The use of active therapeutic tactics and the rejection of conservative treatment of acute destructive cholecystitis are appropriate for the following reasons. Firstly, with conservative therapy, the clinical manifestations of the disease subside in about 50% of patients, while in the rest, the symptoms of the disease progress or persist for a long time, which delays their recovery. Secondly, conservative treatment of acute cholecystitis in elderly and senile patients often obscures clinical symptoms without preventing the progression of destructive changes in the gallbladder. Thirdly, postoperative mortality in early operations is significantly lower than in interventions performed at a later date. Based on these factors, we once again state that for all variants of the clinical manifestation of acute destructive cholecystitis, surgical treatment is indicated, which should be carried out in the first 12-48 hours from the moment of hospitalization of the patient.

Acute inflammation of the gallbladder is one of the most common complications of gallstone disease.
Etiology and pathogenesis. The disease occurs in approximately 25% of patients with chronic calculous cholecystitis. However, in 5-10% of patients with acute cholecystitis, stones in the gallbladder are not determined. The main reasons for
The causes of acute cholecystitis are the microflora in the lumen of the bladder, the violation of the outflow of bile (most often due to the blockade of the neck or cystic duct with a calculus), the stretching of the walls of the bladder and the associated ischemia of its wall. The microflora enters the gallbladder in an ascending way from the duodenum, in a descending way with the flow of bile from the liver, where the infection enters with the blood flow, less often by the lymphogenous and hematogenous routes.
In the vast majority of patients with chronic calculous cholecystitis, bile contains microflora. However, an acute inflammatory process occurs only when the outflow of bile is disturbed. Of secondary importance are ischemia of the bladder wall and the damaging effect of pancreatic juice, pancreas on the mucous membrane of the bladder in pancreatobiliary reflux.
Clinical picture and diagnosis. There are the following clinical and morphological forms of acute cholecystitis: catarrhal, phlegmonous and gangrenous (with or without perforation of the gallbladder) cholecystitis.
Catarrhal cholecystitis is characterized by intense persistent pain in the right hypochondrium, epigastric region with irradiation to the lumbar region, right shoulder blade, shoulder, right half of the neck. At the beginning of the disease, pain can be paroxysmal in nature due to increased contraction of the gallbladder wall. aimed at eliminating occlusion of the neck of the bladder or cystic duct. Often there is vomiting of gastric, and then duodenal contents, which does not bring relief to the patient. Body temperature rises to subfebrile figures. Moderate tachycardia develops up to 100 beats per 1 min. sometimes some increase in blood pressure. The tongue is moist and may be coated with a whitish coating. The abdomen is involved in the act of breathing, there is some lag in the upper sections of the right half of the abdominal wall in the act of breathing. On palpation of the abdomen, there is a sharp pain in the right hypochondrium, especially in the projection of the gallbladder. The tension of the muscles of the abdominal wall is absent or slightly expressed. Positive symptoms of Ortner, Murphy, Georgievsky-Mussi. In 20% of patients, an enlarged, moderately painful gallbladder can be felt. In the blood test, moderate leukocytosis is noted (10-12 * 109 / l).
Catarrhal cholecystitis, like hepatic colic, in most patients is provoked by errors in the diet. Unlike colic, an attack of acute catarrhal cholecystitis is longer (up to several days) and is accompanied by nonspecific symptoms of the inflammatory process (hyperthermia, leukocytosis, increased ESR).
Phlegmonous cholecystitis has more pronounced clinical symptoms. The pain is much more intense than with the catarrhal form of inflammation. They are aggravated by breathing, coughing, changing the position of the body. Nausea and repeated vomiting occur more often, the general condition of the patient worsens, the body temperature reaches febrile numbers, tachycardia increases to 110-120 beats per 1 minute. The abdomen is somewhat swollen due to intestinal paresis, while breathing the patient spares the right half of the abdominal wall, intestinal noises are weakened. On palpation, there is a sharp pain in the right hypochondrium, muscular protection is expressed: it is often possible to determine an inflammatory infiltrate or an enlarged painful gallbladder. Determine the positive symptom of Shchetkin-Blumberg in the right upper quadrant of the abdomen. Symptoms of Ortner, Murphy. Georgievsky-Mussy are also positive. In the blood test, leukocytosis is detected up to 18-22 » 109/l with a shift of the formula to the left, an increase in ESR.
A hallmark of the phlegmonous process is the transition of inflammation to the parietal peritoneum. At the same time, the gallbladder is enlarged in size, its wall is thickened, purple-bluish in color: there is a fibrinous coating on the peritoneum covering it, and purulent exudate in the lumen. If in the catarrhal form of acute cholecystitis, only the initial signs of inflammation (swelling of the bladder wall, hyperemia) are noted during microscopic examination, then in phlegmonous cholecystitis, a pronounced infiltration of the bladder wall with leukocytes, impregnation with purulent exudate, sometimes with the formation of abscesses, are detected.
Gangrenous cholecystitis is characterized by a rapid clinical course, usually a continuation of the phlegmonous stage of inflammation, when the body's defenses are unable to cope with the virulent microflora. The symptoms of severe intoxication with symptoms of local or general purulent peritonitis come to the fore, which is especially pronounced with perforation of the gallbladder wall. The gangrenous form of inflammation is observed more often in elderly and senile people with reduced tissue regenerative abilities, decreased body reactivity and impaired blood supply to the gallbladder wall due to atherosclerotic lesions of the abdominal aorta and its branches. With the transition of the inflammatory process to the gangrenous form, there may be some decrease in pain and an apparent improvement in the general condition of the patient, which is associated with the death of sensitive nerve fibers in the gallbladder. However, this period of imaginary well-being is quickly replaced by increasing intoxication and symptoms of widespread peritonitis. The condition of patients is severe, they are lethargic, inhibited. The body temperature is febrile, severe tachycardia develops (up to 120 beats per minute or more). Breathing becomes rapid and shallow. Dry tongue; the abdomen is swollen due to intestinal paresis, its right sections do not participate in the act of breathing, peristalsis is sharply depressed, and there is no general peritonitis. The protective tension of the muscles of the anterior abdominal wall is expressed, symptoms of peritoneal irritation are revealed. Percussion sometimes determine the dullness of the sound over the right lateral canal of the abdomen. In blood and urine tests, high leukocytosis with a sharp shift of the leukocyte formula to the left, accelerated ESR, disturbance of the electrolyte composition of the blood and acid-base state, proteinuria, cylindruria (signs of destructive inflammation and severe intoxication).
Acute cholecystitis in elderly and especially senile people with a decrease in the overall reactivity of the body and the presence of concomitant diseases has an erased course. Gangrenous cholecystitis most often develops in this category of persons. Old people often do not have intense pain sensations, the protective tension of the muscles of the anterior abdominal wall is erased, there is no high leukocytosis. In this regard, in patients of senile age, there may be quite serious difficulties in the diagnosis of acute cholecystitis, the assessment of the condition and the choice of treatment.
In typical cases, the diagnosis of acute cholecystitis does not present serious problems. However, a similar clinical picture may occur in acute appendicitis, acute pancreatitis, perforated gastric and duodenal ulcers, renal colic, and some other diseases of the abdominal organs.
Among the instrumental methods for diagnosing acute cholecystitis, the leading role belongs to ultrasound. In this case, it is possible to determine the thickening of the wall of the gallbladder, stones in its lumen, exudate in the subhepatic space. Of the invasive research methods, laparoscopy has become widespread, which allows visually assessing the nature of morphological changes in the gallbladder. Both of these methods can also be used as medical procedures in combination with gallbladder puncture and its external drainage.
Treatment. All patients with acute cholecystitis should be in the hospital under the constant supervision of a surgeon. In the presence of symptoms of local or widespread peritonitis, emergency surgery is indicated. In other cases, conservative treatment is carried out. They limit food intake, allowing only alkaline drinking (acidic gastric contents, proteins and fats stimulate the release of intestinal hormones that enhance the motor activity of the gallbladder and the secretory activity of the pancreas). Non-narcotic analgesics are used to reduce pain. It is not advisable to use narcotic analgesics, since due to their pronounced analyzing action, they can significantly reduce pain and objective signs of inflammation (peritoneal symptoms), and make diagnosis difficult.
Narcotic analgesics, causing spasm of the sphincter of Oddi, contribute to the development of biliary hypertension and impaired outflow of pancreatic juice, which is highly undesirable in acute cholecystitis. Pain can be reduced through the use of anticholinergic antispasmodic (atropine, platifillin, baralgin, no-shpa, etc.) agents. An ice pack is placed on the area of the right hypochondrium to reduce the blood filling of the inflammatory organ. The use of a warm heating pad is absolutely unacceptable, since this significantly increases the blood supply to the gallbladder, which leads to further progression of the inflammatory process with the development of destructive changes. To suppress the activity of microflora, broad-spectrum antibiotics are prescribed, with the exception of tetracycline drugs that have hepatotoxic properties. For detoxification and parenteral nutrition, infusion therapy is prescribed in a total volume of at least 2.0-2.5 liters of solutions per day. During treatment, the patient is constantly monitored. Take into account subjective sensations, objective symptoms of the disease. It is advisable to keep an individual observation card, in which the pulse rate, blood pressure, body temperature, and the number of leukocytes in the blood are noted every 4-6 hours. This greatly facilitates the monitoring of the patient, allows you to evaluate the effectiveness of the treatment, to judge the course of the inflammatory process.
In acute cholecystopancreatitis, the complex of drug therapy should also include drugs used to treat acute pancreatitis.
In most patients, relief of an attack of acute cholecystitis is possible. In the process of observation and treatment, it is necessary to examine the patient. To detect stones in the gallbladder, it is advisable to perform an ultrasound scan. If they are detected and there are no contraindications (severe diseases of the vital organs), it is advisable to operate the patient in a planned manner in 24-72 hours or 2-3 weeks after the acute attack subsides.
If against the background of the treatment of acute cholecystitis within 48-72 hours the patient's condition does not improve, abdominal pain and protective tension of the abdominal wall persist or increase, the pulse quickens, remains at a high level or the temperature rises, leukocytosis increases, then urgent surgical intervention is indicated for prevention of peritonitis and other serious complications.
In recent years, punctures and external drainage of the gallbladder have been successfully used to treat acute cholecystitis in patients with an increased operational risk. Under the control of a laparoscope or ultrasound, the gallbladder is punctured, its infected contents (bile, pus) are evacuated through the liver tissue, after which a flexible plastic catheter is installed in the lumen of the bladder for aspiration of the contents and local administration of antibiotics. This allows you to stop the progression of the inflammatory process, including the development of destructive changes in the wall of the gallbladder, quickly achieve a positive clinical effect, avoid forced, risky surgical interventions for the patient at the height of acute cholecystitis and without proper preoperative preparation. This technique is appropriate in elderly and senile patients with an extremely high operational risk.
The situation becomes much more complicated with the development of obstructive jaundice against the background of acute cholecystitis. This complication threatens the patient with cholangitis, damage to hepatocytes, further aggravation of intoxication with the possible development of hepatic and renal failure. Obstructive jaundice often develops in elderly and senile people, whose compensatory capabilities of the body are very limited. Surgical intervention against the background of acute cholecystitis in such patients is quite a big risk. In this situation, a rather promising direction is urgent endoscopic papillotomy. Through the biopsy channel of the duodenoscope, a thin cannula is inserted into the major duodenal papilla, after which its upper wall is dissected using a special papillotome. In this case, the calculi from the ducts either depart on their own. or they are removed with special tweezers, using a Dormia loop (basket) or a Fogarty probe. This manipulation allows you to eliminate biliary and pancreatic hypertension, reduce jaundice and intoxication. Subsequently, an operation on the gallbladder is performed in a planned manner.
Cholecystectomy is the main surgical intervention performed for acute cholecystitis. Removal of the gallbladder can present significant difficulties due to severe inflammatory changes in it and its surrounding tissues. Therefore, it is recommended to remove the bubble “from the bottom”. Cholecystectomy should be supplemented by intraoperative examination of the extrahepatic bile ducts (cholangiography). When choledocholithiasis or stenosis of the terminal section of the common bile duct is detected, the same manipulations are performed that are customary to do in similar cases during elective operations in patients with chronic calculous cholecystitis (choledochotomy, T-shaped drainage, etc.). Drainage is left in the abdominal cavity to control blood and bile leakage.
Choleistostomy with the removal of calculi and infected contents of the gallbladder is indicated in rare cases as a necessary measure in the general serious condition of the patient and a massive inflammatory infiltrate around the gallbladder, especially in elderly and senile patients. This operation allows only to eliminate acute inflammatory changes in the wall of the gallbladder. In the long term after the operation, as a rule, calculi are again formed in the gallbladder and patients have to be operated on again.
Mortality after cholecystectomy performed for acute cholecystitis. makes 6-8%, reaching at persons of advanced and senile age 15-20%.