Differential diagnosis of acute cholecystitis. Acute cholecystitis differential diagnosis Acute calculous cholecystitis differential diagnosis

Recognition of acute cholecystitis in a typical clinical course and timely hospitalization is not very difficult. Diagnostics becomes difficult in an atypical course, when there is no correspondence between pathomorphological changes and their clinical manifestations, as well as in complicated forms. Diagnostic errors occur in 10-15% of cases. In this case, the most common misdiagnoses are acute appendicitis, acute pancreatitis, perforation of gastroduodenal ulcers, acute intestinal obstruction, right-sided pyelonephritis or paranephritis, right-sided lower lobe pneumonia.

- Differential diagnosis of acute cholecystitis with acute appendicitis.

Differential diagnosis of acute cholecystitis with acute appendicitis is often difficult. This happens when the gallbladder is low, when it descends to the right iliac region and its inflammation simulates acute appendicitis. And, conversely, with a high subhepatic location of the appendix, its inflammation clinically differs little from acute cholecystitis. In order to distinguish between the two diseases, the details of the history should be considered. Patients with acute cholecystitis often note that pain in the right hypochondrium was earlier, as a rule, they occurred after ingestion of fatty and spicy foods.

Pain in acute cholecystitis is more intense with a characteristic irradiation to the right shoulder, scapula and supraclavicular region. Symptoms of intoxication and the general manifestation of inflammation in acute cholecystitis are more pronounced than in acute appendicitis. When palpating the abdomen, it is possible to more clearly identify the localization of pain and tension in the abdominal wall, which is characteristic of each of the diseases. In this case, the detected enlarged gallbladder is of great importance. In acute cholecystitis, appendicular symptoms are not determined. The performed ultrasound examination allows detecting signs of acute cholecystitis and its complications. In the most difficult diagnostic situations, diagnostic laparoscopy allows you to resolve all doubts.

- Differential diagnosis of acute cholecystitis with acute pancreatitis

There is much in common in the clinical picture of acute cholecystitis and acute pancreatitis, especially since a combination of these diseases is possible. In both diseases, the onset is associated with errors in the diet, there are pains in the epigastrium, repeated vomiting. Distinctive features of acute pancreatitis is the encircling nature of the pain. On palpation, the greatest pain is in the epigastric region, in the right hypochondrium it is less pronounced than in acute cholecystitis, an increase in the gallbladder is not detected. Acute pancreatitis is characterized by an increase in the level of pancreatic enzymes in the blood plasma, primarily amylase, as well as diastasuria. Ultrasound and diagnostic laparoscopy are of great importance in the differential diagnosis. The latter is of decisive importance in difficult diagnostic situations. In addition, it allows, upon confirmation of a diagnosis, to solve the problem of treatment by performing an adequate operation.

Due to the fact that in acute cholecystitis, gastrointestinal disorders are sometimes very pronounced - repeated vomiting, bloating, intestinal paresis with gas and stool retention - it is necessary to carry out a differential diagnosis with acute intestinal obstruction. It helps in the differential diagnosis that with acute intestinal obstruction, pains are often cramping in nature. Clinical symptoms such as "splash noise", resonating peristalsis, positive Valya's symptom and other specific signs of acute intestinal obstruction also contribute to the correct diagnosis. Plain X-ray of the abdominal cavity, revealing the Kloyber's cups, is of decisive importance.

- Differential diagnosis of acute cholecystitis with gastric and duodenal ulcers

With an atypical course of perforated gastric and duodenal ulcers, when the perforated opening is covered, the clinical picture may resemble that of acute cholecystitis. In these cases, anamnestic data characteristic of both diseases should be taken into account. For perforated ulcers, vomiting is not characteristic, common signs of inflammation at the onset of the disease. An X-ray examination, which reveals free gas in the abdominal cavity during perforation, provides essential assistance in the diagnosis.

- Differential diagnosis of acute cholecystitis with inflammatory kidney disease

The clinical picture of acute cholecystitis can be simulated by right-sided renal colic or inflammatory diseases of the kidneys (pyelonephritis, paranephritis). The pain in the lumbar region, characteristic of these diseases, can radiate to the right hypochondrium. Pain can be determined on palpation of the abdomen in the right hypochondrium and to the right of the navel. Acute diseases of the right kidney are characterized by pain when tapping on the lumbar region on the right, a positive symptom of Pasternatsky. When examining a patient, attention should be paid to anamnestic data on the presence of urological diseases, urine analysis, which allows detecting hematuria or changes characteristic of inflammation (protein, leukocyturia). In some cases, it is useful to perform excretory urography, ultrasound scanning, chromocystoscopy.

- Differential diagnosis of acute cholecystitis with acute viral hepatitis.

Acute viral hepatitis may be accompanied by pain in the right upper quadrant. In contrast to acute cholecystitis, this disease can reveal the prodromal period, important epidemiological data (contact with patients with hepatitis, blood transfusion, administration of biological products). When examining a patient with hepatitis, as a rule, an enlarged gallbladder, infiltration in the right hypochondrium, peritoneal phenomena are not found. In case of suspected hepatitis, a study of the content of liver enzymes in blood plasma is essential.

Viral hepatitis is characterized by a steady increase in the level of transaminases. Although these hepatic enzymes can be increased in acute cholecystitis, after 24-48 hours their concentration returns to normal levels and, with rare exceptions, their values reach the same level as in hepatitis.

- Differential diagnosis of acute cholecystitis with non-viral hepatitis.

An exacerbation of chronic non-viral hepatitis in alcoholics is clinically difficult to distinguish from acute cholecystitis. In this case, there are also severe pain and tenderness on palpation in the right hypochondrium. When studying the anamnesis, it is possible to identify the fact of alcohol abuse. Local and general signs of inflammation are not very pronounced. Hepatomegaly is often found. Peripheral blood leukocytosis and plasma transaminases are usually normal or slightly elevated. Important signs of degenerative and inflammatory changes in the liver are detected by ultrasound examination. An especially accurate diagnosis can be made with a liver biopsy under ultrasound control. In difficult diagnostic cases, one should resort to diagnostic laparoscopy.

Differential diagnosis of acute cholecystitis with acute right-sided pneumonia and pleurisy.

Acute right-sided pneumonia and pleurisy are characterized by cough, chest pain associated with respiratory movements. Auscultation and chest percussion data help in the differential diagnosis. At the same time, weakening of breathing, wheezing, dullness of the percussion tone, characteristic of pneumonia and pleurisy, are revealed. Chest x-ray will reveal infiltration of lung tissue, the presence of fluid in the pleural cavity.

- Differential diagnosis of acute cholecystitis with acute myocardial infarction.

The differential diagnosis with acute myocardial infarction is based on clinical and electrocardiographic data. Unlike acute cholecystitis, pain in acute myocardial infarction is localized behind the sternum and in the left half of the chest, accompanied by hemodynamic disturbances. In this case, general and local signs of inflammation are not characteristic. Changes in the ECG over time are of decisive importance.

Acute cholecystitis is differentiated from 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 the migration of pain from the epigastrium to the right iliac region or throughout the abdomen; with cholecystitis, the pain is precisely localized in the right hypochondrium; vomiting with appendicitis, single. Usually, palpation reveals a compaction of the consistency of the gallbladder and local tension of the muscles of the abdominal wall. Ortner's and Murphy's symptoms are often positive.

2) Acute pancreatitis. This disease is characterized by the encircling nature of the pain, sharp soreness in the epigastrium. Mayo-Robson's symptom is positive. The patient is in a difficult condition, he takes a forced position. The level of diastase in urine and blood serum is of decisive importance in the diagnosis; figures over 512 units are evidence-based. (in urine).

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

3) Acute intestinal obstruction. In acute intestinal obstruction, the pain is cramping, non-localized. There is no rise in temperature. Enhanced peristalsis, sound phenomena (“splash noise”), radiological signs of obstruction (Kloyber's bowls, arcades, feathering symptom) are absent in acute cholecystitis.

4) Acute obstruction of the mesenteric arteries. With this pathology, severe pains of a constant nature arise, but usually with distinct intensifications, are less diffuse in nature 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 pronounced symptoms of peritoneal irritation. Fluoroscopy and angiography are decisive.

5) Perforated stomach and duodenal ulcer. More often men suffer from this, while women suffer more often 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 scapula, etc., with an ulcer, the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (in case of an ulcer - vice versa). The picture is clarified by the presence of an ulcerative history and tarry stools. Radiographically, free gas is found in the abdominal cavity.

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

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Methods and methods for the diagnosis of acute cholecystitis

Acute cholecystitis is an inflammation of the gallbladder that occurs when the normal movement of bile is suddenly disrupted when its outflow is blocked. In this condition, pathological violations of the walls of the organ can also occur.

Very often, in almost 90% of cases, the disease is combined with stones in the gallbladder (calculi), and in 60% of patients, bile is also infected with various pathogenic bacteria.

Methods for the diagnosis of acute cholecystitis

Many methods are used to accurately diagnose the disease. Diagnostics is always carried out in a comprehensive manner, since only in this case it is possible to accurately identify the disease, because its symptoms almost completely coincide with other ailments of the digestive system.

First of all, the doctor conducts a detailed conversation with the patient, during which he finds out the specifics of the existing symptoms, the characteristics of the person's lifestyle, specific complaints and everything that worries the patient. After that, the doctor directs the patient for additional examinations, as well as for consultations with some specialists, in particular, a surgeon.

The doctor can also refer the patient to consultations with related specialists, such as an infectious disease specialist, a pulmonologist, a gastroenterologist and a cardiologist. Consultations of related specialists in most cases are necessary in cases where difficulties arise in making a specific diagnosis.

Also, the patient is sent for laboratory diagnostics, analyzes and hardware diagnostics by various methods.

Laboratory research

If there is a suspicion of cholecystitis in a patient, the doctor necessarily directs him to take tests and conduct certain studies, since one conversation with the patient and identifying the existing symptoms will not be enough to make an accurate diagnosis.

As a rule, laboratory diagnostics for suspected cholecystitis consists in carrying out:

Instrumental diagnostics includes several different procedures at once, allowing to accurately identify the presence of the disease and the peculiarities of its course.

If a patient suspects cholecystitis, it is mandatory to carry out:

Ultrasound examination of the abdominal organs, which allows you to determine the presence of thickening of the gallbladder wall and doubling of its contour, as well as to reveal the accumulation of fluid near the organ and stones in it. Also, using ultrasound, you can identify other pathological conditions, for example, those associated with inflammation.
FEGDS (fibroesophagogastroduodenoscopy). This research procedure is carried out in order to exclude a possible peptic ulcer, since it is this ailment that often causes pain in the patient.
Chest x-ray. Such a study is necessary to exclude the possible presence of diseases and pathologies of the pleura or lungs.

Additional diagnostic methods can also be prescribed, in particular, computed tomography, which is often performed as an alternative to ultrasound examination. The patient can be referred for MRI of the biliary tract, as well as for endoscopic retrograde cholangiopancreatography, if there is a suspicion that the lesion of the biliary tract is of a tumor nature.

Ultrasonography

Ultrasound can be called practically the leading diagnostic method, since it can be used to identify many types of diseases and determine their features.

When conducting an ultrasound scan, the doctor has the opportunity to accurately assess the existing scale of the problem and outline adequate treatment options in order to help the patient as much as possible. Such a diagnostic method is carried out strictly on an empty stomach so that the food masses do not create obstacles to the study of the state of internal organs.

With the help of an ultrasound examination, the doctor can also determine the chronic form of the disease, which has certain signs:

Deformation of the organ, which often occurs during the development of the disease;
Changes in the size of the organ, since with cholecystitis, the gallbladder can greatly increase or decrease;
The presence of heterogeneity in the structure of the gallbladder cavity when it is affected by a disease;
Thickening of the walls of the organ, which can be more than 3 mm.

With the help of ultrasound, it is possible to establish not only the presence of the disease itself, but also all the features of its course, as well as the existing complications, but in some cases it may be necessary to carry out other diagnostic methods.

Laparoscopy

When conducting ultrasound, it is far from always possible to give clear characteristics of the state of the affected gallbladder, in particular, changes in the organ itself, its hepatoduodenal ligament and the neck area that have arisen during the development of the disease, since such changes create difficulties for ultrasound.

When conducting a survey diagnostic laparoscopy, the doctor has the opportunity to carefully examine all internal organs and accurately assess their condition. Also, during laparoscopy, the cavity is examined in order to determine the presence of a pathological effusion and its nature. Such a violation is localized in most cases under the liver, as well as along the lateral canal on the right side. The general condition of the liver and the relationship to its edge of the gallbladder are also assessed.

If the gallbladder is inflamed, then it usually protrudes from the edge of the liver, while it can be open or enveloped in a strand of the greater omentum. For the study, a special trocar with a diameter of only 6 mm is inserted into the area of the right hypochondrium. An endo-clamp is inserted through this trocar, with the help of which it is possible to assess the presence of changes in the wall of the gallbladder, as well as in the tissues surrounding the organ.

If there are no dense changes and infiltrations, and the general period of development of the disease is short, then the doctor can immediately perform a laparoscopic cholecystectomy. In some cases, for example, in those when the doctor does not have sufficient qualifications to perform the operation by the laparoscopic method, the operation is performed with an open access.

Endoscopic retrograde cholangiopancreatography

If cholecystitis in an acute form is complicated by obstructive jaundice, then an ERCP procedure is prescribed for diagnostic purposes. This diagnostic method allows you to identify the exact causes of biliary stasis of an extrahepatic nature, as well as the location of the occlusion of the bile duct. If a stricture of the distal duct is found, then its length is calculated during the procedure.

Also, this type of diagnosis is used to remove tumors, gallstones. With the help of this procedure, the expansion of the bile ducts is also carried out, if there are areas of narrowing in them.

Before starting the procedure, the patient is given certain sedatives by the intravenous route so that he is completely relaxed. In addition, throat treatment is carried out, for which local anesthetics are used, and a special mouth guard is placed in the patient's mouth, designed to protect his teeth.

After that, an endoscope is inserted through the patient's mouth into his digestive system, which is slowly advanced along the esophagus into the stomach and, then, to the duodenum. Then a special thin catheter is passed through the endoscope, which is inserted into the ducts of the gallbladder and pancreas.

The ducts of the gallbladder and pancreas are filled with a radiopaque substance, which is carried out through a catheter, after which a picture is taken immediately. In the course of such a procedure, it is usually possible to expand the ducts when they narrow, as well as wash out small stones from them, and diagnose the state of the gallbladder. If necessary, during the procedure, the tissues of the bladder, pancreas and their ducts are also taken for further research.

Such a procedure is necessarily carried out on an empty stomach, while it is important to temporarily stop taking medications, since many of them can cause complications.

X-ray

When diagnosing the state of the gallbladder and its ducts, along with various procedures, X-ray studies are also used, such as an overview X-ray, cholegraphy, cholecystography and cholangiography.

Quite often, when examining the gallbladder during a survey X-ray, the doctor also discovers pathologies of other organs, as well as some related diseases, often occurring under the symptoms of cholecystitis.

To conduct an X-ray and obtain the most informative results, it is necessary to introduce special contrast agents into the cavity of the organs under study and their ducts.

The introduction of contrast agents can be carried out in various ways, but most often the patient is given a special drug in the required dosage, in particular, Holevid in the amount of 4 - 6 grams or Bilitrast in the amount of 3 - 3.5 grams, which are absorbed into the blood in the intestine and enter the organs under investigation. In this case, the procedure is carried out 14-16 hours after the introduction of funds.

Now you know all the methods for diagnosing acute cholecystitis, you can learn more about the symptoms of the disease and methods of treatment here.

Varieties of cholecystitis

The wording of the diagnosis of acute cholecystitis can be as follows:

Acute cholecystitis acalculous type in a chronic form, with a mild course.
Acute cholecystitis of a stoneless type in a chronic form, with an average severity of the course. The presence of gallbladder dysfunction of the secondary category of the hyperkinetic type.
Acute cholecystitis acalculous type in a chronic form, with a severe course. The presence of gallbladder dysfunction of the secondary category of hypotonic and hypokinetic type.

Gallstones (cholelithiasis). Cholecystitis of calculous type with attacks of biliary colic, mild, moderate or severe.
Acute calculous cholecystitis of the destructive category.
Acute calculous cholecystitis of the catarrhal category. Choledocholithiasis.

Differential diagnosis of acute cholecystitis

If the patient has a suspicion of acute cholecystitis, differential diagnosis is carried out for other acute inflammatory diseases of the abdominal organs.

In particular, the underlying disease must be differentiated from liver abscess, acute cholangitis, pancreatitis, acute appendicitis, perforated duodenal ulcer or stomach. In addition, the disease should be isolated and an attack of right-sided pleurisy, pyelonephritis or urolithiasis should be excluded.

In some cases, the Charcot triad can be supplemented by impaired consciousness, as well as arterial hypotension. This combination of symptoms is called the Reino pentad.

If the cecum is high, then in the presence of symptoms of cholecystitis, the first step is to exclude possible inflammation of appendicitis.

Pancreatitis in acute form is characterized by the presence of nausea and bouts of vomiting, pain in the epigastric region, which can be given to the back, as well as an increase in the activity of lipase and amylase in the blood.

With pyelonephritis of the right-sided type, pain is usually observed during palpation, as well as signs of an inflammatory process in the urinary tract.

Cholecystitis should be differentiated from other ailments, for example, from myocardial infarction of a lower diaphragmatic nature, acute viral hepatitis, pathologies of the pleura and lungs, vascular ischemia, liver tumors, gonococcal perihepatitis.

Differential diagnosis of acute cholecystitis

Renal colic, in contrast to acute cholecystitis, is characterized by an acute attack of pain in the lumbar region with irradiation to the groin, hip and dysuric disorders. The temperature remains within normal limits, there is no leukocytosis. Abdominal changes with renal colic are rare. In severe cases of renal colic, especially with ureteral stones, bloating, muscle tension in the anterior abdominal wall, and repeated vomiting may occur. In contrast to acute cholecystitis, a positive Pasternatsky symptom is observed and there are no symptoms of peritoneal irritation.

When examining urine, erythrocytes, leukocytes, and salts are found.

ACUTE APPENDICITIS with a high localization of the appendix can simulate cholecystitis.

In contrast to acute appendicitis, acute cholecystitis occurs with repeated vomiting of bile, a characteristic irradiation of pain in the area of the right scapula and shoulder, the right supraclavicular area.

The diagnosis is facilitated by the presence in the patient's history of indications of cholecystitis or cholelithiasis. Acute appendicitis is usually characterized by a more severe course with the rapid development of diffuse purulent peritonitis. Symptoms of acute appendicitis. Often, the correct diagnosis is made during surgery.

PERFORATIVE ULTRA OF THE STOMACH AND 12-TYPE INTESTINAL (mainly covered forms of perforation). Can be misdiagnosed as acute cholecystitis. Therefore, it is necessary to carefully study the history of patients. Acute cholecystitis, in contrast to a perforated ulcer, is characterized by the absence of an ulcer history, the presence of indications of previously transferred attacks of cholelithiasis.

Acute cholecystitis occurs with repeated vomiting, characteristic pain irradiation, fever and leukocytosis, which is not typical for ulcer perforation (triad of symptoms).

Covered perforations occur with an acute onset and pronounced tension of the muscles of the anterior abdominal wall in the first hours after the onset of the disease; often local pains are noted in the right ileal region due to leakage of the contents of the stomach and duodenum, which is not typical for acute cholecystitis. X-ray examination, EGDS, laparoscopy.

ACUTE PANCREATITIS, in contrast to inflammation of the gallbladder, proceeds with rapidly increasing symptoms of intoxication, tachycardia and intestinal paresis. Characterized by pain in the epigastric girdle, accompanied by frequent, sometimes indomitable vomiting.

The diagnosis is facilitated by the presence of an increased content of diastase in the urine and blood and hyperglycemia, characteristic of acute pancreatitis. Pancreatitis symptoms.

Differential diagnosis presents great difficulties (the theory of the "single channel").

DYSKINESIA OF THE CHILD TRACT proceeds with a normal temperature, the condition of the patients is satisfactory, there is no tension in the muscles of the anterior abdominal wall and symptoms of irritation of the peritoneum. Analysis of blood and urine without changes.

GALLERY, in contrast to acute cholecystitis, is characterized by an acute attack of pain, without fever and leukocytosis. After an attack, patients usually have no tension in the muscles of the anterior abdominal wall and symptoms of irritation of the peritoneum, typical for acute cholecystitis. It should be remembered that after an attack of biliary colic, severe acute cholecystitis may develop and, therefore, surgical treatment will be required.

In these cases, after an attack of biliary colic, pain in the right hypochondrium remains and the patient's condition worsens. There is an increase in temperature, leukocytosis, muscle tension of the anterior abdominal wall and pain on palpation in the right hypochondrium.

MYOCARDIAL INFARCTION. Cardiac pathology is of a reflex nature, and after the cure of cholecystitis disappears. Pain in the heart with cholecystitis is called Botkin's cholecystocardial syndrome.

Differential diagnosis between myocardial infarction and cholecystitis is not an easy task when, along with symptoms of acute cholecystitis, there are symptoms of heart muscle damage and ECG data do not exclude a heart attack. Ultrasound and diagnostic laparoscopy are of great importance, which require special anesthetic support and strictly controlled pneumoperitoneum, so as not to further complicate the work of the heart.

If a patient has cholecystitis complicated by jaundice, it is necessary to carry out a differential diagnosis of jaundice, which is characterized by an increase in the level of bilirubin in the blood. There are three main types of jaundice.

Hemolytic (suprahepatic) jaundice occurs as a result of intense breakdown of red blood cells and excessive production of indirect bilirubin. The reason is hemolytic anemia associated with hyperfunction of the spleen in primary and secondary hypersplenism. In this case, the liver is not able to pass a large amount of bilirubin through the hepatic cell (indirect bilirubin). The skin is lemon yellow, there is no itching. Pallor is noted in combination with jaundice. The liver is not enlarged. The urine is dark in color, the stool is intensely colored. There is anemia, reticulocytosis.

Parenchymal (hepatic) jaundice - viral hepatitis, liver cirrhosis, poisoning with some hepatotropic poisons (tetrachloroethane, arsenic and phosphorus compounds). Damage to the hepatocyte occurs, the ability of hepatic cells to bind free bilirubin and translate it into a straight line decreases. Direct bilirubin only partially enters the bile capillaries, a significant part of it returns to the blood.

The disease has a pronounced prodromal period in the form of weakness, lack of appetite, slight fever. In the right hypochondrium there are dull pains. The liver is enlarged and hardened. The skin is saffron-yellow with a ruby tint. In the blood, the level of direct and indirect bilirubin, aminotransferases is increased, the concentration of prothrombin decreases. Feces are colored. But with severe viral hepatitis at the height of the disease, with significant damage to the hepatic cell, bile may not enter the intestines, then the feces will be acholic. With parenchymal jaundice, itching is mild.

To clarify the diagnosis, ultrasound, laparoscopy.

Obstructive jaundice (subhepatic, obstructive) develops as a result of obstruction of the bile ducts and a violation of the passage of bile into the intestine. The reason is calculi in the duct, cancer of the gallbladder with the transition to common bile duct, cancer of the mucous membrane of the duct itself, OBD, the head of the pancreas, metastases of a tumor of another localization in the gate of the liver, or compression of the ducts by a stomach tumor.

Rare causes are cicatricial strictures of the ducts, roundworms in the lumen of the ducts, pericholedocheal lymphadenitis, ligation of the ducts during surgery.

The skin is green-yellow, sometimes yellow-gray. Persistent itching of the skin. Duct obstruction leads to biliary hypertension, which adversely affects the hepatic parenchyma. When cholangitis is attached, fever is observed. The patient's urine is dark, feces are acholic. In the blood - an increase in the content of direct bilirubin. Ultrasound. CPH.

HOLANGITIS is an acute or chronic inflammation of the bile ducts. It is a formidable complication, leading to severe intoxication, jaundice, sepsis. Detoxification. Antibiotic therapy.

Cholecystoduodenal fistula - the attack is resolved, however, the reflux of the intestinal contents into the gallbladder contributes to the continuation of inflammation of the bladder wall. Stones in the intestine - obstructive intestinal obstruction.

11. Treatment of cholecystitis (scheme)

CONSERVATIVE. Hospitalization in the surgical department. Bed rest. Elimination of enteral nutrition (mineral water). Coldness on the stomach. Gastric lavage with cold water. Infusion therapy. Antispasmodics. Analgesics. Antihistamines. If the pain does not relieve, promedol. Omnopon and morphine should not be prescribed - they cause spasm of the sphincter of Oddi and Lutkens. Novocaine blockade of the round ligament of the liver.

The sequence of development of local changes consists of the following components:

1) obstruction of the cystic duct;

2) a sharp increase in pressure in the gallbladder;

3) stasis in the vessels of the gallbladder;

5) destruction of the bladder wall;

7) local and diffuse peritonitis.

Complicated Uncomplicated Canned food. treatment,

(biliary hypertension) (simple) examination

Obturation cholecystitis With hypertension Planned surgery

ducts (KhE, LCE, MCE)

Unblocking Dropsy Destructive Stenosis BDS Choledo-

gallbladder bladder cholecystitis lithiasis

Planned operation Increase group Urgent opera- Jaundice Holan-

(HE) risk radio (HE, LHE, MHE) git

Preoperative Releasing Operations in an urgent order

preparation of the bladder in a row (ChE, choledocholi-

RPHG, EPST, LHE, MHE

The process can develop in three directions:

1. Bubble release. In this case, the treatment continues until the acute symptoms disappear completely, then the patient is examined to identify calculi, the state of the gallbladder, etc.

2. Dropsy of the gallbladder - with a low-virulent infection or its absence, with the preserved ability of the bladder wall to further stretch. Pain and perifocal response subside. For a long time, such a bubble may not bother, but sooner or later an exacerbation occurs. Due to this danger, dropsy of the bladder is a direct indication for a planned operation.

3. Destructive cholecystitis. If conservative treatment is unsuccessful, unblocking did not occur, and an infectious process develops in the turned off gallbladder, which is manifested by an increase in body temperature, leukocytosis, the appearance of symptoms of peritoneal irritation, then this means the onset of destructive cholecystitis (phlegmonous or gangrenous). In this case, the process becomes uncontrollable and dictates the adoption of the most urgent measures.

If within 24 - 48 hours with continuing conservative therapy, the bladder does not unblock, then it is necessary to ascertain the presence of destructive cholecystitis in the patient.

Treatment of obstructive cholecystitis (conservative and surgical).

Emergency operation is performed immediately after the patient is admitted to the hospital or after a vital short-term preparation, which takes no more than a few hours. Indication - peritonitis.

Early surgery (24–72 hours) - with the ineffectiveness of conservative treatment, as well as in cases of cholangitis, obstructive jaundice without a tendency to eliminate them, especially in elderly and senile patients;

Late (planned) - 10-15 days and later after the acute cholecystitis subsided.

1. Preoperative preparation.

3. Access. Kocher, Fedorov, Kera, Rio Branco incisions, Median laparotomy.

4. Cholecystectomy. Callot triangle. Antegrade and retrograde ChE. There are a number of rules to prevent the intersection of the common bile duct. Make sure:

That the cystic duct is a direct continuation of the bladder neck;

That the ligation of the cystic duct can be done under visual control;

That the cystic duct and only it enters the ligature, and the common bile is visible on both sides of the cystic;

The ligation of the cystic duct is carried out directly at the neck.

Intraoperative cholangiography. DPP.

Obstructive jaundice at the time of surgery.

Stones palpable in hepaticoholedochus.

The presence of filling defects and the absence of contrast evacuation into the duodenum on radiographs.

Embedded stone BDS.

History of jaundice and at the time of admission.

Wide cystic duct and small stones in the gallbladder.

Wide extrahepatic bile ducts.

Narrowing of the terminal part of the common bile duct with impaired evacuation of contrast on radiographs.

External drainage of the ducts.

Provides external bile diversion, neutralizes the adverse effects of postoperative biliary hypertension, allows cholephistulography to be performed according to indications.

Drainage according to Vishnevsky. The disadvantage is unreliable fixation in the duct, in some cases, early discharge.

Differential diagnosis

Recognition of the classic forms of acute cholecystitis, especially with timely hospitalization of patients, is not difficult. Difficulties in diagnosis arise in the atypical course of the disease, when there is no parallelism between pathomorphological changes in the gallbladder and clinical manifestations, as well as in the complication of acute cholecystitis with unbounded peritonitis, when, due to severe intoxication and the diffuse nature of abdominal pain, it is impossible to find out the source of peritonitis.

Diagnostic errors in acute cholecystitis occur in 12-17% of cases. Erroneous diagnoses can be such diagnoses of acute diseases of the abdominal organs as acute appendicitis, perforated stomach or duodenal ulcer, acute pancreatitis, intestinal obstruction and others. Sometimes the diagnosis of acute cholecystitis is made with right-sided pleuropneumonia, paranephritis, pyelonephritis. Errors in diagnosis lead to the wrong choice of treatment method and delayed surgical intervention.

Most often, at the prehospital stage, acute appendicitis, intestinal obstruction and acute pancreatitis are diagnosed instead of acute cholecystitis. Attention is drawn to the fact that when referring patients to a hospital, diagnostic errors are more common in the older age group (10.8%) compared with the group of patients under 60 years of age.

Errors of this kind, made at the prehospital stage, as a rule, do not entail special consequences, since each of the diagnoses listed above is an absolute indication for emergency hospitalization of patients in a surgical hospital. However, if such an erroneous diagnosis is confirmed in a hospital as well, this may be the cause of serious tactical and technical miscalculations (incorrectly chosen surgical access, erroneous removal of the secondarily changed appendix, etc.). That is why the differential diagnosis between acute cholecystitis and clinically similar diseases is of particular practical importance.

Distinguish acute cholecystitis from acute appendicitis in some cases it is a rather difficult clinical task. Differential diagnosis is especially difficult when the gallbladder is located low and its inflammation simulates acute appendicitis or, conversely, with a high (subhepatic) location of the appendix, acute appendicitis in many ways resembles acute cholecystitis clinically.

When examining patients, it should be borne in mind that patients of the older age group most often suffer from acute cholecystitis. Patients with acute cholecystitis have a history of repeated attacks of pain in the right hypochondrium with characteristic irradiation, and in some cases direct indications of cholelithiasis. Pain in acute appendicitis is not as intense as in acute cholecystitis and does not radiate to the right shoulder girdle, shoulder and scapula. The general condition of patients with acute cholecystitis, other things being equal, is usually more severe. Vomiting in acute appendicitis - single, in acute cholecystitis - repeated. Palpation of the abdomen allows you to identify the localization of pain and tension in the muscles of the abdominal wall characteristic of each of these diseases. The presence of an enlarged and painful gallbladder finally excludes diagnostic doubts.

There are many similarities in the clinical manifestations of acute cholecystitis and acute pancreatitis: anamnestic indications of cholelithiasis, acute onset of the disease after an error in the diet, localization of pain in the upper abdomen, repeated vomiting. Distinctive features of acute pancreatitis are: girdle pain, severe pain in the epigastric region and much less pronounced in the right hypochondrium, lack of enlargement of the gallbladder, diastasuria, the severity of the general condition of the patient, which is especially characteristic of pancreatonecrosis.

Since in acute cholecystitis, repeated vomiting is observed, and also there are often phenomena of intestinal paresis with bloating and stool retention, a suspicion of acute obstructive intestinal obstruction... The latter is distinguished by the cramping nature of pain with localization uncharacteristic for acute cholecystitis, resonating peristalsis, "splash noise", a positive Valya symptom and other specific signs of acute intestinal obstruction. Plain fluoroscopy of the abdominal cavity is of decisive importance in the differential diagnosis, allowing to detect swelling of intestinal loops (a symptom of "organ pipes") and fluid levels (Kloyber's cup).

Clinical picture perforated ulcer the stomach and duodenum is so characteristic that it rarely has to be differentiated from acute cholecystitis. An exception is covered perforation, especially if it is complicated by the formation of a subhepatic abscess. In such cases, you should take into account the history of ulcers, the acute onset of the disease with "dagger" pain in the epigastrium, the absence of vomiting. Essential diagnostic assistance is provided by an X-ray study, which makes it possible to identify the presence of free gas in the abdominal cavity.

Renal colic, as well as inflammatory diseases of the right kidney and perirenal tissue (pyelonephritis, paranephritis, etc.) may be accompanied by pain in the right hypochondrium and therefore simulate the clinical picture of acute cholecystitis. In this regard, when examining patients, it is imperative to pay attention to the urological history, carefully examine the kidney area, and in some cases it becomes necessary to use a targeted study of the urinary system (urinalysis, excretory urography, chromocystoscopy, etc.).

Instrumental diagnosis of acute cholecystitis

Reducing the incidence of misdiagnosis in acute cholecystitis is an important task in practical surgery. It can be successfully solved only with the widespread use of such modern diagnostic methods as ultrasound, laparoscopy, retrograde cholangiopancreatography (RPCH).

Echoes of acute cholecystitis include a thickening of the wall of the gallbladder and an echo-negative rim around it (doubling of the wall) (Fig. 9).

Rice. 9. Ultrasound picture of acute cholecystitis. There is a thickening of the gallbladder wall (between the black and white arrow) and a small amount of fluid around it (single white arrow)

The high diagnostic accuracy of laparoscopy in acute abdomen allows the method to be widely used for differential diagnostic purposes. The indications for laparoscopy in acute cholecystitis are as follows:

1. Ambiguity of the diagnosis due to the unconvincing clinical picture of acute cholecystitis and the inability to establish the cause of the "acute abdomen" by other diagnostic methods.

2. Difficulties in determining by clinical methods the severity of inflammatory changes in the gallbladder and abdominal cavity in patients with a high degree of operational risk.

3. Difficulties in choosing a method of treatment (conservative or operative) with "blurred" clinical picture of acute "cholecystitis.

According to the indications, laparoscopy in patients with acute cholecystitis allows not only to clarify the diagnosis and the depth of pathomorphological changes in the gallbladder and the prevalence of peritonitis, but also to correctly solve treatment and tactical issues. Complications with laparoscopy are extremely rare.

In case of complications of acute cholecystitis with obstructive jaundice or cholangitis, it is important to have accurate information about the causes of their development and the level of obstruction of the bile ducts before the operation. To obtain this information, RPHG is performed by cannulating the large duodenal nipple under the control of the duodenoscope (Fig. 10, 11). RPHG should be performed in each case of acute cholecystitis, occurring with pronounced clinical signs of impaired outflow of bile into the intestine. With a successful contrast study, it is possible to identify stones in the bile duct, to determine their localization and the level of blockage in the duct, to establish the length of the narrowing of the bile duct. Determining the nature of the pathology in the bile ducts using the endoscopic method allows you to correctly solve questions about the timing of the operation, the amount of surgery on the extrahepatic bile ducts, as well as the possibility of performing endoscopic papillotomy to eliminate the causes. causing obstructive jaundice and cholangitis.

When analyzing cholangiopancreatograms, it is most difficult to correctly interpret the state of the terminal section of the common bile duct due to the possibility of false signs of its lesion appearing on radiographs. The most common misdiagnosis is cicatricial stenosis of the large duodenal nipple, while the X-ray picture of stenosis may be caused by functional reasons "(swelling of the nipple, persistent sphincterospasm). According to our data, the wrong diagnosis of organic stenosis of the large duodenal papilla is made in 13% of cases. Misdiagnosis of nipple stenosis can lead to inappropriate tactics. In order to avoid unjustified surgical interventions on the large duodenal papilla, the endoscopic diagnosis of stenosis should be verified during the operation using an optimal set of intraoperative studies.

Rice. 10. RPHG is normal. PP - pancreatic duct; F - gallbladder; О - common hepatic duct

Rice. 11. RPHG. A common bile duct stone is visualized (marked with an arrow).

In order to shorten the preoperative period in patients with obstructive jaundice and cholangitis, endoscopic retrograde cholangiopancreatography is performed on the first day after the patients are admitted to the hospital.

Therapeutic tactics for acute cholecystitis

The main provisions on therapeutic tactics for acute cholecystitis were developed at the 6th and supplemented at the 15th plenary sessions of the Board of the All-Union Society of Surgeons (Leningrad, 1956 and Kishinev, 1976). According to these provisions, the tactics of the surgeon in acute cholecystitis should be actively expectant. A wait-and-see tactic was recognized as vicious, because the desire to resolve the inflammatory process by conservative measures leads to serious complications and belated operations.

The principles of active-expectant treatment tactics are as follows.

1. Indications for emergency surgery, which is performed in the first 2-3 hours after hospitalization of the patient, are gangrenous and perforated cholecystitis, as well as cholecystitis complicated by diffuse or diffuse peritonitis.

2. Indications for urgent surgery, which is performed 24-48 hours after the patient is admitted to the hospital, are the lack of effect of conservative treatment while the symptoms of intoxication and local peritoneal phenomena persist, as well as cases of an increase in general intoxication and the appearance of symptoms of peritoneal irritation, which indicates about the progression of inflammatory changes in the gallbladder and abdominal cavity.

3. In the absence of symptoms of intoxication and local peritoneal phenomena, patients undergo conservative treatment. If, as a result of conservative measures, it is possible to stop the inflammation in the gallbladder, the question of surgery in these patients is decided individually after a comprehensive clinical examination, including X-ray examination of the bile ducts and gastrointestinal tract. Surgical intervention in this category of patients is performed in the "cold" period (not earlier than 14 days from the onset of the disease), as a rule, without discharging patients from the hospital.

From the listed indications, it follows that a conservative method of treatment can be used only in the catarrhal form of cholecystitis and in cases of phlegmonous cholecystitis, proceeding without peritonitis or with mild signs of local peritonitis. In all other cases, patients with acute cholecystitis should be operated on urgently or urgently.

The success of the operation in acute cholecystitis largely depends on the quality of the preoperative preparation and the correct organization of the operation itself. In an emergency operation, patients need short-term intensive therapy aimed at detoxifying the body and correcting metabolic disorders. Preoperative preparation should not take more than 2-3 hours.

An emergency operation performed for acute cholecystitis has its shadow sides, which are associated with insufficient examination of the patient before the operation and with the impossibility, especially at night, to conduct a full study of the bile ducts. As a result of an incomplete examination of the bile ducts, stones and strictures of the large duodenal nipple are viewed, which subsequently leads to a relapse of the disease. In this regard, it is advisable to perform emergency operations for acute cholecystitis in the morning and afternoon, when it is possible for a qualified surgeon to participate in the operation and use special methods for diagnosing lesions of the bile ducts during its operation. When patients are admitted at night who do not need urgent surgery, they need to carry out intensive infusion therapy during the remaining night hours.

Conservative treatment of acute cholecystitis

Conducting conservative therapy in full and in the early stages of the disease usually allows to stop the inflammatory process in the gallbladder and thereby eliminate the need for urgent surgical intervention, and with a long period of the disease - to prepare the patient for surgery.

Conservative therapy, based on pathogenetic principles, includes a set of therapeutic measures that are aimed at improving the outflow of bile into the intestine, normalizing disturbed metabolic processes and restoring the normal activity of other body systems. The complex of therapeutic measures must include:

hunger for 2-3 days;

local hypothermia - application of an ice bubble to the right hypochondrium;

gastric lavage while maintaining nausea and vomiting;

the appointment of antispasmodics in injections (atropine, platifillin, no-shpa, or papaverine);

antihistamine therapy (diphenhydramine, pipolfen or suprastin);

antibiotic therapy. For antibiotic therapy, drugs should be used that are able to act against etiologically significant microorganisms and penetrate well into bile.

Ceftriaxone 1-2 g / day + metronidazole 1.5-2 g / day;

Cefopyrazone 2-4 g / day + metronidazole 1.5-2 g / day;

Ampicillin / sulbactam 6 g / day;

Amoxicillin / clavulanate 3.6-4.8 g / day;

Gentamicin or tobramycin 3 mg / kg per day + ampicillin 4 g / day + metronidazole 1.5-2 g / day;

Netilmicin 4-6 mg / kg + metronidazole 1.5-2 g / day;

Cefepime 4 g / day + metronidazole 1.5-2 g / day;

Fluoroquinolones (intravenous ciprofloxacinmg) + metronidazole 1.5-2 g / day;

for the correction of disturbed metabolic processes and detoxification, 1.5-2 liters of infusion media are injected intravenously: Ringer-Locke's solution or lactasol - 500 ml, glucose-novocaine mixture - 500 ml (novocaine solution 0.25% - 250 ml and 5% glucose solution - 250 ml), hemodez - 250 ml, 5% glucose solution - 300 ml together with 2% potassium chloride solution - 200 ml, protein preparations - casein hydrolyzate, aminopeptide, alvezin and others;

prescribe vitamins of group B, C, calcium preparations;

taking into account the indications, glycosides, cocarboxylase, panangin, euphyllin and antihypertensive drugs are used.

The appointment of anesthetic drugs (promedol, pantopon, morphine) for acute cholecystitis is considered unacceptable, since pain relief often smoothes the picture of the disease and leads to viewing the moment of perforation of the gallbladder.

An important component of therapeutic measures for acute cholecystitis is the blockade of the round ligament of the liver with a 0.25% solution of novocaine in an amount. It not only relieves pain, but also improves the outflow of infected bile from the gallbladder and bile ducts due to ‘an increase in the contractility of the bladder and the removal of spasm of the sphincter of Oddi. Restoration of the drainage function of the gallbladder and emptying it from purulent bile contribute to the rapid subsiding of the inflammatory process.

Surgical treatment of acute cholecystitis

Surgical approaches... For access to the gallbladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the most widespread incisions are Kocher, Fedorov, Cherni and the upper midline laparotomy.

Surgical volume... With the remaining cholecystitis, it is determined by the general condition of the patient, the severity of the underlying disease and the presence of concomitant changes in the extrahepatic bile ducts. Depending on these circumstances, the nature of the operation may consist in cholecystostomy or cholecystectomy, which, if indicated, is supplemented by choledochotomy and external drainage of the bile ducts or the creation of a biliodigestive anastomosis.

The final decision on the scope of surgery is made after a thorough revision of the extrahepatic bile ducts, which is carried out using simple and accessible research methods (examination, palpation, probing through the cystic duct stump or open common bile duct), including intraoperative cholangiography. Intraoperative cholangiography can reliably judge the state of the bile ducts, their location, width, presence or absence of stones and strictures. On the basis of cholangiographic data, an intervention on the common bile duct and the choice of a method for correcting its lesion are argued.

Cholecystectomy . Removal of the gallbladder is the main intervention for acute cholecystitis, leading to a complete recovery of the patient. This operation was first performed by K. Langenbuch in 1882. Two methods of cholecystectomy are used - "from the neck" and "from the bottom". The method of removing the gallbladder “from the neck” has undoubted advantages (Fig. 12).

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The main clinical manifestations of cholelithiasis, calculous cholecystitis: sharp pain in the right hypochondrium associated with the intake of fatty and spicy foods, nausea, belching with bitterness. Since calculi in the gallbladder usually do not subjectively manifest themselves, a differential diagnosis of calculous cholecystitis should be carried out. It 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 scapula, etc. Also, acute appendicitis is characterized by the migration of pain from the epigastrium to the right iliac region or throughout the abdomen; with cholecystitis, the pain is precisely localized in the right hypochondrium ; vomiting with appendicitis, single. Usually, palpation reveals a compaction of the consistency of the gallbladder and local tension of the muscles of the abdominal wall. Ortner's and Murphy's symptoms are often positive.

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

I Conservative treatment.

Indications:

Single stones;

The volume of the stone is not more than half of the gallbladder;

Acalcified stones;

Functioning gallbladder.

Conservative therapy is as follows:

a) Diet. It is necessary to exclude spices, pickles, smoked meats, spicy, fried, fatty foods from the diet. Take food in small portions 5-6 times a day. It is recommended to limit the consumption of table salt to 4 g per day. Alcohol is categorically excluded. Antibiotics are not indicated during remission.

b) Mineral waters are used.

c) UHF - therapy, diathermy and inductothermy of the gallbladder region, as well as mud therapy.

d) In the presence of dull recurring or persistent pain in the right hypochondrium in the interictal period, it is advisable to conduct a course of therapy with atropine, no-spa, papaverine. Blockade of the round ligament of the liver.

e) The litholytic method is based on the dissolution of stones in the gallbladder. Chenodeoxycholic acid is used as a litholytic. Only gallstones are affected. The course of treatment is 1-1.5 years. After discontinuation of the drug, in some cases, re-formation of stones is possible.

Surgical diseases Tatiana Dmitrievna Selezneva

38. Differential diagnosis and treatment of acute cholecystitis

Differential diagnostics. 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 the mesenteric vessels, right kidney stones or mars also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia. Dyskinesia of the biliary tract 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 disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the closing apparatus of the lower end of the common bile duct.

Dyskinesia includes:

1) atonic and hypotonic gallbladders;

2) hypertensive gallbladders;

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 types of these disorders in patients.

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

With cholecystography in the position of the patient on his 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.

Treatment. When a diagnosis of acute cholecystitis is established, the patient must be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out for health reasons in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent - with the failure of vigorous conservative treatment within the first 24–48 hours from the onset of the disease.

Operations are performed within 5 to 14 days and later with a fading attack of acute cholecystitis and an observed improvement in the patient's condition, that is, in the phase of decreasing the severity of the inflammatory process.

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

Indications for choledochotomy - obstructive jaundice, cholangitis, obstruction in the distal common bile duct, stones in the ducts.

the author

From the book Surgical Diseases the author Tatiana Dmitrievna Selezneva

From the book Urology author O. V. Osipova

From the book Faculty Pediatrics author N.V. Pavlova

From the book Hospital Therapy the author O. S. Mostovaya

From the book Children's Infectious Diseases. Complete reference the author author unknown

From the book Internal Medicine the author Alla Konstantinovna Myshkina

From the book Surgical Diseases the author Tatiana Dmitrievna Selezneva

author N.V. Gavrilova

From the book Infectious Diseases: Lecture Notes author N.V. Gavrilova

From the book How to avoid medical errors the author Richard K. Riegelman

From the book of Senestopathy the author Imant R. Eglitis

From the book Treating Dogs: A Veterinarian's Handbook the author Nika Germanovna Arkadieva-Berlin

There are many similarities in the clinical manifestations of acute cholecystitis and acute pancreatitis: anamnestic indications of cholelithiasis, acute onset of the disease after an error in the diet, localization of pain in the upper abdomen, repeated vomiting. Distinctive features of acute pancreatitis are: girdle pain, severe pain in the epigastric region and much less pronounced in the right hypochondrium, no enlargement of the gallbladder, diastasuria, the severity of the general condition of the patient, which is especially characteristic of pancreatonecrosis.

Since in acute cholecystitis, repeated vomiting is observed, and there are often phenomena of intestinal paresis with bloating and stool retention, a suspicion of acute obstructive intestinal obstruction... The latter is distinguished by the cramping nature of pain with localization uncharacteristic for acute cholecystitis, resonating peristalsis, "splash noise", a positive Valya symptom and other specific signs of acute intestinal obstruction. Plain fluoroscopy of the abdominal cavity is of decisive importance in the differential diagnosis, allowing to detect swelling of intestinal loops (a symptom of "organ pipes") and fluid levels (Kloyber's cup).

Instrumental diagnosis of acute cholecystitis

Echoes of acute cholecystitis include a thickening of the wall of the gallbladder and an echo-negative rim around it (doubling of the wall) (Fig. 9).

Rice. 9. Ultrasound picture of acute cholecystitis. There is a thickening of the gallbladder wall (between the black and white arrow) and a small amount of fluid around it (single white arrow)

1. Ambiguity of the diagnosis due to the unconvincing clinical picture of acute cholecystitis and the inability to establish the cause of the "acute abdomen" by other diagnostic methods.

2. Difficulties in determining by clinical methods the severity of inflammatory changes in the gallbladder and abdominal cavity in patients with a high degree of operational risk.

3. Difficulties in choosing a method of treatment (conservative or operative) with "blurred" clinical picture of acute "cholecystitis.

When analyzing cholangiopancreatograms, it is most difficult to correctly interpret the state of the terminal section of the common bile duct due to the possibility of false signs of its lesion appearing on radiographs. The most common misdiagnosis is cicatricial stenosis of the large duodenal nipple, while the X-ray picture of stenosis may be caused by functional reasons "(swelling of the nipple, persistent sphincterospasm). According to our data, the wrong diagnosis of organic stenosis of the large duodenal papilla is made in 13% of cases. Misdiagnosis of nipple stenosis may lead to incorrect "tactical actions. In order to avoid unnecessary surgical interventions on the duodenal papilla, the endoscopic diagnosis of stenosis should be verified during the operation using an optimal set of intraoperative studies.

Rice. 10. RPHG is normal. PP - pancreatic duct; F - gallbladder; О - common hepatic duct

Rice. 11. RPHG. A common bile duct stone is visualized (marked with an arrow).

In order to shorten the preoperative period in patients with obstructive jaundice and cholangitis, endoscopic retrograde cholangiopancreatography is performed on the first day after the patients are admitted to the hospital.

Therapeutic tactics for acute cholecystitis

The principles of active-expectant treatment tactics are as follows.

3. In the absence of symptoms of intoxication and local peritoneal phenomena, patients undergo conservative treatment. If, as a result of conservative measures, it is possible to stop the inflammation in the gallbladder, the question of surgery in these patients is decided individually after a comprehensive clinical examination, including X-ray examination of the bile ducts and gastrointestinal tract. Surgical intervention in this category of patients is performed in the "cold" period (not earlier than 14 days from the onset of the disease), as a rule, without discharging patients from the hospital.

Conservative treatment of acute cholecystitis

hunger for 2-3 days;

local hypothermia - application of an ice bubble to the right hypochondrium;

gastric lavage while maintaining nausea and vomiting;

the appointment of antispasmodics in injections (atropine, platifillin, no-shpa, or papaverine);

antihistamine therapy (diphenhydramine, pipolfen or suprastin);

antibiotic therapy. For antibiotic therapy, drugs should be used that are able to act against etiologically significant microorganisms and penetrate well into bile.

Drugs of choice:

Ceftriaxone 1-2 g / day + metronidazole 1.5-2 g / day;

Cefopyrazone 2-4 g / day + metronidazole 1.5-2 g / day;

Ampicillin / sulbactam 6 g / day;

Amoxicillin / clavulanate 3.6-4.8 g / day;

Alternative mode:

Gentamicin or tobramycin 3 mg / kg per day + ampicillin 4 g / day + metronidazole 1.5-2 g / day;

Netilmicin 4-6 mg / kg + metronidazole 1.5-2 g / day;

Cefepime 4 g / day + metronidazole 1.5-2 g / day;

Fluoroquinolones (ciprofloxacin 400-800 mg intravenously) + metronidazole 1.5-2 g / day;

prescribe vitamins of group B, C, calcium preparations;

taking into account the indications, glycosides, cocarboxylase, panangin, euphyllin and antihypertensive drugs are used.

An important component of therapeutic measures for acute cholecystitis is the blockade of the round ligament of the liver with a 0.25% solution of novocaine in an amount of 200-250 ml. It not only relieves pain, but also improves the outflow of infected bile from the gallbladder and bile ducts due to "enhancing the contractility of the bladder and relieving spasm of the sphincter of Oddi. Restoration of the drainage function of the gallbladder and emptying it from purulent bile contribute to the rapid subsiding of the inflammatory process.

Surgical treatment of acute cholecystitis