RENAL COLIC, unlike acute cholecystitis, is characterized by an acute attack of pain in the lumbar region with irradiation to the groin, thigh and dysuric disorders. The temperature remains within normal limits, and there is no leukocytosis. Changes from the side abdominal cavity at renal colic are rarely observed. IN severe cases renal colic, especially with ureteral stones, bloating, tension in the muscles of the anterior abdominal wall and repeated vomiting. In contrast to acute cholecystitis, there is positive symptom Pasternatsky and there are no symptoms of peritoneal irritation.
When examining urine, red blood cells, white blood cells, and salts are found.
ACUTE APPENDICITIS with high localization of the appendix can simulate cholecystitis.
In contrast to acute appendicitis, acute cholecystitis occurs with repeated vomiting of bile, characteristic irradiation of pain in the area of the right scapula and shoulder, and the right supraclavicular region.
The diagnosis is facilitated if the patient's history indicates 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 ULCER OF THE STOMACH AND 12-PIECE (mainly covered forms of perforation). May be misdiagnosed as acute cholecystitis. Therefore, it is necessary to carefully study the anamnesis of patients. Acute cholecystitis, in contrast to perforated ulcers, is characterized by the absence of a history of ulcers and the presence of indications of previous attacks of cholelithiasis.
Acute cholecystitis occurs with repeated vomiting, characteristic irradiation of pain, elevated temperature and leukocytosis, which is not typical for ulcer perforation (a triad of symptoms).
Covered perforations occur with an acute onset and pronounced tension in the muscles of the anterior abdominal wall in the first hours after the onset of the disease; Local pain in the right iliac region is often observed due to leakage of the contents of the stomach and duodenum, which is not typical for acute cholecystitis. X-ray examination, endoscopy, laparoscopy.
ACUTE PANCREATITIS, unlike inflammation of the gallbladder, occurs with rapidly increasing symptoms of intoxication, tachycardia and intestinal paresis. Characteristic pain in the epigastrium is of a girdling nature, accompanied by frequent, sometimes uncontrollable vomiting.
The diagnosis is facilitated by the presence of increased levels of diastase in the urine and blood and hyperglycemia, characteristic of acute pancreatitis. Symptoms of pancreatitis.
Differential diagnosis is very difficult (the “single channel” theory).
BILIAL TRACT DYSKINESIA occurs with normal temperature, the patients' condition is satisfactory, there is no tension in the muscles of the anterior abdominal wall and no symptoms of peritoneal irritation. Blood and urine tests are unchanged.
BILIOUS COLIC, unlike acute cholecystitis, is characterized by an acute attack of pain, without fever and leukocytosis. After an attack, patients usually do not have tension in the muscles of the anterior abdominal wall and symptoms of peritoneal irritation typical of 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 in the anterior abdominal wall and pain on palpation in the right hypochondrium.
RIGHT-SIDED PNEUMONIA.
MYOCARDIAL INFARCTION. Cardiac pathology is reflexive in nature, and disappears after treatment of cholecystitis. Pain in the heart with cholecystitis is called cholecystocardial Botkin syndrome.
Differential diagnosis between myocardial infarction and cholecystitis turns out to be a difficult task when, along with the symptoms of acute cholecystitis, there are symptoms of damage to the heart muscle and ECG data do not allow excluding a heart attack. Great importance has an ultrasound and diagnostic laparoscopy, which requires special anesthetic management 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 intensive breakdown of red blood cells and excessive production of direct bilirubin. Reason – 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 liver cell (indirect bilirubin). The skin is lemon-yellow in color, there is no itching. There is pallor in combination with jaundice. The liver is not enlarged. Urine is dark in color, feces are intensely colored. There is anemia and reticulocytosis.
Parenchymal (hepatic) jaundice - viral hepatitis, liver cirrhosis, poisoning with certain hepatotropic poisons (tetrachloroethane, arsenic, phosphorus compounds). Damage to the hepatocyte occurs, and the ability of liver cells to bind free bilirubin and convert it into direct bilirubin 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. There is dull pain in the right hypochondrium. The liver is enlarged and hardened. The skin is saffron-yellow with a ruby tint. The level of direct and indirect bilirubin and aminotransferases in the blood is increased, and the concentration of prothrombin decreases. The feces are colored. But in severe viral hepatitis at the height of the disease, with significant damage to the liver cells, bile may not enter the intestines, then the feces will be acholic. With parenchymal jaundice, the itching is mild.
To clarify the diagnosis, ultrasound, laparoscopy.
Obstructive jaundice (subhepatic, obstructive) develops due to obstruction of the bile ducts and disruption of the passage of bile into the intestine. The reason is stones in the duct, cancer of the gallbladder with transition to the common bile duct, cancer of the mucous membrane of the duct itself, BDS, the head of the pancreas, metastases of a tumor of another localization into the portal of the liver, or compression of the ducts by a stomach tumor.
Rare causes– 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 skin itching. Obstruction of the ducts leads to biliary hypertension, which adversely affects the hepatic parenchyma. When cholangitis occurs, fever is observed. The patient's urine is dark in color, and the stool is acholic. In the blood - an increase in the content of direct bilirubin. Ultrasound. CHPH.
Complications of cholecystitis
CHOLEDOCHOLITHIASIS.
BDS STENOSIS.
CHOLANGITIS – acute or chronic inflammation of the bile ducts. It is a serious complication, leading to severe intoxication, jaundice, and sepsis. Detoxification. Antibiotic therapy.
Cholecystoduodenal fistula - the attack resolves, but the reflux of 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 surgery department. Bed rest. Elimination of enteral nutrition (mineral water). Cold on the stomach. Gastric lavage cold water. Infusion therapy. Antispasmodics. Analgesics. Antihistamines. If the pain does not go away, take 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.
Obstructive cholecystitis.
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 gallbladder;
3) stasis in the vessels of the gallbladder;
4) bacteriocholy;
5) destruction of the bladder wall;
6) infiltrate;
7) local and diffuse peritonitis.
Acute cholecystitis
Complicated Uncomplicated Preserved. treatment,
(bilious hypertension) (simple) examination
Obturats. cholecystitis With hypertension Planned surgery
ducts (CE, LCE, MCE)
Unblocking Dropsy Destructive Stenosis BDS Choledo-
gallbladder g. bladder cholecystitis lithiasis
Planned surgery Advanced group Urgent surgery Jaundice Cholan-
(HE) risk radio (HE, LHE, MHE) git
Preoperative Release of Operations as a matter of urgency
preparation of the bladder in a row (CE, choledocholi-
totomy, PSP, T-drainage,
RPCG, EPST, LCE, MCE
The process can develop in three directions:
1. Unblocking the bubble. In this case, treatment is continued until the acute symptoms disappear completely, then the patient is examined to identify stones, the condition of the gallbladder, etc.
2. Hydrocele 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 reaction subside. For a long time, such a bubble may not bother you, but sooner or later an exacerbation occurs. Due to this danger, hydrocele is a direct indication for elective surgery.
3. Destructive cholecystitis. If conservative treatment is not successful, unblocking does not occur, and the disabled gallbladder develops infectious process, which is manifested by an increase in body temperature, leukocytosis, and the appearance of symptoms of peritoneal irritation, this means the onset of destructive cholecystitis (phlegmonous or gangrenous). The process in this case becomes uncontrollable and dictates the adoption of the most urgent measures.
If within 24 - 48 hours with continued conservative therapy If the bladder does not unblock, it is necessary to establish that the patient has destructive cholecystitis.
Treatment of obstructive cholecystitis (conservative and surgical).
SURGICAL.
By time:
Emergency surgery - performed immediately after the patient is admitted to the hospital or after vital short-term preparation, which takes no more than a few hours. Indication: peritonitis.
Early surgery (24–72 hours) – in case of ineffectiveness of conservative treatment, as well as in cases of cholangitis, obstructive jaundice without a tendency to eliminate them, especially in elderly and old age;
Late (planned) – 10–15 days or later after acute cholecystitis subsides.
1. Preoperative preparation.
2. Pain relief.
3. Access. Kocher, Fedorov, Kera, Rio Branco incisions, Median laparotomy.
Benign tumors of the gallbladder(papillomas, less often multiple - papillomatosis, fibromas, fibroids, adenomas) do not have a specific clinical picture; they are detected during cystectomy performed for calculous cholecystitis or at autopsy. These tumors are often combined with gallstone disease (especially papillomas). Before surgery, the correct diagnosis can be made using cholecystography and ultrasound echolocation. Unlike a gallbladder stone, during cholecystography, the filling defect or ultrasound structure does not change its position when the patient’s body position changes. A tumor of the gallbladder is an indication for surgery - for cholecystectomy, since it cannot be excluded malignant degeneration.
Malignant tumors of the gallbladder(cancer, sarcoma). Gallbladder cancer ranks 5th–6th in the structure of all malignant organ tumors gastrointestinal tract(2 8% of all malignant tumors). There has been an increase in the incidence of gallbladder cancer among the population of developed countries, as well as an increase in the incidence of cholelithiasis. Gallbladder cancer occurs more often in women over 40 years of age, who also have gallstone disease more often. It follows from this that cholelithiasis plays a significant role in the development of gallbladder cancer. According to some reports, gallbladder cancer in 80–100% of cases is combined with cholelithiasis. Apparently, frequent trauma and chronic inflammation of the mucous membrane of the gallbladder are the triggering point in dysplasia of the gallbladder epithelium. Gallbladder cancer is distinguished by rapid metastasis of the tumor through the lymphatic tract and infiltration adjacent parts of the liver, which leads to the development of obstructive jaundice. According to histological structure, adenocarcinoma and scirrhus are the most common, and mucinous, solid and poorly differentiated cancer are less common.
Clinic and diagnosis: in the early stages, gallbladder cancer is asymptomatic or with signs of calculous cholecystitis, which is associated with a frequent combination of gallbladder cancer and cholelithiasis. In later stages, it is also not possible to identify pathognomonic symptoms of the disease and only in the phase of generalization of cancer are observed as general signs cancer process (weakness, fatigue, lack of appetite, weight loss, anemia, etc.), and local symptoms (enlarged tuberous liver, ascites and obstructive jaundice). Cholecystography does not have much information in the diagnosis of gallbladder cancer, since the presence of a filling defect and a “disconnected” gallbladder can be obtained both with gallbladder cancer and with calculous cholecystitis. Much information can be obtained using ultrasound echolocation, computed tomography, hepatoscanning. The most valuable research method is laparoscopy, which allows you to determine the size of the tumor, the boundaries of its spread, the presence of distant metastases, and perform a targeted biopsy.
Benign tumors of the bile ducts are rare. Based on their histological structure, adenomas, papillomas, fibroids, lipomas, adenofibromas, etc. are distinguished. These tumors do not have a characteristic clinical picture. Symptoms of biliary hypertension and obstruction of the biliary tract appear. Post-operative diagnosis of benign tumors is extremely difficult, and a differential diagnosis with malignant tumors can only be carried out intraoperatively after choledochotomy or choledochoscopy with targeted biopsy of the tumor area. Treatment: removal of the tumor within healthy tissues, followed by suturing or plastic surgery of the duct. The indication for surgery is the real possibility of malignancy of the tumor, obstructive jaundice. Cancer of the bile ducts is rare, but more common than cancer of the gallbladder. The tumor can be localized in any part of the extrahepatic bile ducts - from the porta hepatis to the terminal part of the common bile duct. Macroscopically, an exophytic form is distinguished, when the tumor grows into the lumen of the duct and quite quickly causes its obstruction, and an endophytic form, in which the duct evenly narrows along its length, its walls become dense and rigid. The most common histological types of extrahepatic bile duct cancer are:
adenocarcinoma and scirrhus. In 30% of patients there is a combination with cholelithiasis. Among the features of the course of biliary tract cancer, one should note its relatively slow growth and late metastasis to regional The lymph nodes and liver.
Clinically, bile duct cancer manifests itself when the lumen of the duct is obstructed and the outflow of bile into the duodenum is impaired. The main symptom of the disease is obstructive jaundice. Jaundice of the skin appears without a previous painful attack in case of bile duct cancer, in contrast to obstructive jaundice caused by choledocholithiasis. The intensity of jaundice increases rapidly; in some patients it is intermittent, which is associated with the disintegration of tumor tissue and a temporary improvement in the patency of the bile ducts. In the icteric phase of the disease, general symptoms cancer process (weakness, apathy, lack of appetite, weight loss, anemia, etc.), cholangitis often develops, which significantly aggravates the course of the disease. When the tumor is localized below the confluence of the cystic duct into the common hepatic duct, an enlarged, tense, painless gallbladder can be palpated (Courvoisier's sign). The liver is also slightly enlarged and can be palpated. When cancer is localized in the right or left hepatic duct and the patency of the common hepatic duct is preserved, jaundice does not develop, which makes it difficult to make a correct diagnosis. Diagnosis: the most informative for bile duct cancer are ultrasound echolocation, percutaneous transhepatic cholangiography, retrograde pancreatocholangiography, laparoscopic puncture of the gallbladder followed by cholangiography. Morphological confirmation of the diagnosis is possible only during surgery after choledochotomy or choledochoscopy with targeted tumor biopsy. Particular difficulties arise with infiltrating tumor growth, when it is necessary to excise part of the duct wall with subsequent microscopic examination of several sections.
Major duodenal papilla cancer observed in 40% of cases of malignant lesions of the pancreaticoduodenal zone. The tumor can originate from the epithelium of the terminal part of the common bile duct, the distal part of the pancreatic duct, and from the mucous membrane of the duodenum covering the major duodenal papilla. Histologically, adenocarcinoma and scirrhus are most often detected. Cancer of the major duodenal papilla grows relatively slowly and metastasizes to regional lymph nodes and distant organs late.
Clinical presentation and diagnosis: at the beginning of the disease, before the development of obstructive jaundice, dull aching pain appears in the epigastric region and right hypochondrium. Later, the symptoms of obstruction of the biliary tract come first: obstructive jaundice, accompanied by intense skin itching, an increase in the size of the liver, an enlarged painless gallbladder can often be palpated, cholangitis often develops. At the icteric stage of the disease, pain in most patients is absent or mildly expressed, progressing quickly general symptoms of the cancer process, intoxication, cachexia, which is associated with a violation of the flow of bile and pancreatic juice into the intestinal lumen, necessary for the hydrolysis of fats and proteins. Due to disruption of the protein synthetic function of the liver, cholemic bleeding occurs. The absorption of fat-soluble vitamins is impaired.
Among instrumental methods diagnostics paralytic duodenography, gastroduodenoscopy, and percutaneous transhepatic cholangiography are of greatest importance.
MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION
STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES No. 2
Head of the department: Professor
Sick:Diagnosis:Gallstone disease, acute cholecystitis
Student curator:4thcourse7 semester groups
Team leader
Curation:frombeforeMedical history No.: Teacher's mark on the test:
GENERAL INFORMATION ABOUT THE PATIENT
Patient's full name:
Age: 48 years old
Address:
Floor: Female
Place of work:
Receipt date:
Admission method: emergency
Date of supervision:
Diagnosis: Gallstone disease, acute cholecystitis
Operation: Laparoscopic cholecystectomy. Drainage
abdominal cavity (10/14/2005 at 9:40)
Anesthesia: endotracheal
Blood type: A(II)Rh+
Outcome of the disease: improvement
Working capacity: recovery is underway
PATIENT'S COMPLAINTS
(At the time of supervision)
The patient complains of severe pain in the right hypochondrium. According to the patient, pain occurs spontaneously, without visible reasons(rarely after meals). The duration of pain is 0.5 – 2 hours. In addition, the patient also complains of dry mouth, nausea, vomiting, and general weakness.
HISTORY OF THE DISEASE(Anamnesismorbi)
Considers himself sick for 14 hours, when severe pain began to occur in the right hypochondrium. The pain sometimes went away on its own and sometimes after eating (it was relieved with the drug Mezim and took activated charcoal). I didn’t go to the doctors. Was strong headache, then sweat started, and after that it began to feel cold, there was an increase in blood pressure = 150/100, the temperature did not bother me. Nausea and vomiting also appeared. The deterioration of the condition was noted over the last 4 hours. Irradiation of pain to the heart and to the right lumbar region.
ANAMNESIS OF LIFE(Anamnesisvitae)
General biographical information: was born in 2010, in a prosperous family, the sixth child. Growth and development according to age. suffered in childhood colds. I was an excellent student at school. Marital status: married with 3 children. Housing conditions: satisfactory, lives in a 3-room apartment. There are 3 people in the family, the material security is satisfactory. Eating regularly while working. Free time schedule: sleep is not restful (disturbed), physical. culture and sports is not involved. At the moment: restful sleep, without headaches.
Working condition: From past diseases: chron. pancreatitis, appendectomy (1981), ischemic heart disease, cholelithiasis. Bad habits: no. Denies diabetes, hepatitis, AIDS
Family hereditary history: not burdened.
Allergy history: Denies allergies.
OBJECTIVE STUDY DATA(statuspraesens)
GENERAL INSPECTION
General condition of the patient: satisfactory
Consciousness: clear
Position: active
Gait: smooth
Posture: straight
Height: 165 cm.
Weight: 80kg..
Brocca index: 80*100%/165-100=123.07% (strong physique)
Pinier index: 165-(80+82)=3 (strong physique)
Quetelet index: 80/(1.65)2=29.38 (strong physique)
Body type: hypersthenic
Body temperature: 36.6
Facial expression: calm
Tongue: moist, coated with white coating
Dental condition: satisfactory
Mucous sclera of the eye, nose, mouth, ear: clean without discharge (no features) - satisfactory.
Face shape: oval, eyes not widened
Skin: Pale pink color. Areas of pigmentation, rashes, spider veins, no hemorrhages were detected.
Scars: In the right iliac region postoperative (appendectomy)
Hair type: by female type.
Skin turgor: preserved, elastic.
Skin moisture: dry.
Nails: regular shape (pink color).
Subcutaneous fat: highly developed.
Swelling: no.
Lymph nodes: not enlarged
Muscular system: Painless, satisfactory degree of development (dynamic and static action is satisfactory).
Skeletal system: The ratio of the bones of the skeleton is proportional. The shape of the bones is correct, without thickening or deformation. There is no pain on palpation. There is no sign of “drum fingers”.
Joints: Regular shape and size. Pain when bending knee joint on the right and left in the area of the medial epicondyle. Full movement.
RESPIRATORY SYSTEM
Inspection: Nose: Normal shape, clean mucosa without discharge.
Larynx: without deformation or swelling.
Shape gr. class: hypersthenic, symmetrical.
Above and Subclavian fossa: moderately expressed, the same on both sides.
Width of intercostal spaces: 1.5 cm.
Epigastric angle: acute.
Ribs in the lateral sections: Moderate oblique direction.
The fit of the shoulder blades to the ch. class: tight, and located on the same level excursion gr.cl.: 3cm.
Type of breathing: predominantly abdominal, gr.kl. participates in the act of breathing evenly. Breathing occurs silently, without the participation of auxiliary muscles.
BH: 18 in 1 minute.
Breathing: medium depth, rhythmic.
Correlation between inhalation and exhalation phases: not disturbed.
Palpation: Epigastric angle: acute.
Ribs: integrity intact.
Resistance (elasticity): Elastic, elastic, pliable.
Pain: when palpating the ribs, intercostal spaces, pectoral muscles not identified.
Percussion: Comparative: a clear pulmonary sound is determined over the entire surface of the lungs.
Topographic:
Topographic line
Right lung
Left lung
Upper limit
Front height of tops
3 cm above the collarbone
3 cm above the collarbone
Height of the tops at the back
7th cervical vertebra
7th cervical vertebra
Bottom line
Along the parasternal line
Upper edge of 6th rib
Not defined
Along the midclavicular line
Not defined
Along the anterior axillary line
Along the midaxillary line
Along the posterior axillary line
Along the scapular line
Along the paravertebral line
Spinous process 11 breasts. vertebra
Width of heeling fields: 4 cm. at both sides.
Respiratory mobility of the lower edge of the lungs:
Midaxillary line: 7cm right and left
Along the midclavicular lines: on the right 5 cm on the left is not determined
Along the scapular lines: 5cm. right and left
Auscultation: Visicular breathing is detected above the lungs on both sides. Side effects breath sounds and pleural friction noise is not heard. Bronchophony is unchanged on both sides.
CIRCULAR SYSTEM
Inspection: Increased pulsation of the carotid arteries (carotid dancing), swelling of the neck veins, visible pulsations no veins were found.
Protrusion of the heart area, visible pulsations (apical and cardiac impulse, epigastric pulsation) are not visually detected.
Palpation: The apical impulse is located in the V intercostal space 1 cm medially from the left midclavicular line, width 1 cm, low, moderate strength. The phenomenon of diastolic and systolic tremors in the pericardial region, epigastric pulsation is not palpable. On palpation in the area of the heart, pain is not detected.
Percussion:
Relative stupidity
Absolute stupidity
4th intercostal space 0.5 – 1 cm to the right of the edge of the sternum
4th intercostal space on the left edge of the sternum
5th intercostal space 1.-cm medial to the left midclavicular line
From the area of the apical impulse move towards the center (1.5 cm medial)
Parasternal line 3rd intercostal space
4th intercostal space
The diameter is relative. blunt: 12cm.
The width of the vascular bundle is 6 cm, 2nd intercostal space on the left and right.
Heart configuration: normal. Ascultation: Tones: - rhythmic heartbeats
Number of heartbeats – 76
The first tone of normal sonority
Second tone of normal sonority
Additional tones are not heard
Murmurs: not audible, pericardial friction noise is not audible.
Arterial pulse on the radial arteries: symmetrical, elastic, frequency = 76 beats. In 1 minute, rhythmic, moderate tension, full.
Blood pressure on the brachial arteries: 120/70 mm. rt. Art.
DIGESTION SYSTEM
Examination of the oral cavity.
There is no smell; the mucous membrane of the inner surface of the lips, cheeks, soft and hard palate of normal color; there are no rashes or ulcerations; gums do not bleed; the tongue is of normal size and shape, moist, not coated; filiform and mushroom-shaped papillae are quite well expressed; throat of normal color; the palatine arches are well contoured; the tonsils do not protrude beyond the palatine arches; the mucous membrane of the pharynx is not hyperemic, moist, the surface is smooth. The sclera is of normal color.
Dental formula:
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Legend:6 – carious tooth, 6 – extracted tooth, 6 – filled tooth, 6 – prosthetic tooth.
Abdominal examination.
Stomach normal shape, symmetrical, collaterals on the anterior surface of the abdomen and its lateral surfaces are not pronounced; there is no pathological peristalsis; the muscles of the abdominal wall are involved in the act of breathing. When examined in a vertical position, no hernial protrusions were found. In response to coughing, increased epigastric pain does not occur.
Abdominal circumference 90 cm.
Approximate percussion of the abdomen.
Tympanitis of varying severity is detected; dullness in the sloping areas of the abdomen is not noted.
Approximate superficial palpation of the abdomen.
Moderate pain is detected in the area of the right hypochondrium, the Shchetkin-Blumberg symptom is negative. When examining the “weak spots” of the anterior abdominal wall (umbilical ring, aponeurosis of the white line of the abdomen, inguinal rings), no hernial protrusions are formed.
With deep methodical sliding palpation of the abdomen using the Obraztsov-Strazhesko-Vasilenko method:
The sigmoid colon is palpable in the left groin area on the border of the middle and outer thirds of the linea umbilicoiliaceae sinistra for 15 cm, cylindrical in shape, diameter - 2 cm, dense elastic consistency, with a smooth surface, mobility within 3-4 cm, painless, not rumbling; the cecum is palpated in the right inguinal region at the border of the middle and outer thirds of linea umbilicoiliaceae dextra in the form of a cylinder with a pear-shaped extension downwards, soft-elastic consistency, diameter 3-4 cm, slightly rumbling on palpation. The remaining parts of the intestine could not be palpated.
Palpation of the stomach and determination of its lower border:
Using percussion and stetoacoustic palpation, the lower border of the stomach is determined 3 cm above the navel.
Using the method of deep palpation of the greater curvature of the stomach and the splash noise method, the lower border of the stomach could not be determined.
The lesser curvature and the pylorus are not palpable; a splashing noise to the right of the midline of the abdomen (Vasilenko's symptom) is not detected.
Auscultation of the abdomen.
Auscultation of the abdomen reveals normal peristaltic bowel sounds.
Determination of the boundaries of absolute hepatic dullness.
The percussion method is used to determine:
upper limit
along the right anterior axillary line - 7th rib
along the right midclavicular line - 6th rib
along the right parasternal line - 5th rib
bottom line
along the right anterior axillary line - 2 cm downward from the 10th rib. along the right midclavicular line - 4 cm downward from the costal arch
along the right parasternal line - 5 cm downward from the costal arch
along the anterior midline - 9 cm downward from the base of the xiphoid process left border hepatic dullness protrudes beyond the parasternal line along the edge of the costal arch by 2 cm.
dimensions of hepatic dullness:
along the right anterior axillary line - 15 cm,
along the right midclavicular line - 15 cm
along the parasternal line - 13 cm
along the anterior midline - 13 cm
oblique size (according to Kurlov) - 9 cm
the liver is palpated 1 cm below the edge of the costal arch (along the right midclavicular line); the edge of the liver is dense, smooth, with a smooth surface, slightly pointed; the liver is painless; the gallbladder is not palpable; pain on palpation at the point of projection of the gallbladder, symptoms of Ortner, Zakharyin, Vasilenko, Murphy, Georgievsky-Mussi - weakly positive.
Percussion of the spleen.
Along a line running 4 cm posteriorly and parallel to the left costarticular line, the boundaries of splenic dullness are determined:
upper - at the level of the 9th rib;
lower - at the level of the 11th rib.
the anterior border of the splenic dullness does not extend beyond the linea costoarticularis sinistra.
dimensions of splenic dullness: diameter - 6 cm; length - 8 cm.
The spleen is not palpable.
Examination of the pancreas.
The pancreas is not palpable; there is no pain on palpation in the Choffard area and the pancreatic point of Desjardins; Mayo-Robson symptom is negative.
Rectal examination.
Upon examination anus maceration, hyperemia skin there is no perianal area. On digital examination: the sphincter tone is normal, there are no tumors, inflammatory infiltrates, compacted hemorrhoids. The prostate gland is of normal shape, consistency and size, painless.
URINARY SYSTEM
Inspection: Lumbar region: skin hyperemia, swelling,
No smoothing of contours is noted.
Suprapubic region: no limited bulge was detected.
Percussion: Lumbar region: Pasternatsky's symptom is negative.
Palpation: The kidneys are not palpable in the supine or standing position.
The bladder is painless, elastic, palpated in the form of a soft elastic spherical formation above the pubic symphysis. Penetrating palpation of the kidneys and ureters on both sides is painless (ureteral and costal vertebral points).
GENITAL ORGAN SYSTEM.
Inspection: Female type of hair growth. The voice is low. Breast glands without pathological changes(no swelling, hyperemia, retractions...).
ENDOCRINE SYSTEM.
Inspection and palpation: Physical and mental development corresponds to age. Secondary sexual characteristics correspond to gender. Tremor of the eyelids, tongue and fingers are not detected.
The shape of the neck is normal, the contours are smooth, and painless on palpation. The thyroid gland is not enlarged, painless, and mobile. Obesity is slight.
NERVOUS SYSTEM AND SENSE ORGANS
Inspection: Memory, attention, sleep are preserved. The mood is cheerful, optimistic. Limitation motor activity: No. There are no deviations in the sensitive area.
State of mind: consciousness is clear, normally oriented in space, time and situation.
Intelligence corresponds to the level of development.
Behavior is appropriate.
Balanced, sociable.
No deviations observed
Motor sphere: Stable gait,
painless.
Cramps and muscle contractures are not detected.
Reflexes: corneal, pharyngeal, tendon-
saved. Pathological (Babinsky and
Rossolimo) - absent.
Exophthalmos and enophthalmos are absent.
PRELIMINARY DIAGNOSIS
RATIONALE FOR THE DIAGNOSIS
According to the following data, the patient may be suspected of having cholelithiasis: the patient complains of pain in the epigastrium and right hypochondrium, of moderate intensity, lasting 0.5 - 2 hours, nausea, vomiting, general weakness, the patient considers herself to be about 14 hours.
Objective examination: pain at the point of projection of the bladder, absence of protective tension in the abdominal muscles. Keri, Murphy, Ortner's symptoms are weakly positive
SURVEY PLAN
3. Wasserman reaction
4. 12-lead ECG
5. X-ray of the chest organs
6. Study of gastric contents by fractional method
7. Duodenal sounding
8. Stool analysis (scatological, dysbacteriosis, protozoa, bacteria)
9. Urine diastasis, blood amylase
10. Renoscopy of the stomach and intestines with targeted radiography
11. Irrigoscopy
12. Esophagoscopy
13. Gastroduodenoscopy with biopsy
14. Sigmoidoscopy, colonoscopy
15. Biochemistry of blood
16. Urine examination for urobilin and bilirubin
17. Examination of feces for stercobilin
18. Cholecystography
19. Radioisotope and ultrasound scanning of the liver and spleen, pancreas
20. Determination of blood immunoglobulin class
21. Blood test for HbS antigen
22. CT scan of the abdominal organs
23. Study of serological reactions (RW, antibodies to HIV, markers viral hepatitis, including antibodies to HBs antigen)
24. Determination of blood group, Rh factor
General blood analysis
Indicators
Data
135 g/l
123 g/l
Leukocytes (9.10.2005)
Red blood cells (10/10/2005)
9.0 10 9 /l
8.8 10 9 /l
8.0 10 9 /l
6.3 10 9 /l
4.2 10 12 /l
3.8 10 12 /l
Myelocytes
Metamyelocytes
Band neutrophils (10/12/2005)
Segmented neutrophils (10/12/2005)
Eosinophils(10/12/2005)
Basophils
Lymphocytes(10/12/2005)
Monocytes
Plasma cells
19 mm/h
Analysis of urine.
10.10.2005
Indicators
Data
Yellow
Transparency
moderately
Relative density
neutral
Negative
Epithelium :
Flat
3-3-2 in sight
Leukocytes
2-1 in sight
Urats 11
Biochemical blood test
12.10.2005
Indicators
Data
Total protein
70 g/l
Creatinine
61 mmol/l
Total bilirubin
10.8 µmol/l
BLOOD GROUP DETERMINATION 12.10.2005
PTI 10/12/2005
MICROREACTION WITH CARDIOLIPIN ANTIGEN 10/12/2005
NEGATIVE
ECG 10/10/2005
Conclusion: Sinus rhythm with heart rate=75, EOS deviated to the left, symptoms of left ventricular myocardial hypertrophy with signs of dystrophy.
SPIROGRAPHY 10/13/2005
Conclusion: - No impairment of bronchial obstruction was detected, without signs of expiratory narrowing of the airways.
Vital capacity is within normal limits.
The condition of the ventilation apparatus is within normal limits.
FIBROESOPHAGOGASTRODOUDENOSKOPY 10/11/2005
The esophagus is freely passable. The cardia rosette closes completely. Load test negative. The stomach contains a moderate amount of transparent yellowish bile, the folds are convoluted and juicy. Perilstaltics can be traced in all departments. The gastric mucosa is hyperemic and moderately thinned. The rounded pylorus is passable, the mucous membrane of the bulb is 12 p.c. strewn with small whitish colored rashes like “semolina”.
Conclusion: Biliary dyskinesia. Superficial subtrophic gastritis. Endoscopic picture of pancreatitis.
Ultrasound Liver: Visualized in fragments through the intercostal space, increased echogenicity.
Gallbladder: After eating, it increases to 100*36 mm., the wall is thickened to 4 m.. in the cavity there are stones up to 14 mm. One of which is fixed at the mouth. CBD is not dilated.
Pancreas: enlargement in the body area up to 23 mm, increased echogenicity, heterogeneous.
Kidneys: Topography and size are normal. Compaction of deformations of the walls of the joints. The outflow of urine is not impaired. Single marked hyperchromic inclusions up to 1-3 mm.
Spleen: not enlarged.
Conclusion: Echo signs of acute calculous cholecystitis are not excluded? Stone at the mouth.
CLINICAL DIAGNOSIS
Cholelithiasis. Acute cholecystitis.
RATIONALE FOR THE DIAGNOSIS
According to the following data, the patient may be suspected of having cholelithiasis: the patient complains of pain in the epigastrium and right hypochondrium, of moderate intensity, lasting 0.5 - 2 hours, nausea, vomiting, general weakness, the patient considers herself to be about 14 hours.
To confirm the diagnosis, the following studies were carried out:
Objective examination: pain at the point of projection of the bladder, absence of protective tension in the abdominal muscles. Keri, Murphy, Ortner's symptoms are weakly positive
Instrumental research methods also prove the correctness of the diagnosis:
Conclusion of an ultrasound specialist: there are signs of acute calculous cholecystitis, the gallbladder is enlarged to 100 * 36 mm, the wall is thickened to 4 mm, the presence of stones in the cavity up to 14 mm in size. and at the mouth of the gallbladder. CBD is not dilated.
DIFFERENTIAL DIAGNOSTICS
Gallstone disease must be differentiated from the following diseases: chronic pancreatitis, chronic gastritis, duodenitis, peptic ulcer of the stomach and duodenum, acalculous cholecystitis, tumor of the right half of the colon, gall bladder cancer. Since the symptoms and clinical course The above diseases are similar and an error in diagnosis can lead to serious complications due to incorrectly chosen treatment tactics. Let us consider separately the differences between each of the above diseases and cholelithiasis:
Peptic ulcer duodenum: This disease is characterized by periods of exacerbation and remission, and cholelithiasis does not have a dynamic course.
Pain in duodenal ulcers is diurnal and rhythmic (hunger pain, night pain); during an exacerbation, long-term pain lasting 3–4 weeks is typical. Gallstone disease is characterized by pain associated with eating fatty, “heavy” foods; the pain is relieved by taking antispasmodics and is short-lived. The pain is usually localized at the point of projection of the gallbladder; Ortner's and Georgievsky's - Mussi's symptoms are positive.
In case of duodenal ulcer, body temperature, as a rule, remains normal, and in case of cholelithiasis it is often subfebrile in nature.
Blood indicators for duodenal ulcer are as follows: ESR is normal, increases with complications, the white blood picture is normal, with complications of bleeding anemia is observed. With cholelithiasis, the ESR increases, and leukocytosis with a shift to the left is observed.
Vomiting after eating 2 - 2.5 hours after eating, which brings relief, is characteristic of duodenal ulcer, but with cholelithiasis, vomiting does not bring relief, it has an admixture of bile. The secretory function of the stomach, as a rule, remains normal, and with duodenal ulcer a hyperacid state is usually observed.
Bleeding from duodenal ulcer usually has characteristic manifestations: vomiting of the " coffee grounds", melena, blanching of the skin, but do not occur with cholelithiasis.
Data from esophagogastroduodenoscopy with histological examination of selected biopsy specimens and x-ray examination of the stomach allow a more accurate diagnosis. This patient does not have esophagogastroduodenoscopic data in favor of peptic ulcer disease. Examination of the gastric mucosa revealed atrophic gastritis, and upon examination of papillae faterii no bile leakage was detected.
Differential diagnosis between gastric ulcer and cholelithiasis:
With a gastric ulcer, pain occurs immediately after eating or 15 to 45 minutes after eating. Evacuation of gastric contents can bring relief in this condition. In case of cholelithiasis, the pain is usually associated with eating fatty, fried, spicy foods and vomiting does not bring relief; it contains bile impurities.
The localization of pain during a peptic ulcer is usually between the xiphoid process and the navel, most often to the left of the midline, irradiating to the left half of the chest, to the interscapular region. In gallstone disease, pain is localized in the right hypochondrium, radiating to right shoulder blade, right shoulder. The pain is located at a characteristic point - the point of projection of the gallbladder; the symptoms of Ortner and Georgievsky-Mussi are also positive.
Acidity gastric juice in case of peptic ulcer it changes, and in case of cholelithiasis it is normal.
The patient does not have characteristic signs of gastric and duodenal ulcers.
Differential diagnosis between acalculous chronic cholecystitis and cholelithiasis:
The clinical picture of acalculous chronic cholecystitis is similar to that of chronic calculous cholecystitis, however, pain in the right hypochondrium is not so intense, but differs in duration, almost constant nature, intensification after dietary disorders (taking fatty, fried foods, especially in excessive quantities). For diagnostics the most informative methods are ultrasound and cholecystocholangiography.
The patient's pain is periodic and of moderate intensity. Ultrasound diagnostic data confirm the presence of structures of increased echogenicity.
Differential diagnosis between a gallbladder tumor and cholelithiasis.
In a tumor of the gallbladder and bile ducts, signs of generalization of the cancer process are revealed: general signs such as weakness, increased fatigue, lack of appetite, weight loss, anemia; combined with local symptoms– enlarged tuberous liver, ascites and jaundice.
This patient has tumor process rejected by ultrasound data.
Differential diagnosis between acute appendicitis and cholelithiasis.
Nature of the pain: in the epigastrium, of moderate intensity (constant pulling), then moves to the right iliac region. Other complaints: nausea, vomiting, stool retention, fever. Development: acute. Objective examination: soreness and muscle tension in the right iliac region, with irritation of the peritoneum, Voskresensky, Rozdolsky, Obraztsov, Ravzing, Sitkovsky, intoxication is pronounced. Additional examinations: changes in the CBC indicating inflammation.
Differential diagnosis between renal colic and cholelithiasis.
Nature of the pain: in the lower back (paroxysmal), extremely intense with irradiation to the groin, reduced by the use of antispasmodics. Other complaints: possible dysuria. Anamnesis: urolithiasis disease. Development: acute. Objective examination: palpation of the abdomen is usually painless, positive sm Pasternatsky, there is no intoxication. Additional examinations: erythrocyturia.
ETIOLOGY AND PATHOGENESIS
The morphological substrate of cholelithiasis is gallstones of the biliary tract. Gallstones consist of the usual components of bile - bilirubin, cholesterol, calcium. Most often, mixed stones are found, but when one component predominates, they speak of cholesterol, pigment or calcareous stones.
There are three main reasons for their formation: disruption of the physicochemical balance of bile composition, inflammatory changes in the epithelium of the gallbladder and stagnation of bile.
Violation of the physico-chemical balance of bile composition.
With cholelithiasis, a change in the normal content of cholesterol, lecithin, and bile salts in bile occurs. Micellar structures consisting of bile acids and lecithin promote the dissolution of cholesterol in bile, which is part of the micelles. In micellar structures there is always a certain reserve of cholesterol solubility. When the amount of cholesterol in bile exceeds the limits of its solubility, the bile becomes supersaturated with cholesterol, and it begins to crystallize and precipitate. The lithogenicity of bile is characterized by the lithogenicity index, which is determined by the ratio of the amount of cholesterol found in a given bile to the amount of cholesterol that can be dissolved at a given ratio of bile acids, lecithin, cholesterol.
Bile becomes lithogenic with the following changes in the ratio of its components:
1) increase in cholesterol concentration (hypercholesterolemia)
2) decrease in phospholipid concentration
3) decrease in the concentration of bile acids.
The reasons leading to a decrease in the flow of bile acids into bile can be divided into three groups:
1) Reduced synthesis of bile acids and disruption of mechanisms feedback, as well as mechanisms regulating the synthesis of bile acids: liver dysfunction, taking hormonal drugs (corticosteroids, oral contraceptives, etc.), pregnancy, increased levels of estrogenic hormones, poisoning with hepatotoxic poisons.
2) Violation of the enterohepatic circulation of bile acids (significant losses of bile acids occur during resection of the distal small intestine, diseases of the small intestine).
3) Drainage of bile acids from the gallbladder, which is observed with atony of the gallbladder and prolonged fasting.
Stagnation of bile
Violation of the coordinated work of the biliary tract sphincters causes dyskinesias of various types. There are hypertonic and hypotonic dyskinesias of the bile ducts and gallbladder.
With hypertensive forms of dyskinesia, an increase in sphincter tone occurs. Spasm in the common part of the sphincter of Oddi causes hypertension in the ducts and gallbladder.
In hypotonic forms of dyskinesia, the sphincter of Oddi relaxes, followed by reflux of duodenal contents into the bile ducts, which leads to infection of the ducts. With dyskinesia, there is a violation of the evacuation of bile from the gallbladder and ducts, which is a predisposing factor for stone formation.
Biliary tract infections
Of significant importance in the process of cholesterol crystallization and the subsequent growth of stones is the condition of the mucous membrane of the gallbladder, which carries out the selective exchange of inorganic and organic ions, as well as the motor-evacuation function, when disrupted, the turbulence of the bile duct is reduced and conditions are created for the retention of crystals. As a result of inflammation, microparticles enter the lumen of the bladder, which act as a matrix for the deposition of crystals of a substance located in a supersaturated solution on them.
Mechanisms of formation of pigmented gallstones
Pigment stones can form under several conditions:
· When the liver is damaged, bile is released from it, containing pigments not normal structure. The latter precipitate, which happens with cirrhosis of the liver.
· When pigments of normal structure are released, but in excessive quantities - more than can be dissolved in a given volume of bile.
· When normal excreted pigments are converted into insoluble compounds in bile, which can occur under the influence of pathological processes in the biliary tract.
Much uncertainty remains regarding the primary trigger mechanism of cholelithiasis. IN Lately, despite numerous confirmations of the hypothesis metabolic disorders bile formation, the role of local, extrahepatic factors of lithogenesis began to be emphasized again. It has been shown that a decrease in the enzymatic conversion of cholesterol, a change in the composition and pool of bile acids, and the secretion of defective vesicles due to the lack of inclusion of phospholipids in them are important, but not the main reasons for the development of cholelithiasis, since the acceleration of nucleation processes naturally manifests itself in the cystic, and not in the hepatic bile. The most likely factor in increasing the activity of activators and inhibiting the activity of nucleation inhibitors in gallbladder bile is the inflammatory process in the gallbladder and the associated hypersecretion of glycoproteins and proteins, products of proteolysis and lipid peroxidation, leukotrienes, as well as impaired metabolic function of the gallbladder.
Judging by the experimental data, with any method of inducing cholelithiasis, stone formation occurs against the background of the indicated morphological changes in the wall of the gallbladder.
TREATMENT
conservative therapy includes :
¨ Compliance with the diet within the 5th table, namely limiting the consumption of foods that enhance the secretory activity of the stomach, pancreas, and bile secretion;
¨ Taking anticholinergic antispasmodics (No-Spa, Baralgin, Spazmogard, Spazmalgin, Papaverine, Platyfillin);
¨ Drugs that regulate gastrointestinal motility, such as Cerucal, Reglan;
¨ To reduce pain, painkillers are used: non-narcotic analgesics and antispasmodic analgesics (analgin, baralgin, and so on).
¨Sol. Papaverini hydrochloridi- 2.0 ml X 3 times a day intramuscularly
¨Sol. "No-Spa" - 2.0 ml X 3 times a day intramuscularly
¨ Ampicillini - 1.0 ml X 4 times a day intramuscularly
¨ Vicasoli- 1.0 ml X 3 times a day intramuscularly
¨ Gastrocepini - 2.0 ml X 2 times a day intramuscularly
¨ Tab. Maninili – 2 tablets 2 times a day
¨Sol. NaCl 0.9% - 500.0 ml
Sol. Ac. Ascorbinici 5% - 5.0 ml
Cocarboxilasae – 150.0 mg
Operational
Preoperative epicrisis:
Balnaya was admitted as an emergency with complaints of pain in the right hypochondrium, erygastric pain, dry mouth, nausea, vomiting, and general weakness.
Examined according to ultrasound data: Gall bladder: After eating, it increases to 100*36 mm, the wall is thickened to 4 m.. there are stones in the cavity up to 14 mm. One of which is fixed at the mouth. CBD is not dilated.
A clinical diagnosis was made: Gallstone disease. Acute cholecystitis.
Due to a history of attacks of pain in the right hypochondrium during meals, the presence of signs of chronic. cholecystitis for the purpose of prevention possible complications and rehabilitation of the biliary tract, the patient is indicated for surgical treatment. Laparascopic cholecystectomy is planned. The patient agrees to the operation, the possibility of conversion has been warned.
Blood type: A(II) Rh+ Lech. Doctor: N. Operation protocol No. 255.
FULL NAME: Salmanova Alfira Fazalovna.
Age : 48 years old. No. source: 22540.
Diagnosis: Cholelithiasis. Acute cholecystitis.
Operation: Laparascopic cholecystectomy. Drainage of the abdominal cavity.
Surgeons: Timerbullatov M.V., Garifullin.
Anesthesiologist: O/s: Date: . Start of operations: 9:40 . Duration: 25 minutes.
Under endotracheal anesthesia after treatment surgical field, trocar laparocentesis is introduced into the umbilical region. A tense carboxyperitoneum was produced using an insufflator. A video laparoscope and manipulation trocars were introduced into the abdominal cavity at 4 standard points. During an inspection of the abdominal organs, it was revealed that the liver was not enlarged, homogeneous, the gallbladder was 8 * 4 * 4 cm, the wall was not enlarged to 4 mm, with signs chronic inflammation. The gallbladder was isolated from the adhesions, the elements of Calot's triangle were identified, the cystic duct was isolated separately, and the arteries were sutured and cut off. A cholecystectomy was performed from the cervix with coagulation hemostasis of the gallbladder bed. The gallbladder was evacuated from the epigastric access. The subhepatic space was sanitized and drained with tubular drainage. Hemostasis control. Stitches on the wound. Aseptic dressing. Macropreparation - the gallbladder contains stones 2.5 * 10 mm, sent for histological examination.
DIARY
DATE
The patient's condition
The general condition is relatively satisfactory, complaints of weakness, vesicular breathing. The tongue is dryish, covered with a white coating, the abdomen is soft, not swollen, painless, diuresis is not impaired, stools are formed.
The patient after surgery, the condition corresponds to the surgery, consciousness is clear, complaints of pain in the wound, weakness, no dyspepsia, breathing and hemodynamics are satisfactory, the abdomen is soft, not bloated
The patient is bothered by low-intensity pain in the epigastrium and right hypochondrium; the temperature is 36.8°C. There was no chair. Urination is not impaired.
Objectively: the patient’s condition is currently of moderate severity. In the lungs there is vesicular breathing, the pulse is 78 beats per minute, symmetrical, with the correct rhythm. Blood pressure – 130/80 mm Hg. Art. The tongue is moist and coated with a whitish coating. The abdomen is moderately swollen and does not participate in the act of breathing. No protective muscle tension is detected. The gallbladder is not palpable, Shchetkin Blumberg's sign is negative.
Curator – Zalikin M.A.
The patient's condition has improved over the past period. The patient has no longer been bothered by pain over the past 2 days. Temperature – 36.7°C. The stool is normal. Urination is not impaired.
Objectively: the patient’s condition is currently satisfactory. In the lungs there is vesicular breathing, the pulse is 80 beats per minute, symmetrical, with a regular rhythm. Blood pressure – 130/80 mm Hg. Art. The tongue is moist and coated with a whitish coating. The abdomen is moderately swollen and does not participate in the act of breathing. No protective muscle tension is detected. The gallbladder is not palpable, the Shchetkin-Blumberg sign is negative.
Curator – Zalikin M.A.
FORECAST
Health forecast: recovery
Prognosis for life: favorable.
Forecast for work: operational.
EPICRISIS
Staged: continuation of treatment in City Clinical Hospital No. 21 in 1 surgical department.
TEMPERATURE SHEET
BIBLIOGRAPHY
1. Diagnosis of diseases of internal organs. Volume 1. A.N. Okorov. Minsk 2001
2. Propaedeutics of internal diseases. V.Kh.Vasilenko. Moscow “Medicine” 1983.
3. Clinical classifications of diseases of internal organs. BSMU. Ufa 1996.
4. Medicines. M.D. Mashkovsky. Moscow “Medicine” 1986.
5. Pharmacology. D.A. Kharkevich. Moscow 2001.
6. Surgical diseases Kuzin M.I. Moscow 2000
7. Rodionov V.V., Filimonov M.I., Moguchev V.M. Calculous cholecystitis. – M.: Medicine, 1991. – 320 p.
8. Shaposhnikov A. V. Cholecystitis. Pathogenesis, diagnosis and surgical treatment. – Publishing house Rostov University, 1984. – 224 p.
9.Movchun A.A., Koloss O.E., Oppel T.A., Abdullaeva U.A. Surgical treatment of chronic calculous cholecystitis and its complications. – Surgery, 1998, No. 1, p. 8.
Differential diagnosis of cholelithiasis encounters great difficulties when distinguishing from non-calculous cholecystitis, since in most cases cholecystitis is combined with cholelithiasis, and it is more correct in such cases to talk about calculous cholecystitis. Usually the only question that arises is about the advisability of surgical treatment. In acute cholecystitis, most surgeons insist on urgent surgery. In uncomplicated cholelithiasis, biliary colic is not preceded by dyspeptic symptoms; biliary colic goes away suddenly, after which patients immediately experience not only significant relief, but usually feel healthy. The liver and gall bladder are painless on palpation, usually there is no “temperature tail”, and there are no “elements of inflammation” in the duodenal contents. The method of contrast cholecystography is of great importance.
With biliary dyskinesia, there is a clearer connection between the occurrence of pain syndrome and negative emotions, and the absence of tension in the abdominal wall during biliary colic; The diagnosis is confirmed by negative results of duodenal intubation and mainly by contrast cholecystography data, which does not reveal stones.
Differentiation of cholelithiasis from right-sided renal colic in most cases does not encounter any particular difficulties. Irradiation of pain is characteristic: upward - with biliary colic; down, into the leg, into the groin, into the genitals - with kidney disease. The presence of dysuric phenomena in renal colic, hematuria or erythrocyturia following a painful attack is important.
Sometimes it is necessary to differentiate cholelithiasis from peptic ulcer in the presence of atypical pain, in particular with duodenal ulcer. In addition to anamnestic data, the results of deep palpation also indicate a peptic ulcer, which often reveals a dense, sharply painful cord - a spasmodic pyloroduodenal area. The diagnosis is confirmed by x-ray.
In some cases, differentiation of cholelithiasis from pancreatitis is necessary. Localization of pain on the left in the epigastric region and to the left of the navel with irradiation into the sinus, into left side spine, left shoulder blade, left half shoulder girdle characteristic of diseases of the pancreas and is usually not observed in gallstone disease. It also matters increased content diastases in urine.
Differential diagnosis with acute appendicitis in most cases does not cause difficulties, however, in doubtful cases, surgery should be resorted to (S.P. Fedorov).
Finally, in some cases, diagnostic difficulties arise when differentiating obstructive jaundice when the common bile duct is blocked by a stone with obstructive jaundice in cancer of the biliary tract and pancreas. The rapid development of jaundice, its connection with a previous pain syndrome, the presence of biliary colic in the anamnesis indicate cholelithiasis, while the relatively slow and gradual development of jaundice gives reason to suspect a malignant tumor. X-ray (with contrast cholegraphy) reveals single or multiple stones. Less often, shadows of stones are visible on a plain radiograph.
Pain syndrome in cholelithiasis should be differentiated from the following conditions.
■ Biliary sludge: sometimes a typical clinical picture of biliary colic is observed. Ultrasound reveals the presence of bile sediment in the gallbladder.
■ Functional diseases gallbladder and biliary tract: no stones are found during examination. Signs of impaired contractility of the gallbladder (hypo- or hyperkinesia), spasm of the sphincter apparatus (dysfunction of the sphincter of Oddi) are detected.
■ Pathology of the esophagus: esophagitis, esophagospasm, hiatal hernia. Characterized by pain in the epigastric region and behind the sternum in combination with typical changes during endoscopy or x-ray examination upper sections Gastrointestinal tract.
■ Peptic ulcer of the stomach and duodenum: characterized by pain in the epigastric region, sometimes radiating to the back and decreasing after eating, taking antacids and antisecretory drugs. An endoscopy is required.
■ Diseases of the pancreas: acute and chronic pancreatitis, pseudocysts, tumors. Typical pain is in the epigastric region, radiating to the back, provoked by food intake and often accompanied by vomiting. The diagnosis is supported by increased activity of amylase and lipase in the blood serum, as well as typical changes in the results of radiological diagnostic methods. It should be taken into account that cholelithiasis and biliary sludge can lead to the development of acute pancreatitis.
■ Liver diseases: characterized by dull pain in the right hypochondrium, radiating to the back and right shoulder blade. The pain is usually constant (which is not typical for pain syndrome with biliary colic), associated with liver enlargement, and liver tenderness on palpation is characteristic.
■ Colon diseases: irritable bowel syndrome, tumors, inflammatory lesions(especially when the hepatic flexure of the colon is involved in the pathological process). Pain syndrome is often caused by motor disorders. The pain is often relieved by bowel movements or passing gas. For differential diagnosis of functional and organic changes, colonoscopy or irrigoscopy is recommended.
■ Diseases of the lungs and pleura: it is necessary to carry out x-ray examination chest organs.
■ Skeletal muscle pathology: pain in the right upper quadrant of the abdomen associated with movements or taking a certain body position. Palpation of the ribs may be painful; Increased pain is possible with tension in the muscles of the anterior abdominal wall.
Treatment
Goals of therapy: removal of gallstones (either the stones themselves from the biliary tract, or the gallbladder along with the stones); cupping clinical symptoms without surgical intervention (if there are contraindications to surgical treatment); preventing the development of immediate complications (acute cholecystitis, acute pancreatitis, acute cholangitis) and distant (gallbladder cancer).
Indications for hospitalization in a surgical hospital: recurrent biliary colic; acute and chronic cholecystitis and their complications; obstructive jaundice; purulent cholangitis; acute biliary pancreatitis.
Indications for hospitalization in a gastroenterological or therapeutic hospital: chronic calculous cholecystitis– for a detailed examination and preparation for surgical or conservative treatment; exacerbation of cholelithiasis and the condition after cholecystectomy (chronic biliary pancreatitis, dysfunction of the sphincter of Oddi).
Duration of inpatient treatment: chronic calculous cholecystitis – 8–10 days, chronic biliary pancreatitis (depending on the severity of the disease) – 21–28 days.
Treatment includes diet therapy, the use of medications, external lithotripsy methods and surgery.
Diet therapy: at all stages, 4–6 meals a day are recommended with the exclusion of foods that increase the secretion of bile, the secretion of the stomach and pancreas. Avoid smoked meats, refractory fats, and irritating seasonings. The diet should include a large amount of plant fiber with the addition of bran, which not only normalizes intestinal motility, but also reduces the lithogenicity of bile. With biliary colic, fasting is necessary for 2-3 days.
Oral litholytic therapy is the only effective conservative method treatment of cholelithiasis. To dissolve stones, bile acid preparations are used: ursodeoxycholic and chenodeoxycholic acids. Treatment with bile acid preparations is carried out and monitored on an outpatient basis.
The most favorable conditions for the outcome of oral lithotripsy are: early stages of the disease; uncomplicated course of cholelithiasis, rare episodes of biliary colic, moderate pain syndrome; in the presence of pure cholesterol stones (“float up” during oral cholecystography); in the presence of non-calcified stones (CT attenuation coefficient less than 70 Hansfeld units); with stone sizes no more than 15 mm (in combination with shock wave lithotripsy - up to 30 mm), the best results are observed with stone diameters up to 5 mm; with single stones occupying no more than 1/3 of the gallbladder; with intact contractile function gallbladder.
Daily doses of drugs are determined taking into account the patient’s body weight. The dose of chenodeoxycholic acid (as monotherapy) is 15 mg/(kg day), ursodeoxycholic acid (as monotherapy) – 10–15 mg/(kg day). Preference should be given to ursodeoxycholic acid derivatives, as they are more effective and have fewer side effects. The most effective is considered to be a combination of ursodeoxycholic and chenodeoxycholic acids at a dose of 7–8 mg/(kg·day) of each drug. The drugs are prescribed once at night.
Treatment is carried out under ultrasound control (once every 3–6 months). If there are positive dynamics on ultrasound 3–6 months after the start of therapy, it is continued until the stones are completely dissolved. The duration of treatment usually varies from 12 to 24 months with continuous use of drugs. Regardless of the effectiveness of litholytic therapy, it reduces the severity of pain and reduces the likelihood of developing acute cholecystitis.
The effectiveness of conservative treatment is quite high: with proper selection of patients, complete dissolution of stones is observed after 18–24 months in 60–70% of patients, but relapses of the disease are common.
The absence of positive dynamics according to ultrasound data after 6 months of taking the drugs indicates the ineffectiveness of oral litholytic therapy and indicates the need to discontinue it.
Since the pain syndrome in biliary colic is associated to a greater extent with spasm of the sphincter apparatus, the prescription of antispasmodics (mebeverine, pinaverium bromide) in standard daily doses for 2–4 weeks is justified.
Antibacterial therapy indicated for acute cholecystitis and cholangitis.
Methods of surgical treatment: cholecystectomy - laparoscopic or open, extracorporeal shock wave lithotripsy.
Indications for surgical treatment for cholecystolithiasis: the presence of large and small stones in the gallbladder, occupying more than 1/3 of its volume; course of the disease with frequent attacks biliary colic, regardless of the size of the stones; disabled (non-functioning) gallbladder; GSD complicated by cholecystitis and/or cholangitis; combination with choledocholithiasis; Cholelithiasis complicated by the development of Mirizzi syndrome; Cholelithiasis complicated by dropsy, empyema of the gallbladder; GSD complicated by perforation, penetration, fistulas; Cholelithiasis complicated by biliary pancreatitis; Cholelithiasis, accompanied by obstruction of the common bile duct and obstructive jaundice.
In asymptomatic cases of cholelithiasis, as well as in a single episode of biliary colic and infrequent pain attacks, a wait-and-see approach is most justified. If indicated, lithotripsy may be performed in these cases. It is not indicated for asymptomatic stone carriers, since the risk of surgery outweighs the risk of developing symptoms or complications.
In some cases, and only according to strict indications, it is possible to perform laparoscopic cholecystectomy in the presence of asymptomatic stone carriers to prevent the development of clinical manifestations of cholelithiasis or gallbladder cancer. Indications for cholecystectomy for asymptomatic stone carriers: calcified (“porcelain”) gallbladder; stones larger than 3 cm; upcoming long stay in the region with a lack of qualified medical care; sickle cell anemia; upcoming organ transplantation to the patient.
Laparoscopic cholecystectomy is characterized by less trauma, shorter postoperative period, shorter hospital stay, better cosmetic results. In any case, one should keep in mind the possibility of converting the operation to open if attempts to remove the stone are unsuccessful. endoscopic method. There are practically no absolute contraindications to laparoscopic procedures. TO relative contraindications include acute cholecystitis with a disease duration of more than 48 hours, peritonitis, acute cholangitis, obstructive jaundice, internal and external biliary fistulas, liver cirrhosis, coagulopathy, unresolved acute pancreatitis, pregnancy, morbid obesity, severe cardiopulmonary failure.
Shock wave lithotripsy is used very limitedly, as it has a fairly narrow range of indications and a number of contraindications and complications. Extracorporeal shock wave lithotripsy is used in following cases: the presence in the gallbladder of no more than three stones with a total diameter of less than 30 mm; the presence of stones that “pop up” during oral cholecystography ( characteristic feature cholesterol stones); a functioning gallbladder, according to oral cholecystography; reduction of the gallbladder by 50%, according to scintigraphy.
It should be borne in mind that without additional treatment with ursodeoxycholic acid, the recurrence rate of stone formation reaches 50%. In addition, the method does not prevent the possibility of developing gallbladder cancer in the future.
Endoscopic papillosphincterotomy is indicated primarily for choledocholithiasis.
All patients with cholelithiasis are subject to dispensary observation in outpatient settings. It is especially necessary to carefully monitor patients with asymptomatic stone-carrying stones, give a clinical assessment of the anamnesis and physical signs. If any dynamics appear, a laboratory examination and ultrasound are performed. Similar measures are carried out if there is a single episode of biliary colic in the anamnesis.
When carrying out oral litholytic therapy, regular monitoring of the condition of stones using ultrasound is necessary. In the case of therapy with chenodeoxycholic acid, it is recommended to monitor liver function tests once every 2–4 weeks.
For the purpose of prevention, it is necessary to maintain an optimal body mass index and a sufficient level physical activity. A sedentary lifestyle contributes to the formation of gallstones. If the patient is likely to rapidly lose weight (more than 2 kg/week for 4 weeks or more), it is possible to prescribe ursodeoxycholic acid drugs at a dose of 8–10 mg/(kg·day) to prevent the formation of stones. Such an event prevents not only the formation of stones itself, but also the crystallization of cholesterol and an increase in the bile lithogenicity index.
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