Biliary tract diseases. Method for differential diagnosis of cholelithiasis, cholesterosis and gallbladder polyps Differential diagnosis of biliary tract diseases

DYSFUNCTIONAL DISORDERS OF THE BILIARY TRACT

ICD-10 codes

K82.8. Dyskinesia of the gallbladder. K83.4. Dystonia of the sphincter of Oddi.

Biliary tract dysfunction (DT) is a clinical symptom complex caused by motor-tonic dysfunction of the gallbladder, bile ducts and their sphincters, persisting for more than 12 weeks in the last 12 months (Rome Consensus, 1999). DBT is divided into two types: gallbladder dysfunction and sphincter of Oddi dysfunction.

The prevalence of functional disorders of the biliary tract is high, especially among preschool children, and significantly exceeds that of organic diseases of the biliary tract (Fig. 7-1). The frequency of primary dyskinesias of the gallbladder in children is 10-15%. In diseases of the gastroduodenal zone, concomitant disorders of biliary motility are found in 70-90% of cases.

Rice. 7-1. Prevalence and stages of formation of biliary pathology

Etiology and pathogenesis

The main cause of DBT is an irrational diet: large gaps between meals, violation of the frequency of meals, eating dry food, etc.

In patients with primary DBT There are neurovegetative changes and psychoemotional disorders. Such children are characterized by hyperkinetic forms of dysfunction of both the gallbladder and the sphincter of Oddi (Fig. 7-2, a).

who are developmental anomalies(kinks, constrictions) of the gallbladder (Fig. 7-2, b), surgical interventions on the abdominal organs.

Pain syndrome with hypokinesia occurs as a result of stretching of the gallbladder. As a result, acetylcholine is released, the excess production of which significantly reduces the formation of cholecystokinin in the duodenum. This, in turn, further slows down the motor function of the gallbladder.

Rice. 7-2. DBT: a - ultrasound: primary dyskinesia of the gallbladder; b - cholecystography: secondary dyskinesia (gall bladder constriction)

Classification

In the working classification, the following variants of DBT are distinguished (in practice, the term “biliary dyskinesia” is used):

By localization - dysfunction of the gallbladder and sphincter of Oddi;

By etiology - primary and secondary;

According to the functional state - hypokinetic(hypomotor) and hyperkinetic(hypermotor) form.

Separately allocate sphincter of Oddi dystonia, which is detected using additional research methods in the form of 2 forms - spasm and sphincter hypotension.

Dyskinesia of the gallbladder is most often a manifestation of autonomic dysfunction, but can occur against the background of damage to the gallbladder (with inflammation, changes in the composition of bile, cholelithiasis), as well as in diseases of other digestive organs, primarily the duodenum, due to disturbances in the humoral regulation of its function .

Clinical picture

The main symptom is pain, dull or sharp, after eating and after exercise with a typical irradiation - upward to the right shoulder. There may be nausea, vomiting, bitterness in the mouth, signs of cholestasis, liver enlargement, pain on palpation, positive cystic symptoms, and often there is bad breath. Pain on palpation is observed in the right hypochondrium, in the epigastric region and in the Shoffard area. The differences between the hyperkinetic and hypokinetic forms of DBT are presented in Table. 7-1.

Table 7-1. Clinical features of forms of gallbladder dyskinesias

Diagnostics

Diagnosis of DBT is based on the results of ultrasound using choleretic breakfasts and dynamic hepatobilis scintigraphy. The first method is considered a screening method, since it does not allow obtaining information about the condition of the bile ducts and the sphincter apparatus of the biliary tract. Provided that the area of ​​the gallbladder is reduced by 1/2-2/3 of the original, its motor function is regarded as normal; with the hyperkinetic type of dyskinesia, the gallbladder contracts by more than 2/3 of its original volume, with the hypokinetic type - by less than 1/2.

A more valuable and informative method is dynamic hepatobiliary scintigraphy using short-lived radiopharmaceuticals labeled with 99m Tc, which not only provide visualization of the gallbladder and identification of anatomical and topographical features of the biliary tract, but also allow one to judge the functional state of the hepatobiliary system, in particular the activity of the Lutkens sphincters, Mirizzi and Oddi. Radiation exposure is equal to or even lower than the child's radiation dose when taking one x-ray (cholecystography; see fig. 7-2, b).

Fractional duodenal intubation allows you to assess the motor function of the gallbladder (Table 7-2), bile ducts and sphincters of the biliary tract and the biochemical properties of bile.

Table 7-2. Differences in forms of DBT according to the results of duodenal intubation

End of table. 7-2

Differential diagnosis

Treatment

Considering the role of reflex effects, a rational daily routine, normalization of work and rest, sufficient sleep - at least 7 hours a day, as well as moderate physical activity - play an important role. In addition, patients should avoid physical fatigue and stressful situations.

At hyperkinetic form of JVP recommend neurotropic drugs with a sedative effect (bromine, valerian, persen*, tranquilizers). Valerian in tablets of 20 mg is prescribed: for young children - 1/2 tablet, 4-7 years - 1 tablet, over 7 years - 1-2 tablets 3 times a day.

Antispasmodic drugs to relieve pain: drotaverine (no-spa*, spasmol*, spasmonet*) or papaverine; mebeverine (duspatalin *) - from 6 years old, pinaverium bromide (dicetel *) - from 12 years old. No-shpu* in 40 mg tablets is prescribed for pain in children 1-6 years old - 1 tablet, over 6 years old - 2 tablets 2-3 times a day; papaverine (20 and 40 mg tablets) for children from 6 months - 1/4 tablet, increasing the dose to 2 tablets 2-3 times a day by 6 years.

Choleretic agents (choleretics), having a cholespasmolytic effect: cholenzim*, allochol*, berberine*, are prescribed in a course of 2 weeks a month for 6 months. Bile + powder of the pancreas and small intestinal mucosa (cholenzyme *) in tablets of 500 mg is prescribed:

children 4-6 years old - 100-150 mg, 7-12 years old - 200-300 mg, over 12 years old - 500 mg 1-3 times a day. Activated carbon + bile + stinging nettle leaves + garlic bulbs (allochol*) for children under 7 years old: 1 tablet, over 7 years old - 2 tablets 3-4 times a day for 3-4 weeks, the course is repeated after 3 months .

At hypokinetic form of JVP They recommend neurotropic stimulating agents: aloe extract, ginseng tincture, pantocrine, eleutherococcus, 1-2 drops per year of life, 3 times a day; pantocrine (red deer antlers extract) in a bottle of 25 ml, in ampoules of 1 ml; ginseng tincture in 50 ml bottles.

Cholekinetics (domperidone, magnesium sulfate, etc.) and enzymes are also indicated.

At spasm of the sphincter of Oddi therapy includes cholespasmolytics (duspatalin *, drotaverine, papaverine hydrochloride), enzymes. At sphincter of Oddi insufficiency- prokinetics (domperidone), as well as pro- and prebiotics for microbial contamination of the small intestine.

Tubages according to Demyanov (blind probing) are prescribed 2-3 times a week (10-12 procedures per course), which should be combined with taking choleretics 2 weeks a month for 6 months. This procedure improves the flow of bile from the bladder and restores its muscle tone.

The following are recommended for tubing: cholekinetics: sorbitol, xylitol, mannitol, sulfuric acid mineral waters (“Essentuki” No. 17, “Naftusya”, “Arzni”, “Uvinskaya”). Medicinal herbs with cholekinetic effects are also prescribed: immortelle flowers, corn silk, rose hips, tansy, mountain ash, chamomile flowers, centaury herb and infusions from them.

Prevention

Nutrition according to age, tonic physical therapy, physiotherapeutic procedures, and vitamin therapy are indicated.

Forecast

The prognosis is favorable; with secondary DBT, it depends on the underlying gastrointestinal disease.

ACUTE CHOLECYSTITIS (CHOLECYSTOCHOLANGITIS)

ICD-10 code

K81.0. Acute cholecystitis.

Cholecystocholangitis is an acute infectious and inflammatory lesion of the wall of the gallbladder and/or bile ducts.

Among emergency surgical diseases of the abdominal organs, acute cholecystitis is second only to appendicitis.

ditsitu. The disease is observed mainly in economically developed countries, in adolescents and adults.

Etiology and pathogenesis

The leading causes of cholecystitis are the inflammatory process caused by various microorganisms and impaired bile outflow. More often, staphylococci, streptococci, E. coli, etc. are found in the gallbladder. Helminthic (ascariasis, opisthorchiasis, etc.) and protozoal (giardiasis) invasions play a certain role. The infection enters the gallbladder in the following ways:

. hematogenous- from the general circulation of blood

system of the common hepatic artery or from the gastrointestinal tract through

. lymphogenous- through connections of the lymphatic system of the liver and gallbladder with the abdominal organs;

. enterogenous (ascending)- with damage to the common bile duct, functional disorders of the sphincter apparatus, when the reflux of infected duodenal contents into the bile ducts occurs (Fig. 7-3).

Rice. 7-3. Pathogenesis of acute cholecystitis

Stones, kinks in the elongated or tortuous cystic duct, its narrowing and other anomalies in the development of the biliary tract lead to disruption of the outflow of bile. Against the background of cholelithiasis, up to 85-90% of cases of acute cholecystitis occur.

Due to the anatomical and physiological connection of the biliary tract with the excretory ducts of the pancreas, the development of enzymatic cholecystitis, associated with the flow of pancreatic juice into the gallbladder and the damaging effect of pancreatic enzymes on the walls of the bladder. As a rule, these forms of cholecystitis are combined with symptoms of acute pancreatitis.

The inflammatory process of the gallbladder wall can be caused not only by microorganisms, but also by a certain composition of food, allergic and autoimmune processes. The integumentary epithelium is reconstructed into goblet and mucous variants, which produce large amounts of mucus. The cylindrical epithelium becomes flattened, microvilli are lost, as a result of which absorption processes are disrupted.

Clinical picture

Acute cholecystitis usually manifests itself picture of an “acute belly”, which requires immediate hospitalization. In children, in addition to acute and paroxysmal pain, nausea, repeated vomiting mixed with bile, and an increase in body temperature to 38.5-39.5 ° C or more are simultaneously noted. Symptoms of peritoneal irritation are determined, in particular the Shchetkin-Blumberg symptom. In the blood, leukocytosis (12-20x 10 9 /l), neutrophilia with a shift of the formula to the left, increased ESR. Laboratory testing reveals an increase in enzymes that are biochemical markers of cholestasis (alkaline phosphatase, γ-glutamyl transpeptidase, leucine aminopeptidase, etc.), acute phase proteins (CRP, prealbumin, haptoglobin, etc.), and bilirubin.

Acute cholangitis, This is a severe disease that can be fatal if diagnosed untimely or treated irrationally. Characteristic Charcot's triad: pain, fever, jaundice

Ha; there is a high risk of developing liver and kidney failure, septic shock and coma. Diagnostic tests are the same as for acute cholecystitis.

Diagnostics

Using ultrasound and CT, double thickening of the walls of the gallbladder (Fig. 7-4, a), as well as the bile ducts and their expansion are determined. Thus, we can talk about cholecystocholangitis, since the inflammatory process, not limited to the gallbladder, can spread to the bile ducts, including the major duodenal papilla (odditis). As a result, the functional activity of the gallbladder (deposition of bile with its subsequent release) is disrupted. This condition is referred to as disabled, or non-functioning, gallbladder.

Diagnostic laparoscopy, being an invasive method, is used only in the most complex cases (Fig. 7-4, b). The absolute indication for its implementation is the presence of obvious clinical manifestations of acute destructive cholecystitis, when ultrasound does not reveal inflammatory changes in the gallbladder.

Rice. 7-4. Acute cholecystitis: a - ultrasound; b - laparoscopic picture; c - macroscopic specimen of the gallbladder

Classification

The classification of acute chelecystitis is presented in table. 7-3. Table 7-3. Classification of acute cholecystitis

Pathomorphology

The main morphological form of acute cholecystitis is catarrhal, which in some children can transform into phlegmonous and gangrenous (Fig. 7-4, c), thereby necessitating surgical treatment.

Treatment

The principles of conservative treatment and subsequent clinical observation are discussed in the section “Chronic cholecystitis”.

Conservative treatment consists of the use of broad-spectrum antibiotics and detoxification therapy. To relieve pain, it is advisable to carry out a course of therapy with antispasmodics, a blockade of the round ligament of the liver, or a perinephric novocaine blockade according to Vishnevsky.

In patients with a primary attack of acute cholecystitis, surgery is indicated only if destructive processes develop in the gallbladder. If the inflammatory process and catarrhal cholecystitis quickly subside, surgical intervention is not performed.

Forecast

The prognosis of the disease in children is often favorable. Periodic episodes of acute cholecystitis lead to chronic cholecystitis.

CHRONIC CHOLECYSTITIS

ICD-10 code

K81.1. Chronic cholecystitis.

Chronic cholecystitis is a chronic inflammatory disease of the gallbladder wall, accompanied by motor-tonic disorders of the biliary tract and changes in the biochemical properties of bile.

In pediatric practice, cholecystocholangitis is more common, i.e. In addition to the gallbladder, the bile ducts are involved in the pathological process. The explanation for the tendency toward generalization of gastrointestinal lesions is the anatomical and physiological characteristics of childhood, the common blood supply, and the neuroendocrine regulation of the digestive organs.

Etiology and pathogenesis

Patients have a hereditary history aggravated by hepatobiliary pathology. The disease occurs against the background of impaired motor function of the gallbladder, bile dyscholia and/or congenital anomalies of the biliary tract in children with impaired immunological reactivity (Fig. 7-5).

Acute cholecystitis plays a certain role in the pathogenesis of chronic cholecystitis. Endogenous infection from the underlying sections of the gastrointestinal tract, viral infection (viral hepatitis, enteroviruses, adenoviruses), helminths, protozoal invasion, fungal infection realize the infectious inflammatory process in the wall of the gallbladder. Aseptic damage to the gallbladder wall may be caused by exposure to gastric and pancreatic juices due to reflux.

Giardia does not live in a healthy gallbladder. Bile in cholecystitis does not have antiprotozoal properties, so Giardia can be on the mucous membrane of the gallbladder and support (in combination with

Rice. 7-5. Pathogenesis of chronic cholecystitis

microorganisms) inflammatory process and dyskinesia of the gallbladder.

Clinical picture

The disease most often occurs in latent (asymptomatic) form. A fairly defined clinical picture is present only during an exacerbation, including abdominal right hypochondrium, intoxication and dyspeptic syndromes.

Older children complain of abdominal pain localized in the right hypochondrium, sometimes a feeling of bitterness in the mouth, which is associated with eating fatty, fried foods rich in extractive substances and seasonings. Sometimes psychoemotional stress and physical activity provoke pain. On palpation, moderate, fairly stable enlargement of the liver and positive cystic symptoms may be observed. During an exacerbation, there are always phenomena of nonspecific intoxication: weakness, headaches, low-grade fever, vegetative and psycho-emotional instability. If the pathological process spreads to the liver parenchyma (hepatocholecystitis), transient subictericity of the sclera may be detected. Dyspeptic disorders in the form of nausea, vomiting, belching, decreased appetite, and unstable stool are common.

Diagnostics

The following ultrasound criteria are important in diagnosing the disease:

Thickening and compaction of the walls of the gallbladder more than 2 mm (Fig. 7-6, a);

An increase in the size of the gallbladder by more than 5 mm from the upper limit of the age norm;

The presence of a shadow from the walls of the gallbladder;

Sludge syndrome.

Duodenal intubation reveals dyskinetic changes in combination with changes in biochemical

ical properties of bile (discholia) and the release of pathogenic and opportunistic microflora during bacteriological examination of bile. In biochemical liver tests, moderate signs of cholestasis are observed (increased cholesterol, β-lipoproteins,

alkaline phosphatase).

X-ray studies(cholecystography, retrograde cholangiopancreatography), given their invasiveness, are carried out according to strict indications (if it is necessary to clarify the anatomical defect, in order to diagnose stones). The main diagnostic method in childhood is ultrasound (see Fig. 7-6, a).

Rice. 7-6. Chronic cholecystitis: a - ultrasound diagnostics; b - histological picture (hematoxylineosin staining; χ 50)

Pathomorphology

Characteristic is a pronounced thickening of the walls of the bile duct due to the proliferation of connective tissue, as well as moderate inflammatory infiltration in the wall of the duct and surrounding tissues (Fig. 7-6, b).

Differential diagnosis

Differential diagnosis of acute and chronic cholecystitis is carried out with other diseases of the gastroduodenal zone, DBT, hepatitis, chronic pancreatitis, appendicitis, perforated duodenal ulcer, right-sided pneumonia, pleurisy, subphrenic abscess, myocardial infarction.

Treatment

Treatment in a hospital during an exacerbation: bed rest with a gradual expansion of physical activity, since hypokinesia contributes to stagnation of bile. During the period of severe symptoms of exacerbation of cholecystitis, drinking plenty of fluids is prescribed, but it should be remembered that mineral water is contraindicated!

Intramuscular administration of drugs is indicated antispasmodic action: papaverine, drotaverine (no-shpa*), analgin (baralgin*); To relieve biliary colic, a 0.1% solution of atropine* orally (1 drop per year of life per dose) or belladonna extract * (1 mg per year of life per dose) is effective. An antispasmodic drug with an m-anticholinergic effect, pinaverium bromide (dicetel *), is recommended for children no earlier than 12 years of age and adolescents, 50 mg 3 times a day, available in film-coated tablets, No. 20. In case of severe pain, tramadol (tramal *, tramalgin *) in drops or parenterally.

Indications for use antibacterial therapy- signs of bacterial toxicosis. Broad-spectrum antibiotics are prescribed: ampiox*, gentamicin, cephalosporins. Severe course of the disease requires treatment

changes in third generation cephalosporins and aminoglycosides. Reserve drugs include ciprofloxacin (tsipromed*, tsiprobay*), ofloxacin. The course of treatment is 10 days. The simultaneous use of probiotics is recommended. Without denying the possibility of giardiasis cholecystitis, anti-giardiasis drugs are recommended.

Indications for parenteral infusion therapy are the impossibility of oral rehydration, severe infectious toxicosis, nausea, and vomiting. Drugs with detoxification and rehydration effects are also prescribed.

Choleretic drugs indicated during the period of beginning remission, taking into account the type of existing gallbladder dyskinesia (see “Dysfunctional disorders of the biliary tract”).

Holosas * in the form of syrup in 250 ml bottles, children 1-3 years old are prescribed 2.5 ml (1/2 tsp), 3-7 years old - 5 ml (1 tsp), 7-10 years - 10 ml (1 dessert spoon), 11-14 years - 15 ml (1 tablespoon) 2-3 times a day. Holagol * in 10 ml bottles is prescribed to children from 12 years old, 5-20 drops 3 times a day.

In the acute period, vitamins A, C, B1, B2, PP are prescribed; in the period of convalescence - B 5, B 6, B 12, B 15, E.

Physiotherapy, herbal medicine, and mineral waters of low mineralization are prescribed during the period when acute manifestations subside.

Prevention

Therapeutic exercise improves the flow of bile and is therefore an important component of disease prevention. At the same time, patients are prohibited from excessive physical activity and very sudden movements, shaking, and carrying heavy objects.

Patients with chronic cholecystitis, DBT or after an episode of acute cholecystitis are removed from the dispensary

observation after 3 years of stable clinical and laboratory remission.

The criterion for recovery is the absence of signs of gallbladder damage on ultrasound of the hepatobiliary system.

During the period of clinical observation, the child should be examined by a gastroenterologist, otolaryngologist and dentist at least 2 times a year. Sanatorium-resort treatment is carried out in the conditions of domestic climatic sanatoriums (Truskavets, Morshin, etc.), carried out no earlier than 3 months after the exacerbation.

Forecast

The prognosis is favorable or transition to cholelithiasis.

CHOLELITHIASIS

ICD-10 codes

K80.0. Gallstones with acute cholecystitis. K80.1. Gallstones with other cholecystitis. K80.4. Bile duct stones with cholecystitis.

Gallstone disease is a disease characterized by a violation of the stability of the protein-lipid complex of bile with the formation of stones in the gallbladder and/or bile ducts, accompanied by a continuously recurrent sluggish inflammatory process, the outcome of which is sclerosis and dystrophy of the gallbladder.

GSD is one of the most common human diseases.

Among children, the prevalence of cholelithiasis ranges from 0.1 to 5%. Cholelithiasis is more often observed in schoolchildren and adolescents, and the ratio between boys and girls is as follows: in preschool age - 2:1, at the age of 7-9 years - 1:1, 10-12 years - 1:2 and in adolescents - 1:3 or 1:4. The increase in incidence in girls is associated with hyperprogesteration. The last factor is the basis of cholelithiasis that occurs in pregnant women.

Etiology and pathogenesis

GSD is considered as a hereditarily caused increase in the formation of 3-hydroxide-3-methylglutaryl-coenzyme A reductase in the body with the presence of specific HLA markers of the disease (B12 and B18). This enzyme regulates cholesterol synthesis in the body.

The risk of gallstone formation is 2-4 times higher in persons whose relatives suffer from cholelithiasis, more often in persons with blood group B (III).

Cholelithiasis in both adults and children is a multifactorial disease. In more than half of children (53-62%), cholelithiasis occurs against the background of anomalies in the development of the biliary tract, including intrahepatic bile ducts. Among metabolic disorders in children with cholelithiasis, alimentary-constitutional obesity, dysmetabolic nephropathy, etc. are more often observed. Risk factors and pathogenesis of cholelithiasis are presented in Fig. 7-7.

Rice. 7-7. Pathogenesis of cholelithiasis

Normal bile, secreted by hepatocytes in an amount of 500-1000 ml per day, is a complex colloidal solution. Normally, cholesterol does not dissolve in an aqueous environment and is excreted from the liver in the form of mixed micelles (in combination with bile acids and phospholipids).

Gallstones are formed from the basic elements of bile. There are cholesterol, pigment and mixed stones (Table 7-4).

Table 7-4. Types of gallstones

Stones consisting of a single component are relatively rare.

The overwhelming majority of stones have a mixed composition with a cholesterol content of over 90%, 2-3% calcium salts and 3-5% pigments. Bilirubin is usually found in the form of a small nucleus in the center of the stone.

Stones with a predominance of pigments often contain a significant admixture of calcareous salts; they are also called pigment-calcareous.

Conventionally, there are two types of stone formation in the biliary tract:

. primary- in unchanged bile ducts, always formed in the gallbladder;

. secondary- the result of cholestasis and associated infection of the biliary system, can be in the bile ducts, including intrahepatic ones.

With risk factors, stones are formed, the growth rate of which is 3-5 mm per year, and in some cases more. In the formation of cholelithiasis, psychosomatic and autonomic disorders (usually hypersympathicotonia) are important.

In table 7-5 presents the classification of cholelithiasis.

Table 7-5. Classification of cholelithiasis (Ilchenko A.A., 2002)

Clinical picture

The clinical picture of cholelithiasis is diverse; in children, as in adults, several variants of the clinical course can be distinguished:

Latent course (asymptomatic form);

Painful form with typical biliary colic;

Dyspeptic form;

Under the guise of other diseases.

About 80% of patients with cholelithiasis do not complain; in some cases, the disease is accompanied by various dyspeptic disorders. Attacks of biliary colic are usually associated with errors in diet and develop after heavy intake of fatty, fried or spicy foods. The pain syndrome depends on the location of the stones (Fig. 7-8, a), their size and mobility (Fig. 7-8, b).

Rice. 7-8. Gallbladder: a - anatomy and pain zones; b - types of stones

In children with stones in the area of ​​the bottom of the gallbladder, an asymptomatic course of the disease is more often observed, while if they are present in the body and neck of the gallbladder, acute early abdominal pain is noted, accompanied by nausea and vomiting. When stones enter the common bile duct, a clinical picture of an acute abdomen occurs. There is a dependence of the nature of the clinical picture on the characteristics of the autonomic nervous system. In vagotonic patients, the disease occurs with attacks of acute pain, while in children with sympathicotonia there is a long course of the disease with a predominance of dull, aching pain.

Children with painful form, in whom an attack of acute abdomen resembles biliary colic in its clinical manifestations. In most cases, the attack is accompanied by reflex vomiting, in rare cases - icterus of the sclera and skin, discolored stool. However, jaundice is not characteristic of cholelithiasis. When it appears, one can assume a violation of the passage of bile, and with the simultaneous presence of acholic feces and dark urine - obstructive jaundice. Attacks of typical biliary colic occur in 5-7% of children with cholelithiasis.

Pain of varying severity accompanied by emotional and psychological disorders (Fig. 7-9). In each subsequent circle, the interactions between nociception (the organic component of pain), sensation (CNS registration), experience (suffering from pain) and pain behavior expand.

Diagnostics

The most optimal diagnostic method is Ultrasound liver, pancreas, gallbladder and biliary tract, with the help of which stones are detected in the gallbladder (Fig. 7-10, a) or ducts, as well as changes in the size and structure of the parenchyma of the liver and pancreas, the diameter of the bile ducts, and the walls of the gallbladder (Fig. 7-10, b), violation of its contractility.

Rice. 7-9. Levels of organization and the ladder of pain

The following are typical for cholelithiasis: changes in laboratory parameters:

Hyperbilirubinemia, hypercholesterolemia, increased activity of alkaline phosphatase, γ-glutamyl transpeptidase;

In urine analysis with complete blockage of the ducts - bile pigments;

The stool is clear or light-colored (acholic). Retrograde pancreatocholecystography carried out for

to exclude obstruction in the area of ​​the papilla of Vater and the common bile duct. Intravenous cholecystography makes it possible to determine violations of the concentration and motor functions of the gallbladder, its deformation, stones in the gallbladder and ductal system. CT used as an additional method to assess the condition of the tissues surrounding the gallbladder and bile ducts, as well as to detect calcification in gallstones (Fig. 7-10, c), more often in adults when deciding on litholytic therapy.

Pathomorphology

Macroscopically, one patient may have stones of different chemical composition and structure in the biliary tract. The sizes of the stones vary greatly. Sometimes they are fine sand with particles less than 1 mm, in other cases one stone can occupy the entire cavity of the enlarged gallbladder and weigh up to 60-80 g. The shape of gallstones is also varied: spherical, ovoid, multifaceted (faceted) , barrel-shaped, awl-shaped, etc. (see Fig. 7-8, b; 7-10, a, c).

Differential diagnosis

Differential diagnosis of pain syndrome in cholelithiasis is carried out with acute appendicitis, strangulated hiatal hernia, gastric and duodenal ulcers, intestinal volvulus, intestinal obstruction, diseases of the urinary system (pyelonephritis, cystitis, urolithiasis, etc.), in girls - with gynecological diseases ( adnexitis, ovarian torsion, etc.). For pain and dyspeptic syndromes, differential diagnosis is carried out with other diseases of the biliary system, hepatitis, chronic pancreatitis, etc. Cholelithiasis is differentiated from esophagitis, gastritis, gastroduodenitis, chronic pancreatitis, chronic duodenal obstruction, etc.

Treatment

In case of exacerbation of cholelithiasis, manifested by pain and severe dyspeptic disorders, hospitalization is indicated. Physical therapy is prescribed taking into account the severity of the disease. In hospital settings it is recommended gentle driving mode within 5-7 days. This mode includes walks in the fresh air, board games and other sedentary games. Toning movement mode is the main one to which children are transferred from the 6-8th day of hospital stay. Games without competitive elements, billiards, table tennis, and walks are allowed.

Perhaps, with no other gastrointestinal disease, diet is as important as with cholelithiasis. In case of latent, asymptomatic stone-carrying, it is enough to follow the dietary recommendations.

Principles of drug treatment:

. improvement of bile outflow;

Carrying out anti-inflammatory therapy;

Correction of metabolic disorders. Indications for conservative treatment:

. single stones;

The volume of the stone is no more than half of the gallbladder;

Acalcified stones;

Functioning gallbladder. Conservative methods indicated in stage I of the disease,

in some patients they can be used at stage II of formed gallstones.

For pain syndrome, medications are prescribed that provide antispasmodic effect: belladonna derivatives, metamizole sodium (baralgin*), aminophylline (eufillin*), atropine, no-spa*, papaverine, pinaverium bromide (dicetel*). Blockade of the round ligament of the liver is advisable. For severe pain, tramadol (tramal*, tramalgin*) is prescribed in drops or parenterally. Tramal* in injections is contraindicated up to 1 year of age, the drug is prescribed intramuscularly for children under 14 years of age at an RA of 1-2 mg/kg, daily dose - 4 mg/kg, for children over 14 years of age - at an RA of 50-100 mg, daily dose - 400 mg (1 ml ampoule contains 50 mg of active ingredient, 2 ml ampoule - 100 mg); for internal use in capsules, tablets, drops is indicated for children over 14 years of age.

Ursodeoxycholic acid preparations: Urdoxa*, Ursofalk*, Ursosan* in suspension for oral administration are prescribed to young children and in capsules from 6 years of age, daily dose - 10 mg/kg, course of treatment - 3-6-12 months. To prevent the re-formation of stones, it is recommended to take the drug for several more months after the stones have dissolved.

In patients, it is advisable to add chenodeoxycholic acid preparations, replacing 1/3 of the daily dose of ursodeoxycholic acid preparations with them. This is due to the different mechanisms of action of bile acids, so their combined use is more effective than monotherapy. The drug contains extract of fumaria officinalis, which has a choleretic and antispasmodic effect, and milk thistle fruit extract, which improves hepatocyte function. Henosan*, henofalk*, henochol* are prescribed orally at a dose of 15 mg/kg per day, the maximum daily dose is 1.5 g. The course of treatment is from 3 months.

up to 2-3 years. If the stone size remains the same for 6 months, continuing treatment is not advisable. After successful treatment in patients with a pronounced predisposition to cholelithiasis, it is recommended for preventive purposes to take Ursofalk* 250 mg/day every 3rd month for 1 month. In combination therapy with ursodeoxycholic acid, both drugs are prescribed at a dose of 7-8 mg/kg once in the evening.

Choleretic And hepatoprotective drugs more often recommended during remission. Gepabene* is prescribed 1 capsule 3 times a day; for severe pain, add 1 capsule at night. The course of treatment is 1-3 months.

Treatment at the stage of formed gallstones. About 30% of patients can be subjected to litholytic therapy. It is prescribed in cases where other types of treatment are contraindicated for patients, as well as in the absence of the patient’s consent to surgery. Successful treatment is more often with early detection of cholelithiasis and much less often with a long history of the disease due to calcification of stones. Contraindications to this therapy are pigment stones, cholesterol stones with a high content of calcium salts, stones with a diameter of more than 10 mm, stones whose total volume is more than 1/4-1/3 of the volume of the gallbladder, as well as dysfunction of the gallbladder.

Extracorporeal shock wave lithotripsy(remote stone crushing) is based on the generation of a shock wave. In this case, the stone fragments or turns into sand and is thus removed from the gallbladder. In children, the method is rarely used, only as a preparatory step for subsequent oral litholytic therapy for single or multiple cholesterol stones up to 20 mm in diameter and provided there are no morphological changes in the gallbladder wall.

At contact litholysis(dissolution) of gallstones, a dissolving substance is injected directly into the gallbladder or into the bile ducts. The method is an alternative in patients with high operational risk and is becoming increasingly widespread abroad. Only cholesterol stones are dissolved, and the size and number of stones are not of fundamental importance. Methyl tert-butyl ethers are used to dissolve gallstones, propionate esters are used to dissolve stones in the bile ducts.

On the stage chronic recurrent calculous cholecystitis The main method of treatment is surgery (in the absence of contraindications), which consists of removing the gallbladder along with stones (cholecystectomy) or, which is used much less frequently, only stones from the bladder (cholecystolithotomy).

Absolute indications The following cases require surgical intervention: malformations of the biliary tract, dysfunction of the gallbladder, multiple mobile stones, choledocholithiasis, persistent inflammatory process in the gallbladder.

Indications for surgery depend on the age of the child.

Ages 3 to 12 carry out planned surgical intervention to all children with cholelithiasis, regardless of the duration of the disease, clinical form, size and location of gallstones. Cholecystectomy at this age is pathogenetically justified: removal of an organ usually does not lead to disruption of the functional capacity of the liver and biliary tract, and postcholecystectomy syndrome rarely develops.

In children from 12 to 15 years old Conservative treatment should be preferred. Surgery is performed only for emergency indications. During the period of neuroendocrine restructuring, disruption of compensatory mechanisms and the manifestation of genetically determined diseases are possible. The rapid (within 1-2 months) formation of alimentary-constitutional obesity, the development of arterial hypertension, exacerbation of pyelonephritis, the occurrence of interstitial nephritis against the background of previously occurring dysmetabolic nephropathy, etc. are noted.

There are gentle surgical interventions, which include endoscopic operations and operations requiring standard laparotomy.

Laparoscopic cholelithotomy- removal of stones from the gallbladder - is performed extremely rarely due to the likelihood of recurrent stone formation in the early stages (from 7

up to 34%) and later (after 3-5 years; 88% of cases) periods.

Laparoscopic cholecystectomy can lead to a cure for 95% of children with cholelithiasis.

Prevention

During the period of remission, children do not show any complaints and are considered healthy. Nevertheless, conditions for an optimal daily routine should be created for them. Food intake should be regulated, without significant breaks. Overloading with audiovisual information is unacceptable. Creating a calm and friendly environment in the family is of exceptional importance. Physical activity, including sports competitions, is limited. This is due to the fact that when the body is shaken, for example running, jumping, or sudden movements, stones may move in the bile ducts, which can result in abdominal pain and biliary colic.

In case of cholelithiasis, the use of mineral waters, thermal procedures (paraffin baths, mud therapy), cholekinetics is contraindicated, since, in addition to antispasmodic and anti-inflammatory effects, bile secretion is stimulated, which can cause stone herniation and obstruction of the biliary tract.

Forecast

The prognosis for cholelithiasis can be favorable. Properly performed treatment and preventive measures can achieve complete restoration of the child’s health and quality of life. Outcomes can be acute cholecystitis, pancreatitis, Mirizzi syndrome (a stone lodged in the neck of the gallbladder with subsequent development of the inflammatory process). Chronic calculous cholecystitis develops gradually, in the form of a primary chronic form. Hydrocele of the gallbladder occurs when the cystic duct is obstructed by a stone and is accompanied by the accumulation of transparent contents mixed with mucus in the bladder cavity. The addition of infection threatens the development of empyema of the gallbladder.

The invention relates to medicine, in particular to gastroenterology and hepatology, and concerns the differential diagnosis of cholelithiasis, cholesterosis and gall bladder polyps. To do this, parietal formations of the gallbladder with increased echogenicity are identified, and then ursosan is administered to the patient at a dose of 8-12 mg/kg once for 14-18 days. With a decrease in echogenicity and displacement of gallbladder formations, cholesterosis of the gallbladder is diagnosed. When the formation of the gallbladder is displaced against the background of an increase in its volume, cholelithiasis is diagnosed. If a non-displaceable formation is present, a gallbladder polyp is diagnosed. The method provides high accuracy in diagnosing cholelithiasis, cholesterosis and gallbladder polyps.

The invention relates to medicine and can be used as a method for the differential diagnosis of cholelithiasis, cholesterosis and gall bladder polyps.

There is a known method for ultrasound diagnosis of cholelithiasis, adopted as an analogue (1 - Diseases of the digestive organs in children. P/r Mazurina A.V.M., 1984. - 630 pp.).

There is a known method for diagnosing cholelithiasis by endoscopic retrograde cholangiopancreatography (2 - P.Ya. Grigoriev, E.P. Yakovenko. A short formulary guide to gastroenterology and hepatology. M., 2003. - 128 pp.), adopted as a prototype.

However, the method of endoscopic retrograde cholangiopancreatography is not a publicly available research method and does not allow differential diagnosis of cholelithiasis, cholesterosis and gallbladder polyps.

The purpose of the invention is to improve the accuracy of diagnosis of cholelithiasis, cholesterosis and gallbladder polyps.

The technical result is achieved by determining the contractile function of the gallbladder, identifying parietal formations of the gallbladder with increased echogenicity, prescribing the drug ursosan to the patient at a dose of 8-12 mg/kg once for 14-18 days, and when the echogenicity decreases and displacement of the gallbladder formations, cholesterosis is diagnosed gallbladder, when the formation of the gallbladder is displaced against the background of an increase in its volume, cholelithiasis is diagnosed, and in the presence of a non-displaceable formation, a polyp of the gallbladder is diagnosed.

The method is carried out as follows.

Upon admission, patients are diagnosed with signs of chronic intoxication: headaches, increased fatigue, sleep disturbances, appetite, and sometimes low-grade fever. Sometimes patients are bothered by periodic pain in the right hypochondrium and a feeling of bitterness in the mouth - symptoms of biliary dyspepsia. In some cases, pain and intoxication syndrome are absent.

From the anamnesis it is known that for several years she has been periodically experiencing epigastric pain.

An ultrasound examination of the liver and biliary tract is performed. The liver is not enlarged, the echogenicity is diffusely increased. An ultrasound examination reveals a decrease in the contractile function of the gallbladder. Gallbladder size 5.8x3 cm, bend in the body or neck; wall - 2.8-3.3 mm, blurred; on the wall there are three non-displaceable formations from 8 to 10 mm, without a shadow or in the presence of an acoustic shadow. The initial volume of the gallbladder and its contractile function are calculated.

The condition of the gallbladder wall based on ultrasound examination can be:

Unchanged: the thickness of the wall closest to the sensor does not exceed 3 mm, the wall is echo-uniform throughout, single-layer, its internal and external contours are smooth (normal);

Inflammatory changes in the wall of the gallbladder (chronic cholecystitis): wall thickness is more than 3 mm, its internal or external contour is uneven, unclear, echogenicity is increased and/or heterogeneous, layering is noted;

Cholesterosis of the gallbladder: reticular form - multiple small (up to 1-3 mm) hyperechoic inclusions are visualized in the thickness of the wall, which, as a rule, do not give an acoustic shadow;

In the polyposis form - single or multiple round-oval hyperechoic space-occupying formations adjacent to one of the walls of the gallbladder, having somewhat bumpy contours, a fairly homogeneous structure, non-displaceable, without an acoustic shadow; polypous-reticulate form - a combination of echographic signs of polypous and reticular form.

Depending on the echographic picture of the gallbladder bile, 3 main forms of the condition of the gallbladder bile (biliary sludge) were identified:

Suspension of hyperechoic particles: point, single or multiple displaced hyperechoic formations that do not provide an acoustic shadow, detected when the patient changes body position;

Echo-heterogeneous bile with the presence of single or multiple areas of increased echogenicity, having clear or blurred contours, displaced, located, as a rule, along the posterior wall of the gallbladder, without an acoustic shadow behind the clot;

Putty-like bile (PG): echoheterogeneous bile with the presence of areas approaching the echogenicity of the liver parenchyma, displaced, with clear contours, not giving an acoustic shadow, or in rare cases with a weakening effect behind the clot. In some cases, complete filling of the gallbladder with putty-like bile was revealed, while anechoic areas in the lumen of the gallbladder were not visualized.

The formation of biliary sludge in the gallbladder occurs against the background of significant changes in the biochemical composition of gallbladder bile, indicating the presence of lithogenic properties. Moreover, in patients with biliary sludge in the form of echo-heterogeneous bile with the presence of clots and putty-like bile, in 100% of cases a decrease in the pool of bile acids and an increase in the level of cholesterol and phospholipids in the bile are detected, and hypercholesterolemia is noted in the blood serum. In patients with biliary sludge in the form of a suspension of echogenic particles, the lithogenic properties of bile are due to a decrease in the level of phospholipids; 45% of patients in this group have an increase in cholesterol levels and a decrease in the pool of bile acids in bile, and hypercholesterolemia in the blood serum.

Before the start of the course of ursotherapy with the drug Ursosan at a dose of 8-12 mg/kg once for 14-18 days, the volume of the gallbladder was 12.5±2.6 cm 3 ; ejection fraction - 41.8±11.6%; the average volume of the gallbladder after completion of the three-month course was 24.1±5.6 cm 3, the ejection fraction was 64.2±12.1%.

After the treatment, an ultrasound examination showed the presence of the following changes in the condition of the gallbladder: single or multiple round-oval hyperechoic space-occupying formations adjacent to one of the walls of the gallbladder, having somewhat bumpy contours, a fairly homogeneous structure, not displaced, without an acoustic shadow, which indicates presence of polyps.

In some patients, after treatment, there was a decrease in the number and displacement of small hyperechoic inclusions in the wall of the gallbladder, which did not provide an acoustic shadow, which indicates the presence of biliary sludge.

In a number of patients, treatment led to strengthening of the contour and displacement of the hyperechoic formation against the background of a decrease in the echogenicity of bile, which indicates the presence of cholelithiasis.

The method is confirmed by the following examples.

Patient A-skaya, 37 years old, was admitted with complaints of flatulence, poorly controlled with medication and subicteric sclera, headache, increased fatigue, and a feeling of bitterness in the mouth.

Upon examination, the skin is of normal color, the sclera is somewhat icteric. Palpation of the epigastric region is painful.

From the anamnesis it is known that over the past months she has periodically experienced pain in the epigastrium.

An ultrasound examination of the liver and biliary tract is performed. The liver is not enlarged, the echogenicity is diffusely increased. Gallbladder size 5.8x3 cm, bend in the body; wall - 2.8 mm, blurred; on the wall there are two non-displaceable formations from 6 to 8 mm, without an acoustic shadow. The initial volume of the gallbladder and its contractile function are calculated. The volume of the gallbladder was 9.9 cm3; ejection fraction - 43.4%.

Condition of the gallbladder wall based on ultrasound examination: inflammatory changes in the gallbladder wall: wall thickness 3.5 mm, its internal or external contour is uneven, unclear, increased echogenicity, layering is noted.

The echographic picture of cystic bile is characterized by the presence of two non-displaceable formations without an acoustic shadow.

Biochemical analysis of the composition of gallbladder bile reveals a slight increase in cholesterol levels.

Treatment is carried out with the drug Ursosan at a dose of 8 mg/kg once for 14 days. The average volume of the gallbladder after completion of the course of treatment with Ursosan was 18.5 cm 3, the ejection fraction was 52.1%.

After the treatment, an ultrasound examination showed the presence of the following changes in the condition of the gallbladder: single or multiple, round-oval hyperechoic space-occupying formations adjacent to one of the walls of the gallbladder, having somewhat bumpy contours, a fairly homogeneous structure, not displaced, without an acoustic shadow, which indicates about the presence of polyps.

Subsequent follow-up

Patient Ts., 40 years old, upon admission complains of low-grade fever, sleep disturbances, and appetite; I am concerned about periodic pain in the right hypochondrium, which has been bothering me for the last two years.

On examination, the tongue is coated with a yellowish coating, the sclera is clean. Palpation of the gallbladder area is painful.

An ultrasound examination of the liver and biliary tract is performed. The echogenicity of the liver is diffusely increased. Gallbladder size 6.2x3.4 cm, bend in the neck; wall - 3-4 mm, blurred; on the wall there are three non-displaceable formations measuring from 4 to 6 mm with the presence of an acoustic shadow.

The condition of the gallbladder wall, based on ultrasound examination, is characterized by the presence of inflammatory changes in the gallbladder wall: the thickness of the wall is more than 3 mm, its internal contour is uneven, unclear, and increased echogenicity.

The echographic picture of cystic bile is characterized by its heterogeneity, with the presence of areas of compaction.

Before the start of the course of ursotherapy with the drug Ursosan at a dose of 12 mg/kg once for 18 days, the volume of the gallbladder was 10.5 cm 3 ; ejection fraction - 30.2%; the average volume of the gallbladder after completion of the three-month course was 29.7 cm 3, the ejection fraction was 76.3%.

After the treatment, an ultrasound examination showed the presence of the following changes in the condition of the gallbladder: displacement of three hyperechoic space-occupying formations with an acoustic shadow adjacent to one of the walls of the gallbladder, which allows us to establish the presence of cholelithiasis in the patient.

The patient was treated with ursodeoxycholic acid with a positive result. The patient was discharged in a state of clinical remission.

Patient T., 44 years old, complains of increased fatigue, sleep and appetite disturbances, and a feeling of bitterness in the mouth. From the anamnesis it is known that epigastric pain does not bother her.

Ultrasound examination showed that the liver was not enlarged, but its echogenicity was diffusely increased. Gallbladder size 6.5x3.5 cm, bend of the neck; wall - 3.3 mm, blurred; on the wall there is one formation measuring 2-3 mm, without an acoustic shadow.

The bile is echo-heterogeneous with the presence of areas approaching the echogenicity of the liver parenchyma and does not produce an acoustic shadow.

Before the start of the course of ursotherapy with the drug Ursosan at a dose of 10 mg/kg once for 16 days, the volume of the gallbladder was 15.1 cm 3 ; ejection fraction - 53.8%; the average volume of the gallbladder after completion of the three-month course was 26.6 cm 3, the ejection fraction was 76.3%.

After treatment, an ultrasound examination showed a displacement of the identified formation, a decrease in the echogenicity of bile, which indicates the presence of cholesterosis of the gallbladder.

The patient was treated according to standard methods. After treatment, the disappearance of clinical symptoms and positive dynamics of the echographic picture of the gallbladder are noted.

Follow-up observation for 16 months did not reveal the formation of gallstones.

A differential diagnosis of cholelithiasis, cholesterosis and gallbladder polyps was carried out in 52 patients. 18 patients were diagnosed with cholelithiasis at an early stage, 8 patients were diagnosed with gallbladder polyps, and in the remaining cases, cholesterosis was diagnosed.

CLAIM

A method for differential diagnosis of cholelithiasis, cholesterosis and gallbladder polyps by ultrasound, characterized in that the contractile function of the gallbladder is determined, parietal formations of the gallbladder of increased echogenicity are identified, the patient is prescribed the drug ursosan at a dose of 8-12 mg/kg once for 14- 18 days and with a decrease in echogenicity and displacement of gallbladder formations, cholesterosis of the gallbladder is diagnosed, if the formation of the gallbladder is displaced against the background of an increase in its volume, cholelithiasis is diagnosed, and in the presence of a non-displaceable formation, a polyp of the gallbladder is diagnosed.

Gallstone disease (GSD) is a disease characterized by the formation of stones in the gallbladder (cholecystolithiasis) and the common bile duct (choledocholithiasis), which can occur with symptoms of biliary (biliary, hepatic) colic in response to transient stone obstruction of the cystic or common bile duct, accompanied by spasm of smooth muscles and intraductal hypertension.

Between the ages of 21 and 30, cholelithiasis affects 3.8% of the population, from 41 to 50 years – 5.25%, over 60 years – up to 20%, over 70 years – up to 30%. The predominant gender is female (3–5:1), although there is a tendency for the incidence to increase in men.

Factors predisposing to the formation of gallstones (primarily cholesterol): female gender; age (the older the patient, the higher the likelihood of cholelithiasis); genetic and ethnic characteristics; nature of nutrition - excessive consumption of fatty foods high in cholesterol, animal fats, sugar, sweets; pregnancy (history of multiple births); obesity; starvation; geographical areas of residence; diseases of the ileum - short colon syndrome, Crohn's disease, etc.; the use of certain medications - estrogens, octreotide, etc.

Classification

1. By the nature of the stones

1.1 Composition: cholesterol; pigmented; mixed.

1.2 By localization: in the gallbladder; in the common bile duct (choledocholithiasis); in the hepatic ducts.

1.3 By number of stones: single; multiple.

2. According to the clinical course

2.1 latent flow;

2.2 with the presence of clinical symptoms: painful form with typical biliary colic; dyspeptic form; under the guise of other diseases.

3. Complications: acute cholecystitis; hydrocele of the gallbladder; choledocholithiasis; obstructive jaundice; acute pancreatitis; purulent cholangitis; biliary fistulas; stricture of the major duodenal papilla.

Clinical picture

Often cholelithiasis is asymptomatic (latent course, characteristic of 75% of patients), and stones are discovered accidentally during an ultrasound. The diagnosis of cholelithiasis is made based on clinical data and ultrasound results. The most common variant is biliary colic: observed in 60–80% of people with gallstones and 10–20% of people with stones in the common bile duct.

The main clinical manifestation of cholelithiasis is biliary colic. It is characterized by acute visceral pain localized in the epigastric or right hypochondrium; less often, pain occurs only in the left hypochondrium, precordial region or lower half of the abdomen, which significantly complicates diagnosis. In 50% of patients, pain radiates to the back and right scapula, interscapular area, right shoulder, and less often to the left half of the body. The duration of biliary colic ranges from 15 minutes to 5–6 hours. Pain lasting more than 5–6 hours should alert the doctor to complications, especially acute cholecystitis. The pain syndrome is characterized by increased sweating, a grimace of pain on the face and restless behavior of the patient. Sometimes nausea and vomiting occur. The onset of pain may be preceded by the consumption of fatty, hot, spicy foods, alcohol, physical activity, and emotional experiences. Pain is associated with overstretching of the gallbladder wall due to increased intravesical pressure and spastic contraction of the sphincter of Oddi or cystic duct. With biliary colic, the body temperature is usually normal, the presence of hyperthermia in combination with symptoms of intoxication (tachycardia, dry and coated tongue), as a rule, indicates the addition of acute cholecystitis.

The presence of jaundice is considered a sign of biliary obstruction.

When collecting anamnesis, it is necessary to especially carefully question the patient regarding episodes of abdominal pain in the past, since as cholelithiasis progresses, episodes of biliary colic recur, become protracted, and the intensity of pain increases.

Nonspecific symptoms are also possible, for example, heaviness in the right hypochondrium, manifestations of biliary dyskinesia, flatulence, and dyspeptic disorders.

An objective examination may reveal symptoms of chronic cholecystitis (vesical symptoms). I'M WITH. Zimmerman (1992) systematized the physical symptoms of chronic cholecystitis into three groups as follows.

Symptoms of the first group (segmental reflex symptoms) are caused by prolonged irritation of the segmental formations of the autonomic nervous system innervating the biliary system, and are divided into two subgroups:

1. Viscero-cutaneous reflex pain points and zones– characterized by the fact that finger pressure on organ-specific points of the skin causes pain:

Painful McKenzie point located at the intersection of the outer edge of the right rectus abdominis muscle with the right costal arch;

Painful Boas point– localized on the posterior surface of the chest along the paravertebral line on the right at the level of the X-XI thoracic vertebrae;

Zakharyin-Ged zones of cutaneous hypertension– extensive areas of severe pain and hypersensitivity, spreading in all directions from the Mackenzie and Boas points.

2. Cutaneous-visceral reflex symptoms– are characterized by the fact that impact on certain points or zones causes pain going deeper towards the gallbladder:

Aliyev's symptom– pressure on the Mackenzie or Boas points causes not only local pain directly under the palpating finger, but also pain going deeper towards the gallbladder;

Eisenberg's sign-I– with a short blow or tapping with the edge of the palm below the angle of the right shoulder blade, the patient, along with local pain, feels a pronounced irradiation deep into the area of ​​the gallbladder.

The symptoms of the first group are natural and characteristic of exacerbation of chronic cholecystitis. The most pathognomonic symptoms are those of Mackenzie, Boas, and Aliev.

Symptoms of the second group are caused by the spread of irritation of the autonomic nervous system beyond the segmental innervation of the biliary system to the entire right half of the body and right limbs. In this case, a right-sided reactive autonomic syndrome is formed, characterized by the appearance of pain upon palpation of the following points:

Bergmann orbital point(at the upper inner edge of the orbit);

Jonash's occipital point;

Mussi-Georgievsky point(between the legs of the right m. sternocleidomastoideus)

– right-sided phrenicus symptom;

Kharitonov's interscapular point(at the middle of a horizontal line drawn through the middle of the inner edge of the right shoulder blade);

Lapinski's femoral point(middle of the inner edge of the right thigh);

point of the right popliteal fossa;

plantar point(on the back of the right foot).

Pressure on the indicated points is produced by the tip of the pointer

body finger. Symptoms of the second group are observed in the often recurrent course of chronic cholecystitis. The presence of pain at several points simultaneously, or even more so at all points, reflects the severity of the disease.

Symptoms of the third group are detected by direct or indirect (by tapping) irritation of the gallbladder (irritative symptoms). These include:

Murphy's sign– While the patient is exhaling, the doctor carefully immerses the tips of the four half-bent fingers of his right hand under the right costal arch in the area where the gallbladder is located, then the patient takes a deep breath, the symptom is considered positive if during exhalation the patient suddenly interrupts it due to the appearance of pain when the fingertips touch with a sensitive, inflamed gallbladder. At the same time, a grimace of pain may appear on the patient’s face;

Ker's sign– pain in the right hypochondrium near the gallbladder with deep palpation;

Hausmann's sign– the appearance of pain with a short blow with the edge of the palm below the right costal arch at the height of inspiration);

Lepene-Vasilenko symptom– the occurrence of pain when delivering jerky blows with the fingertips while inhaling below the right costal arch;

Ortner-Grekov symptom– the appearance of pain when tapping the right costal arch with the edge of the palm (pain appears due to shaking of the inflamed gallbladder);

Eisenberg-II sign– in a standing position, the patient rises on his toes and then quickly falls on his heels; with a positive symptom, pain appears in the right hypochondrium due to shaking of the inflamed gallbladder.

The symptoms of the third group are of great diagnostic importance, especially in the remission phase, especially since in this phase the symptoms of the first two groups are usually absent.

Symptoms of involvement of the solar plexus in the pathological process

With a long course of chronic cholecystitis, the solar plexus may be involved in the pathological process - secondary solar syndrome.

The main signs of solar syndrome are:

Pain in the navel area radiating to the back (solaralgia), sometimes the pain is burning in nature;

Dyspeptic symptoms (they are difficult to distinguish from the symptoms of dyspepsia due to exacerbation of chronic cholecystitis itself and concomitant pathology of the stomach);

Palpation identification of pain points located between the navel and the xiphoid process;

Pekarsky's symptom is pain when pressing on the xiphoid process.

Diagnostics

For the uncomplicated course of cholelithiasis, changes in laboratory parameters are uncharacteristic. With the development of acute cholecystitis and concomitant cholangitis, leukocytosis may appear, an increase in ESR, an increase in the activity of serum aminotransferases, cholestasis enzymes (alkaline phosphatase, gamma-glutamyl transpeptidase), and bilirubin levels.

If there is a clinically justified suspicion of cholelithiasis, an ultrasound scan is first necessary. The diagnosis of cholelithiasis is confirmed using CT, magnetic resonance cholangiopancreatography, cholecystography, endoscopic cholecystopancreaticography.

Mandatory instrumental studies

■ Ultrasound of the abdominal organs as the most accessible method with high sensitivity and specificity for identifying gallstones. For stones in the gall bladder and cystic duct, ultrasound sensitivity is 89%, specificity is 97%; for stones in the common bile duct, sensitivity is less than 50%, specificity is 95%. A targeted search is required: dilation of intra- and extrahepatic bile ducts; stones in the lumen of the gallbladder and bile ducts; signs of acute cholecystitis in the form of thickening of the gallbladder wall more than 4 mm, identification of a “double contour” of the gallbladder wall.

■ Plain radiography of the gallbladder area: the sensitivity of the method for detecting stones is less than 20% due to their frequent X-ray negativity.

■ Endoscopy: carried out to assess the condition of the stomach and duodenum, to examine the major papilla of the duodenum if choledocholithiasis is suspected.

Additional instrumental studies

■ Oral or intravenous cholecystography. A significant result of the study can be considered a “disconnected” gallbladder (extrahepatic bile ducts are contrasted, but the bladder is not detected), which indicates obliteration or blockage of the cystic duct.

■ CT scan of the abdominal organs (gallbladder, bile ducts, liver, pancreas) with quantitative determination of the Hansfeld attenuation coefficient of gallstones; The method makes it possible to indirectly judge the composition of stones by their density.

■ Endoscopic cholecystopancreaticography: a highly informative method for studying the extrahepatic ducts if a common bile duct stone is suspected or to exclude other diseases and causes of obstructive jaundice.

■ Dynamic cholescintigraphy allows you to assess the patency of the bile ducts in cases where endoscopic cholecystopancreaticography is difficult. In patients with cholelithiasis, a decrease in the rate of entry of the radiopharmaceutical into the gallbladder and intestines is determined.

Differential diagnosis

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 of the 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 of the upper 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.

■ Diseases of the colon: 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: an X-ray examination of the chest organs is necessary.

■ 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); relief of clinical symptoms without surgical intervention (if there are contraindications to surgical treatment); preventing the development of complications, both immediate (acute cholecystitis, acute pancreatitis, acute cholangitis) and long-term (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 for the 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 preserved contractile function of the 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 is 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 of 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, a shorter postoperative period, shorter hospital stay, and better cosmetic results. In any case, one should keep in mind the possibility of converting the operation to an open one if attempts to remove the stone using the endoscopic method are unsuccessful. There are practically no absolute contraindications to laparoscopic procedures. 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 the following cases: the presence of no more than three stones in the gallbladder with a total diameter of less than 30 mm; the presence of stones that “pop up” during oral cholecystography (a characteristic sign of 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 an outpatient setting. 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 of 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.

Gallstone disease (GSD) is a disease caused by impaired metabolism of cholesterol and/or bilirubin and characterized by the formation of stones in the gall bladder (cholecystolithiasis) and/or in the bile ducts (choledocholithiasis).

ICD-10 K80

general information

Clinical picture

Diagnostics

Treatment

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 of the 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 of the upper 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.

■ Diseases of the colon: 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: an X-ray examination of the chest organs is necessary.

■ 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); relief of clinical symptoms without surgical intervention (if there are contraindications to surgical treatment); preventing the development of complications, both immediate (acute cholecystitis, acute pancreatitis, acute cholangitis) and long-term (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 for the 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 preserved contractile function of the 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 is 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 of 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, a shorter postoperative period, shorter hospital stay, and better cosmetic results. In any case, one should keep in mind the possibility of converting the operation to an open one if attempts to remove the stone using the endoscopic method are unsuccessful. There are practically no absolute contraindications to laparoscopic procedures. 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 the following cases: the presence of no more than three stones in the gallbladder with a total diameter of less than 30 mm; the presence of stones that “pop up” during oral cholecystography (a characteristic sign of 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 an outpatient setting. 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 of 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.