Acute cholecystitis. Methods and methods for diagnosing acute cholecystitis Acute cholecystitis differential diagnosis

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Moscow State University of Medicine and Dentistry

Department of Faculty Surgery No. 2

Head department: d.m.s., prof. Khatkov I. E.

Lecturer: ass. Zhdanov Alexander Vladimirovich

Disease history

Head Chair

MD, prof. Khatkov I. E.

Teacher

ass. Zhdanov Alexander Vladimirovich

Moscow 2010

PASSPORT DATA

Surname, name, patronymic of the patient

Age: 62

Marital status: Married

Education: secondary special

Profession, position, place of work: pensioner

Place of residence

Time of admission to the clinic: November 21, 2010

COMPLAINTS ON ADMISSION

Complaints of a sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, vomiting twice - not bringing relief, dry mouth, weakness, subfebrile temperature.

History of present illness ANAMNESIS MORBI

He considers himself ill since 1990, when he first had an attack of acute pain in the right hypochondrium. Was diagnosed with acute cholecystitis. So far, the patient has been hospitalized 4 times due to an exacerbation of the disease. In 2005, according to the results of ultrasound, a diagnosis of gallstone disease was made. Treated conservatively. A few days after the onset of the attack, under the influence of treatment, the pain subsided.

The onset of this attack is acute. 11/20/2010 the patient felt a sharp intense pain in the right hypochondrium, radiating to the lumbar region, which appeared a few hours after eating a fatty meal. Vomiting brought no relief. Independently tried to stop the pain by taking no-shpy - without effect. After 16 hours from the onset of the attack, the patient was hospitalized by ambulance in City Clinical Hospital No. 68.

History of life (Anamnesis vitae)

Brief biographical data: born in 1947, in Moscow, in a family of employees, the first child. He grew and developed, keeping up with his peers.

Education: secondary special.

Family and gender history: Married since 1969, two children.

Work history: Started working at the age of 20 as a fitter at a factory.

Working conditions: daily work, 8 hours a day, with a break for lunch, indoors.

Occupational hazards: not noted.

Household history: Lives in a panel house in a two-room apartment with an area of 47 m2, with his wife. Has a separate bathroom, centralized water supply; did not stay in the zones of ecological disasters.

Meals: regular, 3 times a day, varied, medium-calorie. There are addictions to salty, fatty foods.

Bad habits: does not smoke, does not abuse alcohol, does not use drugs, is not a drug addict.

Past diseases: arterial hypertension since 2002.

As a child, he suffered from acute respiratory viral infections, acute respiratory infections, chickenpox.

Postponed operations: tonsillectomy in 1971, appendectomy in 1976.

Venereal disease, jaundice denies. Blood and blood substitutes were not transfused.

Allergic history: not burdened. Intolerance to drugs and food allergies denies.

Insurance history: for the last calendar year, he did not take a sick leave for this disease.

Heredity: mother died at the age of 82 (suffered from cholelithiasis). My father died at 47 from cancer.

The present state of the patient (Status praesens)

General condition of the patient: satisfactory

State of mind: clear

Patient position: active

Body type: correct

Constitution: hypersthenic

Posture: correct

Gait: fast

Height - 167 cm

Weight - 95 kg

Body temperature: 36.7 C

Facial examination:

Facial expression is calm, there is no pathological mask; the shape of the nose is correct; nasolabial folds are symmetrical.

Eye and eyelid examination:

Puffiness, dark coloration, ptosis were not noted; exophthalmos, enophthalmos were not found.

Conjunctiva pale pink; sclera white; the shape of the pupils is correct, symmetrical, the reaction to light is preserved; pulsations of the pupils, rings around the pupil were not detected.

Head and neck examination:

Musset's symptom was not detected; the size and shape of the head is correct; curvature and deformation of the neck in the anterior section associated with an increase in the thyroid gland, no lymph nodes were found; pulsation of the carotid arteries is moderate; pulsations and swelling of the jugular veins, Stokes collar were not detected.

Skin covers:

The skin is flesh-colored, skin moisture is moderate, skin turgor and elasticity are preserved, no pathological elements were detected.

Skin appendages:

Male pattern hair, according to sex and age; chestnut hair, not brittle, not dry, thinning and premature loss were not detected. The shape of the nails is correct, pink in color, longitudinal striation is revealed, there is no transverse striation; Quincke's pulse was not detected; the symptom of drumsticks and watch glasses is absent.

Visible mucous membranes:

The conjunctiva is pale pink in color, moderately moist, the vascular pattern is not pronounced, no pathological elements were detected.

The mucous membrane of the nose is pale pink, moderately moist.

The oral mucosa is pale pink, moist, the vascular pattern is moderately pronounced, no pathological elements were detected.

Subcutaneous fat:

Excessively developed, places of greatest deposition of fat - on the abdomen. The thickness of the skin fold on the abdomen near the navel was 4.5 cm, on the back at the angle of the shoulder blade 3.5 cm. No edema was detected.

The lymph nodes:

Occipital, parotid, submandibular, anterior cervical, posterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal are not palpable.

Muscular system:

Muscles are developed satisfactorily; muscle tone is preserved. Muscle strength is preserved, symmetrical throughout the limb. Pain and induration were not noted on palpation.

Skeletal system:

When examining the bone of the correct form, pain on palpation and tapping of the bones of the skeleton was not noted. The symptom of "drumsticks" was not detected.

Joints of the correct form, painless on palpation. The color of the skin and the local temperature of the skin over the joints corresponds to the color of the skin and the temperature of the surrounding tissues; active and passive movements in the joints are performed in full, painlessly.

Inspection of the hands and feet:

The brushes are of the correct form, pale pink, no edema was detected, muscle atrophy was not detected, the syndrome of "drumsticks", Bouchard's, Heberden's nodules, tophi, the symptom of "hepatic palms" were not detected.

Feet of the correct form, pale pink, no edema, no tophi.

EXAMINATION OF THE RESPIRATORY ORGANS INSPECTION

Chest shape:

The shape of the chest is hypersthenic: the supraclavicular and subclavian fossae are weakly expressed, the intercostal spaces are smoothed, the epigastric angle is obtuse, the shoulder blades and collarbones moderately protrude; Respiratory excursions are symmetrical on both sides.

Curvature of the spine: absent

The circumference of the chest at the level of the IV rib: 101 cm, on inspiration - 104 cm, on exhalation - 100 cm.

Excursion of the chest: 4 cm.

Breathing: Breathing is free, through the nose.

Type of breathing abdominal. Respiratory movements are symmetrical, the muscles of the abdomen are involved in the act of breathing. The number of respiratory movements per minute is 19. Breathing is superficial, rhythmic.

PALPATION

Determination of painful areas:

No painful areas were found on palpation of the chest.

Definition of resistance:

The chest is resistant.

PERCUSSION

Comparative percussion: A clear pulmonary sound is determined over the entire surface of the lungs during percussion.

Topographic percussion.


The height of the standing tops of the lung:
	4 cm above the collarbone	4 cm above the collarbone
		At the level of the spinous process of the VII vertebra
Krenig margin width
Inferior border of the lungs:
along the sternum line
along the mid-clavicular line
along the anterior axillary line
along the mid-axillary line
along the posterior axillary line
along the scapular line
along the spinal line
Respiratory excursion of the lower edge of the lungs 5 cm 5 cm
along the mid-axillary line

AUSCULTATION OF THE LUNGS

Basic breath sounds:

Vesicular breathing is heard over the entire surface of the lungs, except for the interscapular space from the VII cervical to the IV thoracic vertebrae - in this area, bronchial breathing.

Adverse breath sounds:

no respiratory sounds were detected.

Bronchophony:

Bronchophony over the symmetrical areas of the chest is not changed over the entire surface of the lungs.

RESEARCH OF THE CARDIOVASCULAR SYSTEM

Inspection of the heart area:

Protrusion of the heart area, apex beat, cardiac beat, pulsations in the II intercostal space near the sternum, pulsations of the arteries and veins of the neck, pathological pericardial pulsations, epigastric pulsations, vein dilatation in the epigastric region were not detected.

HEART PALPATION

The apex beat is localized 1.5 cm outward from the left mid-clavicular line along the 5th intercostal space, the area is 1.5 cm, the strength, height and resistance are moderate. Cardiac impulse, trembling in the region of the heart is not determined by palpation.

PERCUSSION OF THE HEART

Limits of relative dullness of the heart:

Right: IV intercostal space, 1 cm outward from the right edge of the sternum

Left: V intercostal space 1.5 cm medially from the left mid-clavicular line

Upper: along the upper border of the III rib along the left edge of the sternum.

The diameter of the relative dullness of the heart is 11 cm.

Width of the vascular bundle 5 cm

The configuration of the heart is normal.

Limits of absolute dullness of the heart:

Right - on the left edge of the sternum

Left - 2 cm medially from the left border of relative dullness of the heart

Upper - at the level of the IV rib.

AUSCULTATION OF THE HEART

Heart sounds are rhythmic, muffled. Heart rate 80 in 1 minute.

Auscultation of the heart at the 1st point:

Auscultation of the heart at the 2nd point:

A melody of two tones is heard: 1 and 2 tone. 1 tone follows after a long pause. The tone ratio is correct: tone 2 is louder than tone 1, but not more than 2 times. Splitting or bifurcation of 2 tones was not revealed. Accent 2 tones over the aorta was not detected.

Auscultation of the heart at the 3rd point:

Auscultation of the heart at the 4th point:

A melody of two tones is heard: 1 and 2 tone. 1 tone follows after a long pause, coincides with the pulsation of the carotid artery. The ratio of tones is correct: 1 tone is louder than 2, but not more than 2 times. Bifurcation and splitting of 1 tone was not revealed.

Auscultation of the heart at the 5th point (Botkin-Erb point): A melody of 2 tones is heard: 1 and 2 tone. 1st and 2nd tone are approximately equal in volume.

Additional tones and noises were not revealed.

A pericardial friction rub was not detected.

RESEARCH OF VESSELS

Examination of the arteries: pulsations of the carotid arteries, angiocapillary pulse were not detected during examination. On palpation of the carotid, temporal, radial, brachial, ulnar, femoral, popliteal arteries and arteries of the rear of the foot, local expansions, narrowings, tortuosity, seals were not detected; pulsation is moderate; the arterial wall is elastic and smooth.

When listening to the carotid and femoral arteries, Traube's double tone, Vinogradov-Durozier's double murmur were not detected.

Arterial pulse on the radial arteries: synchronous on both radial arteries, rhythmic, tense (hard), moderate filling, large, regular shape, uniform, frequency 68 beats per minute. No pulse deficit was detected.

Blood pressure (BP): systolic 135 mm Hg, diastolic 80 mm Hg

Examination of veins. On examination, swelling and pulsation of the cervical veins were not detected, no visible pattern of the veins of the chest and abdominal wall was detected, and varicose veins of the lower extremities were not detected.

On palpation, swelling and pulsation of the cervical veins were not detected. "The noise of the top" on the jugular veins was not detected. Seals and soreness of the veins were not detected.

STUDY OF THE DIGESTIVE ORGANS

Gastrointestinal tract

INSPECTION

At the time of examination, he complained of heaviness in the right hypochondrium.

Oral cavity:

The tongue is pink, moderately moist, covered with a gray coating, the papillary layer is normal. There are no cracks or ulcers. Gingiva, soft and hard palate of pink color, hemorrhages, ulcerations were not found.

Belly:

The abdomen is symmetrical, regular in shape, participates in the act of breathing. Visible peristalsis of the stomach and intestines is not observed. Venous collaterals and striae are absent. The navel is retracted. There are no hernial protrusions.

Abdominal circumference at the level of the navel - 113 cm.

PERCUSSION

A tympanic percussion sound is heard over the entire surface of the abdomen. Free or encysted fluid in the abdominal cavity is not defined. Fluctuation symptom is negative.

PALPATION

Superficial approximate palpation: The abdomen is soft, mild pain in the right hypochondrium. The muscles of the abdominal wall are not tense. Divergence of the rectus abdominis muscles is not observed. Superficially located tumor-like formations, inflammatory infiltrate, umbilical hernia and white line hernia were not detected. The Shchetkin-Blumberg symptom was not detected.

Methodical deep sliding palpation (according to Obraztsov-Strazhesko):

The sigmoid colon is palpable as a painless cylinder, 2 cm in diameter, moderately mobile, does not growl.

The caecum is palpated as a painless cylinder, 2 cm in diameter, moderately mobile, rumbling.

The ascending colon is palpated as a painless cylinder, 3 cm in diameter, moderately mobile, does not growl.

The descending colon is palpated as a painless cylinder, 3 cm in diameter, moderately mobile, does not growl.

The greater curvature of the stomach is palpated as a soft, painless roller.

The pyloric part of the stomach is not palpable.

AUSCULTATION

Bowel sounds are heard. In the projection of the abdominal part of the aorta and renal arteries, tones and noises are not heard. The noise of friction of the peritoneum is absent.

surgical calculous cholecystitis

STUDY OF THE LIVER AND GALL BLADDER

Inspection:

There are no protrusions in the area of the right hypochondrium and epigastric region, there is no restriction of breathing in this area.

Percussion of the liver:

Upper limit of absolute stupidity:

on the right midclavicular line - 6th rib.

along the anterior median line - 6th rib.

The lower limit of absolute stupidity:

on the right mid-clavicular line - 1 cm below the edge of the costal arch.

along the anterior midline - on the border between the upper and middle third of the line drawn from the xiphoid process to the navel.

on the left costal arch - at the level of the 8th rib.

Liver sizes according to Kurlov:

on the right mid-clavicular line - 9 cm.

along the anterior median line - 7 cm.

on the left costal arch - 6 cm.

Palpation:

The edge of the liver is smooth, painful. The gallbladder is not palpable. Ortner's and Murphy's signs are positive, Mussy's sign (phrenicus sign) is negative.

Auscultation:

friction noise the peritoneum in the region of the right hypochondrium is absent.

SPLEEN EXAMINATION

Inspection:

There is no protrusion in the region of the left hypochondrium. There is no respiratory restriction in this area.

Percussion:

Length - 7 cm

Diameter - 5 cm

Palpation:

The spleen is not palpable.

Auscultation:

Friction noise in the region of the left hypochondrium was not detected.

Examination of the pancreas

Palpation:

The pancreas is not palpable.

URINARY SYSTEM

Dysuric disorders:

Difficulty urinating, the presence of involuntary urination, false urge to urinate, cramps, burning, pain during urination, frequent urination, no nighttime urination.

Lumbar region:

There is no protrusion in the lumbar region. The halves of the lumbar region are symmetrical.

Percussion:

The symptom of tapping is negative on both sides.

Palpation:

The kidneys are not palpable.

Bladder:

The bladder is not palpable.

NEURO-MENTAL SPHERE

Consciousness is clear, easily comes into contact, the mood is calm, speech is unchanged. Sensitivity is preserved, vision, hearing, smell are normal. The motor sphere is unchanged.

RECTAL EXAMINATION

The sphincter tone was preserved, the ampoule was empty, the walls were painless, no organic pathologies were detected at the height of the finger, brown feces were on the glove.

PRELIMINARY DIAGNOSIS

Based on complaints, examination, anamnesis, the patient was diagnosed with acute calculous cholecystitis.

SURVEY PLAN

1) Complete blood count

2) Urinalysis

3) Blood test: determine the blood group, Rh factor. serological tests: RW, HIV, HbsAg

4) Biochemical blood test for:

- total protein and its fractions

- bilirubin and its fractions

- cholesterol

- urea

- creatinine

- AST, ALT

- blood glucose

5) Ultrasound of the abdominal organs

6) X-ray of the chest and abdomen

7) ECG

8) EGDS

9) Intravenous cholangiography

10) Fibrocholedochoscopy

11) Endoscopic retrograde cholangiopancreatography

12) Hepatocholescintigraphy

DATA OF LABORATORY AND INSTRUMENTAL RESEARCH METHODS

General blood analysis:

Hemoglobin - 138 g/l

Erythrocytes - 5.28*1012/l

Leukocytes - 7.8 * 109 / l

Platelets - 248*109/l

General urine analysis:

Color - straw-yellow

Transparency - transparent

Relative density - 1010

Reaction - sour

Leukocytes - 1-0-2 in the field of view

Erythrocytes - 1-0-2 in the field of view

Blood chemistry:

Ultrasound of the abdominal organs:

Gallbladder size 10*4 cm, wall 0.5 cm, content: calculus 1.5 cm.

Choledoch 0.5 cm

Pancreas with clear, uneven contours, medium size, homogeneous structure, increased echogenicity.

The liver is not enlarged, homogeneous structure.

The spleen is 4*4 cm in size and has a homogeneous structure.

The kidneys are located symmetrically, with clear, even contours, of medium size, the renal sinuses are not dilated, normal echogenicity, parenchyma thickness is 1.8 cm, the structure is homogeneous

Conclusion: acute calculous cholecystitis

Electrical axis of the heart in a semi-horizontal position. The rhythm is sinus, correct. Pathological changes were not revealed.

X-ray of the abdominal organs:

There were no signs of intestinal obstruction and violation of the integrity of the hollow abdominal organ.

RATIONALE FOR THE DIAGNOSIS

The diagnosis of acute calculous cholecystitis was made on the basis of:

The patient complains of a sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, vomiting twice - not bringing relief, weakness, subfebrile temperature.

History data. Cravings for fatty and salty foods. The pain appeared after eating fatty foods. It was not stopped by No-shpy.

In 1990 he was diagnosed with acute cholecystitis, in 2005 he was diagnosed with acute calculous cholecystitis.

The patient's mother suffered from gallstone disease.

Data of an objective examination: the presence of pain in the right hypochondrium; moist, gray-coated tongue; positive symptoms Ortner, Murphy.

Data from additional instrumental studies. Ultrasound: gallbladder 10*4 cm in size, wall 0.5 cm, contents: calculus 1.5 cm.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis of acute calculous cholecystitis must be carried out with acute pancreatitis, peptic ulcer, acute appendicitis and an attack of renal colic.

1) With acute appendicitis:

Appendicitis most often affects young people. With cholecystitis, the elderly and more often women get sick. An attack of cholecystitis is caused by an error in the diet, the use of fatty, plentiful food. Appendicitis starts for no apparent reason. However, the irradiation of pain in cholecystitis and appendicitis is of a different nature. With cholecystitis, irradiation to the lumbar region. Soreness at the point of the gallbladder allows you to exclude appendicitis.

Acute appendicitis is characterized by: it begins with acute pain in the epigastric region - for a short time, after 2-4 hours the pain moves to the right iliac region (Kocher-Volkovich symptom), combined with tension in the abdominal wall. Positive symptoms of Rovsing, Sitkovsky, Voskresensky, Bartomier-Michelson. These symptoms were not found in this patient.

2) With acute pancreatitis:

Between acute pancreatitis and cholecystitis there are a number of common symptoms: sudden onset of the disease, acute pain, repeated vomiting that does not bring relief. But unlike acute pancreatitis, where pain radiates under the left shoulder blade, epigastric region, to the left hypochondrium, in acute cholecystitis the pain is localized in the right hypochondrium and does not have a girdle character. Body temperature subfebrile. In this patient, ultrasound showed no changes in the pancreas; positive symptoms of Ortner-Grekov, Murphy; the symptoms of Kerte, Voskresensky, Mayo-Robson, specific for acute pancreatitis, are negative. Thus, the diagnosis of acute pancreatitis can be ruled out.

3) with peptic ulcer:

Pain in the epigastric region, of varying intensity, associated with food intake, relieved by taking antacids. Pain in cholecystitis does not have the same pattern as in peptic ulcer disease, and vomiting and bleeding are common symptoms of an ulcer. Pain and vomiting that occur at the height of a painful attack are characteristic of an ulcer. Diseases of the gallbladder lead to an increase in temperature, and peptic ulcer occurs with a normal temperature. With an ulcer, dyspeptic disorders are manifested - constipation, diarrhea, as well as the presence of an ulcerative history and a chronic course.

4) with renal colic

The stones of the right kidney give bouts of pain - renal colic. Pain in the lower back, paroxysmal, extremely intense, relieved by the use of antispasmodics. Pain radiates down to the thigh, pubis, testicle. With cholecystitis, pain radiates upward: to the shoulder, shoulder blade, neck. The behavior of patients with cholecystitis and renal colic is different. Patients with renal colic are usually restless, trying to change their position, which is not typical for cholecystitis. Of great importance is the study of urine. In renal colic we often find blood in the urine. Possible dysuria. History of urolithiasis.

Treatment

Mandatory urgent hospitalization of a patient with suspected acute cholecystitis in a surgical hospital.

In acute calculous cholecystitis, conservative treatment makes sense. When complications occur, surgical treatment is indicated.

Bed rest, locally on the area of the right hypochondrium put an ice pack.

Nutrition - food restriction (hunger), only alkaline drinking is allowed. When the process subsides, table number 5.

Relief of pain syndrome:

1) Non-narcotic analgesics:

Rep: Sol. Analgini 50% - 2 ml

Sol. Dimedroli 1% - 1ml

S. i/m

2) If the pain does not subside, narcotic analgesics are used:

Rep: Sol. Morphini hydrochloridi 1% - 1 ml

Sol. Natrii chloridi 0.9% - 20 ml

M.D.S. Every 10-15 minutes, until a positive effect is obtained, 4-10 ml of the resulting solution is injected.

3) Antispasmodics:

Rep: Sol. Papaverini Hydrochloridi 2% - 2 ml

S. IM, 3 times a day

Relief of the inflammatory process (antibacterial therapy):

Rep: Sol. Ampicillini 0.5

S. IM, 4 times a day

Rep: Sol. Imipenemi

S. IM, 500 mg every 12 hours. Use with cilastatin.

Detoxification therapy:

Rep: Sol. Glucozi 5%-200 ml

Sol. KCl-3%-30 ml

S. in/in

Rep: Sol. Natrii Chloridi 0.9% - 400 ml

Sol. Euphyllini 2.4% - 10 ml

S. in / in, drip

After subsiding of an acute attack of the patient, it is necessary to operate in a planned manner in 2-3 weeks. If against the background of the treatment of acute cholecystitis within 48-72 hours the patient's condition does not improve, abdominal pain persists or intensifies, the protective tension of the muscles of the anterior abdominal wall persists or increases, the pulse quickens, the body temperature remains high or the body temperature rises, leukocytosis increases indicated urgent surgical intervention.

Surgical treatment of calculous cholecystitis

Early laparoscopic cholecystectomy is the main treatment.

The operation is usually performed immediately after the symptoms of the disease have subsided. With such an operation, mortality and complication rates are lower than with a planned operation performed after 6-8 weeks of conservative treatment.

Patients with acute cholecystitis complicated by peritonitis, gangrenous cholecystitis, perforation of the gallbladder wall are subject to emergency cholecystectomy.

Percutaneous cholecystostomy in combination with antibiotic therapy is the method of choice in the treatment of severely ill patients and elderly patients with complications of acute cholecystitis.

Contraindications for laparoscopic cholecystectomy are:

* High risk of poor tolerance to general anesthesia.

* Obesity that interferes with the normal functioning of the body.

* Signs of perforation of the gallbladder (abscess, peritonitis, formation of a fistulous tract).

* Giant gallstones or suspected malignancy.

* Severe liver disease with portal hypertension and severe coagulopathy.

In these cases, it is recommended to perform an abdominal operation - cholecystectomy.

It consists in removing the gallbladder to prevent the recurrence of gallstone disease.

The standard operation is performed through four very small punctures, which are located on the anterior abdominal wall.

Positive aspects of cholecystectomy:

Due to a more uniform flow of bile into the intestine after surgery, an increase in the rate of enterohepatic circulation of bile acids decreases the lithogenicity of bile;

Removal of the gallbladder - places where bile can crystallize;

A functionally defective organ is removed, which can become a source of serious complications;

The source of infection is removed.

The advantage of laparoscopic surgery is an immeasurably less surgical trauma compared to a standard wide incision. This made it possible not only to activate the patients earlier and to reduce the length of their stay in the hospital. It is much more important to reduce the number of common complications caused by major surgery (pneumonia, thromboembolism, heart failure), which in turn improves the results of treatment of elderly and debilitated patients.

Not a small role is played by the fact that postoperative hernias are much less common after laparoscopic surgery.

It is desirable to perform cholecystectomy by the laparoscopic method, the advantages of this method are:

Minor injury;

The diameter of the stones is more than 2 cm;

Reducing the length of the patient's stay in the hospital;

Significant reduction in the need for narcotic analgesics in the postoperative period;

Reducing mortality in the group of elderly patients with severe concomitant diseases.

Performing cholecystectomy from a minilaparotomic access, 4-5 cm long. This technology arose in parallel with laparoscopy and consists in performing the operation with modified instruments using a specially designed system of retractors. In terms of the amount of surgical trauma caused, cholecystectomy from a minilaparotomic access is slightly inferior to laparoscopy, but it is cheaper and allows for a more extensive intervention while maintaining a cosmetic effect.

Diary: (from 24.11.2010 Time: 11.30)

Complaints of aching, low intensity pain in the right hypochondrium, without irradiation, weakness. Nausea, no vomiting. The condition is satisfactory, consciousness is clear, the patient is adequate. Skin and visible mucous membranes of normal color and moisture. Sclera of normal color. In the lungs, vesicular breathing is carried out in all departments, there are no wheezing. NPV 19 per minute. The heart sounds are muffled, the pulse on the radial arteries is the same, the frequency is 80 in 1, rhythmic, satisfactory filling and tension. BP 130/80 mmHg The tongue is moderately moist, with a gray coating. The abdomen is of normal shape, not swollen, participates in the act of breathing. On palpation, soft, moderately painful in the right hypochondrium. Shchetkin-Blumberg's symptoms are negative, Ortner's, Murphy's are positive. On percussion, there is no dullness in sloping areas of the abdomen. During auscultation, intestinal noises are heard, active. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination independent, painless. Diuresis is adequate. Urine straw yellow, clear. Physiological functions are normal.

Diary: (from 25.11.2010 Time: 12.00)

Complaints of slight pain in the right hypochondrium, without irradiation. Nausea, no vomiting. The condition is satisfactory, consciousness is clear, the patient is adequate. Skin and visible mucous membranes of normal color and moisture. Sclera of normal color. In the lungs, vesicular breathing is carried out in all departments, there are no wheezing. NPV 18 per minute. The heart sounds are muffled, the pulse on the radial arteries is the same, the frequency is 78 in 1, rhythmic, satisfactory filling and tension. BP 140/70 mmHg Tongue moderately moist, clean. The abdomen is of normal shape, not swollen, participates in the act of breathing. On palpation, soft, moderately painful in the right hypochondrium. Symptoms of Shchetkin-Blumberg, Ortner, Murphy are negative. On percussion, there is no dullness in sloping areas of the abdomen. During auscultation, intestinal noises are heard, active. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination independent, painless. Diuresis is adequate. Urine straw yellow, clear. Physiological functions are normal.

Epicrisis

Patient Latyshev Viktor Georgievich, 62 years old, was admitted to the surgical department on 11/21/2010 with complaints of sharp intense pain in the right hypochondrium radiating to the lumbar region, nausea, vomiting twice - not bringing relief, dry mouth, weakness, subfebrile temperature. The real deterioration occurred within 17 hours. From the anamnesis it was established that these symptoms appeared after ingestion of fatty foods. He independently tried to stop the pain attack with No-shpa, but to no avail.

On examination at the time of admission - general condition of moderate severity, clear consciousness, active position, temperature 37.8 °C; breathing is rhythmic, with a frequency of 20 per minute, with auscultation - vesicular breathing, there are no side respiratory sounds; heart sounds are muffled, rhythmic, BP 130/85 mm Hg, rhythmic pulse with a frequency of 80 beats / min; the tongue is moist, lined with a gray coating, the abdomen is not swollen, soft, painful in the right hypochondrium, symptoms of Ortner-Grekov and Murphy are positive.

Ultrasound of the abdominal organs and kidneys - chronic calculous cholecystitis.

Based on the data obtained, the diagnosis was made - acute calculous cholecystitis. Conservative therapy was started, with pronounced positive dynamics (pain syndrome decreased, temperature subsided, according to ultrasound - a decrease in the thickness of the gallbladder wall).

With the complete cessation of pain, a planned radical operation - cholecystectomy is indicated.

Forecast:

For life - favorable, with the preservation of working capacity. Relapses of the disease are possible, while maintaining the gallbladder.

Prevention of acute cholecystitis consists in observing a rational diet, physical education, preventing disorders of fat metabolism, and eliminating foci of infection.

Bibliography

1) M.I. Kuzin, O.S. Shkrob, M.A. Chistov "Surgical diseases" M., 1986

2) A.A. Rodionov "Educational and methodological manual on surgical diseases for 4th year students" M., 1990

3) O.E. Bobrov, S.I. Khmelnitsky, N.A. Mendel "Essays on the surgery of acute cholecystitis" Kirovograd, POLIUM, 2008

4) N.I. Gromnatsky "Diseases of the digestive system" LLC "Medical Information Agency" 2010

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Main reasons

Calculous cholecystitis has the main cause - it is an infectious disease. Microorganisms live in the human intestine, which contribute to the improvement of the digestion process, but they can sometimes be fraught with considerable danger.

There are certain factors that provoke an increase in microorganisms, which subsequently cause the organ to malfunction:

Calculous cholecystitis has a rather extensive etiology. The development of the disease is also noted against the background of autoimmune diseases and allergic reactions.

Many people suffer from chronic cholecystitis due to prolapse of the organs that are in the abdominal cavity, or as a result of a congenital disorder of the gallbladder structure. Very often, this disease develops against the background of pancreatitis, as a result of a failure in secretion production.

Symptoms

According to the clinical course, calculous cholecystitis can be chronic and acute, while in the first case, remission is replaced by exacerbation. The period of exacerbation quite often resembles the clinical manifestation of acute inflammation of the organ.

The primary symptoms suggestive of the presence of cholecystitis are:

Vomiting and nausea.
Heartburn.
There is bitterness in the mouth.
Sensation of pain in the right hypochondrium.
Belching.

The most striking manifestation is hepatic colic, which has the following clinical signs of chronic calculous cholecystitis:

An objective examination may reveal certain symptoms that indicate the presence of this disease. All of them are that in the process of palpation there is a sharp pain.

At the stage of remission, calculous cholecystitis in most cases proceeds with few symptoms. Remission with errors in the diet is replaced by exacerbation.

Diagnostics

If this disease is suspected, the diagnostic search consists of additional research methods:

Ultrasonic.
X-ray.
Biochemical study of blood with the determination of the total level of protein, its fractions, as well as cholesterol, triglycerides.
Fibrogastroduodenoscopy and others.

Complications

In case of late diagnosis or late treatment, calculous cholecystitis can turn into the following complications:

Dropsy.
Purulent inflammation (empyema).
Acute inflammation in the bile ducts, acute cholangitis.
Perforation of the biliary wall with further development of peritonitis.
Violation of absorption in the intestine with all the ensuing consequences.
Malignant oncological processes.
Re-inflammation of the pancreas.
Narrowing (stenosis) of the papilla of Vater (large duodenal papilla).
Obstructive jaundice, which develops in violation of the function of the outflow of bile (blockage of the gallbladder, its outflows or large duodenal papilla).
Formation of stones (choledocholithiasis).

Differential diagnosis of chronic calculous cholecystitis

Cholecystitis is distinguished from renal colic, inflammation of the pancreas, appendicitis, perforated duodenal ulcer and stomach.

Compared with acute cholecystitis in renal colic, acute pain is felt in the lumbar region. The pain radiates to the hip and genital area. Along with this, there is a violation of urination. With renal colic, leukocytosis is not fixed and the temperature does not rise. Urinalysis indicates the presence of salts and formed components of the blood.

With a high location of the appendix, acute appendicitis can provoke acute calculous cholecystitis (diet is described below). The difference between acute appendicitis and cholecystitis is that in the latter case, pain radiates to the shoulder area and right shoulder blade, and there is also vomiting with bile. With appendicitis, there are no Mussi-Georgievsky symptoms.

In addition, acute appendicitis is much more difficult, the development of peritonitis is active. The differential diagnosis of chronic calculous cholecystitis in this case is simplified by the presence in the medical history of information that the patient has gallstones in the gallbladder.

In some cases, a perforated ulcer of the duodenum and stomach is disguised as acute cholecystitis. However, unlike ulcers in acute cholecystitis, in the case history, as a rule, there are indications of the presence of stones in the organ.

Acute cholecystitis is characterized by pain that radiates to other parts of the body, as well as vomiting with bile. Initially, the feeling of pain is localized in the hypochondrium on the right, increasing gradually, fever begins.

Hidden perforated ulcers manifest themselves acutely. In the first hours of the disease, the muscles of the anterior region of the abdominal wall are very tense. Very often, patients complain of pain in the right iliac, due to the fact that the contents of the stomach flow into the cavity. With cholecystitis, hepatic dullness is observed.

In acute pancreatitis, intoxication increases, intestinal paresis, palpitations are observed - this is precisely its main difference from cholecystitis. In the case of inflammation of the pancreas, pain is often accompanied by severe vomiting. It is quite difficult to distinguish acute gangrenous calculous cholecystitis from acute pancreatitis, so the diagnosis is carried out in a hospital.

Diet

Cholecystitis is a rather serious disease. Proper nutrition with such a diagnosis favors a quick recovery. In this case, therapeutic nutrition should be aimed at reducing acidity and secreting bile.

Smoked and fried foods are excluded from the diet. It is necessary to include fresh vegetables and fruits, vegetable oil, cereals in the menu.

What can not be eaten if calculous cholecystitis is diagnosed? The menu should be compiled taking into account certain requirements:

Avoid fried and fatty foods.
You need to eat often, while portions should be small.
Reduce consumption of sweet and flour products.
Avoid hot and cold food.
Give preference to baked, boiled and stewed foods.
Minimize strong tea and coffee.
There are no more than three eggs per week, while it is desirable to exclude the yolk.
Eat more vegetable and dairy foods, as fiber improves motility and normalizes stools, and milk normalizes the acid-base balance.
Stick to the diet, eat at the same time.

With a disease such as calculous cholecystitis, the diet after surgery should be the same as in the chronic form of the disease.

Food

Proper nutrition with such a disease can provide a long period of remission. From the diet should be removed food that contributes to the formation of stones and the burden of the liver.

You need to include foods containing fiber, milk proteins, vegetable oil in the menu, and consume plenty of fluids. Reduce the amount of foods high in fat and cholesterol.

List of allowed products

To prevent a possible attack of calculous cholecystitis, it is advisable to familiarize yourself with the list of allowed products:

Milk products.
Vegetable and cereal soups, greens (with the exception of rhubarb, sorrel and spinach), vegetables, cereals, boiled meat and fish.
Cheese, cod liver, soaked herring.
Wheat and rye bread from yesterday's baking, unbread biscuits.
Sunflower, olive and butter (small amount).

Calculous cholecystitis: how to treat?

The classic therapy for this disease is the removal of pain and hospitalization. In the case of the chronic form, treatment can be carried out on an outpatient basis. Bed rest, sulfa drugs or antibiotics, as well as fractional dietary nutrition are prescribed. When the inflammation subsides, physiotherapy procedures are allowed.

Treatment (exacerbation of calculous cholecystitis) is carried out in this way:

According to the prescribed studies, the doctor determines the stage and form of the disease.
A diagnosis is made.
If an acute inflammatory process is detected, the patient is prescribed anti-inflammatory drugs ("No-shpa", "Papaverine hydrochloride") and antibiotics with a wide spectrum of action.
After the inflammation is removed and the source of infection is suppressed, choleretic drugs are prescribed that accelerate the emptying of the gallbladder and weaken the inflammatory process.

If stones are found in the gallbladder ducts or in the organ itself, and the inflammatory process is pronounced, then an operation is prescribed. Depending on the location of the calculi and their size, either deposits are removed or the gallbladder as a whole. The failure of conservative treatment or the diagnosis of "gangrenous calculous cholecystitis" are absolute indicators for this appointment.

ethnoscience

At the moments of subsiding of the acute process, it is allowed to use alternative treatment. To restore the function of the organ, decoctions and infusions are used (from corn stigmas, immortelle, etc.), which have an antimicrobial and astringent effect.

It is useful for the patient to include mineral waters (Essentuki No. 4 and No. 17, Slavyanskaya, Naftusya, Mirgorodskaya) and choleretic teas in the diet. Of the medicinal preparations based on plants, it is allowed to use Allochol and Cholagol.
In chronic cholecystitis, probeless tubage should be used 2-3 times a week. On an empty stomach, warm water or decoction (1 glass) is drunk. After 30 minutes, you need to drink Allohol, and then again a decoction of herbs. Next, you need to lie on your left side, while on the right you should put a heating pad. It is recommended to stay in this position for 1.5-2 hours.

Therapy of a disease such as calculous cholecystitis (treatment and diet should be carried out only under the supervision of specialists) involves the use of traditional medicine. In the chronic form, such treatment significantly alleviates the condition, and most importantly, leads to positive results.

In general, treatment with traditional medicine can be divided into two main areas:

Through choleretic herbs.
Homeopathic preparations, involving the impact on stones that have a certain chemical composition, with a similar composition. For example, if phosphate or oxolinic acid was found in the urine test, then these same acids are prescribed during the treatment. With cholecystitis without stones, drugs are used that activate the immune system.

Decoction recipes

Oregano grass (a teaspoon) should be brewed with boiling water (a glass), and then infused for two hours. In case of biliary tract disease, you need to drink 3 times a day for 1/4 cup.
Leaves of medicinal sage (2 tsp) are brewed with boiling water (2 cups), then infused and filtered for half an hour. In inflammatory processes in the liver or gallbladder, you need to drink 1 tbsp. spoon every two hours.
Veronica brook (a teaspoon) is brewed with boiling water (a glass), after which it is infused for half an hour. You need to drink 3 times a day for 1/4 cup.
Corn stigmas (a tablespoon) are brewed with boiling water (a glass), and then infused for 60 minutes and filtered. You should drink every 3 hours for 1 tbsp. spoon.
Grass agrimony (10 g) is brewed with water (3 cups) and boiled for 10 minutes. Drink a decoction before meals three times a day for a glass.
Rhizomes of wheatgrass (20 g) are brewed with boiling water (1.5 cups) and infused for several hours, and then filtered. With cholecystitis, take 3 times a day, one glass. The course is 1 month.
St. John's wort grass (a tablespoon) is brewed with boiling water (a glass), boiled for 15 minutes, and then filtered. You need to drink 3 times a day for 1/4 cup. This decoction is characterized by choleretic and anti-inflammatory action.
Hop seedlings (2 tablespoons) are brewed with boiling water (1.5 cups), wrapped and infused for 3 hours. With cholecystitis, drink a decoction half an hour before meals, 1/2 cup 3-4 times a day.
Carefully grind the flowers of chamomile, immortelle, trefoil, dill seed and joster taken in the same amount. Mix everything and pour the resulting mixture (3 tsp) with boiling water (2 cups). Next, the contents of the glass are infused for 20 minutes and filtered. Take daily after meals in the morning and in the evening before bedtime, 1/2 or 1/4 cup.
Finely chop 3 parts sand immortelle flowers, 2 parts fennel fruit, wormwood herb, yarrow herb or mint leaf and dill. Pour the resulting mixture (2 tsp) with boiling water (2 cups). Insist for 8-12 hours and strain. Drink before meals 3-4 times a day for 1/3 cup.
Chamomile flowers (a tablespoon) are brewed with boiling water (a glass). For cholecystitis, use warm for enemas. Do enemas 2-3 times a week.
Ivy-shaped budra (a teaspoon) is brewed with boiling water (a glass) and infused for about 60 minutes, then it is filtered. You need to drink 3 times a day for 1/3 cup (before meals).
Peppermint (a tablespoon) is brewed with boiling water (a glass) and infused for half an hour. During the day, drink in small sips (at least three times).

In most cases, people suffer from chronic cholecystitis for many years. Its course and the frequency of exacerbations are directly related to the desire of a person to overcome this disease by all possible methods and means. If you are sick, then try to adhere to a healthy and proper lifestyle (physical activity, rational nutrition, proper rest and work). Also, do not forget about drug treatment, while during periods of remission it is advisable to additionally use traditional medicine.

The human body is a reasonable and fairly balanced mechanism.

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

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

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

Hepatic colic is a typical manifestation of cholelithiasis.

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

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

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

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

Differential Diagnosis

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

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

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

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

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

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

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

Since repeated vomiting is observed in acute cholecystitis, and also often there are phenomena of intestinal paresis with bloating and stool retention, acute obstructive intestinal obstruction may be suspected. The latter is distinguished by the cramping nature of pain with localization uncharacteristic of acute cholecystitis, resonant peristalsis, "splash noise", Val's positive symptom and other specific signs of acute intestinal obstruction. Of decisive importance in the differential diagnosis is an overview fluoroscopy of the abdominal cavity, which makes it possible to detect swelling of the intestinal loops (a symptom of "organ tubes") and fluid levels (Kloiber's cups).

The clinical picture of a perforated ulcer of the stomach and duodenum is so characteristic that it rarely has to be differentiated from acute cholecystitis. An exception is covered perforation, especially if it is complicated by the formation of a subhepatic abscess. In such cases, one should take into account an ulcerative history, the most acute onset of the disease with a “dagger” pain in the epigastrium, and the absence of vomiting. Significant diagnostic assistance is provided by X-ray examination, which allows to identify the presence of free gas in the abdominal cavity.

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

Instrumental diagnosis of acute cholecystitis

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

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

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

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

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

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

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

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

When acute cholecystitis is complicated by obstructive jaundice or cholangitis, it is important to have accurate information about the causes of their development and the level of bile duct obstruction before surgery. To obtain this information, RPCH is performed by cannulating the major duodenal papilla under the control of a duodenoscope (Fig. 10, 11). RPCG should be performed in each case of acute cholecystitis occurring with severe clinical signs of impaired bile outflow into the intestine. With the successful completion of a contrast study, it is possible to identify bile duct stones, determine their localization and the level of blockage of the duct, and determine the extent of the narrowing of the bile duct. Determining the nature of the pathology in the bile ducts using the endoscopic method allows you to correctly resolve issues about the timing of the operation, the amount of surgical intervention on the extrahepatic bile ducts, as well as the possibility of performing endoscopic papillotomy to eliminate the causes. causing obstructive jaundice and cholangitis.

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

Rice. 10. RPCH is normal. PP - pancreatic duct; G - gallbladder; O - common hepatic duct

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

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

Therapeutic tactics in acute cholecystitis

The main provisions on therapeutic tactics for acute cholecystitis were developed at the VI and supplemented at the XV plenums of the Board of the All-Union Society of Surgeons (Leningrad, 1956 and Chisinau, 1976). According to these provisions, the tactics of the surgeon in acute cholecystitis should be active-expectant. Expectant tactics are recognized as vicious, because the desire to resolve the inflammatory process by conservative measures leads to serious complications and belated operations.

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

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

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

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

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

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

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

Conservative treatment of acute cholecystitis

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

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

hunger for 2-3 days;

local hypothermia - the use of a "bubble" with ice on the area of the right hypochondrium;

gastric lavage while maintaining nausea and vomiting;

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

antihistamine therapy (diphenhydramine, pipolfen or suprastin);

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

Drugs of choice:

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

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

Ampicillin/sulbactam 6 g/day;

Amoxicillin / clavulanate 3.6-4.8 g / day;

Alternate mode:

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

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

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

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

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

prescribe vitamins of group B, C, calcium preparations;

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

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

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

Surgical treatment of acute cholecystitis

Surgical accesses. For access to the gallbladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the Kocher, Fedorov, Czerny incisions and upper median laparotomy are the most widely used.

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

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

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

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Differential diagnosis of acute cholecystitis

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Acute cholecystitis is distinguished from acute inflammation of the pancreas, renal colic, perforated gastric and duodenal ulcers, or appendicitis.

Renal colic differs from acute cholecystitis in that it causes acute pain in the lumbar region. This pain radiates to the genital area and thighs. At the same time there is a violation of urination. With renal colic, the temperature does not rise, leukocytosis is not fixed. Urinalysis shows the presence of formed components of blood and salts. There are no symptoms of peritoneal irritation, but Pasternatsky's symptom is detected.

Acute appendicitis with a high location of the appendix can provoke acute cholecystitis. The difference between acute cholecystitis and acute appendicitis is that with it there is vomiting with bile, and pain radiates to the right shoulder blade and shoulder area. In addition, with appendicitis, the symptom of Mussi-Georgievsky is not detected. Diagnosis is facilitated by the presence of information in the medical history that the patient has gallstones. Unlike acute cholecystitis, acute appendicitis is more severe, with rapid development of peritonitis.

In some cases, a perforated ulcer of the stomach and duodenum is disguised as acute cholecystitis. However, in acute cholecystitis, unlike ulcers, the history of the disease usually has indications of stones in the gallbladder.

Acute cholecystitis is characterized by vomiting with bile content and pain that radiates to other parts of the body. Initially, pain sensations are localized in the right hypochondrium, gradually increase, fever begins.

Hidden perforated ulcers begin acutely. In the first few hours of the disease, the muscles of the anterior abdominal wall become very tense. The patient complains of localized pain in the right iliac due to the fact that the contents of the stomach flow into the cavity. Similar phenomena are not observed in acute cholecystitis. In addition, hepatic dullness persists in acute cholecystitis.

Acute pancreatitis is characterized by increasing intoxication, palpitations, intestinal paresis - this is its main difference from acute cholecystitis. Pain sensations are observed mainly in the left hypochondrium or above the stomach, have a girdle character. Pain with inflammation of the pancreas is often accompanied by severe vomiting. Distinguishing between acute pancreatitis and acute cholecystitis is very difficult, so the diagnosis has to be carried out in stationary conditions.

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Differential Diagnosis

Acute cholecystitis is differentiated with the following diseases:

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

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

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

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

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

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

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

Clinical diagnosis:

Cholelithiasis, chronic calculous cholecystitis.

Rationale for the diagnosis:

The diagnosis was made on the basis of:

Complaints provided by the patient about discomfort and periodic dull pains of girdle character, appearing after ingestion of any kind of food, in the right hypochondrium, spreading to the epigastric region;

History of the disease: the appearance of similar pains about 1 year ago, in September 2015, after eating mostly fatty foods, which were not stopped by painkillers. As a result of inpatient treatment in the Central District Hospital of Ussuriysk for acute cholecystitis, she was admitted for planned surgical treatment;

Data of objective examination:

1. the general condition of the patient is satisfactory, the skin and visible mucous membranes are pink, clean,

2. peripheral lymph nodes are not enlarged,

3. vesicular breathing is heard in the lungs, there are no wheezing,

4. heart sounds are clear, rhythmic, blood pressure is 120/80 mm Hg, pulse is 76 beats per minute,

5. the tongue is moist, the abdomen is not swollen, soft, painless in all departments, the liver is not enlarged, stools and diuresis are regular (normal);

Instrumental studies: Ultrasound of the abdominal organs - the presence of stones up to 2-3 cm, enlargement and diffuse changes in the liver;

Laboratory research:; increase in the level of bilirubin in the blood, to a greater extent due to direct; the presence of leukocytosis, a sharp shift of the leukocyte formula to the left, an increase in ESR.

All of the above in favor of the diagnosis: cholelithiasis. Chronic calculous cholecystitis.

differential diagnosis.

Differential diagnosis should be carried out with those nosological units that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis.

Pain syndrome:

With cholelithiasis, chronic calculous cholecystitis - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall, painful symptoms of Murphy, Georgievsky-Mussi, Ortner-Grekov. Increased pain, worsening condition is associated with errors in the diet, eating fatty foods.

With duodenal ulcer - daily daily rhythm of pain, hunger - pain, food intake - pain subsides, hunger - pain. On palpation, pain in the right upper quadrant of the abdomen. The condition worsens significantly in the spring and autumn periods.

In chronic pancreatitis, the pains are localized in the epigastric region, are dull in nature and radiate to the back. The pain gets worse after eating or drinking. Palpation of the abdomen usually reveals its swelling, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation pain is noted at the Desjardin point or in the Chauffard zone. Often a painful point is detected in the left costovertebral angle (Mayo-Robson symptom). Sometimes a zone of skin hyperesthesia is determined, corresponding to the zone of innervation of the 8-10th thoracic segment on the left (Kach's symptom) and some atrophy of the subcutaneous fat layer in the projection area of the pancreas on the anterior abdominal wall (Grott's sign).

With choledocholithiasis - pain in the upper abdomen, more on the right, radiating to the back.

Dyspeptic syndrome:

With cholelithiasis, chronic calculous cholecystitis - dryness, bitterness in the mouth, nausea, sometimes vomiting, stool disorders (more often diarrhea), there is a natural connection with the intake of fatty foods. Patients are usually adequately nourished.

With duodenal ulcer - a similar symptomatology. Vomiting relieves, aggravated by fasting. Patients are often asthenic.

In chronic pancreatitis - a characteristic symptomatology, there is a natural relationship with the intake of alcohol, spicy, fried foods. Stool disorders - diarrhea, steato-amylo-creatorrhoea. Patients are asthenic.

With cholelithiasis, choledocholithiasis - dyspeptic syndrome is similar to chronic cholecystitis.

Laboratory data:

With cholelithiasis, chronic calculous cholecystitis - normal blood and urine values, there may be a slight leukocytosis, ESR increases. In blood biochemistry - transaminases, hepatic fraction of alkaline phosphatase, amylase slightly increase, total bilirubin may increase (due to direct) - cholestatic syndrome is slightly pronounced.

In duodenal ulcer - iron deficiency, normal urine values, with an exacerbation of the disease, a slight leukocytosis in the KLA is possible, transaminases are within the normal range, bilirubin is normal. The cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase, alkaline phosphatase increase, transaminases, dysproteinemia may increase, in the urine - normal, cal - steatorrhea, creatorrhea, amylorrhea. Coagulogram without features.

With cholelithiasis, choledocholithiasis - a slight leukocytosis is possible in the KLA, ESR increases, bilirubin in the urine, urobilin will be absent, and stercobilin will also be absent in the feces. Feces like white clay. Biochemistry - transaminases increase sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Pronounced cholestatic syndrome. Changes in the coagulogram include an increase in bleeding time, a decrease in the prothrombin index (lower limit of normal), and an increase in INR.

Instrumental methods: ultrasound, FGDS.

With cholelithiasis, chronic calculous cholecystitis - the gallbladder is enlarged, the wall of the bladder is compacted, in the lumen - hyperechoic bile (suspension), calculi. Diffuse changes in the parenchyma of the liver, pancreas are possible. On X-ray positive calculi, with cholecystography - calculi (filling defects), enlargement, gallbladder dystopia is possible. Duodenal sounding - inflammatory changes in bile (portion B).

In the case of peptic ulcer of the duodenum, FGDS is used (ulcerative defect, cicatricial changes, stenosis), pH-metry, urease test are also carried out in parallel. With duodenal sounding, inflammatory bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to conduct FGDS - x-ray with barium - a symptom of a niche is detected.

In chronic pancreatitis - on ultrasound, diffuse changes in the gland, calcification, fibrosis, cystic changes, a decrease in the size of the gland, the patency of the Wirsung duct decreases (an inflammatory change in the wall, calcifications in the duct are possible).

With cholelithiasis, choledocholithiasis on ultrasound - a diffusely altered liver, expansion of the intrahepatic ducts, stones in the common bile duct. When duodenography under conditions of artificially controlled hypotension, the pathology of the organs of the pancreatoduodenal zone is revealed. RPCH - the ability to see the external and internal hepatic ducts, as well as the ducts of the pancreas. CRCP - it is possible to determine both the nature and localization of obturation in the area of the hepatoduodenal zone.

Etiology and pathogenesis of the underlying disease.

Calculous cholecystitis is a disease caused by the presence of stones in the gallbladder and bile ducts. There are cholesterol, pigment and mixed stones (calculi).

Etiology There are the following main groups of etiological factors leading to the development of calculous cholecystitis: 1. Inflammatory process in the gallbladder wall of bacterial, viral (hepatitis virus), toxic or allergic etiology. 2. Cholestasis. 3. Violations of lipid, electrolyte or pigment metabolism in the body. 4. Dyskinesia of the gallbladder and biliary tract, which is often caused by impaired neuroendocrine regulation of the motility of the biliary tract and gallbladder, physical inactivity. 5. Alimentary factor (unbalanced diet with a predominance of coarse animal fats in the diet to the detriment of vegetable fats). 6. Congenital anatomical features of the structure of the gallbladder and biliary tract, anomalies in their development. 7. Parenchymal diseases of the liver.

Pathogenesis There are two main concepts of the pathogenesis of calculous cholecystitis: 1) the concept of metabolic disorders; 2) inflammatory concept.

To date, these two concepts are considered as possible pathogenetic options (mechanisms) for the development of calculous cholecystitis - hepatic-metabolic (the concept of metabolic disorders) and vesico-inflammatory (inflammatory concept). According to the concept of metabolic disorders, the main mechanism for the formation of gallstones is associated with a decrease in the cholate-cholesterol ratio (bile acids / cholesterol), i.e. with a decrease in the content of bile acids in bile and an increase in cholesterol. Lipid metabolism disorders (general obesity, hypercholesterolemia), alimentary factors (excess of animal fats in food), lesions of the hepatic parenchyma of toxic and infectious genesis can lead to a decrease in the cholate-cholesterol coefficient. A decrease in the cholate-cholesterol ratio leads to a violation of the colloidal properties of bile and to the formation of cholesterol or mixed stones. According to the inflammatory concept, gallstones are formed under the influence of an inflammatory process in the gallbladder, leading to physicochemical changes in the composition of bile. A change in the pH of bile to the acid side, characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular, protein fractions of bile, the transition of a bilirubin micelle from a suspended state to a crystalline one. In this case, a primary center of crystallization is formed, on which desquamated epithelial cells, microorganisms, mucus, and other components of bile are layered. According to modern concepts, one of these mechanisms may dominate in the initial stage of development of calculous cholecystitis. However, in the later stages of the disease, both mechanisms function. The formation of stones initiates the stagnation of bile, the inflammatory process, the stones serve as centers of bile crystallization. Thus, the vicious circle closes and the disease progresses.

What is gallbladder dyskinesia

Differential diagnosis of cholelithiasis should be carried out with acute appendicitis, peptic ulcer of the stomach and duodenum, biliary dyskinesia, pancreatitis.

1. Acute appendicitis.

In acute appendicitis, pain is sudden, constant, dull, often occurs in the evening and at night, of moderate intensity, localized at the onset of the disease in the epigastric region (Kocher's symptom), less often in the umbilical region (Kümmel's symptom) or throughout the abdomen. Subsequently, within 2-12 hours, it moves to the right iliac region (Volkovich's symptom). Characterized by the absence of irradiation of pain (except for the pelvic, retrocecal and subhepatic location of the process), undulating nausea and once or twice vomiting after the onset of pain, stool retention, increased heart rate. Positive symptoms of Rovsing, Razdolsky, Sitkovsky, Voskresensky, Obraztsov, Krymov. The patient has intermittent, cutting pains, localized in the right hypochondrium and radiating to the lower back. Symptoms of acute appendicitis are negative, which makes it possible to exclude this pathology.

2. Peptic ulcer of the duodenum.

Pain in duodenal ulcer are daily and rhythmic in nature (hungry, night pain), during an exacerbation, prolonged pain lasting 3-4 weeks is characteristic. This patient is characterized by pain associated with the intake of fatty, “heavy” food, which is of a short duration. Soreness is localized in the right hypochondrium. The secretory function of the stomach, as a rule, remains normal, and with duodenal ulcer, a hyperacid state is usually observed. Bleeding in duodenal ulcer usually has characteristic manifestations: vomiting in the form of "coffee grounds", melena, blanching of the skin, and this patient does not have these manifestations. Vomiting and bleeding are absent. Based on the above phenomena, the data of instrumental studies, the diagnosis of duodenal ulcer is excluded.

3. Peptic ulcer of the stomach.

With gastric ulcer, pain occurs immediately after eating or 15-45 minutes after eating. Relief in this condition can bring the evacuation of gastric contents. This patient is characterized by pain associated with the intake of fatty, "heavy" food, physical exertion, psycho-emotional stress. Localization of pain in peptic ulcer, as a rule, between the xiphoid process and the navel, more often to the left of the midline, irradiation to the left half of the chest, to the interscapular region. In this patient, the pain is localized in the right hypochondrium. Soreness is located at a characteristic point - the projection point of the gallbladder, Ortner's symptom is also positive. Therefore, this patient does not have characteristic signs for gastric ulcer, which is confirmed by the data of esophagogastroduodenoscopy.

4. Dyskinesia of the biliary tract.

Biliary dyskinesia unite a variety of functional disorders of the biliary system, in which clinical signs of organic lesions (inflammation or stone formation) are not established. The development of dyskinesia is based on violations of the complex innervation of the sphincters of the biliary tract. Clinically, biliary dyskinesias are characterized by recurrent biliary colic, which can be significant and simulate cholelithiasis. Pain attacks often occur in connection with strong emotions and other neuropsychic moments; less often they appear under the influence of significant physical exertion. With dyskinesia of the biliary tract, the connection between the onset of pain syndrome and negative emotions, the absence of tension in the abdominal wall during biliary colic, negative results of duodenal sounding, and mainly data from contrast cholecystography, which does not reveal calculi, stand out more clearly.

5. Pancreatitis.

Pancreatitis is inflammation of the pancreas. Pancreatitis is characterized by attacks of pain, which may be preceded by dyspeptic phenomena. Pain can have different localization depending on which part of the organ is involved in the pathological process. When the head of the gland is affected, they are localized in the epigastric region or in the right hypochondrium, with damage to the body of the gland in the epigastric region, with diffuse damage - throughout the upper abdomen. Pain usually radiates posteriorly to the lumbar region, shoulder blade. External examination may reveal jaundice. Differential diagnosis is facilitated by a peculiar localization of pain in the left side of the epigastric region, to the left of the navel, with irradiation to the back, to the left side of the spine, which is characteristic of pancreatic diseases and is usually not observed in cholelithiasis. The high content of diastase in the urine is also important in acute pancreatitis.

Etiology and pathogenesis.

Gallstone disease is considered as a polyetiological disease. The question of the cause of stone formation is currently not fully understood.

Among the main causes of stone formation, most authors include the following:

Violation of the physico-chemical composition of bile.

With cholelithiasis, there is a change in the normal composition of bile - cholesterol, lecithin, bile salts. Micellar structures, consisting of bile acids and lecithin, contribute to the dissolution of cholesterol in the bile, which is part of the micelles. In micellar structures, there is always a certain limit of cholesterol solubility. When the amount of cholesterol in bile exceeds the limits of its solubility, bile becomes supersaturated with cholesterol, and cholesterol precipitates. The lithogenicity of bile is characterized by the lithogenicity index, which is determined by the ratio of the amount of cholesterol (IL) present in the studied bile to the amount of cholesterol that can be dissolved at a given ratio of bile acids, lecithin, and cholesterol. Silt equal to one shows the normal saturation of bile, above one - its oversaturation, below one - its unsaturation. Bile becomes lithogenic with the following ratio changes:

- an increase in the concentration of cholesterol (hypercholesterolemia);
- decrease in the concentration of phospholipids;
- decrease in the concentration of bile acids.

It has been established that in the body of patients with a significant degree of obesity, bile is produced, supersaturated with cholesterol. The secretion of bile acids and phospholipids in obese patients is greater than in healthy individuals with normal body weight, but their concentration is insufficient to keep cholesterol in a dissolved state. The amount of secreted cholesterol is directly proportional to body weight and its excess, while the amount of bile acids largely depends on the state of enterohepatic circulation and does not depend on body weight. The consequence of this disproportion is the oversaturation of bile in obese people.

J. Deaver (1930) described the five F principle, according to which patients with gallstones can be suspected: female (woman), fat (full), forty (40 years and older), fertile (pregnant), fair (blonde). As can be seen from the foregoing, this principle is not devoid of pathogenetic foundations.

The reasons leading to a decrease in the flow of bile acids into bile can be divided into the following groups:

- primary violation (decrease) in the synthesis of bile acids and violation of the feedback mechanisms that regulate the synthesis of bile acids: impaired liver function, poisoning with hepatotropic poisons, taking hormonal contraceptives, chronic hepatitis, various forms of liver cirrhosis, pregnancy, increased levels of estrogen hormones;
- violation of enterohepatic circulation of bile acids (significant losses of bile acids occur during resection of the distal small intestine, diseases of the small intestine); Another mechanism for turning off bile acids from circulation - their deposition in the gallbladder - is observed with atony of the gallbladder, prolonged starvation.

Stagnation of bile.

In itself, the presence of a gallbladder ("bile sump") in the biliary system is a predisposing factor to stagnation of bile. In addition to this, with cholelithiasis, it is often possible (in 65 - 80%) to detect a violation of the function of the gallbladder. Violation of the coordinated work of the sphincters causes various dyskinesias in nature. Allocate hypertonic and hypotonic (atonic) dyskinesia of the bile ducts and gallbladder. In hypertensive forms of dyskinesia, there is an increase in the tone of the sphincters. So, spasm of the common part of the sphincter of Oddi (Westphal fibers) causes hypertension in the ducts and gallbladder. An increase in pressure is associated with the entry of bile and pancreatic juice into the ducts and gallbladder, while the latter can cause a picture of enzymatic cholecystitis. Spasm of the cystic duct sphincter is possible, which also causes congestion in the bladder. With hypotonic (atonic) forms of dyskinesia, the sphincter of Oddi relaxes, followed by reflux of the contents of the duodenum into the bile ducts (infection of the ducts occurs). At the same time, against the background of atony and poor emptying of the gallbladder, stagnation and an inflammatory process develop in it. Both in hypertonic and hypotonic forms of dyskinesia, there is a violation of the evacuation of bile from the gallbladder and ducts, which is a favorable factor for stone formation in the biliary system.

Biliary tract infections.

The initiating factor in the formation of gallstones, in addition to increasing the lithogenicity of bile, is the inflammatory process in the mucous membrane of the gallbladder. As a result of inflammation, microparticles enter the lumen of the bladder, which are a matrix for the deposition of crystals of a substance in a supersaturated state on them. Inflammation of the gallbladder may be the result of bacteriocholia against the background of various forms of biliary dyskinesia and gallbladder, which cause bile stasis. Bile does not have bactericidal properties, which is explained by its alkaline reaction. Inflammation can be aseptic in nature - with various allergic, autoimmune reactions, as well as with the reflux of pancreatic juice into the bile ducts and gallbladder.

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

In the study of urine, erythrocytes, leukocytes, salts are found.

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

Unlike acute appendicitis, acute cholecystitis occurs with repeated vomiting of bile, a characteristic irradiation of pain in the region of the right shoulder blade and shoulder, and the right supraclavicular region.

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

PERFORATIVE ULCER OF THE STOMACH AND 12-TYPE INTESTINE (mainly covered forms of perforation). May be misdiagnosed as acute cholecystitis. Therefore, it is necessary to carefully study the anamnesis of patients. For acute cholecystitis, in contrast to a perforated ulcer, the absence of an ulcerative history is characteristic, the presence of indications of previous attacks of cholelithiasis.

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

Covered perforations occur with an acute onset and a pronounced tension in the muscles of the anterior abdominal wall in the first hours after the onset of the disease; often there are local pains in the right iliac region due to leakage of the contents of the stomach and duodenum 12, which is not typical for acute cholecystitis. X-ray examination, endoscopy, laparoscopy.

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

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

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

Biliary tract dyskinesia proceeds with normal temperature, the condition of the patients is satisfactory, there is no tension in the muscles of the anterior abdominal wall and symptoms of peritoneal irritation. Analysis of blood and urine without changes.

Biliary 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 condition of the patients worsens. There is an increase in temperature, leukocytosis, tension in the muscles of the anterior abdominal wall and pain on palpation in the right hypochondrium.

RIGHT-SIDE PNEUMONIA.

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

The differential diagnosis between myocardial infarction and cholecystitis is not an easy task when, along with the symptoms of acute cholecystitis, there are symptoms of damage to the heart muscle and ECG data do not rule out a heart attack. Of great importance is ultrasound and diagnostic laparoscopy, which requires special anesthesia and strictly controlled pneumoperitoneum, so as not to complicate the work of the heart even more.

If a patient has cholecystitis complicated by jaundice, it is necessary to conduct 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 (prehepatic) jaundice occurs as a result of intensive breakdown of red blood cells and excessive production of indirect bilirubin. The reason is hemolytic anemia associated with hyperfunction of the spleen in primary and secondary hypersplenism. In this case, the liver is not able to pass a large amount of bilirubin through the liver cell (indirect bilirubin). The skin is lemon-yellow, there is no pruritus. There is pallor in combination with jaundice. The liver is not enlarged. Urine is dark in color, feces are intensely colored. There is anemia, reticulocytosis.

Parenchymal (hepatic) jaundice - viral hepatitis, cirrhosis of the liver, poisoning with some hepatotropic poisons (tetrachloroethane, arsenic, phosphorus compounds). Hepatocyte damage occurs, the ability of hepatic cells to bind free bilirubin and convert it into direct 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 are dull pains in the right hypochondrium. The liver is enlarged and compacted. The skin is saffron-yellow with a ruby tint. In the blood, the level of direct and indirect bilirubin, aminotransferases is increased, the concentration of prothrombin decreases. 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 intestine, then the feces will be acholic. With parenchymal jaundice, itching is small.

To clarify the diagnosis of ultrasound, laparoscopy.

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

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

The skin is green-yellow, sometimes yellow-gray. Persistent pruritus. Obstruction of the ducts leads to biliary hypertension, which adversely affects the hepatic parenchyma. With the addition of cholangitis, fever is observed. The patient's urine is dark in color, the feces are acholic. In the blood - an increase in the content of direct bilirubin. ultrasound. ChPH.

Complications of cholecystitis

CHOLEDOCHOLITHIASIS.

STENOSIS OF BDS.

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

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

11. Treatment of cholecystitis (scheme)

CONSERVATIVE. Hospitalization in the surgical department. Bed rest. Exclusion of enteral nutrition (mineral water). Cold on the stomach. Gastric lavage with cold water. infusion therapy. Antispasmodics. Analgesics. Antihistamines. If the pain is not relieved - 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 the gallbladder;

3) stasis in the vessels of the gallbladder;

4) bacteriocholia;

5) destruction of the bladder wall;

6) infiltrate;

7) local and diffuse peritonitis.

Acute cholecystitis

Complicated Uncomplicated Canned. treatment,

(biliary hypertension) (simple) examination

obturation cholecystitis With hypertension Elective surgery

ducts (CE, LCE, MCE)

Deblocking Dropsy Destructive Stenosis OBD Choledo-

gallbladder g. bladder cholecystitis lithiasis

Planned Operation Upgrade Group Urgent operation Jaundice Cholan-

(ChE) risk walkie-talkie (ChE,LHE,MHE) git

Preoperative Release of the Operation in urgent

bladder preparation in a row (ChE, choledocholi-

totomy, PSP, T-drainage,

RPHG, EPST, LHE, MHE

The process can develop in three directions:

1. Bubble release. In this case, treatment is continued until the acute phenomena disappear completely, then the patient is examined to identify stones, the condition of the gallbladder, etc.

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

3. Destructive cholecystitis. If conservative treatment is not successful, deblocking did not occur, and an infectious process develops in the off gallbladder, which is manifested by an increase in body temperature, leukocytosis, and the appearance of symptoms of peritoneal irritation, then 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 there is no deblocking of the bladder, then it is necessary to ascertain the presence of destructive cholecystitis in the patient.

Treatment of obstructive cholecystitis (conservative and surgical).

SURGICAL.

By time:

An emergency operation is performed immediately after the patient enters the hospital or after a vital short-term preparation, which takes no more than a few hours. The indication is peritonitis.

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

Late (scheduled) - 10-15 days and later after the subsidence of acute cholecystitis.

1. Preoperative preparation.

2. Pain relief.

3. Access. Cuts of Kocher, Fedorov, Kera, Rio Branco, Median laparotomy.