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Cholecystitises

Table of contents
Cholecystitises
Preliminary diagnosis
Final diagnosis
Treatment, prevention

Acute cholecystitis — the acute inflammatory disease of a gall bladder proceeding, as a rule, with suddenly developing disturbance of circulation of bile as a result of blockade of a gall bladder. Destructive processes in a bubble wall are quite often noted. At most of patients it is connected with cholelithiasis (ZhKB). Acute cholecystitis develops against a chronic inflammation of a gall bladder more often. Acute cholecystitis can be considered as acute complication of chronic diseases of a gall bladder, most often — ZhKB. Quite often for the patient it is vital that the doctor timely distinguished development of this complication and did not regard it as an exacerbation of chronic calculous cholecystitis.

Chronic acalculous cholecystitis — the inflammatory disease affecting walls of a gall bladder mainly in a neck zone, proceeding, as a rule, with bile circulation disturbance. Duration of an illness is more than 6 months.

Chronic calculous cholecystitis — the inflammatory disease affecting walls of a gall bladder, connected with existence of stones in it. Duration of a disease is more than 6 months.

Exacerbation of chronic calculous cholecystitis — the exacerbation of an inflammatory disease of a gall bladder connected with existence in it of stones, proceeding usually without acute disorder of a zhelchedinamika and always without destructive processes in a wall of a gall bladder.

At the ZhKB latent forms (kamnenositelstvo) the stones which are freely lying in a bubble gleam do not cause inflammatory changes of walls and disturbances of circulation of bile.

Epidemiology
Diseases of a gall bladder and zhelchevyvodyashchy ways — widespread pathology of internals. ZhKB suffer to 10% of adult population of the developed countries. The number of patients with diseases of zhelchevyvodyashchy ways at least twice exceeds number of the persons suffering from a peptic ulcer. In recent years incidence of acute cholecystitis increased in the country by 5 times. Cholecystectomias from 350 000 to 500 000 people are exposed annually, the lethality at the same time is close to 1,5%. Rather low lethality is reached partially due to rather early performance of the majority of operations in a planned order, out of the expressed exacerbation of cholecystitis.

The USA annually finds about 1 million new diseases of a cholelithiasis, from them almost at 80 000 (8%) stones in bilious channels reveal. For comparison we will note that in the same place in a year about 25 000 new diseases of a pancreas carcinoma, a half of which proceeds with jaundice, diagnose. Besides, reveal 7000 — 8000 new diseases of carcinomas of the bilious channels which are also proceeding with jaundice. At 80 — 85% of the patients suffering from ZhKB in the developed countries cholesteric stones are defined. They contain more than 60% of cholesterol. At other 20 — 15% of patients reveal pigmental stones. They develop against hemolitic and a sickemia, cirrhosis and enzymopathic hyperbilirubinemias more often.

Long time the question of allocation of acalculous cholecystitises remained not clear. Now the majority of controversial issues are resolved and this nosological form got the rights of nationality. Acalculous cholecystitises meet at young age, stone more often — on average and elderly, and every decade of life the frequency of stone cholecystitises increases.
In population kamnenositel meet, apparently, considerably more often than patients with the ZhKB active forms. If to sum up these literatures and own supervision, then in gastroenterological hospitals of a therapeutic profile patients with various diseases of a gall bladder and channels make from 6 to 30%. At these patients reveal in 60 — 70% stone cholecystitises, their complications and effects (including a postcholecystectomy syndrome), in 20 — 30% acalculous cholecystitises and in 5 — 10% functional and rare diseases of a gall bladder and channels. According to some information, in a gastroenterological hospital of ZhKB it is provided by the following clinical options: chronic calculous cholecystitises (i.e. the ZhKB active forms) — 65%, latent forms (kamnenositel) — 15%, a postcholecystectomy syndrome — 20%.

Etiology and pathogeny
Stones first of all and almost only develop in a gall bladder. Formation of stones in not changed (unimpaired) general bilious channel is observed very seldom.
In development of diseases of bilious ways and a bubble an important role is played by an overeating and a hypodynamia. Cholecystitises (especially stone) the people having obesity have more often. As the contributing factor serves excess consumption of meat and animal fats. At a vegetarian diet cholecystitises and ZhKB meet less often.

Stagnation of bile, change of its structure (diskholiya) and infectious and inflammatory processes in bilious channels and a bubble are the reasons of development of stones.

In the last decades ideas of products of bile as difficult secretory process in which crucial role is assigned to a hepatocyte were approved. Forming of defective bilious micelles in which the excess amount of cholesterol and the reduced content of phospholipids and bile acids is noted creates premises for forming of stones: bile becomes litogenny. By such way the most widespread stones — cholesteric are formed.

The opinion on iatrogenic diseases of a gall bladder and zhelchevyvodyashchy ways is expressed. A diet with high content of fat, the limited motive mode promote increase of a litogennost of bile. Vagisection (disturbance of normal emptying of a bubble), a resection of distal departments of a small bowel (disturbance of hepatoenteric circulation of bile acids), and also ligatures of the general bilious channel quite often are the factors promoting development of ZhKB.

Emergence of ZhKB can be promoted by also long drug intake (oral contraceptives, etc.).

More rare pigmental stones are usually formed owing to hemolysis or the broken exchange of bilious pigments, in particular at patients with hemolitic anemias, cirrhosis, enzymopathic hyperbilirubinemias, etc.

In many cases development of stone cholecystitis is preceded by the acalculous cholecystitis breaking normal emptying of a gall bladder.

In turn in development of acalculous cholecystitis a main role is played, apparently, by an infection. Usually the contagium comes to a gall bladder in the hematogenous and lymphogenous way, is more rare — ascending, i.e. from a duodenum. In particular, we observed at women the first symptoms of acalculous cholecystitis 3 — 6 months later after an acute adnexitis, and at persons of both sexes — 3 — 6 months later after an acute appendicitis, heavy food toxicoinfection, etc. As more rare reasons of development of acalculous cholecystitis serve injuries, sepsis, burns.

Serious significance is attached also to damage of a wall of a gall bladder by the pancreatic enzymes getting there owing to increase of pressure in an ampoule of the general bilious channel. Such forms of cholecystitises belong to enzymatic. We happened to observe only one case of a heavy course of such cholecystitis at the patient who had alcoholic cirrhosis and cystous pancreatitis. It developed the enzymatic cholecystitis which was complicated by multiple small perforation of a wall of a gall bladder. Purulent peritonitis was a proximate cause of death.

A certain significance is attached also to the circulatory disturbances in a bubble wall which are observed at persons with the expressed atherosclerotic damage of arteries of a bubble is more rare — at general diseases of vessels (a nodose periarteritis, etc.). At persons with cholecystitises of the traumatic nature the important role in a course of a disease belongs to also vascular component.

Rather seldom found acute acalculous cholecystitis is connected, as a rule, with disturbance of blood circulation in a wall of a bubble or with throwing in a gall bladder of pancreatic enzymes.

At patients with cholecystitis from walls of a gall bladder and directly from vesical bile sow escherichias, proteas, a streptococcus, staphylococcus, etc. As a rule, the pathogenic or opportunistic monoculture is sowed. Quite often bile from the inflamed bubble does not give growth of microbes at all. Meanwhile in the bile received from a duodenum at patients with acute and chronic cholecystitises, the bacterial flora is sowed almost always and has, as a rule, the combined character.

Acute and chronic cholecystitises etiologically differ from each other a little. Much in common at them and in a pathogeny. However there are also essential distinctions.

Acute cholecystitises are, as a rule, connected with an acute disorder of a zhelchedinamika. Now this element of a pathogeny is conventional. Even the term — "acute obturatsionny cholecystitis" appeared. Usually acute disorder of a zhelchedinamika in the form of blockade of a bubble occurs owing to a stone vklineniye in a neck of a gall bladder or a vesical channel.

Perhaps, the phenomenon, fundamental for acute cholecystitis — the expressed inflammatory (inflammatory and destructive) process of a wall of a bubble for the second time develops, the considerable thickening of its walls revealed at ultrasonography appears one of reflections of what.

At acute obstruction of a gall bladder acute cholecystitis not always develops. At short blockade of not infected bubble, as a rule, there is only an attack of cholecystis colic. At most of similar patients quickly enough the zhelchedinamika is recovered as the stone or returns to a bubble cavity, or prolabirut to the general bilious canal. At minority colic also quickly abates, however infringement of a stone and consequently, blockade of a bubble remain. Perhaps, in these cases incomplete disturbance of a zhelchedinamika in a zone of infringement of a stone takes place. At patients with a short attack of cholecystis colic of the expressed symptoms of acute cholecystitis does not develop and, in particular, is not registered, according to ultrasonography, a considerable thickening of walls of a bubble. Thus, it is necessary to distinguish the simple migration of a stone which is followed by cholecystis colic, and the complicated migration of a stone leading to acute cholecystitis.

Pathogenetic differences of an exacerbation of chronic kulkulezny cholecystitis consist first of all in lack of an acute disorder of a zhelchedinamika, slower development of inflammatory process and less intensive inflammatory process in a bubble wall that is confirmed, in particular, by its smaller thickening, smaller decrease in echogenicity and smaller loss of clearness of contours according to ultrasonography.

Features of a pathogeny of acalculous cholecystitis. Allocate 3 stages of development of this disease.
Stage of I. By means of X-ray contrast research and ultrasonography non-constant and insignificant disturbance of evacuation of bile (emptying of a bubble) is registered. In a form and the sizes the bubble does not differ from normal, however pathological changes in area of a neck of a bubble are expressed quite clearly.
Stage of II. Disturbances of evacuation of bile are expressed clearly and constantly. The bubble quite often has spherical shape, is a little increased in sizes. Changes in area of a neck of a bubble are also expressed clearly.
Stage of III. Continuous and considerable disturbance of evacuation of bile is noted. The area of its plane image is significantly increased. Changes in area of a neck are expressed clearly.

Classification
There are no conventional classifications including all main forms of diseases of a gall bladder and channels still. We give the most widespread classification.

 

Acute cholecystitis

Stone (frequent option)

Catarral
Purulent
Phlegmonous

Acalculous (very much
rare option)

 

 

Complications: paravesical abscess, perforation of a bubble, choledocholithiasis. subhepatic (obturatsionny) jaundice, bilnarny gepatopatnya, biliary pancreatitis, a purulent cholangitis (perhaps, with abscessing), septikopiyemnya, septic hepatitis

Chronic cholecystitis

Stone

Typiform
Atypical form
Kardialgicheskaya
Ezofagalgicheskaya
Intestinal

Acalculous
(mainly cervical)

 

 

Complications: a bubble edema, the stenosing duodenal papillitis, a choledocholithiasis, a biliariy hepatopathy, biliary pancreatitis

 

Approximate formulation of the diagnosis:
1. Cholelithiasis, acute calculous, catarral cholecystitis.
2. Cholelithiasis, an active form, an exacerbation of the chronic calculous cholecystitis complicated by a bubble edema.
3. Cholelithiasis, latent form (kamnenositelstvo), stones of a gall bladder.
4. Chronic acalculous mainly cervical cholecystitis in an aggravation stage with disturbance of evakuatorny function of a gall bladder.


 
"Functional disorders of a large intestine   Chronic hepatitises"