At chronic cholecystitis the gall bladder is usually surrounded with commissures, its wall is sclerosed, thickened, sometimes reaches 1 cm. Contents of a bubble can be serous, sometimes and purulent.
Outcome of chronic cholecystitis is the sclerosis of a bubble which shrivels, turning into a lump of cicatricial fabric, the cavity of a bubble disappears. In such cicatricial bubble stones, the mass of calcium and layers of cholesterol usually are found (cholesterosis). Sometimes the bubble containing stones is similar to the cut garnet fruit. Others (except existence of stones) there are no pathoanatomical differences between cholecystitis with stones and without stones.
Etiology and risk factors of cholecystitis
The infection can get gematogenno, limfogenno or from intestines. The main role in development of a disease is played by such microorganisms as E. Coli, streptococci, staphylococcus, proteas, etc., is more rare than a shigella, tifo-paratyphoid sticks, mushrooms. It is necessary to exclude a parasitic infection (an opisthorchosis, a clonorchosis, a lambliasis, a fascioliasis). Promote development of a disease: • stagnation of bile; • change of physical and chemical properties; • bile infection; • dysfunction of a gall bladder and dysfunction of a sphincter of Oddi. Carry injuries to risk factors of acalculous cholecystitis abdominal cavity, operative measures (at stomach operations, a duodenum), sepsis.
It is necessary to carry to key symptoms of chronic cholecystitis: the stupid, aching pains in the field of the right hypochondrium; dispepsichesky phenomena.
Clinical displays of chronic cholecystitis
It is possible to allocate the following syndromes: painful, dispepsichesky, cholestatic, intoksikatsionny, astenovegetativny.
The aching pains in the field of the right hypochondrium arise in 1 — 3 h after meal, especially fat more often. Pains amplify at the movement. Pains can irradiate in a right shoulder-blade. Are often combined with loss of appetite, with an eructation bitterness, heartburn, nausea, a meteorism. Sometimes, in the presence of stones, pains can gain sharp pristupoobrazny character — "bilious colic". The chair is characterized by alternation of locks and diarrheas, the meteorism, a flatulention is noted.
Attacks of pains at an exacerbation of chronic cholecystitis are followed by the vomiting which is not giving noticeable simplification (unlike a peptic ulcer), a leukocytosis and temperature increase.
The bezbolevy periods lasting from several weeks about several months are observed.
At acalculous cholecystitis the pain syndrome is usually moderately expressed. In most cases it is the long stupid, pulling, aching pains, is much more rare — kolikoobrazny. In general the clinical picture slightly differs from a clinical picture of calculous cholecystitis.
Treatment of patients in the period of an aggravation, chronic cholecystitis and a cholangitis
1. In the first days hunger is shown to patients. Further — when subsiding an aggravation, the diet corresponding to a table No. 5 is appointed. The milk and vegetable food with restriction of animal fat is recommended. Food has to be fractional, i.e. frequent and not plentiful. This principle of treatment is proved by cholagogue action of food. Meal is the best cholagogue means interfering stagnation of bile. Fluidifying of bile is provided with plentiful reception of liquid, not less than 1,5 l a day.
2. At a pain syndrome use of cholinolytics and myotropic spasmolysants is necessary: atropine, Drotaverinum (Nospanum), mebeverin (dyuspatalin). Atropine and Platyphyllinum are contraindicated at glaucoma, adenoma of a prostate and can be replaced with an Euphyllinum. Also use non-narcotic analgesics (analginum, baralgiya).
3. Before receiving results of crops of bile it is necessary to appoint antibiotics of a broad spectrum of activity (amikacin, levomycetinum, ampicillin, tsefoperazon) or ciprofloxacin. 2 times a day, metronidazole on 500 mg 3 times a day, furasolidone on 100 mg 4 times a day have good effect Biseptolum in a dose of 960 mg. For example: tseftriakson 2 g intravenously in combination with amikacin of 0,5 g 3 times a day and metronidazole on 0,5 g 3 times a day.
4. Perhaps, use of the fermental drugs containing bile (festal, digestal). Sick acalculous cholecystitis, besides, showed cholagogue drugs — choleretics (Allocholum, holepzy, Flaminum, Cholagolum) on 1 — 2 tablets a day, within 10 — 20 days. 3 times a day which exerts the weakening impact on Oddi's sphincter use gimekromon (odeston) 200 — 400 mg. More rare than a holekinetika (sorbite, xylitol). Phytotherapy use (corn stigmas, peppermint etc.) is possible.
Methods of dissolution bilious, stones
1. Therapeutic dissolution of stones. Indications to this method the following: the cholesteric stones which are not exceeding in a longitudinal axis 2 cm, the kept function of a gall bladder. Use the following drugs. Ursodezoksikholevy acid (ursofalk, ursosan): 8 — 12 mg/kg of body weight once within a day, within 4 months. Dissolution of stones is observed approximately in 50% of cases. Further — a maintenance therapy of 4 — 6 mg/kg of body weight a day during 2 flyings. By-effects — diarrhea. Chenodesoxycholic acid (henosan): 750 mg/days. Recurrence after treatment makes more than 10%. Drugs are used only at X-ray negative stones.
2. Shock and wave lithotripsy (crushing of stones). It is applied at the size of cholesteric stones to 3 cm and at normal function of a bubble. Among side effects 35% of patients have a tranzitorny hepatic colic, at 2% — pancreatitis. After a shock and wave lithotripsy appoint ursodezoksikholevy acid in a maintenance dose.