Acute cholecystitis

Acute cholecystitis - non-specific inflammation of the gallbladder. In 85-95% of gallbladder inflammation combined with stones. More than 60% of cases of acute cholecystitis of bile seeded microbial associations: most E. coli, Streptococcus, Salmonella, Clostridium, etc. In some cases, acute cholecystitis occurs when casting pancreatic enzymes into the gallbladder (cholecystitis enzyme)..

Perhaps getting an infection in the gall bladder in sepsis. Collagen, leading to narrowing and thrombosis of cystic artery can cause the development of gangrenous forms of acute cholecystitis. Finally, about 1% of cases the cause of acute cholecystitis is a tumor of its defeat, leading to obstruction of the cystic duct.

Thus, in the majority of cases of acute cholecystitis for necessary obstruction of cystic duct or gallbladder Hartmann in his pocket. Stagnation of bile with the rapid development of infection causes the typical clinical picture of the disease. Violation of the barrier function of the mucous membrane of the gall bladder may be due to necrosis as a result of a significant increase in the intraluminal pressure at the obstruction of the cystic duct; moreover, a direct pressure on the stone mucosa leads to ischemia, necrosis and ulceration. Violation of the barrier function of the mucosa leading to the rapid spread of inflammation of all layers of the bladder wall and the emergence of somatic pain.

Symptoms within. Most often it occurs in women older than 40 years. Early symptoms of acute cholecystitis are very diverse. While inflammation is limited to the mucosa, there is only visceral pain without clear localization, often exciting epigastric region and the navel. The pain is usually a dull character. Muscle tension and local tenderness is not defined. Changes in the blood during this period can be omitted.

Diagnosis is primarily based on history (the appearance of pain after errors in diet, unrest, bumpy ride), pain on palpation of the liver and the edge of the area of ​​the gall bladder. However, in case of total obstruction of the cystic duct and the rapid accession of infection pain is greatly enhanced, moves in the right upper quadrant, radiating to the supraclavicular region, interscapulum, lumbar region. Nausea, vomiting, sometimes repeated (especially in holetsistopankreatit). Skin can be ikterichnost (in 7-15% of acute cholecystitis combined with choledocholithiasis). Low-grade temperature, but it can quickly rise and reach 39 m. FROM.

On examination: patients often increased supply, tongue coated. Abdomen tense, lagging behind when breathing in the right upper quadrant, which can be palpated tight painful gall bladder or inflammatory infiltrate (depending on the duration of the disease). Local positive symptoms Ortner - Grekov, Murphy, Shchetkina - Blumberg.

The blood -leykotsitoz with a shift to the left, increasing the level of serum amylase and urine diastase (holetsistopankreatit), hyperbilirubinemia (choledocholithiasis, major duodenal papilla swelling, compression of the common bile duct infiltration, holetsistogopatit).

Substantial assistance in the diagnosis has an ultrasound examination of the gallbladder and biliary tract (90% efficiency). In typical cases, the diagnosis of acute cholecystitis is simple. The differential diagnosis is carried out with a perforated gastric ulcer and duodenal ulcer, acute appendicitis, acute pancreatitis, renal colic, myocardial infarction, basal-sided pneumonia, pleurisy, herpes zoster lesions with intercostal nerves.

Complications: diffuse peritonitis. Acute cholecystitis is one of the most common causes of peritonitis. Clinical picture: the typical onset of the disease, usually for 3-4 day marked a significant increase of pain, muscle tension throughout the abdominal wall, diffuse pain and positive symptoms of irritation of the peritoneum around the abdomen. Several different clinical picture with perforated cholecystitis: at the time of perforation of the gallbladder may be short-term pain relief (imaginary well-being), followed by increase of peritoneal signs and increased pain.

Subhepatic abscess occurs as a result of delimitation of the inflammatory process in destructive cholecystitis due to the greater omentum, hepatic angle of the colon and its mesentery. Duration of the disease is usually more than 5 days. Patients expressed pain in the right half of the abdomen, fever, and sometimes hectic nature. On examination, the tongue is coated, is behind the stomach while breathing in the right half, sometimes the eye is determined by education, partially displaces aspirated. On palpation -Voltage muscles and painful fixed infiltration of various sizes. When the overview X-ray examination of the abdominal and thoracic cavity detect colon paresis, limited mobility of the right dome of the diaphragm, possibly a slight accumulation of fluid in the sinus. Very rarely detect the liquid level in the cavity of the abscess. The diagnosis helps ultrasound of the liver and biliary tract.

Empyema of the gallbladder caused by obstruction of the cystic duct with the development of infection in the gall bladder while preserving the mucosal barrier function. Under the influence of conservative therapy the pain inherent in acute cholecystitis is reduced, but completely fails, worried feeling of heaviness in the right upper quadrant, slight fever, the blood may be a slight leukocytosis. The abdomen was soft, in the right upper quadrant palpable moderately painful gallbladder, agile, with clear contours. During surgery puncture the bubble of pus obtained without admixture of bile.

Treatment of acute cholecystitis. Emergency hospitalization in the surgical hospital. It shows the emergency operation If there is generalized peritonitis. Before the operation - premedication with antibiotics. Operation of choice is cholecystectomy with the audit of the biliary tract, sanitation and drainage of the abdominal cavity. Mortality in emergency surgical interventions reaches 25-30%, it is particularly high in septic shock.

In the absence of phenomena of peritonitis shown holding conservative therapy with a simultaneous examination of the patient (respiratory, cardiovascular, ultrasound to detect stones in the gall bladder). The complex consists of conservative therapy: locally - cold intravenous antispasmodic, detoxification therapy, broad-spectrum antibiotics. When confirming calculous cholecystitis character (ultrasound) and the absence of contraindications of the respiratory and circulatory suitable early (no later than 3 days from the onset) surgery: it is technically easier, it prevents the development of complications of acute cholecystitis, gives the minimum lethality. In severe comorbidity, especially in the elderly, for the adequate preparation of the patient for surgery can be used laparoscopic bladder puncture with aspiration and washing the contents of his oral antiseptics and antibiotics. After 7-10 days of carrying out an operation - cholecystectomy with the audit of the biliary tract.

Prevention of acute cholecystitis is timely surgical treatment of gallstone disease.