CHOLELITHIASIS

Gall -bladder disease is a disease caused by the presence of gallstones in the gallbladder and bile ducts. The frequency of their formation increases with age, in men gallstones occur 3 times less frequently than in women.

In the formation of gallstones, factors such as heredity (the presence of cholelithiasis in relatives), unbalanced nutrition with a predominance in the diet of coarse-dispersed animal fats (pork, sheep, beef) to the detriment of plant matter are important; Neuroendocrine disorders, in particular, associated with dysfunction of the endocrine system of an age-related nature and hypothyroidism of the thyroid gland; Diabetes mellitus , disorders of fat metabolism with an increase in body weight, damage to the hepatic parenchyma of toxic and infectious remez; Hypodynamia and bile stasis. Also gallstones are formed under the influence of the inflammatory process in the gallbladder.

Gallstones - dense formations, the number of which can be from one to several thousand, the value - up to several centimeters in diameter, weight - up to 30 grams or more. In the gallbladder, stones of a rounded shape are more common, in the common bile duct - ellipsoidal or oblong, in the intrahepatic ducts - branched. Depending on the composition, cholesterol, pigment-cholesterol, cholesterol-pigment-lime, pigment and calcareous stones are distinguished; On the cut they have a pigment nucleus and a layered structure.

Clinical picture . The disease can be asymptomatic (latent form). Migration of gallstones and blockage of the bladder duct by them is manifested by a sudden severe pain attack. The provoking factors are the use of fatty or spicy food, often negative emotions, sharp physical tension, work in an inclined position. Sometimes a painful attack occurs during menstruation, after childbirth. Pain often occurs at night, localized in the right hypochondrium and epigastric region, spread to the entire upper half of the abdomen and irradiate into the right scapula, the right shoulder, neck, are permanent, gradually growing. The intensity of the pain is so great that the patients groan, rush in bed, can not find a position that facilitates their condition. Often the attack is accompanied by nausea, indomitable vomiting. Possible icteric sclera and slight darkening of urine. The abdomen is swollen, with palpation sharply painful in the right hypochondrium. The anterior abdominal wall is strained, especially in the projection of the gallbladder (in the elderly, muscle tension may be absent). Duration of acute attack from several minutes to 6 hours.

If the pain syndrome is not accompanied by the phenomena of acute cholecystitis and is quickly stopped after the use of antispasmodics and analgesics, one speaks of hepatic (or biliary) colic caused by temporary blockage of the gallbladder or common bile duct with a stone and a spasm of their smooth musculature. After stopping such a colic, patients feel healthy until the next pain attack, which can occur after several days, weeks, months or years. When the bladder duct obstructs with a stone, inflammation of the gallbladder (cholecystitis) can develop as a result of mechanical irritation, exposure to chemical factors, and infection. In the case of acute cholecystitis, there is a long duration of a pain attack, muscle tension in the right upper quadrant, an increase in body temperature , and leukocytosis . Chronic cholecystitis is manifested by dull pain in the right upper quadrant after a bias in the diet or dyspepsia.

Feeling of heaviness in the epigastric region, heartburn , flatulence , nausea , diarrhea occur after eating and are permanent or periodic, often associated with abundant food, especially the reception of fatty foods or fried foods. At palpation pain can be noted in certain painful points.

Complications . As a result of prolonged pressure by the stone on the mucous membrane of the bladder, ulcers and bedsores may appear in it, diverticular-like protrusions, internal and external bile fistulas, perforations with development of subhepatic or subdiaphragmatic abscesses, bile peritonitis. Prolonged blockage of the cystic duct can lead to the development of edema of the gallbladder or its empyema. When the outlet of the common bile duct is obstructed by a stone, mechanical (subhepatic) jaundice occurs. Prolonged finding of the stone in the bile duct and attachment of the infection lead to the development of cholangitis.

The diagnosis is confirmed by ultrasound examination, which makes it possible to detect stones in the gall bladder 0.5 cm in size. Diagnostic value also includes an overview radiography of the gallbladder area, cholecystography, cholangiography, choleography. A greater accuracy of recognition of concrements in the gallbladder containing calcium salts is provided by computer X-ray tomography.

Treatment . In chronic painful form of cholelithiasis, diet is the basis of treatment: diet No. 5, exclusion of spices, smoked foods, animal fats, fractional food (5 to 6 times a day) without overeating, mineral waters. Pain shows heat (warmer, warming compress) on the gallbladder, spasmolytic agents (atropine in droplets, no-shpa , papaverine, etc.). Physiotherapeutic methods (UHF currents, diathermy, inductothermy), mud therapy and mineral baths, sanatorium treatment are used only in the absence of signs of exacerbation of the disease. The appointment of cholagogue preparations is undesirable, because the migration of stones caused by them can lead to blockage of the bile duct and provoke an attack of hepatic colic, the development of other complications. Specific therapy for cholesterol (roentgenogenic) gallstones includes the treatment of chenodeoxycholic (chenophalcus) and ursodeoxycholic acid (ursophalk) with acids. Long-term intake of these drugs inside allows in a number of cases to achieve drug dissolution of stones due to a decrease in the secretion of cholesterol in bile.

In case of acute attack or exacerbation of cholelithiasis, the patient should be hospitalized in the surgical department, where the question of indications for an emergency operation is first of all decided. In the absence of symptoms of peritonitis, measures are taken to relieve pain and eliminate inflammatory changes in the gallbladder and bile ducts. For this purpose, subcutaneously or intramuscularly injected papaverine, but-shpu, platifillin, as well as baralgin and other analgesics; Conduct antibacterial and detoxification therapy. Morphine and omnipon are contraindicated because they cause a spasm of the sphincter of Oddi.

Under the influence of the treatment, hepatic colic usually quickly (after several hours) is stopped without any consequences. In chronic cholecystitis with recurring severe attacks or exacerbations, surgical treatment should be recommended in a state of complete remission (after 4-5 months), which is most safe for the patient.

Laparoscopic manipulations and operations on the gallbladder have been developed and are successfully used: puncture and decompression of the bladder with evacuation of purulent contents, washing of its cavity and introduction of antibiotics, microcholecystostomy, laparoscopic cholecystolithotomy. Thanks to this, it is possible to stop an acute attack and after a proper preparation to carry out a radical operation in the most favorable for the sick period. For the same purpose, papillotomy is used - dissection of the falcon nipple (large papilla of the duodenum) and removal of stones from the common bile duct by means of a special fibroduodenoscope. In some cases, palliative surgery is possible - cholecystotomy and cholecystolithotomy, cholecystotomy. A promising direction is ultrasonic crushing of stones - lithotripsy.