Phes clinical guidelines. Postcholecystectomy syndrome: causes, symptoms, diagnosis and treatment

Postcholecystectomy syndrome is a disease that includes a whole complex of various clinical manifestations that arose during an operation, the essence of which was the excision of the gallbladder or the extraction of stones from the bile ducts.

The trigger mechanism is a violation of the circulation of bile after removal of the gallbladder. Also, clinicians identify a number of other reasons, among which the inadequate implementation of cholecystectomy is not the last.

The clinical picture of this disorder is nonspecific and is expressed in the occurrence of recurring pain in the abdomen and the area under the right ribs. In addition, there is a disorder of the stool, weight loss and weakness of the body.

Diagnosis is aimed at the implementation of a wide range of laboratory and instrumental examinations, which must necessarily be preceded by a study of the medical history to establish the fact of a previous cholecystectomy.

Treatment is completely dictated by the severity of the course of the disease, which is why it can be both conservative and surgical.

The international classification of diseases of the tenth revision allocates a separate code for such a pathology. The code for postcholecystectomy syndrome according to ICD-10 is K91.5.

Etiology

The final pathogenesis of the development of such an ailment remains not fully understood, however, it is believed that the main cause is the incorrect process of bile circulation, which occurs against the background of surgical removal of the gallbladder or stones localized in the bile ducts. Such a pathology is diagnosed in 10-30% of situations after a previous cholecystectomy.

Among the predisposing factors that cause postcholecystectomy syndrome, it is customary to single out:

inadequate preoperative preparation, making it impossible to adequately perform cholecystectomy;
insufficient diagnosis;
unskilled operation - this should include improper introduction of drains, injury to the vessels of the gallbladder or biliary tract, as well as partial removal of calculi;
decrease in the volume of produced bile and bile acids;
chronic diseases of the digestive system;
the course of diseases that negatively affect the violation of the outflow of bile into the intestine;
microbial damage to the duodenum and other organs of the gastrointestinal tract;
partial stenosis or complete obstruction of the duodenal papilla of Vater.

In addition, pathologies formed both before and after the operation can affect the occurrence of PCES. Such diseases should include:

dyskinesia of the sphincter of Oddi and;
or ;
adhesive process localized under the liver;
diverticula and fistulas;
or ;
papillostenosis;
formation of a cyst in the common bile duct;
bile duct infection.

It is worth noting that in about 5% of patients, the causes of the appearance of such a disease are not possible to find out.

Classification

The term "postcholecystectomy syndrome" includes a number of pathological conditions, namely:

violation of the normal functioning of the sphincter of Oddi;
the true formation of stones in the biliary tract, damaged during cholecystectomy;
false recurrence of stones or their incomplete removal;
stenosing course of the duodenal, i.e. narrowing of the lumen of the major duodenal papilla;
active adhesive process with localization in the subhepatic space;
chronic course of cholepancreatitis is a simultaneous inflammatory lesion of the biliary tract and pancreas;
gastroduodenal ulcers or other defects that violate the integrity of the gastric mucosa or duodenum, having different depths;
cicatricial narrowing of the common bile duct;
long stump syndrome, i.e. the part of the cystic duct left after surgery;
persistent pericholedochal.

Symptoms

Despite the fact that postcholecystectomy syndrome has a large number of clinical manifestations, they are all nonspecific, which is why they cannot accurately indicate the course of this particular disease, which also complicates the process of establishing the correct diagnosis.

Since pain is considered the main symptom of the disease, it is customary for clinicians to divide it into several types:

bilious - the focus is the upper abdomen or the area under the right ribs. Often there is irradiation of pain in the back area and in the right shoulder blade;
pancreatic - localized closer to the left hypochondrium and spreads to the back. In addition, there is a decrease in the intensity of the symptom when the torso is tilted forward;
combined - often has a shingles character.

Regardless of the etiological factor, the symptomatic picture of such a pathology includes:

sudden onset of severe attacks - in the vast majority of situations last about 20 minutes and can be repeated for several months. Often, such a pain syndrome appears after eating food at night;
disorder of the act of defecation, which is expressed in profuse diarrhea - urges can reach 15 times a day, while feces have a watery consistency and a fetid odor;
increased gas formation;
an increase in the size of the anterior wall of the abdominal cavity;
the appearance of a characteristic rumbling;
the formation of cracks in the corners of the oral cavity;
weight loss - can be mild (from 5 to 8 kilograms), moderate (from 8 to 10 kilograms) and severe (from 10 kilograms up to extreme exhaustion);
weakness and fatigue;
constant sleepiness;
decrease in working capacity;
bouts of nausea ending in vomiting;
fever and chills;
tension and anxiety;
bitter taste in the mouth;
release of a large amount of sweat;
development ;
and belching;
yellowness of the sclera, mucous membranes and skin - such a symptom of postcholecystectomy syndrome develops quite rarely.

In cases of such a disease in children, the symptoms will fully correspond to the above.

Diagnostics

The appointment and study of laboratory and instrumental examinations, as well as the implementation of primary diagnostic measures, is carried out by a gastroenterologist. Comprehensive diagnosis begins with the clinician performing the following manipulations:

study of the medical history - to search for chronic ailments of the gastrointestinal tract or liver, which increase the chances of developing PCES;
analysis of life and family history;
a thorough physical examination, involving palpation and percussion of the anterior wall of the abdominal cavity, assessment of the condition of the patient's appearance and skin, as well as measurement of temperature indicators;
a detailed survey of the patient - to compile a complete symptomatic picture and establish the severity of clinical signs.

Laboratory diagnostics consists in the implementation of:

blood biochemistry;
general clinical analysis of blood and urine;
microscopic studies of feces;
analysis of faeces for eggs of worms.

The following instrumental procedures have the greatest diagnostic value:

radiography and ultrasonography;
MSCT of the peritoneum;
CT and MRI;
scintigraphy and gastroscopy;
FGDS and ERCP;
manometry and sphincterotomy;

Treatment

As mentioned above, the therapy of postcholecystectomy syndrome can be both conservative and surgical in nature.

Inoperable treatment of the disease is primarily aimed at the use of such medicines:

nitroglycerin preparations;
antispasmodics and painkillers;
antacids and enzymes;
antibacterial substances;
vitamin complexes;
immunomodulators;
adaptogens.

The main place in the elimination of the disease is given to the diet for postcholecystectomy syndrome, which has several rules:

eating small meals;
the number of meals per day can reach 7 times;
enrichment of the menu with dietary fiber, vitamins and micronutrients;
a complete rejection of fried and spicy foods, muffins and confectionery, cooking oil and lard, fatty meats, poultry and fish, semi-finished products and smoked meats, marinades and strong coffee, ice cream and other sweets, as well as alcoholic beverages;
eating a large number of dietary varieties of meat and fish, legumes and crumbly cereals, greens and non-acidic berries, vegetables and fruits, low-fat dairy products and wheat bread, weak tea and compotes;
cooking dishes in the most gentle ways - boiling and steaming, stewing and baking, but without the use of fat and without getting a golden crust;
abundant drinking regime;
control over the temperature of food - it should not be too hot or too cold;
minimizing the use of salt.

The sparing menu No. 5 is taken as the basis of diet therapy.

The use of physiotherapeutic procedures in the process of PCES therapy is not excluded, including:

After consulting with the attending physician, the use of non-traditional methods of therapy is allowed. Folk remedies involve the preparation of healing decoctions based on:

calendula and cudweed;
valerian and hop cones;
centaury and calamus root;
corn stigmas and celandine;
bird mountaineer and chamomile flowers;
hypericum and elecampane roots.

Surgical treatment of postcholecystectomy syndrome consists in the excision of newly formed or incompletely removed stones or scars during the previous operation, as well as in draining and restoring the patency of the bile ducts.

Possible Complications

Ignoring clinical signs or unwillingness to seek repeated medical care is fraught with the development of:

bacterial overgrowth syndrome;
exhaustion or;
skeletal deformities;
in men;
violation of the cycle of menstruation in women.

In addition, the possibility of such postoperative complications is not excluded:

divergence of surgical sutures;
wound infection;
abscess formation;

Prevention and prognosis

The main preventive measures that prevent the development of such a disease are considered to be:

careful diagnosis and preparation of the patient before cholecystectomy;
timely detection and elimination of gastroenterological diseases or liver pathologies that can provoke PCES;
proper and balanced nutrition;
complete rejection of bad habits;
regular complete preventive examination in a medical institution.

The prognosis of postcholecystectomy syndrome is directly dictated by the etiological factor that provoked the development of such a symptom complex. However, in the vast majority of situations, a favorable outcome is observed, and the development of complications is observed in approximately every 5 patients.

Let's talk about the symptoms and treatment of postcholecystectomy syndrome. This pathological condition can develop after the removal of the gallbladder. The clinical picture is manifested by pain and other unpleasant symptoms.

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The site provides background information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious physician. All drugs have contraindications. You need to consult a specialist, as well as a detailed study of the instructions! .

Symptoms and treatment

The postcholecystectomy syndrome does not include the consequences of operations that were performed with violations, postoperative pancreatitis or cholangitis.

Patients with stones in the bile ducts and when they are squeezed are not included in this group. Approximately 15% of patients develop the disease.

In older people, this figure reaches about 30%. Women get sick 2 times more often than men.

Characteristic symptoms

Symptoms of the development of the syndrome are as follows:

Pain attacks. According to the difference, the intensities will be both strongly pronounced and subsiding. Dull or cutting pains develop in almost 70% of patients.
Dyspeptic syndrome is determined by nausea, vomiting, heartburn, diarrhea, and bloating. Belching is observed with a taste of bitterness.
Malabsorption syndrome develops due to impaired secretory function. Food is poorly absorbed in the duodenum.
The body weight decreases, and at a pace that is not characteristic of the characteristics of the patient's body.
Hypovitaminosis is the result of poor digestibility of healthy foods and vitamins.
An increase in temperature is characteristic in moments of acute conditions.
Jaundice is a sign of liver damage and a violation of its functioning.

Features of the treatment of PCES

The principles of treatment should be based on the manifestation of the symptomatic picture.

The syndrome develops due to disturbances in the activity of the digestive organs.

All medical therapy is selected only in a strict individual order. The gastroenterologist prescribes medications that support the treatment of the underlying pathology.

Mebeverin or Drotaverin help to stop pain attacks. In surgical treatment, methods are determined by a medical consultation.

Causes of the disease

The operation provokes a certain restructuring in the work of the biliary system. The main risk in the development of the syndrome concerns people who have long suffered from gallstone disease.

As a result, various pathologies of other organs develop in the body. These include gastritis, hepatitis, pancreatitis, duodenitis.

If the patient, before the operation, was examined correctly and the cholecystectomy itself was carried out technically flawlessly, the syndrome does not occur in 95% of patients.

Postcholecystectomy syndrome occurs due to:

Infectious processes in the biliary tract;
Chronic pancreatitis - secondary;
With adhesions in the area below the liver, provoking a deterioration in the work of the common bile duct;
Granulomas or neurinomas in the area of the postoperative suture;
New stones in the bile ducts;
Incomplete removal of the gallbladder;
Injuries in the region of the bladder and ducts as a result of surgical procedures.

Pathological disorders in the circulation of bile directly depend on the gallbladder.

If it is removed, then there is a failure in the reservoir function and deterioration in general well-being is possible.

Not always experts can accurately determine the causes of the development of this syndrome. They are diverse, and not all of them have been studied to the end.

In addition to the reasons described, it is impossible to establish the real one. The syndrome can occur both immediately after the operation, and after many years.

Classification according to Galperin

Damage to the bile ducts are early and late. The early ones are also called fresh, obtained during the operation itself to remove the gallbladder. Late ones are formed as a result of subsequent interventions.

Damage to the ducts, unnoticed immediately after surgery, provokes health problems.

The syndrome can manifest itself in any period of recovery.

The famous surgeon E.I. Galperin in 2004 proposed a classification of bile duct injuries, which are one of the main causes of postcholecystectomy syndrome.

The first classification is determined by the complexity of the damage and the nature of the outflow of bile:

Type A develops when bile contents leak from the duct or hepatic branches.
Type B is characterized by significant damage to the ducts, with increased secretion of bile.
Type C is observed in the case of pathological obstruction of the bile or hepatic ducts, if they have been clipped or ligated.
Type D occurs when the bile ducts are completely divided.
Type E is the most severe type, in which bile contents leak out or into the abdominal cavity, peritonitis develops.

The second depends on the time at which the damage was detected:

Damage during the operation itself;
Injuries that were recognized in the postoperative period.

This classification is important for a thorough diagnosis and identification of methods of surgical treatment of postcholecystectomy syndrome.

Clinical and ultrasound signs

When diagnosing the syndrome, it is necessary to analyze the history of the disease and the patient's complaints. How long does the symptomatic picture last, at what period after the operation did the symptoms occur.

The consultation of doctors reveals the complexity and duration of previous surgical interventions.

It matters what degree of development of gallstone disease was before the removal of the gallbladder to determine the main methods of treatment.

It is important for specialists to find out about the hereditary predisposition to diseases of the gastrointestinal tract.

Laboratory examination includes the following list:

A clinical blood test is needed to determine the presence of inflammatory lesions, to detect the level of leukocytes and possible anemia.
A biochemical blood test is performed to monitor the level of digestive enzymes, which may indicate abnormalities in the functioning of the liver, pancreas, or dysfunction of the sphincter of Oddi.
General urinalysis to prevent complications in the genitourinary system.
Coprogram and analysis of feces for eggworm.

Ultrasound of the abdominal cavity is necessary for a thorough study of the condition of the bile ducts, liver, and intestines. The method allows to detect stagnation of bile in the ducts and the presence of their deformation.

Retrograde cholecystopancreatography is indicated for suspected presence of stones in the bile ducts, their simultaneous removal is possible. Computed tomography helps to identify various lesions and the formation of tumors of various localization.

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Differential diagnosis of pathology

Differential diagnosis is required to make an accurate and correct diagnosis. Through this method of research, it is possible to distinguish a disease from another with an accuracy of 100 percent.

A similar symptomatic picture of the course of the disease may indicate different diseases that require different treatment.

These differences are sometimes difficult to determine and require a detailed study of the entire history.

Differential diagnosis consists of 3 stages:

At the first stage, it is important to collect all these about the disease, the study of the anamnesis and the causes that provoke development, a necessary condition for the competent choice of diagnostic methods. The causes of some diseases will be the same. Similar to the syndrome, other problems with the digestive tract can develop.
At the second stage, it is necessary to examine the patient and identify the symptoms of the disease. The stage is of paramount importance, especially when providing first aid. The lack of laboratory and instrumental studies makes it difficult to make a diagnosis, and doctors must provide first aid.
At the third stage, this syndrome is studied in the laboratory and using other methods. The final diagnosis is established.

In medicine, there are computer programs that facilitate the work of doctors. They allow for differential diagnosis in whole or in part.

Doctors advise in the treatment of the syndrome to rely on the elimination of the causes that cause pain. Functional or structural disorders in the work of the gastrointestinal tract, liver or biliary tract often provoke paroxysmal pain.

To eliminate them, antispasmodic drugs are shown:

Drotaverine;
Mebeverine.

Enzyme deficiency is the cause of digestive problems, and causes pain.

Then the use of enzyme drugs is indicated:

Creon;
Festal;
Panzinorm forte.

As a result of the operation, the intestinal biocenosis is disturbed.

There is a need to restore the intestinal microflora with the help of antibacterial drugs:

doxycycline;
Furazolidone;
Intetrix.

Course therapy with these drugs is required for 7 days.

Then treatment is necessary with agents that activate the bacterial level:

Bifidumbacterin;
Linex.

Drug therapy is carried out taking into account the underlying pathology that causes the syndrome.

Indications for the use of any drugs are possible only on the basis of the recommendations of a gastroenterologist. The principles of drug treatment can be replaced by surgical procedures.

Characteristic signs of exacerbation

After removal of the gallbladder in the body, the process of stone formation does not stop. Especially if the earlier provoking factors were serious pathologies of the liver and pancreas.

Exacerbations of postcholecystectomy syndrome can occur against the background of non-compliance with the diet. Overeating and fatty foods are dangerous.

The patient's food system cannot cope with the digestion of heavy foods. An exacerbation develops with diarrhea, fever, deterioration in general well-being.

The most dangerous symptom is a pain attack. It can come on suddenly, and is distinguished by a strong, often increasing localization almost throughout the abdomen.

Improper intake of medications, ignoring the recommendations of doctors, the use of folk remedies also cause an exacerbation. Severe course is characterized by difficulty in diagnosis and treatment.

Another cause of exacerbation sometimes becomes blockage of the ducts with new stones.

The pain attack factor develops suddenly and strongly. Painkillers don't help.
The patient sweats, dizziness develops, fainting occurs. Urgent hospitalization required.

Urgent diagnosis is important already in the first hours after an exacerbation. Treatment will include surgery.

Features of nutrition and diet

A necessary condition for the treatment of the disease is the observance of a balanced diet. To improve the functioning of the digestive system, nutrition is shown according to the principle of diet No. 5.

Its main features are to fulfill the requirements:

The optimal diet is in fractional parts, at least 6 times a day;
Hot and cold dishes are contraindicated;
Mandatory inclusion of products containing fiber, pectin, lipotropic substances;
Fluid intake of at least 2 liters per day;
Fats and proteins should be about 100 g;
Carbohydrates about 450 g;
It is forbidden to eat fried, fatty and smoked foods;
Dishes shown for consumption are: vegetable and cereal soups, lean meats in boiled or baked form;
Green vegetables, muffins, sweet foods, fatty dairy products, legumes and mushrooms are not recommended.

Pay attention to sufficient intake of vitamins, especially groups A, K, E, D and folic acid. Be sure to increase the intake of iron supplements.

Doctors advise to reduce body weight slowly. Any physical and emotional stress is contraindicated.

The need for surgical treatment

Conservative treatment will be ineffective if large stones form in the ducts. Then surgery is scheduled. This method is also shown with rapid weight loss, severe pain attacks, combined with vomiting.

The most sparing method is endoscopic papillosphincterotomy.

Through surgical methods, the bile ducts are restored and drained. Diagnostic operations are prescribed less often when the already mentioned methods to identify the problem did not help.

Surgical operations are prescribed for the development of scars in previously operated areas. Surgical treatment of the syndrome is accompanied by various complications.

Poor-quality seams that have diverged along the edges of the wound provoke the spread of bile throughout the body. They need to be reapplied. Infection in the surgical wound will cause a purulent lesion.

All preventive measures should include a careful examination of the patient in the first days after surgical treatment. It is important to avoid inflammatory processes in the pancreas, stomach and biliary tract.

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Diseases of the hepatobiliary system, which is responsible for the function of digestion and the excretion of metabolic products, are amenable to conservative treatment. Only in rare cases, with the formation of stones in the gallbladder that block the excretory ducts, they resort to surgical intervention. Postcholecystectomy syndrome (PCS) is a condition in which, after suppression, a violation of the motor activity of the annular muscle and duodenum (duodenum) is manifested. The pathological process is accompanied by pain and dyspepsia (digestive dysfunction).

Causes of postcholecystectomy syndrome

Pathology develops some time after cholecystectomy (in about 15% of cases). Against the background of removal of the organ, a violation of circulation in the biliary region develops. The gallbladder is the storage and supplier of secretions to the intestines. The result of insufficient supply of the digestive system is its dysfunction. The patient's state of health worsens, the preoperative symptoms based on the pain syndrome return. A number of factors can provoke PHES:

Diagnostic measures that were not carried out in full, affecting the quality of surgical intervention.
Damage to the vessels of the excretory tract that occurred during cholecystectomy, inadequate installation of drains.
Insufficient production of bile acids by the liver.
The cause of the anomaly is often chronic diseases of the digestive tract, which prevent the export of secretions to the duodenum.
Vasoconstriction in the major duodenal papilla or microbial destruction of the microflora.

One of the causes of PCES is a fragment of a dense formation (stone) left during the operation in the bile ducts.

Pathologies in history can serve as a trigger for the development of the syndrome:

inflammation of the intestinal mucosa (duodenitis) or pancreas (pancreatitis);
insufficient food advancement (dyskinesia), sphincter of Oddi dysfunction, gastroesophageal reflux pathology;
protrusion of the wall of the duodenum, the presence of a fistula (fistula), ulcerative lesions;
the formation of adhesions in the subhepatic area, cysts in the duct, hernia of the diaphragm;
irritable bowel syndrome, dysbacteriosis, papillostenosis;
hepatitis, liver fibrosis.

Poor condition after cholecystectomy can be influenced by one or more reasons. In 3% of cases, the pathogenesis cannot be determined. The manifestation of the anomaly occurs in adult patients. Gallstone disease requiring surgery in a child is an extremely rare phenomenon. The development of PCES at an early age is recorded in isolated cases.

Classification and main symptoms

The clinical picture of the pathology depends on the causes, the postcholecystectomy syndrome is classified into three types:

The first group includes the consequences of a surgical intervention on the organs of the hepatobiliary system, which was undertaken after an incorrect diagnosis. As a result of the error, the patient's state of health did not improve, symptoms of PCES appeared.
The second type is an incorrectly performed cholecystectomy, which damaged the bile duct (choledoch) or, when the organ was removed, an unacceptably long fragment remained. Possible appearance of a fistula on the seam or localization of the inflammatory process in the pancreas.
The third group, the most common, is dysfunction of the digestive tract, directly spasm of the sphincter that regulates the outflow of bile into the duodenum.

The main symptom of the syndrome is pain attacks lasting 15–25 minutes for two months or longer. They are localized in the upper part of the peritoneum, extending to the hypochondrium and back on the right side in case of disruption of the choledochus and the annular muscle. If the function of the pancreatic sphincter is affected, the pain radiates to the left side or is girdle in nature, subsiding when bending over. Unpleasant sensations can appear immediately after eating, start abruptly during sleep at night, along with vomiting and nausea.

Postcholecystectomy syndrome is also accompanied by secondary symptoms:

Diarrhea with frequent liquid bowel movements, with a sharp specific odor. Steatorrhea, characterized by oily, glossy stools.
Dyspepsia against the background of the growth of pathogenic bacteria in the intestinal microflora.
Excessive gas formation, bloating of the abdominal cavity.
Hypovitaminosis due to poor absorption of duodenum.
Violation of the epidermis in the corners of the mouth in the form of cracks.
Weakness, fatigue.

An accompanying symptom is a loss of body weight of 5–10 kilograms, up to exhaustion.

Diagnostics

The clinical picture of the abnormal condition after removal of the gallbladder does not have a specific symptomatology characteristic of the disease. Therefore, it is necessary to diagnose postcholecystectomy syndrome taking into account an integrated approach. Activities are aimed at finding out the cause for a full-fledged therapy.

To determine the conditions underlying the development of pathology, a laboratory blood test is prescribed, the results confirm or exclude the presence of an inflammatory process. Instrumental research is aimed at identifying dysfunction of internal organs that affect the functioning of the biliary system. Diagnosis is based on the application:

X-ray of the stomach with the use of a special substance to detect ulcers, spasms, neoplasms, oncological tumors.
MSCT (spiral computed tomography), which allows to determine the state of the vessels and digestive organs, the fact of inflammation of the pancreas.
MRI (magnetic resonance imaging) of the liver.
Ultrasound (ultrasound) of the peritoneum to detect the remnants of stones that block the ducts.
X-ray of the lungs, perhaps the cause of pain is the presence of abnormal processes in the organ.
Fibrogastroduodenoscopy of the duodenum.
Scintigraphy, which allows to identify a violation of the supply of bile, the procedure is carried out using a special marker that shows the place of stagnation of the secret.
Manometry of the common duct and sphincter.
ECG (electrocardiogram) of the heart muscle.

An obligatory method for making a diagnosis and the most informative one is endoscopic retrograde cholangiopancreatography (ERCP), which allows determining the condition of the bile ducts, the rate of secretion production, and the location of stones.

Treatment

The elimination of pathology is carried out by conservative therapy, if it is based on a violation of the internal organs. Repeated surgical intervention is indicated when fragments of stones or divergence of the edges of the surgical suture of the biliary system are found. To normalize the condition of patients with postcholecystectomy syndrome, treatment with alternative medicine recipes is recommended.

Preparations

Drug therapy is carried out by the appointment:

enzymes: Panzinorm, Pancreatin, Creon;
probiotics: Enterol, Laktovit, Duyufalak;
calcium channel blocker "Spasmomen";
hepatoprotectors: Galstena, Hofitol, Gepabene;
anti-inflammatory drugs: Ibuprofen, Paracetamol, Aceclofenac;
anticholinergics: "Platifillin", "Spazmobru", "Atropine";
antibacterial drugs: "Biseptol", "Erythromycin", "Ceftriaxone";
antispasmodics: Gimekromon, Mebeverin, Drotaverin;
mineral and vitamin complex in the composition, which contains iron.

The tactics of treatment depends on the disease, which was the trigger for the development of postcholecystectomy syndrome.

Folk remedies

You can be treated for an illness with the advice of alternative medicine after consulting a doctor, provided that there is no allergic reaction to the components. Recipes are aimed at normalizing the functioning of the liver and removing stones from the gallbladder. To obtain infusions and decoctions, a collection of medicinal herbs and natural ingredients is used. Recommendations of folk healers:

To remove stones, nettle root (100 g) is crushed, poured with pre-prepared boiling water (200 g), aged in a water bath for 1 hour, filtered, drunk 5 times 1 teaspoon.
In case of liver and gallbladder disease, a remedy prepared from hogweed seeds and honey in equal proportions is recommended, taken 5 minutes before breakfast, lunch and dinner, 0.5 tbsp. l.
Fresh chopped ivy (50 g) is poured into 0.5 liters of dry red wine, infused for seven days, consumed in a small sip after a meal.

To normalize the work of the digestive tract, complicated by the manifestation of diarrhea or constipation, the following is recommended: for liquid defecation - mix horsetail juice (50g) with quince syrup (50g), divide into three times, drink during the day. With a difficult act, an effective way is to take sesame oil one teaspoon in the morning, afternoon and evening.

Comprehensive treatment of postcholecystectomy syndrome (PCES) will avoid a complete disruption of the digestive system.

What is postcholecystectomy syndrome

One of the methods of treatment of diseases of the gallbladder is cholecystectomy - an operation to remove this organ. Basically, it is carried out with cholelithiasis.

But practice shows that the operation does not always relieve a person from complaints, because of which he had his gallbladder removed. 30-40% of operated patients again experience pain in the right hypochondrium and epigastric region, they have digestive disorders. Unpleasant symptoms may appear days or years after surgery.

The term "postcholecystectomy syndrome" combines a group of diseases that are accompanied by pain, indigestion, jaundice, itching of the skin in patients who have undergone cholecystectomy. This term is convenient as a preliminary diagnosis and helps to find out the causes of recurrence of complaints.

The most common cause of the resumption of pain are bile duct stones. In rare cases, this is due to the presence of a bile duct cyst. Unsatisfactory well-being can also be caused by liver diseases that develop or increase as a result of bile stasis.

It is worth noting that the removal of the gallbladder does not relieve the patient of metabolic disorders and the tendency to form stones.
To avoid a complete disorder in the digestive system, it is necessary to promptly treat postcholecystectomy syndrome (PCS).

Treatment of postcholecystectomy syndrome

The treatment of the syndrome should be comprehensive and aimed at eliminating disorders of the organs and systems that caused unpleasant symptoms (liver, biliary tract, pancreas, digestive tract).

The basis of therapy is the observance of the correct diet (table No. 5). Without this, the drug is useless. The choice of drug treatment depends on the results of the examination, the patient's condition, the main symptoms.

With an increased tone of the sphincter of Oddi, drugs are prescribed to eliminate spasm:

Muscle antispasmodics (,).
Nitrates: , .
Anticholinergics:,.
A drug with choleretic and antispasmodic action.

To treat postcholecystectomy syndrome with increased pressure inside the duodenum, antibiotics are prescribed, since it is the bacteria in the intestine that stimulate fermentation and increase pressure inside this hollow organ. For this, , are used.

With diarrhea, lactic acid bacteria are prescribed ().

All medicines have a list of contraindications and side effects and are prescribed only by a doctor.

Surgical methods of PCES treatment are possible, which are aimed at draining and restoring the patency of the bile ducts.

Questions from readers

October 18, 2013 Hello, please tell me 3 months ago I had an operation, my gallbladder was removed, can I visit a fitness club or is it too early, and when is it possible. Thank you

Nutrition rules for postcholecystectomy syndrome

With postcholecystectomy syndrome with a reduced rate of bile excretion, diet No. 5g is indicated.

The daily calorie content of food is about 3000 kcal. Nutrition fractional, 4-6 times a day. In the diet, you need to pay attention to foods containing vitamins of group B.

Diet basis:

Wheat and rye bread
Animal and vegetable fats in the ratio 1:1. From animal fats you can butter, from vegetable fats - olive and corn
Lean meats (boiled, baked, steamed)
Lean fish
Boiled eggs or scrambled eggs
Vegetable and milk soups
sweet fruits
Boiled or baked vegetables
Fluid is normal

Seasonings, onions, garlic, spices, chocolate, sour fruits, carbonated drinks, alcohol are prohibited.

With PCES in the acute stage, diet No. 5shch is recommended. Its calorie content is 2000 kcal per day. It includes a normal amount of protein food, a reduced content of carbohydrates and fats (vegetable oil is excluded). Fiber, spices, chocolate are prohibited. Meals 5-6 times a day, a normal amount of liquid.

Allowed:

Yesterday's bread, crackers
Vegetable pureed soups
Lean meat and fish in the form of steam cutlets, soufflé
1 egg per day
boiled vegetables
Sweet fruits and berries in the form of compotes, kissels, jelly
A small amount of milk, low-fat cottage cheese and kefir, a little sour cream

Almost impossible to eat sweets. Prohibited are fatty meats and fish, raw vegetables and fruits, meat and mushroom broths, onions, garlic, and radishes.

The prognosis of recovery from the syndrome depends on success in the treatment of the underlying disease that caused the complex of PCES symptoms.

14061 0

Surgical treatment in the vast majority of patients with cholelithiasis and cbc leads to their complete recovery and restoration of working capacity. However, in a number of patients, it does not lead to an improvement in their condition, and in some, the operation becomes the cause of new, no less serious diseases. After surgical treatment (intervention), patients often retain a number of symptoms of the disease that were before the operation, or new ones appear.

This condition of patients is characterized by a collective concept, a commonality of symptoms called postcholecystectomy syndromes (PCES). The problem of diagnosis and treatment of PCES continues to be very relevant. This is due to the continuous increase in the number of patients suffering from cholelithiasis and painful phenomena after cholecystectomy, serious difficulties in diagnosing and treating this syndrome. Its essence is relative, meaning the sum of various types of disorders and complications that occur after operations on the biliary tract and especially cholecystectomy. PCES develops due to complications or concomitant diseases of other organs.

This term also means a pathological condition, which sometimes has no connection with the operation performed [E.I. Galperin, 1976; E.V. Smirnov, 1976; I.I. Goncharik, 1980; F.R. Burton, 1992]. This syndrome often occurs as a result of diagnostic, tactical and technical errors made during the first operation [B.V. Petrovsky et al., 1980; Sauerbruch, 1992]. The incidence of painful symptoms and complications (pain attacks in the epigastric region, cholangitis, stenosis of the CBD, "forgotten" or newly formed stones, etc.) after operations performed for CCC is 10-20% [B.N. Chernov et al., 1996; Botny et al., 1993, and operations for CBC - about 30% [V.M. Sitenko and A.I. Nechay, 1974].

The term PCES, common in the surgical literature, shows that the main cause of this syndrome is the loss of the gallbladder, that cholecystectomy is not a physiological intervention, and that it is the cause of those pathological changes that develop in the biliary tract and neighboring organs. However, despite this, some authors [P. Malle-Guy, Kestene, 1973] rightly suggest and insist on calling it a syndrome after cholecystectomy, wanting to emphasize the fact that the painful conditions of the liver and biliary tract noted after cholecystectomy are not always associated with the operation performed or with diseases of the biliary system.

Often, it is not so much the removal of the gallbladder that is “guilty” here, but chronically atypically occurring diseases of the liver, pancreas, stomach, duodenum, and even, as the authors note, spondylarthrosis. From this point of view, the term PCES does not sound so good, since the removal of the gallbladder does not always cause painful conditions. It has been established that in 60% of patients, postoperative disorders are caused by stones left in the bile ducts during the first operation, undiagnosed and not eliminated diseases of the biliopancreatic system. According to the literature, the frequency of (residual) stones left in the bile ducts is 2-10% [V.N. Klimov et al., 1982; E. Usche et al., 1993].

Diagnosis of anatomical and functional changes occurring in the hepatopancreatoduodenal region after surgery on the bile ducts presents significant difficulties. In recent years, more informative methods of EI have been successfully used to diagnose these changes, in particular, retrograde cholangiopancreatography, CT and ultrasound. These research methods provide very valuable information for diagnosis.

Thanks to their introduction into clinical practice, it became possible not only to significantly reduce the number of reoperations for these complications, but also to significantly reduce (7%) mortality. Depending on the disease, the causes of PCES are different: a mechanical obstruction in the bile ducts, inflammatory processes in the organs of the hspatopancreatoduodenal zone, diseases of other organs and systems.

PCES is divided into two groups, due to:
1) concomitant cholecystitis diseases (cirrhosis, hepatitis, I B, CP);
2) technical and tactical errors made during the operation, as well as functional disorders of the nervous system and dysfunction of the biliary tract [A.I. Krakowski et al., 1978].

Patients of the second group only need reoperation, in which PCES is mainly due to stones left (residual) in the biliary tract or re-formed (relapse) stones, cicatricial narrowing or fibrosis of the common choledochus, inflammatory-cicatricial changes in the EDA and OBD, biliary hypertension, CP , as well as external biliary fistulas, an excessively long stump (more than 1 cm) of the cystic duct, post-traumatic cicatricial narrowing, incomplete removal of the YL, adhesive process in the abdominal cavity, inflammation of the pericholedochal lymph nodes (pericholedocheal lymphadenitis) [V.T. Zaitsev, 1982; S.S. Balalykin, 1986].

The clinical picture of PCES is mainly due to a violation of the natural outflow of bile and its characteristic disorders (hepatic colic, jaundice, pruritus). The clinical symptoms of PCES often correspond to the phenomena existing in patients before the operation. In addition to the pain syndrome, which usually manifests itself in the form of biliary or pancreatic colic, the clinical phenomena of biliary hypertension, symptoms of mammary glands and cholangitis, etc. are also characteristic. The pain is usually localized in the upper right quadrant of the abdomen.

Our observations and literature data show that the development of PCES is due to a number of contributing factors (disturbance of cholesterol metabolism, the development of a pathological process, new anatomical and physiological conditions in connection with the removal of YL) [Kh.Kh. Mansurov, 1982].

It is known that cholecystectomy performed for HCC does not relieve the patient from metabolic disorders, dyscholia. These disorders persist after cholecystectomy.

Moreover, after cholecystectomy in most patients, bile continues to be a lithogenic, low cholatocholesterol ratio. In addition, after the removal of YL, the reflex and humoral effects on its part on the sphincter of the ampulla of the liver and pancreas and on cholekinesis are eliminated, and the fall of this role is accompanied by a violation of the passage of bile, digestion, especially fat and other lipid substances. The bactericidal property of bile decreases, as a result of which the microflora of the duodenum spreads, the growth and activity of intestinal microbes is weakened, the circulation of bile acids and other components of bile in the liver-intestinal zone is disturbed.

Under the influence of pathogenic microflora, bile acids undergo deconjugation, which leads to inflammation of the intestinal mucosa, the development of reflux gastritis, duodenitis and colitis. There are duodenal dyskinesia, hypertensia, duodenogastric reflux, reverse flow of duodenal contents into the common bile duct and pancreatic duct [PL. Grigoriev, E.P. Yakovenko, 1993]. Against this background, reactive pancreatitis and hepatitis join the violation of the sphincter of the ducts.

Thus, the development of PCES from the very beginning is associated with a violation of the cholic composition of bile, its passage in the duodenum, the motor function of the sphincter of the hepatopancreatic ampulla (dyskinesia), and then a decrease in the digestive process, dysbacteriosis, deconjugation of bile acids, the development of duodenitis and other disorders occurring in the digestive tract. system.

The causes of PCES are different. Their frequent combination, unclear clinical picture, and lack of awareness of practitioners in this area lead to the fact that many causes remain unclear. The causes of the developing pain syndrome after cholecystectomy are divided into two groups: pain associated with the operation and not associated with it.

The group of recurrent pain syndrome associated with surgery includes incomplete removal or newly formed CBD stones, residual GB stump or long RA stump, cicatricial stenosis of the hepatobiliary duct accompanied by compression of the choledochus, indurated pancreatitis, cicatricial narrowing of the Vater papilla, ascending cholangitis that occurs after CDA , closure (obliteration) BDA, CP, chronic cholangiohepatitis, duodenobiliary dyskinesia, paracholedochal lymphadenitis, adhesive process of the abdominal cavity.

Causes of pain that are not associated with the operation are hernia of the alimentary opening of the diaphragm (HAD), duodenal ulcer, chronic gastritis, urolithiasis, malignant tumors of the stomach, benign tumors of the pancreas, duct cancer and polychistoses of the liver.

In order to avoid such omissions, it is recommended to perform a thorough revision during each operation on the biliary tract (intraoperative cholangiography, probing of the ducts, diagnostic choledochotomy, x-ray television cholangiography with double contrast) [B.V. Petrovsky et al., 1980].

There is no doubt that the use of methods for diagnosing acute and chronic cholecystitis and further improvement of surgical treatment will lead to better success in the surgical treatment of patients with diseases of the biliary system.

Based on clinical data, it has been proven that the PP stump (stone in the stump or its purulent inflammation) does not play a special role in the diagnosis of PCES and that the question of a "new bubble" or a large stump is artificial in most cases. Filed by a number of authors [P. Malle-Guy, 1973 and others], among the causes of PCES, dystonia of the sphincter of Oddi is 0.2%.

The formation of stones in the bile ducts is often associated with obstruction of the outflow of bile (cicatricial stenosis, hypertension of the sphincter of Oddi, sclerosis of the pancreatic head, etc.).

Residual gallbladder or a large stump of the PP, especially if there are stones in them, are the cause of the disease of patients and must be removed.

A number of authors are of the opinion that after cholecystectomy with a free outflow of bile into the duodenum, there is no expansion of the ducts. The latter occurs only in cases where the obstruction to the outflow of bile is not removed during the operation or occurs after it.

In this regard, when a pronounced expansion of the ducts and a pain syndrome are combined, it is indicated to perform a second surgical intervention, the purpose of which is to revise the bile ducts and eliminate the identified obstacles. After cholecystectomy, a relatively long-term severe complication is "cicatricial narrowing" of the ducts, which in most cases occurs as a result of damage to the ducts during surgery.

The reasons for the development of pathological conditions after operations on the biliary tract and cholecystectomy are divided into three groups: organic lesions of the biliary tract, diseases of the organs of the hepatopancreatoduodenal zone and lesions of other organs and systems.

The group of organic lesions of the biliary tract includes: "forgotten stones" in the lumen of the bile ducts, narrowing of the OBD, insufficiency of the sphincter of Oddi, cicatricial narrowing of the bile ducts, residual gallbladder or an excessively long stump of the bile duct, iatrogenic damage to the hepaticocholedochus and the resulting cicatricial narrowing, IT of the bile pathways, cholangitis.

Diseases of the organs of the hepatopancreatoduodenal zone: chronic hepatitis, biliary dyskinesia, chronic hepatitis and cirrhosis, tumors of the biliopancreatic system, paracholedochal lymphadenitis.

Lesions of other organs and systems: stomach and duodenal ulcers, gastritis, duodenitis, tumors of the stomach and intestines, chronic colitis, hernia of the POD, duodenal dyskinesia, reflux esophagitis (OC), diencephalic syndrome.

The first group of reasons is associated with both a technical defect and insufficient examination of the bile duct during surgery. Only the causes of this group are directly or indirectly related to past cholecystectomy.

The last group of causes is associated with defects in the preoperative examination of patients and with undiagnosed diseases of the digestive system.

Diseases of other organs and systems are usually detected in the postoperative period.

A common cause of PCES is the leaving of stones in the ducts, which occurs mainly with insufficient and defective intraoperative revision, when emergency special methods (cholangiography, etc.) are not used during the operation to study the bile duct, as well as due to technical difficulties and as a result of insufficient experience of the surgeon .

The reason for the development of PCES can also be “immersed” in the lumen of the bile ducts and inlaid drainages [A.I. Krakowski et al., 1978], which lead to their obstruction.

The cause of PCES can also be postoperative duodenitis, which is accompanied by a violation of the motor and evacuation functions of the duodenum, dyspeptic symptoms, a feeling of heaviness and pain in the epigastric region.

After removal of the gallbladder at different times, symptoms of reactive pancreatitis may be observed, in which there are pains of a girdle character, accompanied by nausea, bitterness in the mouth, and flatulence. These phenomena are due to the activation of the inflammatory process in the upper gastrointestinal tract, suppression of the excretory function of the pancreas, etc. The cause of PCES is more often cholangitis, choledocholithiasis, cicatricial-inflammatory changes in OBD, etc.

Inflammation of the intrahepatic bile ducts (cholangitis) often also develops. After surgery, this occurs in the presence of internal fistulas and BDA. Cholangitis is a constant companion of bile duct obstruction with stones and their cicatricial narrowing and is manifested by hyperemia of the bile ducts and edema, and in more severe cases, bile duct phlegmon occurs.

With the latter, the bile is cloudy, thickens and eventually acquires a purulent character. In the parenchyma of the liver, multiple destructive foci, abscesses, etc. are formed. With the reverse development of the inflammatory process as a result of cicatricial changes in the biliary tract, their narrowing, fibrous degeneration of the liver, and even biliary cirrhosis may occur.

Distinguish:
1) acute;
2) chronic recurrent;
3) primary sclerosing cholangitis.

In the pathogenesis of acute cholangitis, the main role is played by the rapid obliteration of the bile ducts, as a result of which the pressure rises sharply in them, there is a massive penetration of microbes and their toxins into the bile ducts. The cause of the development of cholangitis is often E. coli, staphylococci, streptococci, anaerobic microbes, bacteroids, etc. [IN AND. Kochorovsts et al., 1984; M.W. Laung et al, 1994]. The infection can also spread through the hematogenous route, but often it passes through the OBD.

The severity of clinical symptoms depends on the morphological changes occurring in the walls of the bile ducts. Depending on the severity of these changes, catarrhal, phlegmanous, purulent and obstructive cholangitis are distinguished. Catarrhal and phlegmanous cholangitis are usually manifested by fever, sometimes yellowness of the skin, moderate pain in the right hypochondrium, and so on. Purulent cholangitis can have a fulminant course, in which from the very first hours the temperature rises to 40 C, septic shock develops, NP, etc.

With purulent cholangitis, multiple small or separate large abscesses form in the liver. This complication is manifested by pain in the right hypochondrium, chills, fever, temperature deviation of the hectic type, profuse sweating, liver enlargement and severe pain in the right hypochondrium. The blood shows leukocytosis with a neutrophilic shift. The amount of urobilin in the urine increases.

Developing against the background of choledocholithiasis and cicatricial stenosis of the ducts, cholangitis can become recurrent. Each relapse is manifested by the periodic appearance of jaundice and chills, which disappear when the outflow of bile is restored. During the formation of abscesses, there are significant changes in the blood and urine, hylsrleukocytosis, a shift of the leukoformula to the left, and toxic granularity of neutrophils. Hyperbilirubinemia and dysproteinemia are noted.

In severe forms of acute cholangitis, NP may develop. There is a feeling of heaviness and pain in the right hypochondrium. There are phenomena of severe intoxication, jaundice. If the bile ducts are obstructed, then the feces are discolored. Prolonged blockage of the biliary tract, even after its elimination, often causes the development of chronic cholangitis and biliary sclerosis.

Chronic recurrent cholangitis proceeds almost imperceptibly. It develops with partial obstruction and stenosis of the biliary tract and in the presence of BDA, when reflux of intestinal contents occurs. With a long course of such cholangitis, biliary cirrhosis often develops.

Chaledocholipiasis. As is known, the main site of stone formation is the GB, from which they enter the CBD [K. Niederle et al., 1982; A. Sobanski, 1986]. This is evidenced by the chemical composition of the stones in the bile ducts [S.Yu. Knubovich, 1981; A.G. Petrosyan, 1984]. The primary formation of stones in the bile ducts is noted only in 3-5.7% of cases [V.V. Vinogradov et al., 1977; A. Sobanski, 1988].

The primary formation of stones in the bile ducts is facilitated by infection, IT CBD, ligatures applied to hepaticocholedochus, impaired bile outflow and motor function of the gastrointestinal tract, pregnancy, tumors, the presence of pancreatitis, narrowing of the OBD and hepaticocholedochus, duodenochole-docheal reflux, etc. [Yu.M. Dederer et al., 1983].

Choledocholithiasis is characterized by recurrent attacks of pain in the right hypochondrium, which are accompanied by jaundice, cholangitis, itching, chills and fever. An increase in the level of bilirubin and the presence of pronounced cholangitis are also characteristic. In some cases, choledocholithiasis can occur without pronounced symptoms.

Stenosis of the OBD. Among the reasons for the violation of the outflow of bile, a narrowing of the BDS occupies a special place. It accounts for 55.4% of all interventions performed on the choledochus [AA. Movchun, 1984; B.V. Petrovsky et al., 1986]. Distinguish between primary and secondary narrowing of the OBD.

Primary narrowing occurs without changes in the bile ducts. Secondary narrowing occurs on the basis of already existing changes in the hepatocholedocheal region [V.V. Vinogradov et al., 1973]. Depending on the cause of occurrence, there are: a) post-traumatic narrowing; b) inflammatory constrictions; and c) constrictions of reflex origin. Post-traumatic narrowings occur as a result of injuries from stones and injuries caused during operations.

Narrowings of reflex origin occur with stone and chronic acalculous cholecystitis and as a result of a prolonged spasm of OBD. OBD stenosis can also occur in diseases of neighboring organs [K. Fularton et al, 1992]. Most often (in 26-30% of patients) there are cicatricial-inflammatory narrowing of the OBD and amlullary cholelithiasis [B.V. Petrovsky et al., 1980; RA. Megrabyan et al., 1984].

Inflammatory lesion of OBD (panillitis). It occurs in 27.5-75% of cases, mainly in diseases of the biliopancreatoduodenal zone [V. Lembke et al., 1994]. Paggillitis is predominantly (88%) observed in the postoperative period. Violation of the patency of the BDS with papillitis leads to hypertension in the bile and pancreatic ducts and the development of cholangitis. As a result of papillitis, sclerosis of the BDS tissue develops, which in 7-39.3% of patients causes the formation of cicatricial papillostenosis [A. .Janaka et al., 1992].

Diagnostics. For the correct diagnosis of patients with PCES, it is necessary to carefully study their causes both before surgery and in the postoperative period. A carefully collected anamnesis and the correct recording of data from the study of the hepatopancreobiliary system help to identify the causes of the development of PCES. In the study of these patients, in addition to the use of well-known biochemical methods, the activity of PS enzymes is also studied. For this group of patients, RI of the gastrointestinal tract, as well as a contrast study of the bile ducts, is considered mandatory. To determine the state of the pancreatic duct, RPCG is performed.

After cholecystectomy, reactive hepatitis, colitis, intestinal dysbacteriosis and other pathological processes often develop, the diagnosis of which is based on data from a study of the clinical picture of these diseases. To identify the causes of PCES, it is very important to use methods of contrast examination of the biliary tract. In the presence of a biliary fistula, it is considered mandatory to perform fistulocholangiography. The latter makes it possible to clarify the causes of obstruction of the CBD and the functioning of the fistula, determine the level of obstruction, the place of communication of the fistula with the bile duct, and, based on this, choose the tactics of further treatment.

For the diagnosis of acute cholangitis, clinical and laboratory studies are important. Especially valuable is the contrast RI, as well as the study of duodenal contents. In case of RI, in addition to the state of the biliary tract, including the papilla of Vater, infusion cholangiography, endoscopic RPCG, percutaneous transhepatic cholangiography, intravenous cholangiography, ultrasound, CT, fistulocholangiography, hepatography, magnetic resonance imaging, choledochoscopy and endosonography are more informative [ AA Pishkin et al., 1992; Rigauts et al, 1992]. These research methods make it possible to obtain a clear and complete picture of the state of the biliary system, especially before repeated operations on them and during the operation.

Currently, in the diagnosis of diseases of the pancreatobiliary zone, especially after cholecystectomy, great importance is attached to endoscopic RPCG.

The indications for this research method are:
1) relapse from unknown causes, jaundice;
2) pain in the upper abdomen, the causes of which may not be clarified by other research methods;
3) the existing suspicion of cholelithiasis, narrowing of the CBD.

RPCH is an effective and reliable method for diagnosing jaundice of various nature. It makes it possible in the vast majority of cases to identify pathological processes occurring in the bile ducts. Without the use of this method, it is almost impossible to identify the true cause of PCES.

Treatment. Treatment of diseases of the biliary tract, which are the cause of PCES, has a number of features. It is very important to establish the correct diet for these patients (diet therapy). The diet should be differentiated, depending on the time elapsed after the operation, the severity of the clinical phenomena of PCES, body weight and the lithogenic properties of bile.

Drug therapy is aimed at correcting and eliminating dyskinesia and other phenomena of the sphincter of Oddi and duodenum. Rational nutrition also plays an important role in the prevention of PCES, especially in the early postoperative period. With cholestasis, a lipotropic diet is prescribed (table No. 5), rich in proteins and lipotropic substances, semi-saturated fatty acids (group B vitamins).

To eliminate pain and dyspeptic phenomena in order to correct the function of the sphincters of the bile ducts and duodenum, nitroglycerin, raglan, cerucal, sulpiride are prescribed, and for the adsorption of bile acids - almagel, phospholugel, cholesteramine, bilignin. To subside inflammatory phenomena, CO is prescribed dynod, vikair, etc., and in order to suppress the activity of pathogenic microflora - enteroseptol, biseptol, furazolidone and erythromycin.

With cholangitis, the important tasks of treatment are: the destruction of infection, detoxification and raising the body's resistance and regenerative abilities, ensuring a free outflow of bile, etc.

With purulent cholangitis, external drainage of the biliary tract and their periodic sanitation are performed.

With the development of nonspecific reactive hepatitis, Essentiale, legalen, lipamide are prescribed, and in the presence of pancreatitis, inhibitors of pancreatic enzymes are also prescribed. To suppress the process of stone formation and prevent obesity, which is closely related to this, a low-calorie diet is prescribed. To regulate the chemical composition of bile, bile preparations (lyobil, cholonerton, ruganol) are recommended. These drugs contribute to the normalization of cholesterol in bile, the correction of the cholate-cholesterol coefficient, the lysis of cholesterol stones, etc. If PCES is caused by organic diseases of the biliopancreato-papillary zone, then repeated surgery is indicated.

The main goal of repeated operations is to restore the free outflow of bile into the DP by choledochotomy or BDA. In the presence of cicatricial stenosis or multiple small stones, a putty-like mass, as well as in the presence of a part of the gallbladder or the presence of an excessively long stump of the PP, they are removed.

The features of the reoperation are due to changes in topographic and anatomical conditions, the development of an extensive adhesive process, which significantly increases the risk of the operation and predetermines the possibility of technical and tactical errors. Technical errors are associated with damage to the bile ducts and neighboring organs and arise as a result of inadequate preparation of patients and the choice of an inadequate method of surgery. The volume of preoperative preparation of patients with PCES depends on the severity of the clinical forms of the disease, the age of the patient and the concomitant pathological process. The volume and nature of the reoperation depend on the specific cause of PCES.

If a long stump of the PP is left or if the gallbladder is not completely removed, they are removed. In such cases, the remaining part of the GB is separated and removed, leaving a short stump of the PP. With a long stump of the PP, its resection is performed. The operation is absolutely indicated for hepatocholedocholithiasis, narrowing of the hepatic, common bile ducts and OBD, as well as in the presence of CP [A.I. Krakowski et al., 1978; E.I. Galperin et al., 1982].

Stones remaining in the CBD can often be removed through a holsdochostomy drainage tube using a Dormia basket, a balloon catheter, and other similar instruments. Small cholesterol stones can decrease in size or completely lyse, and then, by daily washing with a warm solution of 0.25% novocaine and the introduction of a drip method of 40-60 thousand IU of heparin, push out into the lumen of the duodenum. In parallel with this, antispasmodics are prescribed (no-shpa, atropine, platafillin). In some cases, stones can be removed from the lumen of the ducts with a special device.

In recent years, the endoscopic method of removing stones from the lumen of the biliary tract has become widespread. Thanks to the use of this method, the effectiveness of the treatment of choledocholithiasis currently reaches 80-95%. Recently, the method of extracorporeal lithotripsy has also begun to be used, especially in cases where it is not possible to remove stones by the endoscopic method [O.V. Sarukhanyan et al., 1991; DB. Kolesnikov et al., 1993; B.S. Briskin et al., 1997; CD. Becker et al., 1987; K. Ukushima et al., 1992].

These bloodless interventions are performed after 3-4 weeks. after operation. With their inefficiency after 2-3 months. after the first operation, a second operation is performed. In the presence of residual and recurrent choledochal stones, as well as stenosing pancreatitis, repeated surgery in most cases ends with internal drainage of the bile ducts.

If a narrowing of the OBD is detected in the postoperative period, especially in the presence of pancreatitis, transduodenal papillosphincterotomy is performed as a more rational and physiologically justified operation [B.V. Petrovsky et al., 1980; SA. Jones, 1978]. The frequency of this intervention is 30% of reoperations [AS. Movchun, 1984].

In recent years, endoscopic palillotomy by electrocoagulation has begun to be performed in clinical practice. In the process of endoscopy (duodenoscopy), identified FBs are also removed.

Endoscopic papillosphincterotomy is indicated for:
1) choledocholithiae, narrowing of the terminal part of the CBD;
2) primary and secondary (postoperative) stenosis of the OBD;
3) stenosing pallititis or the presence of impacted OBD stones. Thanks to the use of this method, as well as the removal of stones from the CBD by the endoscopic method, it is often possible to save patients from abdominal operations.

After a correctly performed endoscopic papillosphincterotomy, the symptoms of biliary hypertension are usually eliminated, the laboratory and clinical signs of breast cancer disappear, the symptoms of CP are significantly reduced, the symptoms of cholangitis decrease or completely disappear. Literature data indicate that endoscopic papillosphincterotomy is an effective treatment for jaundice resulting from obstructive stenosis, choledocholithiasis, and other causes.

In cases of post-traumatic narrowing of the extrahepatic biliary tract, BDA is applied between the choledochus and the duodenum or TC. In recent years, during operations for cicatricial stenosis of the OBD, they began to use a laser scalpel and special tools [AA Movchun, 1986; R. Saner et al., 1986], with the help of which a bloodless dissection of the OBD and “gluing” of the duodenal mucosa and choledochus are performed, without suturing (sphincteroplasty without sutures).

With high narrowing of the CBD, BDA is applied to restore the outflow of bile, and if it is impossible to perform such an operation, the narrowed area is recanalized, leaving PVC drainage in this place. The latter is excreted according to Felker (Figure 38) or through the liver parenchyma. Drainage is left for 4-6 months.

Figure 38. CBD drainage according to Felker

During repeated operations on the biliary tract, as a rule, cicatricial changes are noted in the hepatoduodenal ligament, which creates significant difficulties in surgical intervention in the area of the choledochus and PA. In the presence of chronic hepatitis, paraarterial sympathectomy is performed to improve blood circulation in the liver [B.V. Petrovsky et al., 1988]. A frequent companion of diseases of the biliary tract is pericholedochal lymphadenitis, which does not always disappear after removal of the gallbladder and often later becomes a cause of dysfunction of the sphincter of Oddi, causes compression of the common gallbladder and contributes to the development of pancreatitis.

Unsatisfactory results of surgical treatment of XX are detected during the first year after the operation. Dynamic dispensary observation of these patients helps to timely identify certain disorders in the hepatoduodenal zone and conduct consistent long-term drug and sanatorium treatment, and, if necessary, repeated surgical intervention. This approach makes it possible to improve the results of treatment of these patients.

In the prevention of PCES, the leading place is occupied by a thorough postoperative examination of patients and the timely implementation of surgical intervention for cholelithiasis, during which it is considered mandatory to conduct a study of the extrahepatic biliary tract. Timely surgical intervention for cholelithiasis is also important. Both the immediate and long-term results of the treatment of these patients are more favorable and PCES is relatively less marked if cholecystectomy is performed in the early period of the disease, even before the development of complications.