Lecture topic: acute cholecystitis. Acute cholecystitis (K81.0) Acute cholecystitis hospital surgery
Acute cholecystitis- symptoms and treatment
What is acute cholecystitis? We will discuss the causes, diagnosis and treatment methods in the article by Dr. E. V. Razmakhnin, a surgeon with 22 years of experience.
Definition of disease. Causes of the disease
Acute cholecystitis is a rapidly progressing inflammatory process in the gallbladder. Stones located in this organ are the most common cause of this pathology.
About 20% of patients admitted to the emergency surgical hospital are patients with complicated forms, which include acute cholecystitis. In older patients, this disease occurs much more often and is more severe due to the large number of existing somatic diseases. In addition, with age, the incidence of gangrenous forms of acute cholecystitis increases. Acalculous acute cholecystitis is uncommon and is a consequence of infectious diseases, vascular pathology (vesical artery thrombosis) or sepsis.
The disease is usually provoked errors in diet - intake of fatty and spicy foods, which leads to intense bile formation, spasm of sphincters in the biliary tract and biliary hypertension.
Contributing factors are stomach diseases , and in particular gastritis with low acidity. They lead to a weakening of protective mechanisms and the penetration of microflora into the biliary tract.
At cystic artery thrombosis against the background of pathology of the blood coagulation system and atherosclerosis, the development of a primary gangrenous form of acute cholecystitis is possible.
Provoking factors if present cholelithiasis Physical activity, “shaky” riding, which leads to the displacement of the stone, blockage of the cystic duct and subsequent activation of the microflora in the lumen of the bladder, can also serve.
Existing cholelithiasis does not always lead to the development of acute cholecystitis; it is quite difficult to predict this. Throughout life, stones in the lumen of the bladder may not manifest themselves, or at the most inopportune moment they can lead to a serious complication that is life-threatening.
If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!
The clinical picture of the disease includes pain, dyspeptic and intoxication syndromes.
Typically, the onset of the disease is manifested by hepatic colic: intense pain in the right hypochondrium, radiating to the lumbar, supraclavicular region and epigastrium. Sometimes, in the presence of symptoms of pancreatitis, pain can become girdling. The epicenter of pain is usually localized at the so-called Kehr's point, located at the intersection of the outer edge of the right rectus abdominis muscle and the edge of the costal arch. At this point the gallbladder comes into contact with the anterior abdominal wall.
The appearance of hepatic colic is explained by sharply increasing biliary (biliary) hypertension against the background of a reflex spasm of the sphincters located in the biliary tract. Increased pressure in the biliary system leads to enlargement of the liver and stretching of the Glissonian capsule that covers the liver. And since the capsule contains a huge number of pain receptors (i.e. noceroreceptors), this leads to the occurrence of pain.
The development of the so-called cholecystocardial Botkin syndrome is possible. In this case, with acute cholecystitis, pain occurs in the heart area, and even changes in the ECG may appear in the form of ischemia. Such a situation can mislead the doctor, and as a result of overdiagnosis (erroneous medical conclusion) of coronary disease, he runs the risk of not recognizing acute cholecystitis. In this regard, it is necessary to carefully understand the symptoms of the disease and evaluate the clinical picture as a whole, taking into account the anamnesis and paraclinical data. The occurrence of Botkin's syndrome is associated with the presence of a reflex parasympathetic connection between the gallbladder and the heart.
After relief of hepatic colic, the pain does not completely go away, as with chronic calculous cholecystitis. It becomes somewhat dull, takes on a constant bursting character and is localized in the right hypochondrium.
In the presence of complicated forms of acute cholecystitis, the pain syndrome changes. With the occurrence of perforation of the gallbladder and the development of peritonitis, the pain becomes diffuse throughout the abdomen.
Intoxication syndrome is manifested by increased temperature, tachycardia (increased heart rate), dry skin (or, conversely, sweating), lack of appetite, headache, muscle pain and weakness.
The degree of temperature rise depends on the severity of the ongoing inflammation in the gallbladder:
- in the case of catarrhal forms, the temperature can be subfebrile - from 37°C to 38°C;
- for destructive forms of cholecystitis - above 38°C;
- when an empyema (ulcer) of the gallbladder or a perivesical abscess occurs, hectic temperature is possible with sharp rises and falls during the day and heavy sweat.
Dyspeptic syndrome is expressed in the form of nausea and vomiting. Vomiting can be either single or repeated with concomitant damage to the pancreas, which does not bring relief.
Pathogenesis of acute cholecystitis
Previously it was believed that the main factor leading to the development of acute cholecystitis was bacterial. In accordance with this, treatment was prescribed aimed at eliminating the inflammatory process. Currently, ideas about the pathogenesis of the disease have changed and treatment tactics have changed accordingly.
The development of acute cholecystitis is associated with a block of the gallbladder, which triggers all subsequent pathological reactions. The block is most often formed as a result of a stone wedging into the cystic duct. This is aggravated by a reflex spasm of the sphincters in the biliary tract, as well as increasing edema.
As a result of biliary hypertension, the microflora located in the biliary tract is activated, and acute inflammation develops. Moreover, the severity of biliary hypertension directly depends on the degree of destructive changes in the wall of the gallbladder.
Increased pressure in the biliary tract is a trigger for the development of many acute diseases of the hepatoduodenal zone (cholecystitis, cholangitis, pancreatitis). Activation of intravesical microflora leads to even greater edema and disruption of microcirculation, which, in turn, significantly increases the pressure in the biliary tract - a vicious circle closes.
Classification and stages of development of acute cholecystitis
Based on morphological changes in the wall of the gallbladder, four forms of acute cholecystitis are distinguished:
- catarrhal;
- phlegmonous;
- gangrenous;
- gangrenous-perforative.
Different severity of inflammation suggests a different clinical picture.
With catarrhal form the inflammatory process affects the mucous membrane of the gallbladder. Clinically, this is manifested by pain of moderate intensity, intoxication syndrome is not expressed, and nausea occurs.
With phlegmonous form inflammation affects all layers of the gallbladder wall. A more intense pain syndrome, fever up to febrile levels, vomiting and flatulence occurs. An enlarged, painful gallbladder may be palpable. Symptoms are revealed:
- With. Murphy - interruption of inhalation when palpating the gallbladder;
- With. Mussi - Georgievsky, otherwise called phrenicus symptom - more painful palpation on the right between the legs of the sternocleidomastoid muscle (the exit point of the phrenic nerve);
- With. Ortner - pain when tapping on the right costal arch.
In gangrenous form intoxication syndrome comes to the fore: tachycardia, high temperature, dehydration (dehydration), symptoms of peritoneal irritation appear.
With perforation of the gallbladder(gangrenous-perforative form) the clinical picture of peritonitis prevails: muscle tension of the anterior abdominal wall, positive symptoms of peritoneal irritation (Mendel village, Voskresensky village, Razdolsky village, Shchetkina-Blumberg village), bloating and severe intoxication syndrome.
Forms of cholecystitis without appropriate treatment can flow from one to another (from catarrhal to gangrenous), and the initial development of destructive changes in the wall of the bladder is also possible.
Complications of acute cholecystitis
Complications can arise with a long course of untreated destructive forms of acute cholecystitis.
If inflammation is limited, it occurs perivesical infiltrate. Its obligatory component is the gallbladder, located in the center of the infiltrate. The composition most often includes the omentum, but may include the transverse colon, antrum of the stomach and duodenum. It usually occurs after 3-4 days of the disease. At the same time, pain and intoxication may decrease somewhat, and dyspeptic syndrome may be relieved. With correctly chosen conservative treatment, the infiltrate can resolve within 3-6 months; if unfavorable, it can abscess with development perivesical abscess(characterized by severe intoxication syndrome and increased pain). Diagnosis of infiltrate and abscess is based on anamnesis of the disease, objective examination data and is confirmed using ultrasound.
Peritonitis- the most dangerous complication of acute destructive cholecystitis. It occurs when the wall of the gallbladder is perforated and bile leaks into the free abdominal cavity. As a result of this, a sharp increase in pain occurs, the pain becomes diffused throughout the abdomen. The intoxication syndrome becomes more severe: the patient is initially excited, groans in pain, but as peritonitis progresses, he becomes apathetic. Peritonitis is also characterized by severe intestinal paresis, bloating and weakened peristalsis. Upon examination, defence (tension) of the anterior abdominal wall and positive symptoms of peritoneal irritation are determined. Ultrasound examination reveals the presence of free fluid in the abdominal cavity. An X-ray examination shows signs of intestinal paresis. Emergency surgical treatment is necessary after short-term preoperative preparation.
Another serious complication of acute cholecystitis is cholangitis- inflammation spreads to the biliary tree. In essence, this process is a manifestation of abdominal sepsis. The condition of the patients is severe, intoxication syndrome is pronounced, high hectic fever occurs with large daily temperature fluctuations, heavy sweats and chills. The liver increases in size, jaundice and cytolytic syndrome occur.
Ultrasound reveals dilation of the intra- and extrahepatic ducts. Blood tests show hyperleukocytosis, increased bilirubin levels due to both fractions, increased activity of aminotransferases and alkaline phosphatase. Without appropriate treatment, such patients quickly die from liver failure.
Diagnosis of acute cholecystitis
Diagnosis is based on a combination of medical history, objective data, laboratory and instrumental studies. In this case, the principle must be respected from simple to complex, from less invasive to more invasive.
When collecting anamnesis(during the survey) patients may indicate the presence of cholelithiasis, previous hepatic colic, diet violations in the form of consumption of fatty, fried or spicy foods.
Clinical data assessed by the manifestations of pain, dyspeptic and intoxication syndromes. In the presence of complications, concomitant choledocholithiasis and pancreatitis, cholestasis syndrome and moderate cytolytic syndrome are possible.
Of the instrumental diagnostic methods, the most informative and least invasive is ultrasonography. At the same time, the size of the gallbladder, its contents, the condition of the wall, surrounding tissues, intra- and extrahepatic bile ducts, and the presence of free fluid in the abdominal cavity are assessed.
In the case of an acute inflammatory process in the gallbladder, ultrasound reveals an increase in its size (sometimes significant). Wrinkling of the bladder indicates the presence of chronic cholecystitis.
When assessing the contents, pay attention to the presence of stones (number, size and location) or flakes, which may indicate the presence of stagnation of bile (sludge) or pus in the lumen of the bladder. In acute cholecystitis, the wall of the gallbladder thickens (more than 3 mm), can reach 1 cm, and sometimes becomes layered (in destructive forms of cholecystitis).
With anaerobic inflammation, gas bubbles can be seen in the wall of the bladder. The presence of free fluid in the peri-vesical space and in the free abdominal cavity indicates the development of peritonitis. In the presence of biliary hypertension against the background of choledocholithiasis or pancreatitis, dilation of the intra- and extrahepatic bile ducts is observed.
Evaluation of ultrasound data makes it possible to decide on treatment tactics even at the admission stage: patient management conservatively, emergency, urgent or delayed surgery.
X-ray methods studies are carried out if a block of the biliary tract is suspected. Plain radiography is not very informative, since stones in the lumen of the gallbladder are usually non-contrast (about 80%) - they contain a small amount of calcium, and they can rarely be visualized.
With the development of such a complication of acute cholecystitis as peritonitis, signs of paresis of the gastrointestinal tract can be identified. To clarify the nature of the biliary tract block, contrast research methods are used:
- endoscopic retrograde cholangiopancreatography - the biliary tract is contrasted retrogradely through the papilla of Vater during duodenoscopy;
- percutaneous transhepatic cholecystocholangiography - antegrade contrast enhancement by percutaneous puncture of the intrahepatic duct.
If making a diagnosis and carrying out differential diagnosis is difficult, CT scan belly. With its help, you can evaluate in detail the nature of changes in the gallbladder, surrounding tissues and bile ducts.
If differential diagnosis with other acute pathology of the abdominal organs is necessary, a diagnostic test can be performed. laparoscopy and visually assess existing changes in the gallbladder. This study can be performed either under local anesthesia or under endotracheal anesthesia (the latter is preferable). If necessary, the issue of switching to therapeutic laparoscopy, that is, performing cholecystectomy - removal of the gallbladder, is decided right on the operating table.
Laboratory diagnostics consists of performing general blood test, where leukocytosis is detected, a shift in the leukocyte formula to the left and an increase in ESR. The severity of these changes will depend on the severity of inflammatory changes in the gallbladder.
IN biochemical blood test there may be a slight increase in bilirubin levels and aminotransferase activity due to reactive hepatitis in the adjacent liver tissue. More pronounced changes in biochemical parameters occur with the development of complications and intercurrent diseases.
Treatment of acute cholecystitis
Patients with acute cholecystitis are subject to emergency hospitalization in the surgical department of the hospital. After carrying out the necessary diagnostic measures, further treatment tactics are determined. In the presence of severe complications - perivesical abscess, destructive cholecystitis with peritonitis - patients are subject to emergency surgery after short preoperative preparation.
Preparation consists of restoring the volume of circulating blood, detoxification therapy by infusion of crystalloid solutions in a volume of 2-3 liters. If necessary, correction of cardiac and respiratory failure is carried out. Perioperative antibiotic prophylaxis is performed (before, during and after surgery).
The surgical approach is selected depending on the technical capabilities of the clinic, the individual characteristics of the patient and the qualifications of the surgeon. The most commonly used is laparoscopic access, which is the least traumatic and allows for full inspection and sanitation.
The mini-access is not inferior to the laparoscopic approach in terms of morbidity and has the advantage of eliminating the need to apply pneumoperitoneum (limit the mobility of the diaphragm). If technical difficulties arise, pronounced adhesions in the abdominal cavity and diffuse peritonitis, it is more advisable to use a laparotomic approach: upper midline laparotomy, Kocher, Fedorov, Rio Branca access. In this case, the upper midline laparotomy is less traumatic, since in this case the muscles are not intersected, however, with oblique subcostal approaches, the subhepatic space is more adequately opened for surgical intervention.
The operation consists of performing a cholecystectomy. It should be noted that the presence of perivesical infiltrate implies certain technical difficulties in mobilizing the neck of the gallbladder. This leads to an increased risk of damage to the elements of the hepatoduodenal ligament. In this regard, we should not forget about the possibility of performing cholecystectomy from the fundus, which makes it possible to more clearly identify the elements of the cervix.
There is also the “Pribrama” operation, which consists of removing the anterior (lower) wall of the gallbladder, suturing the cystic duct in the neck area and mucoclasia (removal of the mucous membrane) by electrocoagulation of the posterior (upper) wall. Performing this operation with a pronounced infiltrate in the area of the bladder neck will avoid the risk of iatrogenic damage. It is applicable for both laparotomic and laparoscopic approaches.
If there are no severe complications of acute cholecystitis, then upon admission of the patient to the hospital, conservative therapy aimed at unblocking the gallbladder. Antispasmodics, anticholinergics, infusion therapy are used to relieve intoxication, and antibiotics are prescribed.
An effective method is to block the round ligament of the liver with a solution of novocaine. The blockade can be performed either blindly using a special technique, or under the control of a laparoscope when performing diagnostic laparoscopy and under ultrasound guidance.
If conservative therapy is ineffective within 24 hours, the question of radical surgery is raised - cholecystectomy.
Of no small importance for determining treatment tactics is the time that has passed since the onset of the disease. If the interval is up to five days, then cholecystectomy is feasible; if it is more than five days, then it is better to adhere to the most conservative tactics in the absence of indications for emergency surgery. The fact is that in the early stages the perivesical infiltrate is still quite loose, it can be divided during surgery. Later, the infiltrate becomes dense, and attempts to separate it may result in complications. Of course, a period of five days is quite arbitrary.
If there is no effect from conservative treatment and there are contraindications for radical surgery - severe pathology of the cardiovascular and respiratory systems, five days have passed since the onset of the disease - it is better to resort to decompression of the gallbladder by cholecystostomy.
Cholecystoma can be applied in three ways: from a mini-access, under laparoscopic control and under ultrasound control. The most minimally traumatic procedure is to perform this operation under ultrasound guidance and local anesthesia. Single and double punctures of the gallbladder with sanitation of its lumen under ultrasound guidance are also effective. A necessary condition is the passage of the puncture channel through the liver tissue to prevent bile leakage.
After stopping the acute inflammatory process, radical surgery is performed in a cold period after three months. Usually this time is enough for the perivesical infiltrate to resolve.
Forecast. Prevention
The prognosis with timely and adequate treatment is usually favorable. After radical surgery, it is necessary for a certain period of time (at least three months) to adhere to diet No. 5 with the exception of fatty, fried and spicy foods. Food intake should be fractional - in small portions 5-6 times a day. It is necessary to take pancreatic enzymes and herbal choleretic agents (they are contraindicated before surgery).
Prevention consists of timely sanitation of stone carriers, that is, performing cholecystectomy as planned for patients with chronic calculous cholecystitis. The founder of biliary surgery, Hans Kehr, said that “carrying a stone in the gall bladder is not the same as wearing an earring in the ear.” In the presence of cholecystolithiasis, factors leading to the development of acute cholecystitis should be avoided - do not break the diet.
Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder.
The most acceptable classification of acute cholecystitis is:
I. Uncomplicated cholecystitis:
1. Catarrhal (simple) cholecystitis (calculous or acalculous), primary or exacerbation of chronic recurrent.
2. Destructive (calculous or acalculous), primary or exacerbation of chronic recurrent:
a) phlegmonous, phlegmonous-ulcerative;
b) gangrenous;
II. Complicated cholecystitis:
1. Occlusal (obstructive) cholecystitis (infected dropsy, phlegmon, empyema, gangrene of the gallbladder).
2. Perforated with symptoms of local or diffuse peritonitis.
3. Acute, complicated by damage to the bile ducts:
a) choledocholithiasis, cholangitis;
b) stricture of the common bile duct, papillitis, stenosis of the papilla of Vater.
4. Acute cholecystopancreatitis.
5. Acute cholecystitis, complicated by profuse bile peritonitis.
The main symptom of acute cholecystitis is pain, which usually occurs suddenly in the middle of full health, often after eating, or at night during sleep. The pain is localized in the right hypochondrium, but can also spread to the epigastric region, with irradiation to the right shoulder, scapula, and supraclavicular region. In some cases, before its appearance, patients feel heaviness in the epigastric region, bitterness in the mouth, and nausea for several days, even weeks. Severe pain is associated with the reaction of the gallbladder wall to an increase in its contents as a result of outflow disturbance due to inflammatory edema, kinking of the cystic duct, or blockage of the latter by a stone.
Irradiation of pain to the heart area is often noted, then an attack of cholecystitis can occur as an attack of angina pectoris (Botkin cholecystocoronary syndrome). The pain intensifies with the slightest physical exertion - talking, breathing, coughing.
There is vomiting (sometimes repeated) of a reflex nature, which does not bring relief to the patient.
On palpation, sharp pain and muscle tension are detected in the right upper quadrant of the abdomen, especially sharp pain in the area where the gallbladder is located.
Objective symptoms are not expressed equally in all forms of acute cholecystitis. Increased heart rate up to 100 – 120 beats per minute, symptoms of intoxication (dry, coated tongue) are characteristic of destructive cholecystitis. With complicated cholecystitis, the temperature reaches 38 °C and higher.
When analyzing blood, leukocytosis, neutrophilia, lymphopenia, and increased erythrocyte sedimentation rate are observed.
Specific symptoms of acute cholecystitis include:
1) Grekov-Ortner symptom - percussion pain that appears in the area of the gallbladder when lightly tapping the right costal arch with the edge of the palm;
2) Murphy's symptom - increased pain that occurs when the gallbladder is felt when the patient takes a deep breath. The doctor places the thumb of the left hand below the costal arch, at the location of the gallbladder, and the remaining fingers along the edge of the costal arch. If the patient's deep breath is interrupted before reaching height due to acute pain in the right hypochondrium under the thumb, then Murphy's symptom is positive;
3) Courvoisier’s symptom – an enlargement of the gallbladder is determined by palpation of the elongated part of its bottom, which protrudes quite clearly from under the edge of the liver;
4) Pekarsky’s symptom – pain when pressing on the xiphoid process. It is observed in chronic cholecystitis, its exacerbation and is associated with irritation of the solar plexus during the development of the inflammatory process in the gallbladder;
5) Mussi-Georgievsky symptom (frenicussymptom) - pain on palpation in the supraclavicular region at a point located between the legs of the sternocleidomastoid muscle on the right;
6) Boas symptom - pain on palpation of the paravertebral zone at the level of the IX - XI thoracic vertebrae and 3 cm to the right of the spine. The presence of pain in this place during cholecystitis is associated with zones of Zakharyin-Ged hyperesthesia.
uncomplicated cholecystitis. Catarrhal (simple) cholecystitis can be calculous or acalculous, primary or as an exacerbation of chronic recurrent cholecystitis. Clinically, in most cases it proceeds calmly. The pain is usually dull, appears gradually in the upper abdomen; amplifying, localized in the right hypochondrium.
On palpation, pain is noted in the area of the gallbladder, and there are also positive Grekov-Ortner and Murphy symptoms. There are no peritoneal symptoms, the number of leukocytes is in the range of 8.0 – 10.0 – 109/l, temperature is 37.6 °C, rarely up to 38 °C, no chills.
Attacks of pain continue for several days, but after conservative treatment they disappear.
Acute destructive cholecystitis can be calculous or acalculous, primary or an exacerbation of chronic recurrent cholecystitis.
Destruction can be phlegmonous, phlegmonous-ulcerative or gangrenous in nature.
With phlegmonous cholecystitis, the pain is constant and intense. Dry tongue, repeated vomiting. There may be a slight yellowness of the sclera and soft palate, which is due to infiltration of the hepatoduodenal ligament and inflammatory swelling of the mucous membrane of the bile ducts. Urine is dark brown. Patients lie on their backs or on their right side, afraid to change their position in the back, since in this case severe pain occurs. On palpation of the abdomen, a sharp tension in the muscles of the anterior abdominal wall in the area of the right hypochondrium is observed, and positive Grekov-Ortner, Murphy, Shchetkin-Blumberg symptoms also occur there. The temperature reaches 38 °C and higher, leukocytosis is 12.0 – 16.0 – 109 / l with a shift in the leukocyte formula to the left. When the inflammatory process spreads to the entire gallbladder and pus accumulates in it, gallbladder empyema is formed.
Sometimes phlegmonous cholecystitis can develop into hydrocele of the gallbladder.
Gangrenous cholecystitis in most cases is a transitional form of phlegmonous, but can also arise as an independent disease in the form of primary gangrenous cholecystitis of vascular origin.
Clinic at first it corresponds to phlegmonous inflammation, then so-called imaginary well-being may occur: pain decreases, symptoms of peritoneal irritation are less pronounced, and temperature decreases. However, at the same time, the phenomena of general intoxication increase: rapid pulse, dry tongue, repeated vomiting, sharpened facial features.
Primary gangrenous cholecystitis from the very beginning proceeds rapidly with symptoms of intoxication and peritonitis.
Complicated cholecystitis. Occlusive (obstructive) cholecystitis develops when the cystic duct is blocked by a calculus and initially manifests itself with a typical picture of biliary colic, which is the most characteristic sign of cholelithiasis. Sharp pain occurs suddenly in the right hypochondrium with irradiation to the right shoulder, scapula, heart area and behind the sternum. Patients behave restlessly; at the height of the attack, vomiting appears, sometimes multiple times. The abdomen may be soft, while a sharply painful, enlarged and tense gallbladder can be palpated.
An attack of biliary colic can last several hours or 1–2 days and, when the stone passes back into the gallbladder, end suddenly. With prolonged blockage of the cystic duct and infection, destructive cholecystitis develops.
Perforated cholecystitis occurs with symptoms of local or diffuse peritonitis. The moment of perforation of the gallbladder may go unnoticed by the patient. If neighboring organs are soldered to the gallbladder - the greater omentum, hepatoduodenal ligament, transverse colon and its mesentery, i.e. the process is limited, then complications such as subhepatic abscess and local limited peritonitis develop.
Acute cholecystitis, complicated by damage to the bile ducts, can occur with clinical manifestations of choledocholithiasis, cholangitis, stricture of the common bile duct, papillitis, stenosis of the papilla of Vater. The main symptom of this form is obstructive jaundice, the most common cause of which is stones of the common bile duct obstructing its lumen.
When the common bile duct is blocked by a stone, the disease begins with acute pain, characteristic of acute calculous cholecystitis, with typical irradiation. Then, after a few hours or the next day, obstructive jaundice appears, becoming persistent, accompanied by severe itching, dark urine and discolored (acholic) putty-like feces.
As a result of infection and its spread to the bile ducts, symptoms of acute cholangitis develop. Acute purulent cholangitis is characterized by symptoms of severe intoxication - general weakness, lack of appetite, icteric discoloration of the skin and mucous membranes. Constant dull pain in the right hypochondrium with irradiation to the right half of the back, heaviness in the area of the right hypochondrium, when tapping along the right costal arch - sharp pain. Body temperature rises in a remitting manner, with profuse sweating and chills. The tongue is dry and coated. On palpation, the liver is enlarged, painful, and has a soft consistency. Leukocytosis with a shift of the leukocyte formula to the left is noted. In a biochemical blood test, an increase in the content of direct bilirubin and a decrease in the content of prothrombin in the blood plasma is observed. The disease can be complicated by life-threatening cholemic bleeding and liver failure.
Differential diagnosis. Acute cholecystitis must be differentiated from a perforated gastric and duodenal ulcer, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, kidney stones localized in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia.
Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Biliary dyskinesia is a violation of their physiological functions, leading to stagnation of bile in them, and subsequently to disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the closing apparatus of the lower end of the common bile duct.
TO dyskinesia include:
1) atonic and hypotonic gallbladders;
2) hypertensive gall bladders;
3) hypertension and spasm of the sphincter of Oddi;
4) atony and insufficiency of the sphincter of Oddi.
The use of cholangiography before surgery makes it possible to recognize the main types of these disorders in patients.
Duodenal intubation makes it possible to establish a diagnosis of atonic gallbladder if there is an abnormally abundant flow of intensely colored bile, occurring immediately or only after the second or third administration of magnesium sulfate.
When cholecystography is performed with the patient lying on his stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile collects.
When a diagnosis of “acute cholecystitis” is made, the patient must be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out for health reasons in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, emergency operations - if vigorous conservative treatment is unsuccessful during the first 24 - 48 hours from the onset of the disease.
Operations are performed within 5 to 14 days and later when an attack of acute cholecystitis subsides and an improvement in the patient’s condition is observed, i.e. in the phase of decreasing the severity of the inflammatory process.
The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.
Indications for choledochotomy are obstructive jaundice, cholangitis, obstruction of patency in the distal parts of the common bile duct, stones in the ducts.
A blind suture of the common bile duct is possible with full confidence in the patency of the duct and, as a rule, with single large stones. External drainage of the common bile and hepatic ducts is indicated in cases of cholangitis with patency of the distal duct.
Indications for the application of biliodigestive anastomosis are lack of confidence in the patency of the papilla of Vater, indurative pancreatitis, and the presence of multiple small stones in the ducts in patients. Biliodigestive anastomosis can be performed in the absence of pronounced inflammatory changes in the anastomosed organs by a highly qualified surgeon. In other conditions, one should limit oneself to external drainage of the biliary tract.
Management of patients in the postoperative period must be strictly individualized. You are allowed to get up after 24 hours; you are discharged and the stitches are removed after about 10 to 12 days.
SCIENTIFIC LIBRARY - ABSTRACTS - Surgery (Acute cholecystitis)
Surgery (Acute cholecystitis)
RUSSIAN STATE
MEDICAL UNIVERSITY
Department of Hospital Surgery
Head Department Professor Nesterenko Yu.P.
Teacher Andreytseva O.I.
Topic: “Acute cholecystitis.”
Completed by a fifth year student
Faculty of Medicine
511a gr. Krat V.B.
Acute cholecystitis is an inflammatory process in the extrahepatic tracts
with predominant damage to the gallbladder, in which
there is a violation of the nervous regulation of the liver and bile glands
pathways for production, as well as changes in the bile ducts themselves to
due to inflammation, bile stagnation and cholesterolemia.
Depending on the pathoanatomical changes, there are
catarrhal, phlegmonous, gangrenous and perforated cholecystitis.
The most common complications of acute cholecystitis are
encysted and diffuse purulent peritonitis, cholangitis, pancreatitis,
liver abscesses. In acute calculous cholecystitis, it may
there is partial or complete blockage of the common bile duct
with the development of obstructive jaundice.
There are acute cholecystitis that developed for the first time (primary
acute cholecystitis) or due to chronic cholecystitis (acute
recurrent cholecystitis). For practical use you can
I Acute primary cholecystitis (calculous, acalculous): a)
complicated cholecystitis (peritonitis, cholangitis, obstruction
II Acute secondary cholecystitis (calculous and acalculous): a)
simple; b) phlegmonous; c) gangrenous; d) perforative; d)
complicated (peritonitis, cholangitis, pancreatitis, obstruction
biliary tract, liver abscess, etc.).
Etiology and pathogenesis of acute cholecystitis:
An inflammatory process in the wall of the gallbladder can be
caused not only by the microorganism, but also by a certain composition of the food,
allergic and autoimmune processes. At the same time, the covering epithelium
restructures into goblet-shaped and mucous membranes, which produce large amounts of
the amount of mucus, the columnar epithelium becomes flattened, they lose
microvilli, absorption processes are disrupted. In the niches of the mucosa
absorption of water and electrolytes occurs, and colloidal solutions of mucus
turn into gel. Lumps of gel slip out of the bladder when the bladder contracts.
niches and stick together, forming the rudiments of gallstones. Then the stones grow and
saturate the center with pigment.
The main reasons for the development of the inflammatory process in the wall
gallbladder is the presence of microflora in the bladder cavity and
violation of the outflow of bile. The main importance is given to infection.
Pathogenic microorganisms can enter the bladder in three ways:
hematogenous, lymphogenous, enterogenous. Most often in the gallbladder
detect the following organisms: E.coli, Staphylococcus,
The second reason for the development of the inflammatory process in the gallbladder
bladder is a violation of the outflow of bile and its stagnation. Wherein
mechanical factors play a role - stones in the gall bladder or its
ducts, kinks of the elongated and convoluted cystic duct, its
narrowing Against the background of cholelithiasis, according to statistics,
occurs in up to 85-90% of cases of acute cholecystitis. If in the wall
sclerosis or atrophy develops in the bladder, then the contractile and
drainage functions of the gallbladder, which leads to more severe
the course of cholecystitis with deep morphological disorders.
Vascular vessels play an unconditional role in the development of cholecystitis.
changes in the bladder wall. On the degree of circulatory disturbance
the rate of development of inflammation, as well as morphological disorders, depend
in the wall.
Clinic of acute cholecystitis:
The clinical picture of acute cholecystitis depends on the pathoanatomical
changes in the gallbladder, duration and course of the disease,
the presence of complications and reactivity of the body. The disease is usually
begins with an attack of pain in the gallbladder area. Pain
radiate to the area of the right shoulder, right supraclavicular space
and the right scapula, in the right subclavian region. Pain attack
accompanied by nausea and vomiting mixed with bile. Usually,
vomiting does not bring relief.
The temperature rises to 38-39 (C, sometimes with chills. In persons
elderly and senile severe destructive cholecystitis
may occur with a slight increase in temperature and moderate
leukocytosis. With simple cholecystitis, the pulse increases accordingly
temperature, with destructive and, especially, perforative
cholecystitis with the development of peritonitis, tachycardia up to 100-120 is noted
beats per minute.
During examination, patients have icteric sclera; pronounced
jaundice occurs when the patency of the common bile duct is obstructed
due to stone obstruction or inflammatory changes.
The abdomen is painful on palpation in the area of the right hypochondrium. IN
muscle tension and symptoms of irritation are determined in the same area
peritoneum, especially pronounced in destructive cholecystitis and
development of peritonitis.
There is pain when tapping on the right costal arch
(Grekov-Ortner symptom), pain when pressing or tapping in
area of the gallbladder (Zakharyin’s symptom) and with deep
palpation when the patient inhales (Obraztsov’s symptom). The patient cannot
take a deep breath with deep palpation in the right
hypochondrium. Characterized by pain on palpation in the right
supraclavicular region (Georgievsky's symptom).
In the initial stages of the disease, with careful palpation you can
identify an enlarged, tense and painful gallbladder.
The latter is especially well contoured during the development of acute
cholecystitis due to hydrocele of the gallbladder. For gangrenous
perforated cholecystitis due to severe muscle tension
anterior abdominal wall, as well as during exacerbation of sclerosing
cholecystitis, the gallbladder cannot be palpated. For severe
destructive cholecystitis there is a sharp pain during
superficial palpation in the area of the right hypochondrium, lung
tapping and pressing on the right costal arch.
A blood test reveals neutrophilic leukocytosis (10 –
20 x 109/l), with jaundice hyperbilirubinemia.
The course of acute simple primary acalculous cholecystitis in
30-50% of cases end in recovery within 5-10 days
after the onset of the disease. Although acute cholecystitis may occur
very difficult with rapid development of gangrene and bladder perforation,
especially in elderly and senile people. During exacerbation
stones can contribute to chronic calculous cholecystitis
faster destruction of the bladder wall due to stagnation and
formation of bedsores.
However, much more often inflammatory changes increase
gradually, over 2-3 days, the nature of the clinical
course with progression or subsidence of inflammatory changes.
Therefore, there is usually sufficient time to assess the flow
inflammatory process, patient's condition and justified method
Differential diagnosis:
Acute cholecystitis is differentiated from the following diseases:
1) Acute appendicitis. In acute appendicitis, the pain is not so
intense, and, most importantly, does not radiate to the right shoulder, right shoulder blade and
etc. Acute appendicitis is also characterized by migration of pain from
epigastrium in the right iliac region or throughout the abdomen, with
cholecystitis pain is precisely localized in the right hypochondrium; vomiting when
appendicitis single. Usually there is a lump on palpation
gallbladder consistency and local abdominal muscle tension
walls. Ortner's and Murphy's signs are often positive.
2) Acute pancreatitis. This disease is characterized by shingles
the nature of the pain, sharp pain in the epigastrium. Noted
positive symptom of Mayo-Robson. Characteristically serious condition
patient, he takes a forced position. Decisive when
diagnosis has the level of diastase in urine and blood serum,
figures over 512 units are evident. (in urine).
With stones in the pancreatic duct, pain is usually localized in
left hypochondrium.
3) Acute intestinal obstruction. For acute intestinal obstruction
pain is cramping, non-localized. There is no increase in temperature.
Increased peristalsis, sound phenomena (“splashing noise”),
X-ray signs of obstruction (Kloiber cups, arcades,
symptom of pinnateness) are absent in acute cholecystitis.
4) Acute obstruction of the mesenteric arteries. With this pathology there are
severe pain of a constant nature, but usually with distinct
enhancements, are less diffuse in nature than with cholecystitis (more
diffuse). A history of cardiovascular pathology is required.
vascular system. The abdomen is well accessible for palpation, without pronounced
symptoms of peritoneal irritation. Fluoroscopy is decisive and
angiography.
5) Perforated ulcer of the stomach and duodenum. More often than not
Men are affected, while cholecystitis most often affects women.
Cholecystitis is characterized by intolerance to fatty foods, frequent
nausea and malaise, which does not happen with a perforated stomach ulcer and
duodenum; pain is localized in the right hypochondrium and
radiate to the right scapula, etc., with an ulcer the pain radiates mainly
in the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). clarify
a picture of a history of ulcers and tarry stools.
X-ray reveals free gas in the abdominal cavity.
6) Renal colic. Pay attention to the urological history. Thoroughly
the kidney area is examined, Pasternatsky’s symptom is positive,
urine analysis, excretory urography, chromocystography for clarification
diagnosis, since renal colic often provokes biliary colic.
Correct assessment of the patient’s condition and the course of the disease during
acute cholecystitis requires clinical experience and careful
monitoring the patient's condition, repeated studies of the number
leukocytes and leukocyte formula, taking into account the dynamics of local and
general symptoms.
In patients with a primary attack of acute cholecystitis, surgery
indicated only for extremely severe disease, rapid
development of destructive processes in the gallbladder. With fast
subsidence of the inflammatory process, with catarrhal cholecystitis
operation is not shown.
Conservative treatment of patients consists of using
broad-spectrum antibiotics, detoxification therapy.
To relieve pain, it is advisable to carry out a course of therapy
atropine, no-spa, papaverine, and also block the round ligament
liver or perinephric novocaine blockade according to Vishnevsky.
Surgical treatment of cholecystitis is one of the most
difficult sections of abdominal surgery, which is explained by the complexity
pathological processes, involvement in the inflammatory process
biliary tract, the development of angiocholitis, pancreatitis, paravesical and
intrahepatic abscesses, peritonitis and a frequent combination
cholecystitis with choledocholithiasis, obstructive jaundice.
During the first 24-72 hours after admission, it is indicated
emergency surgery for those patients with acute cholecystitis who have
the disease worsens despite vigorous treatment with
the use of antibiotics. Early surgery is indicated after subsidence
inflammatory process 7-10 days after the onset of the attack,
patients suffering from acute calculous cholecystitis, exacerbation
chronic cholecystitis with severe and frequently recurring
attacks of the disease. Early surgery contributes to the fastest
recovery of patients and prevention of possible complications in
conservative treatment.
In acute cholecystitis, cholecystectomy is indicated, in the presence of
obstruction of the bile ducts - cholecystectomy in combination with
choledochotomy. In very serious condition of patients,
cholecystotomy. Operations can be performed laparoscopically
method and standard methods with laparotomy.
Laparoscopic operations are performed under local anesthesia. Incision
4-6 cm long, carried out above the bottom of the gallbladder, parallel to the costal
arc. The tissues of the abdominal wall are layered and pulled apart. Output to
wound the wall of the gallbladder, puncture the contents. Gall
the bubble is removed. The bladder cavity is inspected. Moreover, after finishing
X-ray and endoscopic examinations insert plastic
drainage, purse string sutures are applied. The wound is sutured.
Operations requiring standard laparotomy: cholecystotomy,
cholecystostomy, choledochotomy, choledochoduodenostomy.
Accesses: 1) according to Kocher;
2) according to Fedorov;
3) transrectal mini-access 4 cm long.
Cholecystotomy is the application of an external fistula to the gallbladder. At
In this operation, the bottom of the gallbladder is sewn into the wound so that it is
isolated from the abdominal cavity, and opened immediately or the next day,
when adhesions form between the walls of the bladder and the edges of the cut.
This operation is performed as the first stage of surgery in older people
about acute cholecystitis. Subsequent production is required
cholecystectomy to eliminate the biliary fistula.
Cholecystostomy - opening of the gallbladder, removal of the gallbladder
and sewing it up tightly. This operation is performed in weakened
patients with cardiac and respiratory disorders who
a more complex operation may be life threatening. This operation
can give subsequent relapses, as it remains pathologically
altered gallbladder, which serves as a site for the development of infection and formation
new stones. To prevent complications after surgery, it is more beneficial
insert and seal tightly in the bubble a thin rubber drainage.
Cholecystectomy - removal of the gallbladder, most often
In typical cases, the operation is performed in two ways: 1) from the neck; 2) from
Fundal cholecystectomy is technically simpler, but is used less frequently due to
the possibility of leakage of purulent contents into the common bile duct. When selected from
The bottom of the bladder is grabbed with a window clamp, and the peritoneum is incised on the sides
and in a blunt or sharp way separate the bladder from the liver, capturing and
tying individual branches of a. cystica. By separating the bubble from the bed
liver, the main branch of the cystic artery and the cystic duct are ligated. At
In the presence of powerful adhesions, the method of isolation from the bottom is simpler, but bleeding from
branches of the cystic artery somewhat complicates the operation, since when
if bleeding vessels are caught deep in the wound, they can be bandaged
the right hepatic duct passing near the cystic artery.
Cholecystectomy from the cervix is more difficult. First in Calot's triangle
The cystic duct and cystic artery are ligated. Then they start separating
bladder, in order to then peritonize its bed. It is acceptable to leave parts
mucous membrane of the bladder in its bed.
In cases where sclerotic and
surrounded by powerful adhesions of the gallbladder, when finding the neck and
duct encounters insurmountable difficulties, opening the bladder is used to
throughout its entire length and burning out the mucous membrane by electrocoagulation. After
burning out the mucous membrane, the remaining wall of the bladder is turned inward and stitched
with catgut sutures over the scab. Burning of the mucous membrane occurs in severe cases
In cases, there is an advantage over acute removal of the bladder. This operation
is called mucoclasis (according to Primbau).
Choledochotomy is an operation used for examination,
drainage, removal of stones from the duct. The duct is drained for cholangitis
to drain the infected duct contents out. There are three
types of choledochotomy: supraduodenal, retroduodenal and
transduodenal.
After removing the stone, the duct is carefully sutured with thin catgut
with sutures and closed with a second row of sutures placed on the peritoneum. In place
opening of the duct, a tampon is placed, since with the most careful suturing
bile may leak between the sutures and cause biliary peritonitis.
Choledochoduodenostomy - the formation of an anastomosis between the bile duct and
duodenum. This operation is performed when there are narrowings or
impassable strictures of the bile duct. As a disadvantage
choledochoduodenostomy, it is necessary to note the possibility of entry into the duodenal
contents into the duct. However, experience shows that with normal outflow
bile this is not accompanied by dangerous consequences. Short-term
outbreaks of biliary tract infections are treated with antibiotics.
In the postoperative period, prevention of acute
cholecystitis, correction of coagulation and fibrinolytic systems, water
salt and protein metabolism, prevent thromboembolic and
cardiopulmonary complications.
From the second day they begin feeding liquid food through the mouth. At 5-
on the th day, a narrow tampon facing the bed is removed and replaced with another
bubble, leaving in place a wide delimiting tampon, which is 5-6-
1st day is pulled up and removed with a smooth flow on the 8-10th day. K 14
day, usually the discharge from the wound stops, and the wound itself
closes. After removal of the gallbladder, patients are recommended
dieting.
Improving the results of treatment of patients with acute cholecystitis depends
from more active surgical treatment. Cholecystectomy,
performed in a timely manner according to sufficient indications, saves patients
from severe complications and prolonged suffering.
Literature:
1. Avdey L. V. “Clinic and treatment of cholecystitis”, Minsk, Gosizdat, 1963
2. Galkin V.A., Lindenbraten L.A., Loginov A.S. “Recognition and treatment
cholecystitis”, M., Medicine, 1983;
3. Savelyev V. S. "Guidelines for emergency surgery of the abdominal organs
cavities", M., 1986;
4. Smirnov E.V. “Surgical operations on the biliary tract”, L., Medicine,
5. Skripnichenko D.F. "Emergency Abdominal Surgery", Kyiv,
“Health”, 1974;
6. Hegglin R. "Differential diagnosis of internal diseases", M.,
7. "Surgical diseases", edited by Iuzin M.I., Medicine, 1986
Acute cholecystitis, or inflammation of the gallbladder, remains one of the most common diseases encountered by the general public.
In most cases (>90%), the cystic duct is obstructed by a stone. In contrast to biliary colic, constant (and not intermittent) symptoms in the hypochondrium, fever, leukocytosis are noted, and there is also a change in the level of liver enzymes in the blood test. Following obstruction of the cystic duct, the bladder expands, resulting in subserosal, venous and lymphatic stasis, cellular infiltration, and the appearance of limited areas of ischemia. In 50-75% of cases, bacteria play a role in the development of acute cholecystitis. Among them: Escherichia coli, Klebsiella aerogenes, Streptococcus fecalis, Clostridium spp., Enterobacter spp. and Proteus spp. Antibacterial drugs used in treatment must have a sufficient spectrum of action. If left untreated, acute gangrenous cholecystitis (most often developing in patients with diabetes) may develop gallbladder perforation or sepsis, and mortality increases. Another possible complication of cholecystitis is perforation of the gallbladder into the wall of adjacent hollow organs (duodenum, jejunum or colon). In this case, a vesicointestinal fistula is formed. If the stone migrates into the intestinal lumen, gallstones may develop. In cases of untreated acute cholecystitis, gangrenous cholecystitis may develop (most often in patients with diabetes), leading to gallbladder perforation or sepsis, thereby increasing morbidity and mortality.
Symptoms of acute cholecystitis
Most patients with acute cholecystitis will have a history of abdominal symptoms that can be attributed to the bile ducts, although in some cases acute cholecystitis is the first manifestation of cholelithiasis. In all observations of acute cholecystitis, the most characteristic sign is constant pain in the right hypochondrium, symptoms of peritoneal irritation (Blumberg's symptom, Murphy's symptom). Initially, pain develops due to obstruction of the cystic duct and dilatation of the gallbladder, although as inflammation, edema and ischemia develop, pain is caused by irritation of the peritoneum. As with biliary colic, pain is usually localized in the right hypochondrium, but can also develop in the epigastrium, and sometimes radiate to the shoulder and back. Unlike the pain of biliary colic, which usually lasts only a few hours, the pain of acute cholecystitis can last for several days. However, it is worth noting that patients with both acute cholecystitis and biliary colic experience nausea, vomiting and anorexia.
An objective examination of acute cholecystitis usually reveals an elevated temperature. Often an inflamed bladder may be palpated as a tender, swollen mass, but this is not always the case. Diabetic patients, in particular, may have severe cholecystitis with minimal findings on physical examination. Murphy's symptom is considered positive when there is a sudden increase in pain during palpation in the right hypochondrium during inspiration, which is caused by contact of the inflamed gallbladder with the anterior abdominal wall, which is deflected by the palpating hand. Patients often hold their breath mid-inhalation. A similar phenomenon during the right upper quadrant is called an ultrasound Murphy sign (the role of the palpating hand is performed by the sensor).
Diagnosis of acute cholecystitis
Laboratory test data for acute cholecystitis reveal leukocytosis, increased AST and ALT, and alkaline phosphatase. Usually the level of total bilirubin increases slightly (1-2 times), although a significant increase (>2 times) may indicate concomitant obstruction of the common bile duct. Surprisingly, when the disease is detected in patients, even at a very late stage, the biochemical blood test can remain completely normal.
The two most common imaging modalities used in the diagnosis of acute cholecystitis are abdominal ultrasound and biliocintigraphy. Simple x-ray examination is of limited use because only about 15% of gallstones are radiopaque and the gallbladder is not visible at all. An ultrasound is usually performed first. It provides answers to the following questions: “Are gallstones present?”, “Is the gallbladder dilated?”, “Is there thickening of the gallbladder wall and/or the presence of peri-vesical fluid?” and “Are the intrahepatic or extrahepatic ducts dilated?” The main criterion for establishing the diagnosis of cholecystitis is often considered to be thickening of the bladder wall. As a result of such examination, many false positive and false negative results arise. For example, in patients with low serum albumin and a normal gallbladder, paravesical fluid may be detected as a result of anasarca in the absence of inflammation. In addition, patients with severe cholecystitis may have normal gallbladder wall thickness on ultrasound. The most reliable symptoms of the disease that can be detected using ultrasound are stones, enlarged gallbladder and ultrasound Murphy's sign. It is also necessary to always determine the diameter of the extrahepatic ducts to exclude choledocholithiasis.
For patients in whom the diagnosis of acute cholecystitis is questionable, a radioisotope study is performed. If there is no obstruction of the cystic duct, the extrahepatic bile ducts and bladder are identified). If there is an obstruction, the gallbladder will not be visible. The method is very sensitive in patients who have recently eaten, but has a 10-15% false positive rate when fasting for several days. Therefore, its use in the intensive care unit is somewhat limited. In patients with typical acute cholecystitis confirmed by ultrasound, this diagnostic method is not used.
Differential diagnosis
Acute cholecystitis can mimic a number of other acute diseases of the abdominal cavity, such as perforated gastric ulcer, small intestinal obstruction, hepatitis, etc. In addition, differential diagnosis is carried out with pneumonia, ischemic heart disease and herpes zoster (shingles). Usually, a careful history and examination can confirm the diagnosis. Increased serum amylase, sometimes occurring in acute cholecystitis, can make differential diagnosis with pancreatitis difficult. In this case, it is necessary to perform a CT scan of the abdominal organs.
Treatment of acute cholecystitis
Patients with suspected acute cholecystitis should be hospitalized. They are prescribed fasting and infusion therapy. If the diagnosis is confirmed, broad-spectrum intravenous administration is necessary.
In the absence of contraindications (coronary artery disease, pancreatitis), cholecystectomy is performed within 24-36 hours. If the patient seeks help late (after 4-5 days), treatment should be started with antibiotics and laparoscopic surgery should be delayed for 6 weeks. Since the inflammatory process is most pronounced between 72 hours and 1 week from the onset of the disease, success is questioned, and one is inclined to choose open surgery. Except in very low-risk patients, gallbladder removal is always necessary. Such patients can undergo percutaneous cholecystostomy under ultrasound guidance and local anesthesia.
Crushing stones
Extracorporeal shock wave lithotripsy has previously been used to treat gallstone disease. The essence of the method is the effect of a shock wave on the stone. The goal was to break the stones into pieces (approximately 5 mm) that could pass through the cystic duct and sphincter of Oddi. Unfortunately, the effectiveness rate was low and the complication rate was high, so the method was discontinued.
Treatment of acute cholecystitis complicated by biliary pancreatitis
The timing of cholecystectomy depends entirely on the clinical course of the disease. Patients with mild or moderate disease are usually evaluated first. If the symptoms of gallstone pancreatitis subside within the first 48 hours, laparoscopic cholecystectomy is usually performed. If pancreatitis is accompanied by jaundice, then it is performed to exclude common bile duct stones. In addition, if the patient's condition worsens within 48 hours, ERCP is also performed to look for a stone in the ampulla of Vater's papilla. The procedure is performed carefully due to the risk of worsening pancreatitis. As soon as the obstruction (if it has been) is eliminated, treatment begins according to generally accepted principles. When the pancreatitis has resolved (this may take several weeks), the patient is discharged from the hospital and, to prevent future exacerbations of the disease, is prepared for a planned cholecystectomy in a few months.
Laparoscopic cholecystectomy for acute cholecystitis
At the 1992 NIH Consensus meeting, scientists concluded that laparoscopic cholecystectomy provides a safe and effective treatment for patients with gallstone disease and is the treatment of choice for these patients. This operation is widespread today, although the radical method in surgery of the biliary system has been used for more than a century. Previously, the procedure was very traumatic. Access was made through a midline or long incision in the right hypochondrium, which required a very long recovery period. Nowadays, minimally invasive methods are used. This allows patients to return to normal activities much earlier. With the exception of a few relative contraindications (portal hypertension, previous right hypochondrium surgery, cirrhosis), laparoscopic gallbladder removal can be performed in most patients. The advent of laparoscopic methods has made surgery of the biliary system less traumatic. However, not all patients are able to perform laparoscopic surgery. Sometimes during the operation it is necessary to additionally perform a standard laparotomy. While the percentage of transition to elective cholecystectomy is 1-2%, in patients with acute cholecystitis it varies from 5 to 10%. This number is even higher with concomitant diabetes mellitus.
Technical aspects of laparoscopic cholecystectomy
If planned laparoscopic cholecystectomy proceeds without complications, then it can be used. No special bowel preparation is required before surgery. After induction of anesthesia, the patient is placed on the operating table in a supine position. A gastric tube should be inserted for decompression and removed at the end of the operation. Bladder catheterization is not required if an open trocar placement method is used. The abdomen is processed and draped in the usual manner. A small incision is made under the navel down to the fascia. Next, the fascia is grasped with Kocher forceps, lifted and incised. A trocar (usually 10 mm) is inserted and secured. Carbon dioxide is injected at low pressure (15 mmHg). Then three trocars are inserted in the right hypochondrium. They use instruments designed exclusively for laparoscopic surgery. The gallbladder is removed from the edge of the liver, and manipulations begin in the Kahlo triangle. After careful isolation, revision, and clipping of the cystic duct and cystic artery, the bladder is dissected and removed from the abdominal cavity. Careful hemostasis is performed and all trocars are removed under eye control. the abdominal cavity is not carried out if there is no likelihood of postoperative bile leakage (from the bladder bed or unsuccessfully clipped cystic duct). Then the trocar insertion sites are sutured. The patient is taken to the recovery room where he is allowed to resume normal feeding once he is fully conscious to prevent aspiration. After discharge, most patients can resume normal activities 5 days after surgery.
The use of intraoperative cholangiography for laparoscopic cholecystectomy is controversial. Most surgeons use it for suspected choledochal stones if ERCP was not performed before surgery, others for all cases. Its continued use increases the cost of surgery and is not indicated to prevent biliary damage. If, however, the anatomy is unclear, cholangiography can help identify extrahepatic bile ducts. If it is performed, the cholangiogram must be correctly interpreted by both the surgeon and.
The technical aspects of identifying structures during open cholecystectomy correspond to those of the laparoscopic approach. The use of laparoscopic instrumentation and small incisions for trocars is preferable to the traditional surgical instrumentation and incision in the right upper quadrant of the abdomen or the midline approach used in open cholecystectomy.
The article was prepared and edited by: surgeon Acute inflammation of the gallbladder- one of the most common complications of capculous cholecystitis. The main reasons for the development of an acute inflammatory process in the wall of the gallbladder are the presence of microflora in the lumen of the bladder and a violation of the outflow of bile. The microflora enters the gallbladder ascendingly from the duodenum, less often - descendingly from the liver, where microorganisms enter through the lymphogenous and hematogenous routes. Already in the chronic form of inflammation, bile contains microorganisms, but acute inflammation does not occur in all patients. The leading factor in the development of acute cholecystitis is a violation of the outflow of bile from the gallbladder, which occurs when a stone occludes the neck of the gallbladder or the cystic duct. Of secondary importance in the development of acute inflammation are impaired blood supply to the gallbladder wall during atherosclerosis of the visceral branches of the abdominal aorta and the damaging effect of pancreatic juice on the mucous membrane of the gallbladder during reflux of pancreatic secretions into the bile ducts.Clinic of acute cholecystitis
Highlight catarrhal, phlegmonous And gangrenous (with perforation gallbladder and without) clinical forms of acute cholecystitis Catarrhal cholecystitis is characterized by the presence of intense, constant pain in the right hypochondrium and epigastric region. The pain radiates to the right shoulder blade, lumbar region, shoulder girdle, right half of the neck. At the beginning of the development of acute catarrhal cholecystitis, the pain can be paroxysmal in nature due to increased contraction of the gallbladder wall, aimed at eliminating occlusion of the bladder neck or cystic duct. Vomiting of gastric contents often occurs, and then the contents of the duodenum, which does not bring relief to the patient. Body temperature rises to subfebrile. Moderate tachycardia (up to 100 per minute) and sometimes increased blood pressure are observed. The tongue is moist, covered with a whitish or gray coating. The stomach participates in the act of breathing, its right half lags behind somewhat. When palpating the abdomen, sharp pain occurs in the right hypochondrium, especially in the area of the gallbladder projection. Tension of the abdominal wall muscles is expressed insignificantly or completely absent. Positive symptoms of Ortner - Grekov, Murphy, Mussi-Georgievsky are determined.Sometimes it is possible to palpate an enlarged, moderately painful gallbladder. The blood test showed moderate leukocytosis (10-12-109/l).
Catarrhal cholecystitis
Catarrhal cholecystitis, like hepatic colic, in most patients is provoked by errors in diet. Unlike colic, an attack of acute catarrhal cholecystitis is more prolonged (lasts several days) and is accompanied by nonspecific symptoms of inflammation (leukocytosis, increased ESR, edema and hyperemia).Phlegmonous cholecystitis
Phlegmonous cholecystitis has more pronounced clinical symptoms. The pain is much more intense than with the catarrhal form of inflammation; it intensifies with coughing, deep sighing, and changing body position. Nausea and repeated vomiting occur more often, the patient’s general condition worsens, body temperature rises to 38-38.5 ° C, and tachycardia occurs (110-120 per minute). The abdomen is somewhat swollen due to intestinal paresis; when breathing, the patient spares the right half of the abdominal wall, bowel sounds are weakened. On palpation of the abdomen, sharp pain occurs in the right hypochondrium, muscle protection is pronounced, and an inflammatory infiltrate or enlarged gall bladder can often be identified. Positive Shchetkin-Blumberg sign in the right hypochondrium. Positive symptoms of Ortner-Grekov, Murphy, Mussi-Georgievsky.In the blood test, leukocytosis (up to 20-22 109 g/l) with a shift of the leukocyte formula to the left, an increase in ESR. On macroscopic examination, the gallbladder is enlarged in size, its wall is thickened, purple-bluish in color, and there is purulent exudate mixed with bile in the lumen. On the outside wall there is a fibrinous-purulent plaque. The wall is saturated with leukocytes, purulent exudate, sometimes separate small ulcers form in the wall.
