Gallstone disease and cholecystitis. Gallstone disease (chronic stone cholecystitis)

Gallstone cholecystitis is a disease of impaired cholesterol metabolism. Therefore, the goal of dietary nutrition is to reduce cholesterol in the blood, reduce the amount of fats and easily digestible carbohydrates, lose weight if it is excess, and eliminate bile stagnation. Diet No. 5 according to Pevzner meets these requirements. Basic rules:

1. Fractional meals in small portions. The best stimulator for the secretion of bile from the gallbladder is food. Eating 5 times a day.
2. To relieve spasm of the ducts it is necessary warm food.
3. Mineral water (such as Truskavetskaya or Essentuki No. 17) half an hour before meals, 100 ml heated to a temperature of 35 degrees. The total volume of drinking water should be at least two liters, as water reduces the concentration of bile.
4. Cholesterol should not come from food. Therefore, the following are prohibited: fatty meat, cod liver, brains. As well as lard, lamb, beef fat, liver and heart.
5. To remove cholesterol from the body, you need foods with magnesium - porridge from oats, buckwheat, millet, legumes (without exacerbation), vegetables, fruits.
6. Bile acids can dissolve fats. Their production is stimulated by fish, meat, cottage cheese, egg whites, and vegetable oil.
7. Vitamin A, which is found in fish and cream, helps prevent the formation of stones. Carotene (provitamin A) is found in pumpkin, carrots, dried apricots and parsley.
8. There must be bile alkaline reaction so that cholesterol does not precipitate. For this you need calcium from cottage cheese, kefir, yogurt and vegetables, berries, fruits.
9. Constipation should be avoided. Beetroot, prunes, honey, and pumpkin stimulate the intestines. As well as plums, apricots, fresh kefir, curdled milk and yogurt.

Prohibited foods for gallbladder diseases

At all stages of the disease, restrictions are imposed on products that excessively irritate the gallbladder, and an existing stone can provoke an exacerbation in the form of pain attack and blockage of the common bile duct. The diet for cholecystitis of the gallbladder excludes the use of:

• Flour products– baked goods, puff pastry, all fresh baked goods.
• Meat, mushroom or fish broths.
• Any fried, fatty or spicy food.
• Beef fat, pork fat, lard, margarine.
• Liver, brain, kidneys, heart.
• Sausages, smoked and dried meat, sausages and small sausages.
• Fatty fish - trout, tuna, mackerel, sardines.
• Canned fish, salted and dried fish.
• Sour fruits and berries.
• Radishes, radishes, spinach, raw onion and garlic.
• Alcohol.
• Confectionery, cream cakes, chocolate, cocoa.
• Any store-bought sauces, horseradish, vinegar, pepper.

Diet 5b and 5a for exacerbation of cholecystitis

Allowed foods and diet menu No. 5

Gallstone cholecystitis outside the acute stage is usually treated at home, the diet is expanded by adding foods and cooking methods. This diet must be followed for a long time, at least a year. The diet includes:

• Vegetable and cereal soups, borscht and cabbage soup are vegetarian. You can prepare milk soups with pasta.
• From minced meat Meatballs and cutlets are prepared, meat can be boiled and then baked, boiled meat is added to pilaf, and vegetables are stuffed with it. Lean beef, turkey, chicken and rabbit are used.
• Fish is recommended from low-fat varieties: pike, hake, sea or river perch, pike perch. Prepare meatballs, steam cutlets, dumplings or boil them in pieces.
• Vegetables are used to make salads, boiled or baked. You can only add boiled onions. It is recommended to season salads with olive oil and sour cream. You can eat non-acidic sauerkraut, young green peas.
• Dairy products are recommended to be consumed fresh; fermented milk drinks are best prepared at home. Cottage cheese, kefir, yogurt, sour cream, mild cheese are allowed.
• You can make a steamed omelet from eggs; it is permissible to add no more than half of the yolk to the dish per day.
• Cereals are allowed for preparing porridges, casseroles, and first courses. Buckwheat and oatmeal are especially recommended; vermicelli and pasta can be included in casseroles or eaten boiled.
• Drinks include tea with milk, chicory, vegetable and fruit juices, and prepare rosehip infusion. To do this, pour 10 crushed fruits into a thermos with a glass of boiling water overnight. Drink 100 ml.
• Fruits are allowed fresh and in compotes, jelly and mousses.
• For sweets, you can eat marshmallows, marmalade, honey, dried fruits and jam.
• The bread must be yesterday's baked wheat bread. You can eat dry biscuits and cookies.

Diet menu No. 5 for gallstone disease and chronic cholecystitis:

Breakfast: buckwheat porridge with prunes, compote.
Second breakfast: cottage cheese casserole with raisins and candied fruits, jelly.
Lunch: vegetarian borscht, cucumber, tomato and feta salad with herbs, beef cutlets and wheat porridge.
Afternoon snack: pumpkin porridge with rice and jelly.
Dinner: boiled cod, vinaigrette with seaweed, rosehip infusion.
Before bed: yogurt with steamed dried apricots.

Magnesium diet, menu

A special magnesium diet has been developed for patients with chronic calculous cholecystitis. The diet uses an increased dose of magnesium - four times more than in a regular diet. The diet consists of three menus, each of which is prescribed for 3-4 days. When followed, spasm decreases bile ducts, the outflow of bile improves. It is useful if you are prone to constipation. Diet features:

• The first courses are prepared with bran decoction.
• Ground bran is added to porridges during cooking.
• Table salt is excluded; 30 g of sugar and 250 g of bran bread per day are allowed.
• Meat and fish broths are prohibited.
• The diet contains 100 g of protein, 450 g of carbohydrates, 80 g of fat, 1300 mg of magnesium, vitamins A, B1 and ascorbic acid. Total calorie content is within 2850 kcal.

Breakfast: buckwheat porridge with ground and dried oatmeal or wheat bran, tea with a slice of lemon.
Second breakfast: salad raw carrots with vegetable oil.
Lunch: vegetarian borscht, millet porridge with dried apricots, rosehip broth.
Afternoon snack: apricot juice.
Dinner: cottage cheese soufflé and tea with lemon.
Before bed: rosehip decoction.

Breakfast: oatmeal with milk, tea with lemon.
Second breakfast: steamed prunes.
Lunch: vegetarian cabbage soup, boiled beef, boiled beet salad with vegetable oil, apples.
Afternoon snack: grated carrots with apple, rosehip infusion.
Dinner: buckwheat and cottage cheese casserole, tea with lemon.
Before bed: carrot juice.

Breakfast: wheat porridge, carrot salad, tea.
Second breakfast: steamed dried apricots, rye bran decoction.
Lunch: oatmeal soup with vegetables, boiled chicken with stewed cabbage, rosehip decoction.
Afternoon snack: apples.
Dinner: carrot and apple cutlets, cottage cheese soufflé, tea.
Before bed: tomato juice.

Konstantin Viktorovich Puchkov - Doctor of Medical Sciences, Professor, Director of the ANO "Center for Clinical and Experimental Surgery" (Moscow). Certified in the following specialties: surgery, gynecology, urology, coloproctology and oncology

Chronic calculous cholecystitis (cholecystitis, synonymous with cholelithiasis, cholelithiasis)- chronic inflammatory disease of the biliary tract, accompanied by the formation of stones (calculi) in gallbladder and bile ducts. In a narrower sense, the term chronic calculous cholecystitis is used to identify stones in the gallbladder, and the term choledocholithiasis is used to identify stones only in the common bile duct.

Prevalence of chronic calculous cholecystitis.

Since the middle of the 20th century, the number of patients with CC has doubled every 10 years and amounts to about 10% of the population of most developed countries: in our country, about 15 million people suffer from CC; in the USA - over 30 million people. Among patients over 45 years of age, gallstone disease occurs in every third person. As a result, the number of operations for cholecystectomy in the USA in the 70s annually amounted to more than 250 thousand, in the 80s - more than 400 thousand, and in the 90s - up to 500 thousand. Now in the USA the number of cholecystectomies and operations on the biliary ways is about 1.5 million per year and exceeds the number of all other abdominal interventions (including appendectomy).

Rice. 1. Pathological anatomy biliary tract with cholelithiasis - stones in the gall bladder and obstruction of the cystic duct by one of them (diagram).

Rice. 2. Stages of laparoscopic cholecystectomy - clipping of the cystic duct and artery.

Rice. 3. Stage of laparoscopic cholecystectomy - intersection of the artery and duct and isolation of the gallbladder from the liver bed.

Rice. 4. Front view abdominal wall with open cholecystectomy - suture after laparotomy.

Rice. 5. View of the anterior abdominal wall during laparoscopic cholecystectomy - 4 punctures.

Rice. 6. Scheme of laparoscopic transvaginal cholecystectomy using N.O.T.E.S. technology.

Rice. 7. View of the anterior abdominal wall during laparoscopic cholecystectomy using SILS technology.

Causes of development of chronic calculous cholecystitis.

Among the risk factors for the incidence of chronic cholecystitis, the authors note age, female gender, pregnancy and childbirth, overweight and obesity, rapid weight loss, total parenteral nutrition, fasting, family history (simple dominance of lithogenic genes, enzymatic defects in the synthesis of solubilizers and cholesterol excretion), intake of certain medications (fibrate derivatives, contraceptive steroids, estrogens during postmenopause, progesterone, octreotide and its analogues, ceftriaxone), the presence of diseases such as diabetes mellitus, Crohn's disease, liver cirrhosis, biliary system infections, duodenal and choledochal diverticula.

From a practical point of view, very significant risk factors are the so-called controllable factors - obesity, overweight, as well as the use of low calorie diets or hunger to reduce weight. It has been established that CCH occurs in 33% of obese individuals. In the United States, a study was conducted over 10 years that showed that women with excess body weight (body mass index in the range of 25 - 29.9) have an increased risk of developing CC, which, along with hypertension, diabetes mellitus and coronary heart disease increases with the degree of obesity, with a BMI of more than 35 increasing the likelihood of developing the disease by 20 times, both in women (relative risk 17.0) and men (relative risk 23.4). The situation is complicated by the fact that the use of diets with a very low total calorie content, as well as a decrease in body weight by more than 24% of the original, at a rate of 1.5 kg or more per week, represents an additional risk factor for the formation of cholelithiasis.

In the mechanism of gallstone formation, important importance is attached to changes in biochemical composition bile. For the formation of gallstones, the simultaneous existence and long action factors such as oversaturation of bile with cholesterol and the formation of a crystallization nucleus, an imbalance between pronucleating and antinucleating factors, a decrease in the evacuation function of the gallbladder, as well as dysfunction of the enterohepatic circulation bile acids. The basis for the formation of cholesterol stones is the hepatic secretion of vesicles enriched with cholesterol. The mechanisms of development of the vesicles themselves and the factors controlling this process have not been sufficiently studied and are the subject of active research.

Symptoms and clinical manifestations of chronic calculous cholecystitis.

The most common symptom of CCH is pain in the right hypochondrium. The pain is relatively constant, but its intensity can fluctuate, and mild pain does not indicate mild inflammation, and vice versa, severe pain may pass without a trace. The pain associated with cholelithiasis can be cutting, stabbing in nature, and pain can radiate to the lower back, right shoulder blade, or right forearm. Sometimes the pain radiates beyond the sternum, which simulates an attack of angina (Botkin's cholecystocoronary symptom). Pain more often, but absolutely not necessarily, occurs after eating fatty and spicy foods, which require more bile for digestion and cause a strong contraction of the gallbladder. An increase in body temperature is observed in any form of cholelithiasis, including up to 37’-38’C - in the form of short rises accompanying pain; up to 38’-40’C - in the form of sharp attacks with chills and a short normalization of body temperature.

Diagnosis of chronic calculous cholecystitis.

Diagnosis of gallstone disease is based on clinical picture and instrumental examination data. To make a diagnosis of chronic calculous cholecystitis or chronic calculous cholecystitis, it is enough to perform a qualified ultrasound of the upper abdominal cavity, during which stones in the gallbladder and ducts can be identified, the size of the gallbladder, its walls, the condition of the liver and pancreas can be determined. In addition, it is necessary to perform gastroduodenoscopy to determine the condition of the mucous membrane of the esophagus, stomach and duodenum. If there are complications, it may be necessary to perform retrograde cholangiography (x-ray contrast study) or transgastric ultrasound of the bile ducts to detect choledocholithiasis.

To identify chronic calculous cholecystitis, determine the degree of inflammation in the wall of the gallbladder, as well as select the correct individual tactics for surgical treatment, you must send it to my personal email address [email protected] [email protected] copy a complete description of an ultrasound of the abdominal organs, preferably a gastroscopy, it is necessary to indicate the age and main complaints. IN in rare cases if stones in the ducts are suspected, it is necessary to perform an endoscopic ultrasound examination of the ducts and pancreas. Then I will be able to give a more accurate answer to your situation.

Treatment of chronic calculous cholecystitis.

Conservative treatment of chronic colic is carried out in the case of an asymptomatic course, as well as in cases where attacks of biliary colic, having occurred once, do not recur. The goal of conservative therapy is to reduce inflammatory process, improving the outflow of bile and motor function of the gallbladder and ducts, eliminating, if possible, metabolic disorders and concomitant diseases. In cases of long-term stones in the gall bladder, pronounced inflammatory changes in the wall of the gallbladder, obstruction of the bladder neck with stones and reactive changes in neighboring organs (chronic pancreatitis, duodenitis, cholangitis, hepatitis), conservative treatment is ineffective.

Depending on the phase of the pathological process in chronic hepatitis (biliary colic, exacerbation, remission) changes significantly medical tactics, and patients are treated respectively in the therapeutic or surgical departments of a hospital, on an outpatient basis or at a resort. During the period of remission, dietary, medicinal, physical and balneological treatment methods are indicated.
In case of constantly recurring attacks of pain and after relief of biliary colic, surgical treatment of cholelithiasis is recommended in order to avoid the development of the most dangerous complications- biliary peritonitis as a result of rupture of the gallbladder, biliary pancreatitis and mechanical jaundice as a result of the release of a gallstone into the common hepatic duct and resulting obstruction of the biliary tract.

On methods traditional medicine When treating CCH, special attention should be paid. Some patients use folk remedies that supposedly help expel stones from the gallbladder. The most commonly used folk remedies for chronic hepatitis include infusions and decoctions of various choleretic agents - dandelion root, steelweed root, peppermint leaves, trefoil leaves, St. John's wort herb, immortelle flowers, toadflax herb and others. At the same time, patients confidently say that after taking the “medicine”, stone-like, dense formations of a greenish-yellow color the size of a hazelnut are released in the stool, and they believe that these are gallstones removed from the gallbladder. In fact, these are so-called gall fecal stones - clots of bile that have entered the intestines in a significant (more than normal) quantity due to the intense action of the choleretic substance taken. The diameter of the opening of the sphincter of Oddi, which cuts off the common bile duct from the small intestine, in the maximum open state does not exceed 2–3 mm. Therefore, no stones visible to the naked eye can be released into the intestinal lumen with the help of choleretic herbs.

In essence, the therapeutic effect of any folk remedy- this is the effect of a strong choleretic agent, in which the stones themselves remain in the patient’s gall bladder. Intensive use of choleretic drugs leads to increased peristalsis of the gallbladder muscles, stones can move towards the exit and clog cystic duct, causing his swelling, and provoking an attack acute cholecystitis, and then obstructive jaundice with the development of acute pancreatitis.

Surgical methods for the treatment of chronic calculous cholecystitis.

Currently, there are two main methods of surgical treatment of chronic cholecystitis and removal of the gallbladder - traditional cholecystectomy and laparoscopic cholecystectomy.

Both operations are performed under general anesthesia; the entire gallbladder with stones is removed according to the same principle. With traditional cholecystectomy, removal of the gallbladder in patients with chronic cholecystectomy is carried out directly manually, through an incision on the abdominal wall 15–20 cm long. In the second, with special manipulators, a laparoscope and other devices through miniature centimeter incisions on the abdominal wall, transvaginally or through 1 puncture in the periumbilical region .
It should be remembered that if there is a single large or multiple small stones in the gallbladder, the gallbladder is always completely removed. Surgical technologies that allow removing stones from the gallbladder with guarantees that they do not form again have not yet been developed. As a rule, after 6 months they form again.

Since 1988, laparoscopic operations on the gallbladder have become the “gold standard” in abdominal surgery; open interventions (through an incision on the abdominal wall) are performed only in cases of complications of gallstone disease - bladder perforation and peritonitis.

Rice. 8. Patent. A method for temporary fixation of abdominal and pelvic organs during laparoscopic operations.

Puchkov K.V., Puchkov D.K. SURGERY FOR GALLSTONES: laparoscopy, minilaparoscopy, single port, transanal access, simultaneous operations.-M.: ID "MEPRACTIKA-M", 2017, 312 p.

The undoubted advantage of laparoscopic surgery is its good cosmetic effect - only 3 - 4 small incisions, each 5 - 10 mm long, remain on the skin of the abdomen. From the first day after surgery, patients begin to get out of bed, drink, and on the second day take liquid food. Discharge from the hospital occurs on the 2nd - 3rd day. The patient can begin work in 10 - 14 days.

The next breakthrough in laparoscopic technologies in the treatment of cholelithiasis was the development of transvaginal access.

Transvaginal laparoscopic cholecystectomy using N.O.T.E.S. technology

In 2007 in France, and since 2008 in Russia, a new unique technique for removing the gallbladder without punctures on the anterior abdominal wall, leaving no postoperative sutures and scars - this is transvaginal cholecystectomy using N.O.T.E.S. technology! The essence of this technique is access to the diseased organ through posterior arch vagina (puncture - 1 cm). Through a special device inserted through the posterior fornix into the abdominal cavity, laparoscopic instruments and optics are passed, then cholecystectomy is performed, as in laparoscopic surgery. Then the gallbladder is removed from the abdominal cavity also through the posterior vaginal fornix, the puncture of which is punctured with one suture made of synthetic absorbable suture material (resorption period 3–4 weeks).

Advantages of laparoscopic cholecystectomy using N.O.T.E.S. technology are as follows:

• no pain after surgery;
• maximum physical activity;
• hospitalization for only one day;
• excellent cosmetic effect.

The only restriction in the postoperative period is sexual rest for one month. It should be noted once again that transvaginal cholecystectomy does not affect the female genital organs (uterus, appendages, etc.) and does not affect their functioning. After this operation, there are no incisions left on the abdominal wall (maximum one invisible puncture in the umbilical area). The patient is discharged from the hospital the next day and begins work on days 7–10; sports are possible within two weeks.

An equally interesting and more promising method of laparoscopic cholecystectomy turned out to be single-port laparoscopic cholecystectomy through a puncture in the periumbilical region using SILS (single-port surgery) technology.

For men, as well as women who have undergone numerous operations on the pelvic organs, the method of laparoscopic treatment of cholelithiasis using transvaginal access using N.O.T.E.S. technology. (NOTES) is impossible, therefore, since 2008 in the USA, and since 2009 in Russia, another unique method of minimally invasive cholecystectomy began to be used - removal of the gallbladder through one puncture in the periumbilical area using SILS technology!

The essence of this method is to perform laparoscopic cholecystectomy through a special device (port) made of unique soft plastic, which is inserted through a single puncture in the umbilical area. The diameter of this port is 23–24 mm. Laparoscopic instruments and a 5 mm laparoscope are passed through a soft operating port. After the operation is completed, the device along with the gallbladder is removed from the abdominal cavity. A cosmetic suture is applied to a small wound in the umbilical area.

Advantages of the method of minimally invasive cholecystectomy through a single puncture in the periumbilical region using SILS technology over multi-puncture (conventional) laparoscopic access:

• reducing the number of punctures on the abdominal wall;
• reduction of pain after surgery;
• faster recovery after surgery;
• best cosmetic effect.

The maximum benefits of the SILS method are revealed with large and multiple stones in the gall bladder, since the surgeon is forced to expand the puncture in the navel area during conventional laparoscopy to remove the diseased organ with stones.

I have experience of more than 6,000 operations for chronic calculous cholecystitis performed laparoscopically. I have been doing such operations since 1994.
My personal experience is summarized in more than in 30 scientific publications in various professional peer-reviewed scientific publications in Russia and abroad.

Ask questions or schedule a consultation

“When you write a letter, know that it goes to me on my personal email. I always answer all your letters myself. I remember that you trust me with the most valuable things - your health, your destiny, your family, your loved ones, and I do everything possible to justify your trust.

Every day I spend several hours answering your letters.

By sending me a letter with a question, you can be sure that I will carefully study your situation and, if necessary, request additional medical documents.

Huge clinical experience and tens of thousands of successful operations will help me understand your problem even from a distance. Many patients require proper conservative treatment rather than surgery, while others require urgent surgery. In both cases, I outline a course of action and, if necessary, recommend additional examinations or emergency hospitalization. It is important to remember that some patients successful operation preliminary treatment of concomitant diseases and proper preoperative preparation are required.

In the letter, be sure (!) to indicate age, main complaints, place of residence, contact phone number and address email for direct communication.

So that I can answer all your questions in detail, please send along with your request scanned reports of ultrasound, CT, MRI and consultations of other specialists. After studying your case, I will send you either a detailed response or a letter with additional questions. In any case, I will try to help you and justify your trust, which is the highest value for me.

Sincerely yours,

surgeon Konstantin Puchkov"

Ministry of Health of Ukraine

Donetsk State University them. M. Gorky

Department of Hospital Surgery

CASE HISTORY

MANDZYUK ELENA MIRONOVNA.S. Housing and communal services CHRONIC CALCULOUS CHOLECYSTITIS

Curator: 5th year student,

honey. faculty, 12 groups

Khripkova E.V.

Head of the department

Doctor of Medical Sciences, Professor Miminoshvili O.I.

Teacher

Doctor of Medical Sciences, Professor Kot A.G.

Donetsk 2009

Passport part

Name: Mandzyuk Elena Mironovna

Age: 65 years

Profession: pensioner

Place of residence: Konstantinovsky district, Pleshcheevka, st. Voronikhin, 12

Date and time of admission: 03.23.09, 9.00

Referred by: surgeon of the Republic of Belarus, Konstantinovka.

Diagnosis of the referring institution: cholelithiasis. Chronic calculous cholecystitis

Diagnosis on admission: cholelithiasis. Chronic calculous cholecystitis

Clinical diagnosis: cholelithiasis. Chronic calculous cholecystitis

Blood type: B (III)

Rh factor: Rh +

Information on drug tolerance: denies allergic reactions to drugs.

Complaints: dull pain in the right hypochondrium, radiating to the right supra- and subclavian fossa, nausea, dryness, bitterness in the mouth, heartburn, constipation, general weakness.

Anamnesis morbi

Considers himself sick for about 15 years, when after plenty of intake fatty foods, the patient began to feel heaviness, sometimes dull short-term pain in the right hypochondrium, on general health this symptomatology especially affected, and therefore the patient did not seek medical help. The first episode of intense cramping pain, lasting about 4 hours, relieved after IM administration of papaverine, baralgin, or per os no-shpa, occurred about 10 years ago. Due to the fact that the attack of hepatic colic was self-limited, the patient refused hospitalization. About 5 years ago, attacks of hepatic colic became more frequent.

The last attack was on March 15, 2009 with a characteristic intense pain syndrome, nausea, vomiting, associated tachycardia, shortness of breath, which was relieved by intramuscular injections of ketanov and papaverine. On March 16, 2009, the patient was consulted by a m/f surgeon, and he was also sent for examination to the Regional Central Clinical Hospital in Donetsk. The patient was recommended surgical treatment Cholelithiasis, chronic calculous cholecystitis. 03/23/09 - hospitalization at the OC Regional Central Clinical Hospital in Donetsk.

Anamnesis vitae

Living conditions are satisfactory, food is sufficient, not rational, with a predominance of fatty foods. He does not abuse alcohol and does not smoke. Denies tuberculosis, syphilis, hepatitis, typhoid, paratyphoid, HIV and other viral diseases.

Allergic reactions to medications and foods were not observed. There have been no blood transfusions over the past 5 years.

for a year she suffered from acute intestinal infections (salmonellosis?) and refused hospitalization.

year - closed fracture of the left medial malleolus.

Since 1970 she has been suffering from varicose veins (not examined, not treated).

Status praesens objectivus

General condition moderate severity, the patient is active, adequate, clear consciousness. Body temperature 36.80 C.

Height 160 cm. Weight 78 kg. The physique is normosthenic.

The skin and visible mucous membranes are clean and pink. The skin is dry, turgor is reduced, nails and hair are brittle and dull. The tongue is dry, covered with a white coating at the root. The condition of the teeth is satisfactory, the gums, soft and hard palate are unchanged.

Subcutaneous fat is distributed unevenly, excessively on the body. Peripheral lymph nodes have normal palpation properties; mandibular, axillary, and inguinal lymph nodes are palpable. Muscle tone is normal and symmetrical. The function of the joints is preserved.

Respiratory system

Breathing through the nose, free, rhythmic, respiratory rate 17 per minute. The shape of the chest is normosthenic, the intercostal spaces are moderate, the supra- and subclavian fossae are filled, the epigastric angle is straight, the chest is symmetrical. Chest breathing type.

On palpation, the chest is painless and elastic. Voice tremors are the same in symmetrical areas of the chest.

When percussing over symmetrical areas of the chest, there is a clear pulmonary sound.

Percussion boundaries of the lungs are within the age norm.

Auscultation: vesicular breathing, no crepitus, no wheezing. Bronchophony is the same on both sides over symmetrical areas of the chest.

Cardiovascular system.

Blood pressure: 140/100 mmHg, Ps 80/min.

On examination, cyanosis and swelling of the jugular veins are not observed. At 5 m/r, 1.5 cm outward from the left midclavicular line, a high, diffuse, resistant apical impulse is palpated.

The pulse is rhythmic, well filled, symmetrical. The shins are pasty. The subcutaneous veins of the legs are varicose. On the left shin, 3 cm above the medial malleolus, there is an area of ​​induratively changed skin with subcutaneous lesions and hyperpigmentation.

Percussion: expansion 1.5 cm outward of the left border of relative cardiac dullness, right - along the right edge of the sternum at 5 m/r, upper - 3rd rib along the left midclavicular line.

Auscultation: heart sounds are clear, rhythmic, accent of 2 tones over the aorta, systolic murmur over the apex of the heart.

Urinary system.

Urination is not impaired. No pathology was detected during examination.

The kidneys are not palpable. The painful points of the ureters are calm, Pasternatsky’s symptom is symmetrically negative.

Endocrine system.

The thyroid gland is painless on palpation, normal size, elastic consistency, no nodes. Tremor of the hands and eyelids is absent. There are no signs of infantilism, hypogonadism, or eunuchoidism. The size of the nose, jaws, and ears are not increased. The sizes of the feet and palms are proportional.

Surgical status.

When examining the oral cavity, the mucous membranes are not changed, the tongue is dry with a white coating at the root.

The abdomen is enlarged due to the development of subcutaneous fat, does not participate in the act of breathing, is symmetrical, and there is no visible peristalsis.

On superficial palpation, the abdomen is painful in the right hypochondrium at the Kera point, the muscles of the anterior abdominal wall are moderately resistant, and the Shchetkin-Blumberg symptom is questionable. With deep palpation, the symptoms of Murphy, Georgievsky-Mussi, Ortner-Grekov are positive. The liver could not be palpated.

Sections of intestine with normal palpation properties.

When percussing the abdominal cavity, a tympanic sound is heard.

Rectal examination: external sphincter anus tonic, mucous membrane is calm, examination is painless. The rectal ampulla is tonic, filled with feces, the rectal-vaginal septum is painless on palpation. There are traces of brown feces on the glove without visible pathological components.

Preliminary diagnosis

Based on the patient’s complaints of pain in the right hypochondrium, nausea, dry mouth, general weakness; medical history data on poor nutrition, predominance of fatty foods, episodes of hepatic colic and duration of the disease; examination data that revealed pain in the right hypochondrium at the Kera point, moderate resistance of the muscles of the anterior abdominal wall, positive symptoms of Murphy, Ortner-Grekov, Georgievsky-Mussi can suggest cholelithiasis, chronic calculous cholecystitis, suspect ulcerative duodenal disease, chronic pancreatitis, choledocholithiasis.

Patient examination plan

General blood test.

General urine analysis.

Biochemical blood test: bilirubin, urea, amylase, creatinine.

Coagulogram.

Blood test for group affiliation, R.W.

Ultrasound examination of the abdominal organs.

Surgical treatment according to indications.

Consultation of related specialists.

Laboratory results and instrumental research

General blood test dated 23.03. 2009

IndicatorsResultsNormalHemoglobin111 g/l110.0-166.0 g/lRed blood cells4.37x1012/l3.5-5.0 * 1012/lPlatelets231*109/l180.0 - 320.0 * 109/lLeukocytes12*109/l4.0- 9.0*10 9/l Bands 9% 1-6% Segmented 76% 47-72% Lymphocytes 7% 18-40% Monocytes 5% 2-9% Basophils 0-1% Eosinophils 3% 0.5-5.0% ESR 30 mm/hour up to 15 mm/hour

Biochemical blood test

Indicators23.03. 200925.03. 2009NormalCreatinine47 mmol/l50 mmol/l44-97.2 mmol/lGlucose7.2 mmol/l5.5 mmol/l3.3-5.5 mmol/lALT198.0190.028-190 nmol/(s*l)AST170.0166, 028-166 nmol/(s*l) α- Amylase 35.3 37.6 12-32 g/(h*l) Urea 8.3 mmol/l 6.0 mmol/l 2.5 - 8.3 mmol/l Bilirubin 30.0 µmol/l direct - 18.7 µmol/l28, 0 µmol/l direct - 12.3 µmol/l 8.5-20.5 µmol/l direct - 0.86-5.1 indirect - 1.7-17.1

General urine test

Indicators 10/23/08 Norm Quantity, ml 110150 Transparency transparent transparent Reaction Sl-acid Sl-acid Color Straw-yellow Straw-yellow Density 10151015-1025 Protein Negative Leukocytes 4 p/sp 1-5 p/sp Erythrocytes non-single

Microscopic examination

Squamous epithelium 4 in p/z

Hyaline cylinders 0 in p/z

Urate salts +

Ultrasound examination from 23.03. 2009

Consultation with a cardiologist from 03.24.09

Complaints of headache, dizziness, noise in the head, chest pain.

He has been suffering from arterial hypertension for about 8 years (maximum figures are 200 and 100 mm Hg. He takes Enap at a dose of 5 mg 2 times a day. The condition is relatively satisfactory, moderate nutrition, slight swelling of the legs and feet. No wheezing. The tones are clear, rhythmic, accent 2 tones over the aorta, systolic murmur at the apex. At the time of examination, blood pressure was 140/90 mm. rt. Art.

ECG dated March 24, 2009. Conclusion: left ventricular hypertrophy with systolic overload.

Treatment:. KCl 4% - 10.0. NaCl 0.9% - 400.0 intravenously No. 3. Lasix 20 mg.

Enap 10 mg 2 times a day

Concor 2.5 mg. in the morning

Indapamide 1 tablet in the morning

Consultation with an angiosurgeon: varicose veins of the saphenous veins of the legs, CVI stage 3.

Differential diagnosis

calculous cholecystitis cholelithiasis

Differential diagnosis should be carried out with those nosological units that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis, etc.

Pain syndrome:

With cholelithiasis, chronic calculous cholecystitis - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall painful symptoms Murphy, Georgievsky-Mussi, Ortner-Grekov. Increased pain and deterioration of the condition are associated with errors in diet and intake of fatty foods.

With duodenal ulcers, the daily daily rhythm of pain, hunger - pain, eating - pain subsides, hunger - pain. On palpation there is pain in the right upper quadrant of the abdomen. The condition worsens significantly in the spring and autumn periods.

At chronic pancreatitis- pain is localized in the epigastric region, is dull in nature and radiates to the back. The pain intensifies after eating or drinking alcohol. Palpation of the abdomen usually reveals bloating, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation pain is noted at Desjardins' point or in the Choffard area. Often a painful point is detected in the left costovertebral angle (Mayo-Robson symptom). Sometimes a zone of skin hyperesthesia is determined corresponding to the zone of innervation of the 8-10 thoracic segment on the left (Kach's sign) and some atrophy of the subcutaneous fat layer in the area of ​​​​the projection of the pancreas onto the anterior abdominal wall (Groth's sign).

With choledocholithiasis - pain in upper sections abdomen, more on the right, with radiation to the back.

Dyspeptic syndrome:

With cholelithiasis, chronic calculous cholecystitis - dryness, bitterness in the mouth, nausea, sometimes vomiting, stool disorders (usually diarrhea), there is a natural connection with the intake of fatty foods. Patients are usually adequately nourished.

In case of duodenal ulcer, the symptoms are similar. Vomiting brings relief, the condition worsens with fasting. Patients are often asthenic.

For chronic pancreatitis - characteristic symptoms, there is a natural relationship with the consumption of alcohol, spicy, fried foods. Stool disorders - diarrhea, steato-amylocreatorhea. The patients are asthenic.

With cholelithiasis and choledocholithiasis, the dyspeptic syndrome is similar to chronic cholecystitis.

Laboratory data:

In case of cholelithiasis, chronic calculous cholecystitis - normal blood and urine values, there may be slight leukocytosis, ESR increases. In blood biochemistry - transaminases slightly increase, liver fraction of alkaline phosphatase, amylase may increase total bilirubin(due to direct) - cholestatic syndrome is slightly expressed.

In case of duodenal ulcer - iron deficiency, normal urine values, with exacerbation of the disease, slight leukocytosis in the CBC is possible, transaminases are within normal limits, bilirubin is normal. Cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase increases, alkaline phosphatase, transaminases may increase, dysproteinemia, in urine - normal, feces - steatorrhea, creatorrhoea, amilorrhea. Coagulogram without features.

With cholelithiasis, choledocholithiasis, slight leukocytosis is possible in the UAC, ESR increases, bilirubin is present in the urine, urobilin will be absent, and stercobilin will also be absent in feces. Feces like white clay. Biochemistry - transaminases increase sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Cholestatic syndrome is pronounced. In the coagulogram, changes include an increase in bleeding time, a decrease in the prothrombin index (lower limit of normal), and an increase in INR.

Instrumental methods: ultrasound, R ö OBP, FGDS.

In case of cholelithiasis, chronic calculous cholecystitis, the gallbladder is enlarged, the wall of the bladder is compacted, and in the lumen there is hyperechoic bile (suspension) and stones. Diffuse changes in the parenchyma of the liver and pancreas are possible. On R ö OBP - X-ray positive stones, with cholecystography - stones (filling defects), enlargement, dystopia of the gallbladder is possible. Duodenal intubation - inflammatory changes in bile (portion B).

In the case of duodenal ulcer, FGDS is used (ulcerative defect, cicatricial changes, stenosis), and pH-metry and urease test are also carried out in parallel. During duodenal intubation, inflammatory altered bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to conduct FGDS - Rö OBP with barium - detect a niche symptom.

In chronic pancreatitis, ultrasound shows diffuse changes in the gland, calcification, fibrosis, cystic changes, reduction in size of the gland, decreased patency of the Wirsung duct (inflammatory change in the wall, possible calcifications in the duct). At R ö Visualization of calcifications is possible in ABP, although this method is ineffective in verifying the diagnosis.

With cholelithiasis, choledocholithiasis, ultrasound shows diffusely altered liver, dilation of the intrahepatic ducts, stones in the common bile duct. During duodenography under conditions of artificial controlled hypotension, pathology of the organs of the pancreaticoduodenal zone is revealed. RPCG - the ability to see the external and internal hepatic ducts, as well as the pancreatic ducts. CRCP - it is possible to determine both the nature and localization of obstruction in the hepatoduodenal zone.

Clinical diagnosis

Housing and communal services Chronic calculous cholecystitis.

the patient complains of spastic pain in the right hypochondrium, nausea, dry mouth, general weakness; medical history data - repeated episodes of attacks of hepatic colic;

medical history data about poor nutrition, predominance of fatty foods;

objective examination data: subicteric sclera, dry tongue with a coating at the root, dry skin with traces of scratching, on palpation - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall, a dubious Shchetkin-Blumberg symptom, positive Murphy symptoms, Ortner, Georgievsky-Mussi.

data ultrasound examination, which revealed an enlarged liver, diffuse parenchymal changes in the liver, pancreas, chronic calculous cholecystitis, bilateral nephroptosis of the first degree on the right, second degree on the left, calcifications in the kidneys, a slight dissection of the calyces in the kidneys;

laboratory examination data: in biochemical analysis blood: increased concentration of bilirubin (due to the direct fraction), amylase, transaminase at the level of the upper limit of normal; in the CBC there is slight leukocytosis, high ESR.

Treatment plan and methods.

Mode - stationary. A diet with limited fat and easily digestible carbohydrates.

Treatment is surgical - laparoscopic cholecystectomy.

Preoperative epicrisis

Patient Mandzyuk Elena Mironovna, 65 years old, pensioner, living at the address: Konstantinovsky district, Pleshcheevka, st. Voronikhin 12. 03/23/2009 at the Regional Central Clinical Hospital in Donetsk on the referral of a surgeon from the Republic of Belarus in Konstantinovka with a diagnosis of cholelithiasis, chronic calculous cholecystitis for the purpose of surgical treatment.

Complaints upon admission: dull pain in the right hypochondrium, radiating to the right supra- and subclavian fossa, nausea, dryness, bitterness in the mouth, heartburn, constipation, general weakness, worsening of the condition after eating fried fatty foods.

History of the disease: she has been ill for about 15 years when she began to feel heaviness, short-term dull pain in the right hypochondrium after eating fatty foods. About 10 years ago - the first attack of hepatic colic, which was relieved at home with intramuscular injections of antispasmodics. Over the past five years, attacks of hepatic colic have become more frequent, the patient’s condition began to deteriorate, the last attack on March 15, 2009 was stopped at home with intramuscular injections of antispasmodics, the patient sought medical help for the m/f, and was sent for inpatient treatment at the Central Clinical Hospital of the city. Donetsk. Hospitalized on March 23, 2009.

Life history: hepatitis, typhoid, paratyphoid, venereal diseases, tuberculosis, HIV denies. There have been no blood transfusions over the past 5 years. 1999 - suffered from acute intestinal infections (salmonellosis?), 2002 - closed fracture of the left medial malleolus, since 1970 she has suffered from varicose veins of the saphenous veins of the legs (not examined, not treated).

Objective examination: The general condition is of moderate severity, the patient is active, adequate, clear consciousness. Body temperature 36.80 C.

Height 160 cm. Weight 78 kg. The skin and visible mucous membranes are clean and pink. The skin is dry, turgor is reduced, nails and hair are brittle and dull. The tongue is dry, covered with a white coating at the root. The condition of the teeth is satisfactory, the gums, soft and hard palate are unchanged.

Peripheral lymph nodes have normal palpation properties.

On percussion there is a clear pulmonary sound above the lungs, the topographic boundaries of the lungs correspond to the age norm. Auscultation - vesicular breathing, RR 17 per minute, rhythmic, crepitus, no wheezing.

Percussion boundaries of relative cardiac dullness: left - expansion 1.5 cm outward from the left midclavicular line, right - along the right edge of the sternum at 5 m/r, upper - 3rd rib along the left midclavicular line.

Auscultation: heart sounds are clear, rhythmic, accent of 2 tones over the aorta, systolic murmur over the apex of the heart. Ps 80 per minute, blood pressure 140/100 mm Hg. Art.

The abdomen is symmetrical, enlarged due to the pancreas, does not participate in the act of breathing, and there is no visible peristalsis.

On superficial palpation, the abdomen is soft, in the left hypochondrium, lateral flanks, iliac regions, pubic, and periumbilical areas.

On deep palpation, segments of intestine have normal palpation properties.

In the right hypochondrium, pain is noted at the Kera point, moderate resistance of the muscles of the anterior abdominal wall is also detected there, a dubious Shchetkin-Blumberg symptom. The symptoms of Murphy, Ortner, and Mussi-Georgievsky are positive. The liver could not be palpated. The spleen is not palpable.

Auscultation - normal intestinal peristaltic sounds.

Urination is not impaired. The kidneys are not palpable. The painful points of the ureters are calm, Pasternatsky’s symptom is symmetrically negative.

The thyroid gland is painless on palpation, normal size, elastic consistency, no nodes. Tremor of the hands and eyelids is absent. There are no signs of infantilism or hypogonadism. The size of the nose, jaws, and ears are not increased. The sizes of the feet and palms are proportional.

Rectal examination: the external anal sphincter is tonic, the mucous membrane is calm, the examination is painless. The rectal ampulla is tonic, filled with feces, the rectal-vaginal septum is painless. There are traces of brown feces on the glove without visible pathological components.

Laboratory data:

UAC - Hb-111 g/l, Er - 4.37*10 12/l, platelets - 231*109/l, L - 12*10 9/l, band - 9%, segmented 76%, lymphocytes 7%, monocytes 5%, eosinophils 3%, POP - 30 mm/hour.

OAM - quantity 110 ml, transparent, straw yellow, spec. weight - 1015, protein n/o, glucose n/o, L - 4 p/zr, Er n/o, squamous epithelium 4 in p/z, hyaline casts n/o, urate salts +.

Biochemical blood test: creatinine 47 mmol/l, glucose 7.2 mmol/l, ALT - 198.0 nmol/(s*l), AST - 170.0 nmol/(s*l), amylase - 35.3 g/(h*l), urea - 8.3 mmol/l, bilirubin 30.0 µmol/l (direct - 18.7 µmol/l).

Coagulogram: platelets - 231*10 9/l, Duke bleeding time - 4 minutes, Lee-White coagulation time - 7 minutes, thrombotest - 5 degrees, prothrombin time - 13 seconds.

Ultrasound examination from 23.03. 2009.

Liver: CVR dimensions 15 cm, rounded edge (+ 2 cm from under the costal arch), smooth contours, diffuse echogenicity, fine-grained structure, somewhat heterogeneous, no formations.

Gallbladder: dimensions 88x30 mm, the walls are moderately thickened, there is a suspension in the lumen, concretions are an accumulation of small stones at the lower wall.

Ducts: common bile duct - 5x5 mm, portal vein - 11 mm, intrahepatic - not dilated.

Pancreas: head - 29-30 mm, high echogenicity, blurred structure, smooth contours, no formations.

Spleen: normal size, smooth, clear contours, average echogenicity, fine-grained, homogeneous structure.

Right kidney: dimensions 112x54 mm, smooth contours, parenchyma 16 mm, calyx 5-7-9 mm, no formations.

Left kidney: dimensions 108x53 mm, smooth contours, parenchyma 16 mm, upper calyces 10 mm, formations in the sinus with small calcifications.

Position of the kidneys: on the left - 3 cm below the 12th rib, on the right - 1 cm below the 12th rib.

Conclusion: Enlarged liver. Diffuse parenchymal changes in the liver, pancreas, chronic calculous cholecystitis, bilateral nephroptosis of the first degree on the right, second degree on the left, calcifications in the kidneys, slight dissection of the calyces in the kidneys.

Consultations of related specialists:

Cardiologist - ECG dated March 24, 2009. Conclusion: left ventricular hypertrophy with systolic overload.

Diagnosis: stage II hypertension.

Angiosurgeon - varicose veins of the saphenous veins of the legs, CVI stage 3. Laparoscopic cholecystectomy is planned.

Operation protocol

After processing surgical field With chloramine and betadine, a longitudinal incision 2 cm long was made twice 3 cm above the navel, through which the abdominal cavity was punctured with a Veress needle, through which the abdominal cavity was insufflated carbon dioxide- carboxyperitoneum was imposed. After removing the needle and inserting the trocar, a fine-fiber video camera is inserted into the abdominal cavity through the gateway of the latter. The area of ​​the liver and subhepatic space was examined, where an enlarged gallbladder with inflamed walls was detected. Next, through a separate trocar, a clamp - a clipper - is applied to the gallbladder, the bottom of the gallbladder is pulled upward, after isolating the neck and cystic duct in the area of ​​Calot's triangle, tantalum clips are separately applied to the cystic duct and cystic artery. The bubble is removed from the bed and removed. The bottom of the bladder is coagulated until the bleeding stops completely, and PVC drainage is also installed there. The trocar holes are sutured and an aseptic bandage is applied.

Observation diaries

Temperature 37°C, respiratory rate - 18 beats per minute, pulse 80 beats per minute, blood pressure 130/85 mm Hg. Art.

Complaints of pain in the subcutaneous wound, weakness, dizziness, nausea.

Objectively: the severity of the patient’s condition corresponds to the extent of the surgery undergone. The patient is conscious and adequate. The skin and visible mucous membranes are clean and pale. The tongue is dry, with a white coating at the root. Peripheral lymph nodes with normal palpation properties. Cor et pulmon activity without any peculiarities. The abdomen is symmetrical, somewhat swollen, painful in the area of ​​the wound. Intestinal sections normal properties, peristalsis is somewhat reduced, gases escape. The dressing is moderately wet with hemorrhagic contents, and the discharge from the drains is a small amount of serous fluid with a hemorrhagic component.

Complaints of moderate pain in the subcutaneous wound, dry, persistent cough, sore throat.

Objectively: the patient’s condition is relatively satisfactory. The skin and visible mucous membranes are clean and pale. The tongue is dry, with a white coating at the root. Peripheral lymph nodes with normal palpation properties. Cor et pulmon activity without any peculiarities. The abdomen is symmetrical, soft, moderately painful in the area of ​​the wound. Sections of intestine of normal properties, gases are released. Auscultation - normal intestinal peristaltic sounds.

The dressing is clean, dry, the discharge from the drains is a small amount of serous fluid.

Temperature - 36.8˚C, respiratory rate - 18 minutes, pulse 80 beats per minute, blood pressure 130/85 mm Hg. Art.

Complaints of moderate pain in the subcutaneous wound, dry, sore throat.

Objectively: the patient’s condition is relatively satisfactory. The skin and visible mucous membranes are clean and pink. The tongue is wet and cleansed. Peripheral lymph nodes with normal palpation properties. Cor et pulmon activity without any peculiarities. The abdomen is symmetrical, soft, moderately painful in the area of ​​the wound. Sections of intestine of normal properties, gases are released. Auscultation - normal intestinal peristaltic sounds.

The dressing is clean, dry, and the drainage tube is removed.

Follow a diet limiting fatty and spicy foods.

Frequent fractional meals(up to 6 times a day).

Light to moderate physical activity after 3 weeks.

Sanatorium treatment after 6 months.

Calculous cholecystitis is an inflammation of the gallbladder wall, accompanied by the formation of gallstones. This disease is more common in women. Predisposing factors may be endocrine diseases, menopausal syndrome, low physical activity, unhealthy diet and others.

There are three fundamental links in the pathogenesis of stone cholecystitis:

• slowing the outflow of bile from the bile ducts,
• violation of the rheological and physicochemical properties of bile;
• damage to the organ wall.

On the one side, chronic cholecystitis itself promotes the formation of gallstones. On the other hand, inflammation can develop against the background of pre-existing cholelithiasis (GSD). Let's consider the main signs of calculous cholecystitis and methods of treating the disease.

Symptoms of stone cholecystitis

Exacerbation of the disease can be triggered by consumption of fatty and spicy foods, alcohol, hypothermia, excessive physical activity, and sometimes it occurs without visible reasons. As with other types of inflammation of the gallbladder, for chronic calculous cholecystitis the main symptom is abdominal pain. It is usually dull, pulling or aching in nature and in most cases is localized in the area of ​​the right hypochondrium. 20-30% of patients are bothered by pain in the epigastric area or the pain syndrome does not have a clear localization.

Irradiation of pain to the right is characteristic lumbar region, shoulder, under the shoulder blade and lateral surface neck on the right. Distinctive feature calculous cholecystitis - the occurrence of so-called biliary colic. This condition is characterized by sudden onset of acute cramping pain under the right rib. Stone cholecystitis often occurs latently, and its first sign is hepatic colic.

Biliary colic occurs as a result of blockage of the bile duct by stones

In general, inflammation of the bladder against the background of cholelithiasis has a greater variety of clinical manifestations than the acalculous form of the disease. Thus, calculous cholecystitis is characterized by symptoms of jaundice and intoxication of the body with bile acids. The skin, sclera, and mucous membranes acquire a yellowish tint. Patients often complain of itchy skin, and upon examination, scratch marks can be seen on the skin. If the outflow of bile is significantly impaired, the urine becomes dark, and the feces, on the contrary, become discolored. Manifestations of bile intoxication include:

• low blood pressure,
• reduction in heart rate,
• irritability, frequent mood swings,
• headache,
• sleep disorders (patients are drowsy during the day, and suffer from insomnia at night).

As a result of insufficient flow of bile into the duodenum, the digestion process is disrupted, which is manifested by dyspeptic symptoms:

• unstable stool;
• nausea;
• belching;
• metallic or bitter taste, dry mouth.

When the gallbladder suddenly empties, heartburn and vomiting of bile are possible. More information about the manifestations and prevention of the disease can be found in the video at the end of the article.

Complications of stone cholecystitis

Among the complications of calculous cholecystitis, the most significant are:

• choledocholithiasis (blockage of the common bile duct with stones);
• stenosis of the papilla of Vater;
• or pancreatitis;
• reactive cholangitis, hepatitis;
• subphrenic abscess;
• empyema and perforation of the gallbladder;

Important: to avoid serious complications, you need to consult a doctor at the first signs of inflammation.

Treatment of calculous cholecystitis

When diagnosed with chronic calculous cholecystitis, treatment can be either conservative or surgical. The choice of method depends on the severity of symptoms, frequency of exacerbations, composition, size and number of stones, as well as the presence of complications.

Conservative treatment

Non-surgical treatment includes:

• compliance,
• medications.

You can eat stewed and boiled vegetables, cereals, lean poultry (chicken), beef, egg whites. You cannot drink alcohol or sparkling water. In general, the amount of liquid you drink per day should be at least one and a half liters, otherwise the thick bile will stagnate. One of the main principles of nutrition is fractionation: you need to eat at least 5-6 times a day, but do not overeat.

Among medications, the doctor may prescribe antispasmodics, hepatoprotectors, herbal medicines, enzymes, antibiotics (if an infection occurs). For calculous cholecystitis, treatment without surgery is possible if the stones are small (up to 15 mm) and consist of cholesterol. Bile acid preparations are used to dissolve them. Other important condition conservative treatment - normal motor activity of the gallbladder. If these nuances are not taken into account, then litholytic therapy can worsen the patient’s condition and even lead to complications.

Important: in case of cholecystitis against the background of cholelithiasis, any choleretic drugs, as they can cause blockage of the bladder and the development of dangerous complications.

Methods of surgical treatment

Quite often, patients with calculous cholecystitis are treated surgically. The essence of the operation is usually cholecystectomy - removal of the gallbladder along with the stones located in it. Depending on the clinical situation, access can be laparoscopic or laparotomy. Laparoscopy is most often performed as a less traumatic method of intervention.

If complications of cholelithiasis or chronic calculous cholecystitis occur, open laparotomy is resorted to. Opening the abdominal cavity is also indicated in cases of severe deformation of the bladder and the presence of adhesions to surrounding organs. These operations are performed under general anesthesia.

There are also minimally invasive interventions that involve crushing stones and then removing them. Stones are destroyed by directed ultrasound, laser or using a special loop.

Diet after cholecystectomy

Patients operated on for calculous cholecystitis are prescribed a diet after surgery. In the absence of the gallbladder, which serves as a physiological reservoir, frequent unloading of the biliary tract is necessary. Therefore, the patient throughout later life forced to eat small meals. Otherwise, stones may form again in the bubble stump or in the passages themselves. Meals should be at least 5-6 times a day.

After cholecystectomy, there is a deficiency of bile acids responsible for the digestion of fats. Therefore, it is necessary to exclude from the menu lard, lamb and beef fat. The consumption of fatty dairy products and butter should be limited. To compensate for the lack of lipids, the diet includes more vegetable oil. It can be used to season porridges, salads, and vegetable purees.

Gallstone disease(ZhKB)- a chronic disease characterized by the formation of calculi (stones) of the gallbladder and bile ducts. There are three main reasons for the formation of stones - metabolic disorders in the body, inflammatory changes in the wall of the gallbladder, and stagnation of bile.

Cholecystitis is an inflammation of the gallbladder. Acute cholecystitis can be calculous (with gallstones) and non-calculous (without gallstones).

According to the clinical and morphological form, the following types of cholecystitis are distinguished: catarrhal;

Phlegmonous;

Gangrenous (with or without perforation of the gallbladder).

Complications of acute cholecystitis can be:

1) acute pancreatitis;

2) obstructive jaundice;

3) secondary hepatitis;

4) cholangitis;

5) infiltrate;

6) abdominal abscess;

7) peritonitis.

Causes of cholecystitis are anatomical, functional and hereditary predisposition, congenital disorders in the development of bile ducts, physical inactivity, pregnancy, functional chronic and organic changes in the biliary system, infection, acute and chronic diseases of the gastrointestinal tract, allergic diseases, gallstones, violation metabolic processes, helminthic infestation. In the occurrence of acute cholecystitis, provoking factors play an important role, which, against the background of predisposing factors, determine the outbreak of an acute inflammatory process. Provoking moments include all negative impacts, weakening the body, inhibiting its protective functions: overwork, stress, overeating, infectious diseases.

Clinical picture. The disease begins, as a rule, after a violation of the diet - consumption of spicy, fatty foods or alcohol. A manifestation of cholecystitis is hepatic colic - severe arching pain in the right hypochondrium with irradiation to the right supraclavicular region, scapula, right shoulder. Acute cholecystitis is accompanied by frequent vomiting mixed with bile, retention of stool and gases, and an increase in body temperature to 38 - 39°C. Upon examination, the patient’s face is hyperemic, with complications it is pale with pointed features, the tongue is covered with a gray coating, the abdomen is swollen, and does not participate in the act of breathing. When the abdominal muscles are tense, the pain intensifies.

Palpation of the abdomen reveals tension in the abdominal wall muscles, pain in the right hypochondrium, and positive Murphy, Kehr, Ortner, Mussi, Shchetkin-Blumberg symptoms. Has a certain significance in diagnosis laboratory test. A general blood test reveals leukocytosis, shift leukocyte formula to the left, aneosinophilia, lymphopenia, increased ESR. In a general urine test, protein, leukocytes, and casts are determined. The amount of urine decreases. The amount of bilirubin, C-reactive protein, and amylase in the blood increases, and changes appear in the protein fractions of the blood serum.

With choledocholithiasis (common bile duct stones), a violation of the outflow of bile into the duodenum may develop. Then obstructive jaundice appears - the patient has yellowness of the skin and sclera, the urine becomes dark in color and the feces become discolored (acholia).

With hepatitis, the liver enlarges and becomes painful on palpation.

With cholangitis (inflammation of the bile ducts), an enlarged liver, yellowness of the skin and mucous membranes, and hectic fever are observed.

To confirm the diagnosis, ultrasound examination and computed tomography are performed.

Tactics. At the prehospital stage, the patient must be given 1 tablet of nitroglycerin under the tongue, antispasmodics (2 ml of 2% papaverine solution or 2 ml of no-shpa intramuscularly), an antihistamine (1 ml of 1% diphenhydramine solution), and an ice pack placed on the right hypochondrium. The patient is prohibited from drinking and eating. Emergency hospitalization to the surgical department in a lying position on a stretcher is indicated.

Treatment. An attack of acute cholecystitis, as a rule, is controlled by conservative measures in a surgical department.

The patient is prescribed bed rest, table No. 5.

The position in bed should be with the head end of the functional bed elevated. On the first day, it is recommended to apply cold to the area of ​​the right hypochondrium. Nutrition is provided parenterally. In case of uncontrollable vomiting, it is necessary to rinse the stomach. Treatment uses antibiotic therapy, detoxification and desensitization therapy. Pain is relieved with the help of painkillers and antispasmodics.

If conservative treatment is ineffective within 48 - 72 hours, or if there is a destructive and complicated form of cholecystitis, an operation to remove the gallbladder is performed - cholecystectomy.

There are three types of operations: traditional laparotomic cholecystectomy or minimally invasive operations - mini-laparotomic cholecystectomy (using the Mini-Assistant tool kit) and laparoscopic cholecystectomy.

Laparoscopiccholecystectomy- this is the “gold standard” in the treatment of calculous cholecystitis. Laparoscopic operations are performed through three to four punctures of the anterior abdominal wall using a video laparoscopic stand and special instruments under conditions of pneumoperitoneum. The operations are characterized by low trauma, excellent cosmetic results, and a significant reduction in the risk of formation postoperative hernias. Pain in the postoperative period is minor and does not require the use of strong analgesics. The phenomena of intestinal paresis, as a rule, are absent. By the end of the 1st day, patients get up and begin to walk and eat. If the postoperative period is uncomplicated, patients are discharged home 3-4 days after surgery.

With mini-laparotomy cholecystectomy, the operation is performed from one transrectal (through the rectus abdominis muscle) incision 3–5 cm long using special instruments and a “Mini-Assistant” ring retractor. This technique was developed in Russia in Yekaterinburg by Professor I.D. Prudkov.

Rules for patient care. 4-5 hours after recovery from general anesthesia, the patient is placed in bed in the Fowler position. In the first 2 days, parenteral nutrition is provided, medications are administered strictly as prescribed by the doctor. During this period, daily diuresis, homeostasis indicators, blood pressure, pulse rate and body temperature are carefully monitored. Within 2 - 3 days after the operation, a probe is placed in the patient's stomach and it is washed out. Eating food by mouth begins on the 4th day (unsweetened tea, yogurt). An indispensable condition for treatment throughout the entire postoperative period is physical therapy and breathing exercises.

From 3 to 4 days the patient is allowed to get out of bed and walk. Postoperative wound dressings and drainage care are carried out daily. The nurse carefully monitors the discharge through the drainage, noticing disturbances in its function and the admixture of blood. In the first days, up to 500 - 600 ml of bile per day should be released from the drainage installed in the common bile duct. The cessation of outflow through the drainage indicates that the tube has come out of the duct. Any changes should be reported to your doctor immediately. The drains are removed and the sutures are removed on the 5th - 6th day.

Acute pancreatitis

Acute pancreatitis is a pathological process in which edema, autolysis (self-digestion) and necrosis of pancreatic tissue develop with secondary inflammation pancreatic tissue. There are edematous forms of acute pancreatitis and pancreatic necrosis (hemorrhagic, fatty, mixed). Pancreatic necrosis can cause a number of complications - septic shock, multiple organ failure, abscess, pancreatic phlegmon and others purulent complications, bleeding, diffuse peritonitis, false cyst of the pancreas.

TO causes of pancreatitis include features anatomical structure glands and diseases of the bile ducts, alcohol abuse, diseases of the gastrointestinal tract, blunt trauma, chronic infection in the body, pregnancy, long-term use of corticosteroid drugs, allergic diseases.

Clinical picture. According to the clinical course, there are mild, moderate, severe and fulminant forms of acute pancreatitis. The onset of the disease is always acute.

A constant symptom of acute pancreatitis is severe, cutting pain in the epigastrium and in the left hypochondrium of a girdling nature.

Simultaneously with the pain, repeated vomiting appears, which does not bring relief, dyspeptic symptoms, and body temperature rises.

On examination, the patient has a pale face with purple circles under the eyes, the tongue is dry with a gray-brown coating, the abdomen is swollen and does not take part in breathing.

Palpation of the abdomen reveals tension in the abdominal wall, pain in the epigastrium and left hypochondrium, positive symptoms of Kerte, Voskresensky, Mayo-Robson, Razdolsky, Shchetkin-Blumberg. The pain can be very severe, up to painful shock, since the solar plexus is located next to the gland.

Upon percussion, dullness is heard in the epigastric region, and upon auscultation of the abdomen, a decrease or disappearance of bowel sounds is heard. Laboratory research methods are of great importance in diagnosis. A general blood test reveals leukocytosis, with a shift in the leukocyte formula to the left, and an increase in ESR. A biochemical blood test determines an increase in the level of pancreatic enzymes in the blood serum - amylase, lipase, trypsin, as well as the level of blood glucose and bilirubin. In urine analysis, protein, leukocytes and red blood cells appear, diuresis decreases, and an increase in the level of amylase in the urine is noted.

To clarify the diagnosis, ultrasound, computed tomography, and diagnostic laparoscopy are performed.

Tactics. At the prehospital stage, the patient is given 1 tablet of nitroglycerin under the tongue, antispasmodics are administered (2 ml of 2% papaverine solution or 2 ml of no-shpa intramuscularly), an antihistamine (intramuscularly 1 ml of 1% diphenhydramine solution or 2 ml of 2.5% pipolfen solution). The patient is prohibited from drinking and eating. At psychomotor agitation 1 ml of 0.1% atropine solution or 2 ml of 0.5% seduxen (Relanium) solution is prescribed intramuscularly. Emergency hospitalization to the surgical department in a lying position on a stretcher is indicated.

Treatment. The main treatment method for patients with acute pancreatitis is conservative. The patient must be kept at rest. He is placed in the Fowler's position in bed, and cold is applied to the area of ​​the pancreas to suppress its function. Parenteral nutrition is provided for 2 - 3 days. Pain relief, elimination of enzymatic toxemia by introducing anti-enzyme drugs (gordox, contrical), plasma, albumin, detoxification and antibiotic therapy, immunotherapy and desensitizing therapy are also carried out to increase the body's defense reactions and relieve the allergic component. The hormonal pancreatic blockers sandastotin and octreotide are highly effective in the first 3 to 5 days of the disease. To reduce gastric secretion, its blockers are prescribed: famotidine, ranitidine, omeprazole.

Indications for surgical treatment are the ineffectiveness of conservative therapy and the appearance of complicated forms of pancreatitis. Usually a laparotomy is performed with examination of the abdominal cavity, drainage of the omental bursa around the pancreas, and a cholecystostomy is necessarily performed to decompress the bile ducts. Sometimes resection of the tail and body of the pancreas is performed.

Rules for patient care. It is necessary to create rest for the patient, put him in a warm bed in the Fowler position. To create rest for the pancreas, the following measures are performed: a thin probe is inserted into the stomach and gastric and duodenal contents are removed, the stomach is washed with cold alkaline water, an ice pack is placed on the pancreas area. Food and water should not be taken by mouth for 4-5 days, and sometimes more. After canceling table No. O, you are allowed to drink alkaline mineral water (still), then weak tea. The next day, table No. 1 is prescribed, and only after 4-8 days the patient can be allowed to go on tables No. 2 and 5. After the operation, the same care is carried out as after cholecystectomy.

Acute appendicitis

Appendicitis- This nonspecific inflammation vermiform appendix of the cecum. Appendicitis can be acute or chronic. Acute appendicitis is the most common surgical disease. Women get sick 2 times more often than men. Acute appendicitis can be simple (catarrhal), destructive (phlegmonous, gangrenous, perforated), complicated by peritonitis, sepsis, infiltrate, abscess. The cause of appendicitis may be obstruction of the appendix with fecal stone, helminthic infestation, chronic inflammatory processes of the intestines and appendix, congestion in the cecum, angioneurosis, dysfunction of the bauginian valve.

Clinical picture. The disease begins in the midst of complete health. Cutting or pressing pain in the epigastric region with distribution throughout the abdomen. After a few hours they are localized in the right iliac region (Volkovich-Kocher sign). In atypical positions of the appendix (behind the cecum, partially extraperitoneal, pelvic), the pain will correspond to its location. The pain usually radiates to right leg. The patient walks with a limp on his right leg, holds his right groin area with his hands, and lies in bed on his right side. The pain is accompanied by nausea, vomiting, stool and gas retention, increased body temperature, weakness and malaise. The pulse quickens as the temperature rises.

On examination, the patient is pale, the tongue is covered with a white coating, right half the abdomen does not participate in the act of breathing, the abdomen may be somewhat swollen, deep breathing painful in the right groin area. Percussion reveals pain and dullness in the right groin area; palpation reveals pain and tension in the abdominal muscles, especially in the right groin area.

Local pain in most patients with acute appendicitis is observed in the right groin area and is considered one of the main and most important symptoms.

Tension of the muscles of the anterior abdominal wall is different important feature acute appendicitis. It can vary from mild resistance to pronounced muscle protection and depends on the severity of the pathological process in the appendix, its location, and the patient’s condition. Muscle tension must be determined by comparative superficial and deep palpation of all parts of the abdomen, starting with healthy areas.

Special symptoms are detected when using a number of techniques that provoke a pain reaction in the inflamed peritoneum. The Shchetkin-Blumberg symptom is most often detected, which is characteristic of any local or diffuse peritonitis, including those of appendicular origin. Rovsing's symptom is considered positive if a jerk-like shaking of the anterior abdominal wall in the area of ​​the sigmoid colon causes pain in the right iliac fossa. This is believed to be due to retrograde movement intestinal gases into the cecum, causing irritation of the inflamed appendix.

Sitkovsky's symptom is as follows: when the patient turns on his left side, the pain in the ileocecal region intensifies due to the movement of the appendix and the tension of its mesentery. Often, palpation of the right iliac region with the patient positioned on the left side causes a stronger pain reaction than on the back (Barthomier-Michelson symptom). When the hand quickly slides along a stretched shirt from the xiphoid process to the right groin area, a significant increase in pain at the end of the movement is noted in the latter (Voskresensky symptom).

Tapping the tips bent fingers brush along the right iliac region leads to increased pain from the latter (Razdolsky's symptom).

When the appendix is ​​localized near the lumbar or iliopsoas muscle, the inflammatory process can spread to them. Artificial stretching of these muscles is often accompanied by pain and underlies the phenomenon that is used to determine Obraztsov’s symptom. - the appearance of pain in the area of ​​the inflammatory focus if you press the anterior abdominal wall in the right iliac region with your fingers and actively try to lift the straightened right leg. When the appendix is ​​located near the obturator internus muscle, pain appears or intensifies when internally rotating the right thigh, bent at the knee joint.

The patient's examination usually ends with a digital examination through the rectum. Leukocytosis, a shift in the leukocyte formula to the left, and an increase in ESR are observed in the blood.

The appendicular infiltrate is a conglomerate consisting of the appendix, cecum, and greater omentum. It is a complication of acute appendicitis and develops from 3-5 days from the onset of the disease. The patient complains of mild nagging pain in the right iliac region, increased body temperature to 37 - 38 °C, and nausea.

Upon examination, the abdomen is slightly protruded in the right iliac region, palpation gives pain and hardness in this area with clear boundaries, percussion gives pain and dullness. Symptoms of peritoneal irritation are negative or weakly positive.

Let us consider the features of the course and diagnosis of acute appendicitis in children, the elderly and pregnant women.

Features of acute appendicitis in children is a quick start destructive changes in the vermiform appendix, frequent occurrence widespread peritonitis due to incomplete development of the omentum, which reduces the possibility of delimiting the inflammatory process. The clinical picture is often dominated by cramping pain, repeated vomiting, and diarrhea. Body temperature is usually high - up to 39 - 40 ° C; the pulse often does not correspond to the temperature. Symptoms of severe intoxication are expressed. Tension of the abdominal wall muscles may be mild.

Thus, acute appendicitis in children is characterized by a rapid course and resembles gastroenteritis and dysentery in its clinical manifestations. This makes early diagnosis difficult and increases the number of perforated forms of appendicitis.

Due to the decrease protective forces body and severe concomitant diseases acute appendicitis in elderly and senile people has an erased flow. Abdominal pain is mild, body temperature does not rise. The protective tension of the abdominal wall muscles is weak or absent; even with destructive forms of appendicitis, blood tests show slight leukocytosis with a shift in the leukocyte formula to the left.

In elderly and senile people, the blurring of the clinical picture of the disease, the lack of expression of the main symptoms, as well as the tendency to rapid development of destruction of the appendix (due to sclerosis of its vessels) lead to the fact that these patients are admitted to surgical hospitals at a later stage (after a few days) from the onset of acute appendicitis, often with developed complications (appendiceal infiltrate).

Manifestations of acute appendicitis in the first half of pregnancy are no different from its usual manifestations. In the second half of pregnancy displacement of the cecum and appendix by the enlarged uterus leads to a change in the localization of pain in acute appendicitis. Pain can be localized not only in the right iliac region, but also in the right hypochondrium. Patients do not pay attention to these pains and attribute them to symptoms of pregnancy. Vomiting, which is often observed in pregnant women, also does not cause them much concern. Tension of the abdominal wall muscles in the early stages of pregnancy is well expressed, but in later stages, due to strong stretching of the abdominal muscles, it can be quite difficult to identify their protective tension.

Symptoms of Voskresensky and Shchetkin-Blumberg are usually well expressed. If inflamed appendix located behind the enlarged uterus, then symptoms of peritoneal irritation may not be detected. Acute appendicitis in pregnant women is often mistaken for signs of an impending miscarriage, which leads to late hospitalization of patients and late surgery. The risk of miscarriage when performing an appendectomy, even late in pregnancy, is low.

Tactics for acute appendicitis. The tactics are the same as for acute abdomen. At the prehospital stage, everything therapeutic effects contraindicated. A patient with suspected acute appendicitis must be urgently hospitalized in the surgical department for observation or emergency surgery.

Treatment of acute appendicitis. Only surgical treatment is performed. An appendectomy is performed, and in case of peritonitis, also sanitation and drainage of the abdominal cavity is performed.

Treatment of appendiceal infiltrate carried out conservatively. Strict bed rest, cold applied to the infiltrated area, liquid food, antibiotics, and anti-inflammatory drugs are prescribed. When the inflammatory process subsides, they switch to thermal procedures and physiotherapeutic treatment. After 4 weeks, an appendectomy is performed. If there are signs of suppuration of the infiltrate, treatment is surgical.

IN postoperative period after 4-6 hours, if there are no complications, the patient is allowed to drink. The day after surgery, you can get up and eat liquid food. For 5 days, a gentle diet is indicated with the exception of fiber, milk and carbohydrates. Essential has physical therapy. Dressings are carried out daily, sutures are removed on the 7th day.

Intestinal obstruction

Intestinal obstruction is a disease characterized by partial or complete violation movement of contents through the intestines. Obstruction is a very common acute surgical disease of the abdominal organs. Based on their origin, they distinguish between congenital and acquired intestinal obstruction.

It is generally accepted to divide intestinal obstruction into two main forms:

1) dynamic- develops as a result of a violation of intestinal contractility of paralytic or spastic origin and in most cases is functional in nature;

2) mechanical- observed with organic blockade of the intestines.

Mechanical obstruction can be obstructive, strangulation and mixed.

Obstructive obstruction associated with blockage of the intestinal lumen by a tumor, foreign body, a ball of roundworms, a gallstone, feces, and strangulation caused by torsion, compression, strangulation or constriction of the intestine and its mesentery with circulatory disorders and ischemic necrosis.

TO mixed forms include intussusception and adhesive obstruction. The latter sometimes develops after surgical interventions and can occur in both strangulation and obstruction types.

Depending on the location, obstruction is distinguished:

High (small intestinal);

Low (colon).

Moreover, the higher the obstruction, the more severe its manifestations and the worse the prognosis.

According to the clinical course, intestinal obstruction is divided into:

On the acute side;

Chronic;

Partial.

Tactics. If you suspect any type of acute intestinal obstruction the tactics are the same. At the prehospital stage, any therapeutic effects (antiemetics, painkillers, antispasmodics, enemas, heating pads) are strictly contraindicated! Do not give the patient anything to drink or eat. It is necessary to urgently deliver him to the surgical hospital on a stretcher in a position that brings relief. Delay in providing adequate surgical care may lead to intestinal necrosis and poor outcome.

Dynamic obstruction. Disorders of intestinal motility of various origins due to damage to its neuromuscular elements are called dynamic obstruction. This process is usually reversible and may involve part or all of the intestine.

Paralytic obstruction often occurs after abdominal surgery, reflex action from other organs (renal and hepatic colic, myocardial infarction), often due to peritonitis, pancreatitis and others inflammatory diseases abdominal organs. Sometimes paralytic ileus develops with hypokalemia, hyponatremia and diabetic ketoacidosis.

Increased intestinal motor function can reach an excessive degree and cause spastic obstruction , which is observed in lead colic, neuroses, hysteria, helminthiasis, poisoning.

Clinical pictureparalytic obstruction. The clinical picture is quite variable and depends on the cause that caused it. Patients experience constant bursting pain in the abdomen of a generalized nature, retention of stool and gases. Abdominal bloating is moderate, regurgitation and vomiting appear at more late stages diseases resulting from stasis and hypertension in the proximal gastrointestinal tract. The general condition of patients initially suffers little, and only as the disease progresses, dehydration, hemoconcentration and intoxication often increase. The abdomen is evenly swollen, soft, slightly painful on palpation. Bowel sounds are not listened to. In cases where paralytic obstruction develops against the background of other pathological processes in the abdominal cavity (postoperative paresis, inflammation of the peritoneum, pancreatitis, intra-abdominal abscess), the clinical picture shows symptoms of these diseases.

During an X-ray examination, diffuse flatulence is detected in the small and large intestines with single levels of fluids in different parts of the abdominal cavity.

Treatmentparalytic obstruction.

Treatment is aimed at restoring intestinal patency using the following conservative methods:

1) decompression of the proximal gastrointestinal tract using gastric or intestinal tubes;

2) use of pharmacological stimulants intestinal peristalsis(cerucal, prozerin, pituitrin);

3) insertion of a gas outlet tube or administration of siphon and hypertensive enemas;

4) correction of water and electrolyte balance, elimination of hypovolemia;

5) elimination of hypoxia;

6) maintaining cardiovascular activity; 7) relief of pain and intestinal spasm (bilateral perinephric blockade according to Vishnevsky, antispasmodic drugs).

Spontaneous passage of stool and gas, disappearance of abdominal pain and a decrease in bloating are usually the first signs of resolution of dynamic intestinal obstruction. Surgical treatment is rarely used and is indicated when conservative measures are ineffective.