Lecture topic: acute cholecystitis. Acute cholecystitis (K81.0) Acute cholecystitis hospital surgery
Acute cholecystitis- symptoms and treatment
What is acute cholecystitis? We will analyze the causes of occurrence, diagnosis and treatment methods in the article of Dr. Razmakhnin E.V., a surgeon with an experience of 22 years.
Definition of disease. Causes of the disease
Acute cholecystitis is a rapidly progressive 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 on-duty surgical hospital are patients with complicated forms, which include acute cholecystitis. In older patients, this disease is much more common and more severe due to the large number of pre-existing somatic diseases. In addition, with age, the percentage of occurrence of gangrenous forms of acute cholecystitis increases. Acalculous acute cholecystitis is uncommon and is the result of infectious diseases, vascular disease (cystic artery thrombosis), or sepsis.
The disease is usually caused errors in the 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 the protective mechanisms and the penetration of microflora into the biliary tract.
At thrombosis of the cystic artery against the background of the 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 may also serve as physical activity, "jerky" ride, which leads to displacement of the stone, blockage of the cystic duct and subsequent activation of the microflora in the lumen of the bladder.
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 may at the most inopportune moment lead to a serious complication with a threat to life.
If you experience similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!
In the clinical picture of the disease, pain, dyspeptic and intoxication syndromes are distinguished.
Usually 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 shingles. The epicenter of pain is usually localized at the so-called Ker'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 is in contact with the anterior abdominal wall.
The appearance of hepatic colic is explained by a sharply increasing biliary (biliary) hypertension against the background of a reflex spasm of the sphincters located in the biliary tract. An increase in pressure in the biliary system leads to enlargement of the liver and stretching of the Glisson 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 a pain syndrome.
Perhaps the development of the so-called cholecystocardial Botkin syndrome. In this case, with acute cholecystitis, pain occurs in the region of the heart, and even ECG changes in the form of ischemia may appear. Such a situation can mislead the doctor, and as a result of overdiagnosis (erroneous medical opinion) of coronary disease, he risks not recognizing acute cholecystitis. In this regard, it is required to carefully understand the symptoms of the disease and evaluate the clinical picture as a whole, taking into account the history 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 stopping hepatic colic, the pain does not completely go away, as in chronic calculous cholecystitis. It becomes somewhat dull, takes on a permanent 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 diffused throughout the abdomen.
Intoxication syndrome is manifested by fever, 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;
- with destructive forms of cholecystitis - above 38 ° C;
- in the event of an empyema (abscess) of the gallbladder or a perivesical abscess, hectic temperature is possible with sharp rises and falls during the day and torrential sweat.
Dyspeptic syndrome is expressed in the form of nausea and vomiting. Vomiting can be either single or multiple with concomitant damage to the pancreas that does not bring relief.
The pathogenesis of acute cholecystitis
Previously, it was believed that the main factor leading to the development of acute cholecystitis is bacterial. In accordance with this, treatment was prescribed aimed at eliminating the inflammatory process. At present, ideas about the pathogenesis of the disease have changed and, accordingly, treatment tactics have changed.
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 reflex spasm of the sphincters in the bile ducts, as well as increasing edema.
As a result of biliary hypertension, the microflora 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.
An increase in pressure in the biliary tract is a trigger for the development of many acute diseases of the hepatoduodenal zone (cholecystitis, cholangitis, pancreatitis). Activation of the intravesical microflora leads to even greater edema and impaired microcirculation, which, in turn, significantly increases the pressure in the biliary tract - a vicious circle closes.
Classification and stages of development of acute cholecystitis
According to morphological changes in the wall of the gallbladder, four forms of acute cholecystitis are distinguished:
- catarrhal;
- phlegmonous;
- gangrenous;
- gangrenous-perforative.
Different severity of inflammation implies a different clinical picture.
With a catarrhal the inflammatory process affects the mucous membrane of the gallbladder. Clinically, this is manifested by pains of moderate intensity, intoxication syndrome is not expressed, nausea occurs.
With phlegmonous form inflammation affects all layers of the gallbladder wall. There is a more intense pain syndrome, fever to febrile numbers, vomiting and flatulence. An enlarged painful gallbladder may be palpable. Symptoms appear:
- With. Murphy - interruption of inspiration when probing the gallbladder;
- With. Mussi - Georgievsky, otherwise called phrenicus symptom - more painful palpation on the right between the legs of the sternocleidomastoid muscle (exit point of the phrenic nerve);
- With. Ortner - pain when tapping on the right costal arch.
With gangrenous form the 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 bladder wall is also possible.
Complications of acute cholecystitis
Complications can occur with a long course of untreated destructive forms of acute cholecystitis.
In case of delimitation of inflammation occurs perivesical infiltrate. Its obligatory component is the gallbladder, located in the center of the infiltrate. The composition most often includes the omentum, may include the transverse colon, antrum and duodenum. It usually occurs after 3-4 days of the course of the disease. At the same time, pain and intoxication may decrease somewhat, and dyspeptic syndrome can be stopped. With the right conservative treatment, the infiltrate can resolve within 3-6 months, with an unfavorable one, it can abscess with the development perivesical abscess(characterized by pronounced intoxication syndrome and increased pain). Diagnosis of infiltrate and abscess is based on the history of the disease, physical examination data and is confirmed by ultrasound.
Peritonitis- the most formidable complication of acute destructive cholecystitis. It occurs when the wall of the gallbladder is perforated and bile flows into the free abdominal cavity. As a result, there is a sharp increase in pain, the pain becomes diffuse throughout the abdomen. The intoxication syndrome is aggravated: the patient is initially agitated, groans in pain, but with the progression of peritonitis becomes apathetic. Peritonitis is also characterized by severe intestinal paresis, bloating and weakening of peristalsis. On examination, the defense (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. X-ray examination shows signs of intestinal paresis. Emergency surgical treatment is required after a short preoperative preparation.
Another serious complication of acute cholecystitis is cholangitis- inflammation goes to the biliary tree. In fact, this process is a manifestation of abdominal sepsis. In this case, the condition of 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 the expansion of intra- and extrahepatic ducts. In blood tests - hyperleukocytosis, an increase in the level of bilirubin due to both fractions, the activity of aminotransferases and alkaline phosphatase increases. Without appropriate treatment, such patients quickly die from the phenomena of liver failure.
Diagnosis of acute cholecystitis
Diagnosis is based on a combination of anamnesis, objective data, laboratory and instrumental studies. In doing so, the principle from simple to complex, from less invasive to more invasive.
When collecting anamnesis(during the interview) patients may indicate the presence of gallstone disease, previous hepatic colic, a violation of the diet in the form of eating fatty, fried or spicy foods.
Clinical Data assessed by manifestations of pain, dyspeptic and intoxication syndromes. In the presence of complications, concomitant choledocholithiasis and pancreatitis, cholestasis syndrome and a moderately pronounced 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 state of the wall, surrounding tissues, intra- and extrahepatic bile ducts, and the presence of free fluid in the abdominal cavity are evaluated.
In the case of an acute inflammatory process in the gallbladder, an increase in its size (sometimes significant) is determined by ultrasound. Wrinkling of the bladder indicates the presence of chronic cholecystitis.
When evaluating the contents, attention is paid 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, sometimes becomes layered (with destructive forms of cholecystitis).
In anaerobic inflammation, gas bubbles can be seen in the bubble wall. The presence of free fluid in the perivesical 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, there is an expansion of the intra- and extrahepatic bile ducts.
Evaluation of ultrasound data makes it possible to determine the treatment tactics even at the stage of admission: conservative management of the patient, surgery in an emergency, urgent or delayed manner.
X-ray methods studies are carried out if a block of the biliary tract is suspected. Plain radiography is not very informative, since the stones in the gallbladder lumen are usually X-ray 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 detected. To clarify the nature of the block of the biliary tract, contrasting research methods are used:
- endoscopic retrograde cholangiopancreatography - bile ducts are contrasted retrograde through the papilla of Vater during duodenoscopy;
- percutaneous transhepatic cholecystocholangiography - antegrade contrasting by percutaneous puncture of the intrahepatic duct.
If diagnosis and differential diagnosis are difficult, CT scan belly. With its help, it is possible to assess in detail the nature of changes in the gallbladder, surrounding tissues and bile ducts.
If it is necessary to make a differential diagnosis with another acute pathology of the abdominal organs, a diagnostic test can be performed. laparoscopy and visually assess the existing changes in the gallbladder. This study can be performed both under local anesthesia and under endotracheal anesthesia (the latter is preferable). If necessary, right on the operating table, the issue of switching to therapeutic laparoscopy, that is, performing cholecystectomy - removal of the gallbladder, is resolved.
Laboratory diagnostics consists in performing complete blood count, where leukocytosis, a shift of the leukocyte formula to the left and an increase in ESR are detected. 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 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 operation after a short preoperative preparation.
Preparation consists in 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).
Operative access 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 laparoscopic approach, which is the least traumatic and allows for a full revision and sanitation.
Mini-access is not inferior to laparoscopic in terms of trauma and has advantages in the form of no need to impose pneumoperitoneum (to limit the mobility of the diaphragm). In the event of technical difficulties, a pronounced adhesive process in the abdominal cavity and diffuse peritonitis, it is more expedient to use laparotomy access: upper median laparotomy, access according to Kocher, Fedorov, Rio Branca. At the same time, upper median laparotomy is less traumatic, since in this case the muscles do not intersect, however, with oblique subcostal approaches, the subhepatic space is more adequately opened for surgical intervention.
The operation is to perform a cholecystectomy. It should be noted that the presence of perivesical infiltrate implies certain technical difficulties in the mobilization of the gallbladder neck. 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 bottom, which allows you to more clearly identify the elements of the neck.
There is also the “Pribram” operation, which consists in removing the anterior (lower) wall of the gallbladder, flashing the cystic duct in the neck and mucoclasia (removal of the mucous membrane) by electrocoagulation of the posterior (upper) wall. Performing this operation with a pronounced infiltrate in the neck of the bladder will avoid the risk of iatrogenic damage. It is applicable for both laparotomy and laparoscopic access.
If there are no severe complications of acute cholecystitis, then when the patient enters the hospital, conservative therapy aimed at unblocking the gallbladder. Antispasmodics, M-anticholinergics, infusion therapy for the relief of intoxication are used, antibiotics are prescribed.
An effective method is to perform a blockade of the round ligament of the liver with a novocaine solution. The blockade can be performed both blindly using a special technique, and under the control of a laparoscope when performing diagnostic laparoscopy and under ultrasound control.
With the ineffectiveness of conservative therapy within 24 hours, the question of a radical operation is raised - cholecystectomy.
Of no small importance for determining treatment tactics is the time elapsed since the onset of the disease. If the interval is up to five days, then cholecystectomy is feasible, if 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 the operation. Later, the infiltrate becomes dense, and attempts to separate it may result in complications. Of course, a period of five days is quite arbitrary.
In the absence of the effect of conservative treatment and the presence of contraindications for performing a radical operation - 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 imposition of cholecystostomy.
Cholecystoma can be applied in three ways: from a mini-access, under laparoscopic control and under ultrasound control. The most minimally traumatic operation is performed 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, a radical operation is performed in the cold period after three months. Usually this time is sufficient for resorption of the perivesical infiltrate.
Forecast. Prevention
The prognosis for timely and adequate treatment is usually favorable. After a radical operation, 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. Meals 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 in the timely rehabilitation of stone carriers, that is, in performing cholecystectomy in a planned manner for patients with chronic calculous cholecystitis. Even the founder of biliary surgery, Hans Kehr, said that "wearing a stone in the gallbladder is not the same as 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 an inflammation of the gallbladder.
The following classification of acute cholecystitis is most acceptable:
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. Occlusive (obstructive) cholecystitis (infected dropsy, phlegmon, empyema, gangrene of the gallbladder).
2. Perforated with symptoms of local or diffuse peritonitis.
3. Acute, complicated by lesions of 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 perforated bile peritonitis.
The main symptom in acute cholecystitis is pain, which occurs, as a rule, suddenly in full health, often after eating, 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, supraclavicular region. In some cases, before its appearance, patients for several days, even weeks, feel heaviness in the epigastric region, bitterness in the mouth, and nausea. Severe pain is associated with the reaction of the gallbladder wall to an increase in its contents as a result of a violation of the outflow during inflammatory edema, an inflection of the cystic duct, or when the latter is blocked by a stone.
Often there is irradiation of pain in the region of the heart, then an attack of cholecystitis can proceed as an attack of angina pectoris (Botkin's cholecystocoronary syndrome). The pain is aggravated by the slightest physical exertion - talking, breathing, coughing.
There is vomiting (sometimes multiple) of a reflex nature, which does not bring relief to the patient.
On palpation, a sharp pain and muscle tension in the right upper square of the abdomen is determined, especially a sharp pain in the area of the gallbladder.
Objective symptoms are not equally expressed in all forms of acute cholecystitis. Increased heart rate up to 100 - 120 beats per minute, intoxication phenomena (dry, furred tongue) are characteristic of destructive cholecystitis. With complicated cholecystitis, the temperature reaches 38 ° C and above.
When analyzing blood, leukocytosis, neutrophilia, lymphopenia, and an increased erythrocyte sedimentation rate are observed.
Specific symptoms of acute cholecystitis include:
1) a symptom of Grekov - Ortner - percussion pain that appears in the gallbladder area with a slight tapping of the edge of the palm along the right costal arch;
2) Murphy's symptom - an increase in pain that occurs at the time of palpation of the gallbladder with a deep breath of the patient. 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 the height, due to acute pain in the right hypochondrium under the thumb, then Murphy's symptom is positive;
3) symptom of Courvoisier - an increase in 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 an inflammatory process in the gallbladder;
5) Mussi-Georgievsky symptom (phrenicus symptom) - 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 IX-XI thoracic vertebrae and 3 cm to the right of the spine. The presence of pain in this place with 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. 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, there is pain in the gallbladder area, there are also positive symptoms of Grekov - Ortner, Murphy. There are no peritoneal symptoms, the number of leukocytes is in the range of 8.0 - 10.0 - 109 / l, the temperature is 37.6 ° C, rarely up to 38 ° C, there are no chills.
Attacks of pain last for several days, but after conservative treatment they disappear.
Acute destructive cholecystitis can be calculous or acalculous, primary or exacerbation of chronic recurrent.
Destruction can be phlegmonous, phlegmonous-ulcerative or gangrenous in nature.
With phlegmonous cholecystitis, the pain is constant, intense. Dry tongue, repeated vomiting. There may be a slight yellowness of the sclera, soft palate, which is due to infiltration of the hepatoduodenal ligament and inflammatory edema of the mucous membrane of the bile ducts. Urine dark brown. Patients lie on their back or on their right side, afraid to change their position in the back, because in this case severe pain occurs. On palpation of the abdomen, there is a sharp tension in the muscles of the anterior abdominal wall in the region of the right hypochondrium, there are also positive symptoms of Grekov-Ortner, Murphy, Shchetkin-Blumberg. The temperature reaches 38 ° C and above, leukocytosis 12.0 - 16.0 - 109 / l with a shift of the leukocyte formula to the left. With the spread of the inflammatory process to the entire gallbladder and the accumulation of pus in it, an empyema of the gallbladder is formed.
Sometimes phlegmonous cholecystitis can turn into dropsy of the gallbladder.
Gangrenous cholecystitis in most cases is a transitional form of phlegmonous cholecystitis, but it can also occur as an independent disease in the form of primary gangrenous cholecystitis of vascular origin.
Clinic at first it corresponds to phlegmonous inflammation, then the so-called imaginary well-being may occur: pain decreases, symptoms of peritoneal irritation are less pronounced, temperature decreases. However, at the same time, the phenomena of general intoxication increase: frequent pulse, dry tongue, repeated vomiting, pointed facial features.
Primary gangrenous cholecystitis from the very beginning proceeds violently with the phenomena of intoxication and peritonitis.
Complicated cholecystitis. Occlusive (obstructive) cholecystitis develops when the cystic duct is blocked by a calculus and initially manifests itself as a typical picture of biliary colic, which is the most characteristic symptom of cholelithiasis. A sharp pain occurs suddenly in the right hypochondrium with irradiation to the right shoulder, scapula, to the region of the heart and behind the sternum. Patients behave uneasily, vomiting appears at the height of the attack, sometimes multiple. The abdomen may be soft, while a sharply painful, enlarged and tense gallbladder is palpated.
An attack of biliary colic can last several hours or 1 - 2 days, and when the stone returns to the gallbladder, it suddenly ends. With prolonged blockage of the cystic duct and infection, destructive cholecystitis develops.
Perforated cholecystitis proceeds with the phenomena of local or diffuse peritonitis. The moment of perforation of the gallbladder may go unnoticed by the patient. If adjacent organs are soldered to the gallbladder - the greater omentum, the hepatoduodenal ligament, the transverse colon and its mesentery, that is, the process is limited, then complications such as subhepatic abscess, local limited peritonitis develop.
Acute cholecystitis, complicated by lesions of the bile ducts, can occur with clinical manifestations of choledocholithiasis, cholangitis, choledochal stricture, papillitis, stenosis of the Vater nipple. The main symptom of this form is obstructive jaundice, the most common cause of which is the calculi of the common bile duct, which obstruct 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, which becomes persistent, accompanied by severe skin itching, dark urine and discolored (acholic) putty-like feces.
Due to the accession of the infection and its spread to the bile ducts, symptoms of acute cholangitis develop. Acute purulent cholangitis is characterized by severe intoxication - general weakness, lack of appetite, icteric coloration of the skin and mucous membranes. Constant dull pain in the right hypochondrium radiating to the right half of the back, heaviness in the right hypochondrium, with tapping on the right costal arch - a sharp pain. The body temperature rises in a remitting type, with profuse sweating and chills. Tongue dry, lined. The liver on palpation is enlarged, painful, soft consistency. Leukocytosis is noted with a shift of the leukocyte formula to the left. In a biochemical study of blood, an increase in the content of direct bilirubin and a decrease in the content of prothrombin in the blood plasma are observed. The disease can be complicated by life-threatening cholemic bleeding and liver failure.
Differential diagnosis. Acute cholecystitis must be differentiated from perforated gastric and duodenal ulcers, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, nephrolithiasis with localization of the calculus 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. Dyskinesia of the biliary tract is a violation of their physiological functions, leading to stagnation of bile in them, and later to the disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the trailing apparatus of the lower end of the common bile duct.
TO dyskinesia include:
1) atonic and hypotonic gallbladders;
2) hypertonic 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 varieties of these disorders in patients.
Duodenal sounding makes it possible to establish the diagnosis of an atonic gallbladder if an abnormally abundant outflow of intensely colored bile is observed, occurring immediately or only after the second or third administration of magnesium sulfate.
With cholecystography in the position of the patient on the 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 is collected.
When the diagnosis of "acute cholecystitis" is established, the patient should be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out according to vital indications in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent operations - with the failure of vigorous conservative treatment during the first 24-48 hours from the onset of the disease.
Operations are performed in a period of 5 to 14 days and later with a subsiding attack of acute cholecystitis and an observed improvement in the patient's condition, i.e., in the phase of reducing 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 - obstructive jaundice, cholangitis, impaired patency in the distal sections 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 imposition of a biliodigistic anastomosis are the lack of confidence in the patency of the Vater nipple, indurated pancreatitis, 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, it should be limited to external drainage of the biliary tract.
The management of patients in the postoperative period must be strictly individualized. They are allowed to get up in a day, they are discharged and the stitches are removed after about 10-12 days.
SCIENTIFIC LIBRARY - ABSTRACT - Surgery (Acute cholecystitis)
Surgery (Acute cholecystitis)
RUSSIAN STATE
MEDICAL UNIVERSITY
Department of Hospital Surgery
Head Department Professor Nesterenko Yu. P.
Teacher Andreitseva O.I.
Topic: "Acute cholecystitis".
Completed by a 5th year student
medical faculty
511a gr. Krat V.B.
Acute cholecystitis is an inflammatory process in the extrahepatic pathways.
with a predominant lesion of the gallbladder, in which
there is a violation of the nervous regulation of the activity of the liver and bile
ways to develop, as well as changes in the bile ducts themselves to
the soil of inflammation, stagnation of bile and cholesterolemia.
Depending on the pathological changes, there are
catarrhal, phlegmonous, gangrenous and perforative cholecystitis.
The most common complications of acute cholecystitis are
encysted and diffuse purulent peritonitis, cholangitis, pancreatitis,
liver abscesses. In acute calculous cholecystitis,
there is a partial or complete blockage of the common bile duct
with the development of obstructive jaundice.
Distinguish acute cholecystitis, which developed for the first time (primary
acute cholecystitis) or on the basis of 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; e)
complicated (peritonitis, cholangitis, pancreatitis, obstruction
biliary tract, liver abscess, etc.).
Etiology and pathogenesis of acute cholecystitis:
The inflammatory process in the wall of the gallbladder can be
caused not only by a microorganism, but also by a certain composition of food,
allergic and autoimmune processes. However, the covering epithelium
rebuilds into goblet and mucous membranes, which produce a large
the amount of mucus, the cylindrical epithelium flattens, they lose
microvilli, absorption processes are disturbed. In the niches of the mucosa
absorption of water and electrolytes occurs, and colloidal solutions of mucus
turn into a gel. Lumps of gel slip out of the bladder when contracted.
niches and stick together, forming the beginnings of gallstones. Then the stones grow and
impregnate 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 cavity of the gallbladder and
violation of the outflow of bile. The focus is on infection.
Pathogenic microorganisms can enter the bladder in three ways:
hematogenous, lymphogenous, enterogenic. More common in the gallbladder
find the following organisms: E.coli, Staphilococcus,
The second reason for the development of the inflammatory process in the bile
bubble is a violation of the outflow of bile and its stagnation. Wherein
mechanical factors play a role - stones in the gallbladder or its
ducts, kinks of the elongated and tortuous cystic duct, its
constriction. Against the background of cholelithiasis, according to statistics,
occurs in up to 85-90% of cases of acute cholecystitis. If in the wall
bladder develops sclerosis or atrophy, then the contractile and
drainage function of the gallbladder, which leads to a more severe
the course of cholecystitis with deep morphological disorders.
Unconditional importance in the development of cholecystitis is played by vascular
changes in the bladder wall. From the degree of circulatory disorders
the rate of development of inflammation, as well as morphological disorders
in the wall.
Clinic of acute cholecystitis:
The clinic 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. pain
radiate to the right shoulder, right supraclavicular space
and right scapula, in the right subclavian region. pain attack
accompanied by nausea and vomiting with an admixture of bile. Usually,
vomiting does not bring relief.
The temperature rises to 38-39°C, sometimes with chills.
elderly and senile age severe destructive cholecystitis
can occur with a slight increase in temperature and moderate
leukocytosis. The pulse with simple cholecystitis becomes more frequent, respectively.
temperature, with destructive and, especially, perforative
cholecystitis with the development of peritonitis, tachycardia up to 100-120
beats per minute.
In patients, during examination, icterus of the sclera is noted; pronounced
jaundice occurs when the common bile duct is obstructed
due to obstruction by a stone or inflammatory changes.
The abdomen is painful on palpation in the region of the right hypochondrium. IN
the same area is determined by muscle tension and symptoms of irritation
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 pressed or tapped in
gallbladder area (symptom of Zakharyin) and with deep
palpation on inhalation of the patient (obraztsov's symptom). The patient cannot
take a deep breath with deep palpation in the right
hypochondrium. Pain on palpation in the right
supraclavicular region (symptom of Georgievsky).
In the initial stages of the disease, with careful palpation, one can
identify an enlarged, tense and painful gallbladder.
The latter is especially well contoured during the development of acute
cholecystitis due to dropsy of the gallbladder. With gangrenous
perforative cholecystitis due to severe muscle tension
anterior abdominal wall, as well as during exacerbation of sclerosing
cholecystitis palpation of the gallbladder fails. With 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.
When examining blood, neutrophilic leukocytosis is noted (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 can occur
very difficult with the rapid development of gangrene and bladder perforation,
especially in the elderly and senile. With an exacerbation
chronic calculous cholecystitis stones can contribute to
faster destruction of the bladder wall due to stagnation and
bedsore formation.
However, more often inflammatory changes increase
gradually, within 2-3 days, the nature of the clinical
course with progression or remission of inflammatory changes.
Therefore, there is usually enough time to evaluate the current
inflammatory process, the patient's condition and a reasonable method
Differential Diagnosis:
Acute cholecystitis is differentiated with the following diseases:
1) Acute appendicitis. In acute appendicitis, the pain does not happen so
intense, and, most importantly, does not radiate to the right shoulder, right shoulder blade and
etc. Also, acute appendicitis is 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 at
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. Typical severe condition
sick, he takes a forced position. Decisive at
diagnostics has the level of diastase in the urine and blood serum,
Evidence figures over 512 units. (in urine).
With stones in the pancreatic duct, pain is usually localized in
left hypochondrium.
3) Acute intestinal obstruction. For acute intestinal obstruction
pains are cramping, non-localized. There is no rise in temperature.
Increased peristalsis, sound phenomena (“splash noise”),
X-ray signs of obstruction (Kloiber bowls, arcades,
a symptom of pinnation) are absent in acute cholecystitis.
4) Acute obstruction of the arteries of the mesentery. With this pathology, there are
severe pain of a constant nature, but usually with distinct
amplifications, are less spilled than with cholecystitis (more
diffuse). A history of pathology from the side of the cardiovascular system is mandatory.
vascular system. The abdomen is well accessible for palpation, without pronounced
symptoms of peritoneal irritation. X-ray is decisive and
angiography.
5) Perforated ulcer of the stomach and duodenum. More often than not
men suffer from cholecystitis, while women are more likely to suffer from cholecystitis.
Cholecystitis is characterized by intolerance to fatty foods, often
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 shoulder blade, etc., with an ulcer, the pain radiates mainly
in the back. Erythrocyte sedimentation is accelerated (with an ulcer - vice versa). clarify
a picture of the presence of an ulcerative anamnesis and tarry stools.
X-ray in the abdominal cavity we find free gas.
6) Renal colic. Pay attention to the urological history. Thoroughly
examine the kidney area, Pasternatsky's symptom is positive, carry out
urinalysis, excretory urography, chromocystography for clarification
diagnosis, since renal colic often provokes bile.
Correct assessment of the patient's condition and the course of the disease
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 in 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 in the use
broad-spectrum antibiotics, detoxification therapy.
To relieve pain, it is advisable to conduct a course of therapy
atropine, no-shpa, papaverine, as well as blockade of the round ligament
liver or perirenal 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, perivesical and
intrahepatic abscesses, peritonitis and a frequent combination
cholecystitis with choledocholithiasis, obstructive jaundice.
During the first 24-72 hours after admission,
emergency surgery for those patients with acute cholecystitis who have
worsening of the disease despite vigorous treatment with
the use of antibiotics. Early operation shown after fading
inflammatory process after 7-10 days from the onset of the attack,
patients suffering from acute calculous cholecystitis, exacerbation
chronic cholecystitis with severe and often recurring
disease outbreaks. 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 a very serious condition of patients produce
cholecystotomy. Operations can be performed both laparoscopically
method, and standard methods with laparotomy.
Laparoscopic surgeries are performed under local anesthesia. Incision
4-6 cm long is carried out above the bottom of the gallbladder, parallel to the costal
arc. The tissues of the abdominal wall are layered and pushed apart. Withdraw to
wound the wall of the gallbladder, puncture the contents. biliary
the bubble is removed. Conduct an audit of the cavity of the bladder. However, after the end
X-ray and endoscopic studies 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 - the imposition of an external fistula on the gallbladder. At
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 of the walls of the bladder with the edges of the incision are formed.
This operation is carried out as the first moment of operation in the elderly
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 is more beneficial
introduce and seal tightly in the bubble a thin rubber drainage.
Cholecystectomy - removal of the gallbladder, the most common
the operation is performed in typical cases in two ways: 1) from the neck; 2) from
Cholecystectomy from the fundus is technically easier, but less commonly used due to
the possibility of leakage of purulent contents into the choledoch. When separated from
the bottom of the bubble is captured with a terminal clamp, its peritoneum is incised on the sides
and in a blunt or sharp way separate the bladder from the liver, capturing and
tying individual branches a. cystica. By separating the bubble from the bed
liver ligate the main branch of the cystic artery and the cystic duct. At
the presence of powerful adhesions, the method of isolation from the bottom is easier, but bleeding from
branches of the cystic artery complicates the operation somewhat, since with
capture in the depth of the wound of bleeding vessels can be tied up
passing near the cystic artery right hepatic duct.
Cholecystectomy from the cervix is more difficult. First in the Kahlo triangle
ligate the cystic duct and cystic artery. Then they start separating
bladder, then to peritonize its bed. Leave parts allowed
bladder mucosa in its bed.
In cases of detection during the operation of sclerosed and
surrounded by powerful adhesions of the gallbladder, when finding the neck and
duct meets insurmountable difficulties, apply the opening of the bladder on
throughout its length and burning of the mucosa by electrocoagulation. After
burning the mucosa, the remaining wall of the bladder is screwed in and sutured
catgut sutures over the scab. Burning of the mucosa is in severe
cases, an advantage over removing the bladder in an acute way. This operation
is called mucoclasis (according to Primbau).
Choledochotomy is an operation used to examine,
drainage, removal of stones from the duct. The duct is drained for cholangitis
to divert the infected contents of the ducts to the outside. There are three
types of choledochotomy: supraduodenal, retroduodenal and
transduodenal.
After removing the stone, the duct is carefully sutured with thin catgut
sutures and closed with a second row of sutures placed on the peritoneum. In place
opening the duct, a tampon is brought in, since with the most thorough suturing
bile can leak between the stitches and cause biliary peritonitis.
Choledochoduodenostomy - the formation of an anastomosis between the bile duct and
duodenum. This operation is performed with narrowing or
obstructed strictures of the bile duct. Like a disadvantage
choledochoduodenostomy, it should be noted the possibility of hitting the duodenal
content in the duct. However, experience shows that with normal outflow
bile is not accompanied by dangerous consequences. short-term
outbreaks of biliary tract infections are treated with antibiotics.
In the postoperative period, the prevention of acute
cholecystitis, correction of the coagulation and fibrinolytic systems, water-
salt and protein metabolism, prevent thromboembolic and
cardiopulmonary complications.
From the second day, they begin to eat liquid food through the mouth. At 5-
th day remove and replace with others a narrow tampon facing the bed
bubble, leaving in place a wide delimiting tampon, which is 5-6-
The th day is pulled up and removed with a smooth flow on the 8-10th day. K 14
day usually discharge from the wound stops, and the wound itself
closes. After removal of the gallbladder, patients are advised
diet compliance.
Improving the results of treatment of patients with acute cholecystitis depends on
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 faced by the general.
In most cases (>90%), obstruction of the cystic duct by a stone occurs. In contrast to biliary colic, a constant (rather than intermittent) in the hypochondrium, fever, leukocytosis, and there is also a change in the level of liver enzymes in the blood test are noted. After obstruction of the cystic duct, the bladder dilates, resulting in subserous, venous, and lymphatic stasis, cellular infiltration, and limited areas of ischemia. In 50-75% of cases, bacteria play a certain 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 should have a sufficient spectrum of action. If left untreated, acute gangrenous cholecystitis (most common 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 large intestine). In this case, a vesico-intestinal fistula is formed. If the stone migrates into the intestinal lumen, gallstone may develop. In the case of untreated acute cholecystitis, gangrenous cholecystitis can develop (most often in diabetic patients), leading to gallbladder perforation or sepsis, thus increasing morbidity and mortality.
Symptoms of acute cholecystitis
Most patients with acute cholecystitis will have a history of abdominal symptoms that can be correlated with bile ducts, although in some cases acute cholecystitis is the first manifestation of cholelithiasis. In all observations of acute cholecystitis, the most characteristic symptom is constant pain in the right hypochondrium, symptoms of peritoneal irritation (Blumberg's symptom, Murphy's symptom). At first, pain develops due to obstruction of the cystic duct and expansion of the gallbladder, although with the development of inflammation, edema and ischemia, 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 in acute cholecystitis usually reveals an elevated temperature. Often, an inflamed bladder can be palpated as a tender swollen mass, but this is not always the case. Patients with diabetes, in particular, may have severe cholecystitis with minimal findings on objective examination. Murphy's symptom is considered positive with a sudden increase in pain on palpation in the right hypochondrium during inspiration, which is due to the contact of the inflamed gallbladder with the anterior abdominal wall, deflected by the palpating hand. Patients often hold their breath mid-inhalation. A similar phenomenon during the right upper quadrant is called Murphy's ultrasonic symptom (the role of the palpating hand is performed by the sensor).
Diagnosis of acute cholecystitis
Data from a laboratory study in acute cholecystitis reveal leukocytosis, an increase in AsAT and ALT, alkaline phosphatase. Usually, the level of total bilirubin increases slightly (by 1-2 times), although a significant increase (> 2 times) may indicate concomitant choledochal obstruction. Surprisingly, in patients with the detection of the disease, even at a very late stage, a biochemical blood test can remain completely normal.
The two most common imaging modalities used in the diagnosis of acute cholecystitis are abdominal ultrasonography and biliocintigraphy. Plain x-rays are of limited use because only about 15% of gallstones are radiopaque and the gallbladder is not visible at all. The first step is usually an ultrasound. It provides answers to the following questions: "Are gallstones present?" "Is the gallbladder enlarged?" and “Are the intrahepatic or extrahepatic ducts dilated?”. The main criterion for establishing the diagnosis of cholecystitis is often considered a thickening of the bladder wall. As a result of such an examination, many false positive and false negative results occur. For example, in patients with low serum albumin and a normal gallbladder, perivesical fluid can 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 by ultrasound are stones, gallbladder enlargement, and Murphy's ultrasound sign. It is also necessary to always determine the diameter of the extrahepatic ducts in order to rule out choledocholithiasis.
For patients in whom the diagnosis of acute cholecystitis is doubtful, a radioisotope study is performed. If there is no cystic duct obstruction, extrahepatic bile ducts and bladder are identified.) If there is an obstruction, then 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 fasted 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 bowel obstruction, hepatitis and. In addition, differential diagnosis is carried out with pneumonia, coronary artery disease and herpes zoster (shingles). Usually, a careful history and examination can confirm the diagnosis. An increase in serum amylase, which sometimes occurs with acute cholecystitis, can make it difficult to differentiate from pancreatitis. In this case, it is necessary to perform a CT scan of the abdominal cavity.
Treatment of acute cholecystitis
Patients with suspected acute cholecystitis should be hospitalized. They are prescribed hunger and infusion therapy. If the diagnosis is confirmed, broad-spectrum intravenous administration is necessary.
In the absence of contraindications (CHD, pancreatitis,) cholecystectomy is performed within 24-36 hours. If the patient asked for help late (after 4-5 days), treatment with antibiotics should be started and the laparoscopic procedure 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 called into question, and they tend to opt for open surgery. Except in very low-risk patients, removal of the gallbladder is always necessary. Such patients can be performed percutaneous cholecystostomy under ultrasound guidance and local anesthesia.
crushing stones
Extracorporeal extracorporeal shock wave lithotripsy has been used in the past for the treatment of gallstone disease. The essence of the method is the action of a shock wave on a stone. The aim was to crush the stones into pieces (approximately 5 mm) capable of passing through the cystic duct and the sphincter of Oddi. Unfortunately, the success 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 a mild or moderate course are usually examined first. If symptoms subside within the first 48 hours of gallstone pancreatitis, laparoscopic cholecystectomy is usually performed. If jaundice accompanies pancreatitis, then it is performed to exclude choledochal 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 carried out carefully because of the risk of aggravating the course of pancreatitis. As soon as the obstruction (if it was) is eliminated, treatment begins according to generally accepted principles. When the pancreatitis is resolved (which may take several weeks), the patient is discharged from the hospital and prepared for a planned cholecystectomy in a few months to prevent future exacerbation of the disease.
Laparoscopic cholecystectomy for acute cholecystitis
In 1992, at the NIH Consensus conference, 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 through a median or long incision in the right hypochondrium, which required a very long recovery period. Now 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 in concomitant diabetes mellitus.
Technical aspects of laparoscopic cholecystectomy
If the planned laparoscopic cholecystectomy goes without complications, then it can be used. No special bowel preparation is required before surgery. After the introduction into anesthesia, the patient is placed on the operating table in the supine position. The gastric tube must be inserted for decompression and removed at the end of the operation. Bladder catheterization is not required if an open trocar insertion method is used. The abdomen is treated and lined in the usual way. A small incision is made under the navel to the fascia. Next, the fascia is grasped with Kocher clamps, lifted and dissected. A trocar (usually 10 mm) is inserted and secured. Carbon dioxide is injected under low pressure (15 mm Hg). Then three trocars are inserted in the right hypochondrium. 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 in open cholecystectomy correspond to those of the laparoscopic approach. The use of laparoscopic instrumentation and small trocar incisions is preferable to the traditional surgical instrumentation used in open cholecystectomy and an incision in the right upper quadrant of the abdomen or a midline approach.
The article was prepared and edited by: surgeon Acute inflammation of the gallbladder- one of the most frequent 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 gallbladder and a violation of the outflow of bile. The microflora enters the gallbladder in an ascending way from the duodenum, less often in a descending way from the liver, where microorganisms enter by 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 the calculus occludes the neck of the gallbladder or cystic duct. Of secondary importance in the development of acute inflammation are impaired blood supply to the gallbladder wall in atherosclerosis of the visceral branches of the abdominal aorta and the damaging effect of pancreatic juice on the gallbladder mucosa during reflux of pancreatic secretions into the bile ducts.Clinic of acute cholecystitis
Allocate catarrhal, phlegmonous And gangrenous (perforated gallbladder and without it) 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, pain can be paroxysmal in nature due to increased contraction of the gallbladder wall, aimed at eliminating occlusion of the neck of the bladder or cystic duct. Often there is vomiting of gastric contents, and then the contents of the duodenum, which does not bring relief to the patient. Body temperature rises to subfebrile. There are moderate tachycardia (up to 100 in 1 min), sometimes an increase in blood pressure. The tongue is moist, coated with a whitish or gray coating. The abdomen is involved in the act of breathing, its right half is somewhat behind. On palpation of the abdomen, there is a sharp pain in the right hypochondrium, especially in the projection of the gallbladder. The tension of the muscles of the abdominal wall is expressed slightly or absent altogether. Positive symptoms of Ortner - Grekov, Murphy, Mussi-Georgievsky are determined.Sometimes it is possible to palpate an enlarged, moderately painful gallbladder. In the blood test, moderate leukocytosis (10-12-109/l).
catarrhal cholecystitis
Catarrhal cholecystitis, like hepatic colic, in most patients is provoked by errors in the diet. Unlike colic, an attack of acute catarrhal cholecystitis is longer (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 is aggravated by coughing, taking a deep breath, changing the position of the body. Nausea and repeated vomiting occur more often, the general condition of the patient worsens, body temperature rises to 38-38.5 ° C, tachycardia occurs (110-120 in 1 min). The abdomen is somewhat swollen due to intestinal paresis, while breathing the patient spares the right half of the abdominal wall, intestinal noises are weakened. On palpation of the abdomen, there is a sharp pain in the right hypochondrium, muscular protection is expressed, it is often possible to determine an inflammatory infiltrate or an enlarged gallbladder. Positive Shchetkin-Blumberg symptom 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, its wall is thickened, purple-bluish in color, in the lumen - purulent exudate with an admixture of bile. On the wall outside - fibrinous-purulent plaque. The wall is saturated with leukocytes, purulent exudate, sometimes separate small abscesses form in the wall.
