Purulent cholecystitis (cholecystectomy). Acute cholecystitis Pus in the gallbladder treatment

- this is an acute purulent inflammation of the gallbladder, rapidly progressing and often leading to the development of complications (perforation of the gallbladder, peritonitis, etc.). The clinical picture is dominated by pain in the right hypochondrium, intoxication, fever, nausea and vomiting of bile, dyspepsia. Of primary importance for diagnosis are clinical and biochemical blood tests, ultrasound and CT of the liver and gallbladder, hepatobiliary scintigraphy. Treatment is exclusively surgical; detoxification and antibacterial therapy, anesthesia is mandatory.

General information

Ischemia of the wall is the cause of a violation of the contractile activity of the gallbladder, stagnation and thickening of bile, deterioration of its evacuation. As a result, overstretching of the bladder walls occurs, which leads to the progression of ischemia, the development of necrosis and perforation of the bladder wall. Intensive infusion therapy causes a sharp restoration of blood circulation in ischemic areas, which only exacerbates pathological changes, so the treatment of pathology is only surgical.

In critically ill patients in intensive care units, the mechanism of ischemia development is somewhat different. The cholecystokinin pathway to stimulate the contraction of the gallbladder does not function in them due to the inability to receive food and fluid through the digestive tract. In addition, such patients often develop dehydration, centralization of blood circulation. All this leads to primary thickening and stagnation of bile, hyperextension of the gallbladder, obstruction and compression of the vessels of the gallbladder wall and its secondary ischemia against this background.

In the ischemic wall of the gallbladder, local immune mechanisms do not work, therefore, most often colonization by bacteria occurs by the hematogenous route (through the portal vein or hepatic artery). However, cases of ascending infection are not uncommon, when pathogens enter the gallbladder from the intestine (in the presence of an intestinal infection caused by Klebsiella, cocci, Escherichia coli), retrograde through the biliary tract. The developed inflammatory process leads to exudation into the lumen of the gallbladder, the progression of gallbladder hypertension and the formation of a pathogenetic vicious circle.

Symptoms of purulent cholecystitis

Identification of the inflammatory process is usually difficult, since this disease in most cases develops against the background of another severe pathology and has nonspecific manifestations. The pain is quite pronounced, localized in the right side of the abdomen, according to the description it resembles biliary colic. During a painful attack, the patient takes a forced position on his side with his knees pulled up to his chest, the attack is accompanied by increased sweating, pallor of the skin, tachycardia, and a pained grimace on the face. Possible irradiation of pain in the right shoulder blade, shoulder.

Body temperature rises significantly, characterized by hectic fever. Most often, an increase in temperature is accompanied by severe chills, pouring sweat. In elderly and debilitated patients, the temperature can rise only to subfebrile figures (even with the development of empyema and peritonitis). Purulent cholecystitis is usually accompanied by signs of damage to other abdominal organs: flatulence, a feeling of fullness in the abdominal cavity, nausea, vomiting of bile, an attack of acute pancreatitis. With obstruction of the biliary tract, jaundice may develop.

On palpation of the abdomen, there is a sharp pain and tension in the muscles of the anterior abdominal wall in the right hypochondrium, an increase in the size of the liver, positive cystic symptoms - pain increases with tapping on the anterior abdominal wall (Mendel's s-m), percussion in the right costal arch (Ortner's s-m) ), palpation in the area of ​​the right hypochondrium on inspiration (s-m Kera). Sometimes Murphy's syndrome can be detected - on palpation of the right hypochondrium, the patient involuntarily holds his breath; locally positive symptom of Shchetkin-Blumberg - with a sharp withdrawal of the palpating hand from the anterior abdominal wall in the region of the right hypochondrium, the pain increases significantly.

Diagnostics

Consultation of an abdominal surgeon and an endoscopist is required for all patients with suspected purulent cholecystitis. The diagnostic signs of this disease include: pain in the right hypochondrium, positive signs of peritoneal irritation and bladder symptoms, intoxication in combination with fever and leukocytosis, increased liver function tests, the presence of predisposing factors. To verify the diagnosis, a clinical blood test is used (leukocytosis, toxic forms of leukocytes, increased ESR, blood clots or anemia are detected); liver tests (increased levels of bilirubin, ALT, AST, alkaline phosphatase).

On ultrasound of the gallbladder, there is a thickening and doubling of the contour of the bladder wall, the inhomogeneity of its contents, and the accumulation of fluid in the perivesical cavity. Computed tomography of the biliary tract in 95% of cases reveals necrosis of the gallbladder wall, desquamation of the mucosa, perivesical inflammatory infiltrate. Dynamic scintigraphy of the hepatobiliary system makes it possible to assess the outflow of bile, the work of the gallbladder, and also to detect its perforation (in this case, the isotope will accumulate in the perivesical space). abdominal surgery. Conservative therapy is usually used as a preparation of the patient for intervention. Operative treatment should be carried out as soon as possible, since the risk of life-threatening complications in this disease is very high. Two methods are usually used: cholecystostomy (more often as an intermediate option in severe patients) and cholecystectomy by laparotomic or laparoscopic access.

Drug treatment of purulent cholecystitis includes fasting, infusion therapy, pain relief and powerful antibiotic therapy. The use of morphine for pain relief is not recommended, as it causes spasm of the sphincter of Oddi and bile stasis. Often, antispasmodics are included in the treatment regimen.

Forecast and prevention

The prognosis for purulent cholecystitis is unfavorable, since the disease develops rapidly, often accompanied by life-threatening complications. Mortality with fluctuates between 10-50%. Prevention includes the timely elimination of risk factors: early diagnosis and treatment of diseases of the cardiovascular system, helminthiases and other provoking pathologies, adequate correction of the condition of seriously ill patients in the ICU, etc.

A serious disease of the gallbladder is purulent cholecystitis, which is fraught with the development of serious complications. Therefore, its treatment should be carried out immediately and only by specialized specialists. Before starting therapeutic measures, it is important to undergo the necessary diagnostic examination. To achieve relatively favorable prognosis during treatment, all the doctor's recommendations should be impeccably followed, self-medication for this ailment can be fatal.

The triggering of inflammation in the gallbladder can result in suppuration in the organ.

What it is?

In medicine, acute inflammation of the gallbladder, accompanied by pus, is called purulent cholecystitis. It progresses rapidly and in most cases leads to complications. Characterized by cholecystitis with suppuration, painful sensations under the ribs on the right side and signs of intoxication. To confirm the diagnosis, a diagnosis is required, which includes ultrasound, blood tests, and other examination methods. It is possible to cure purulent inflammation of the gallbladder only with the help of surgical intervention, but antibacterial, detoxification and analgesic therapy is also mandatory.

If you do not see a doctor in time, the patient is threatened with serious complications, namely:

• accumulation of purulent edematous fluid in the gallbladder, which as a result leads to perforation of the walls of this organ;
• the appearance of acute inflammation of the pancreas, as well as sepsis and purulent lesions of the peritoneum.

The described disease is extremely rare, but its complexity is the lack of specific symptoms, with which it was possible to quickly identify the disease. Especially often, cholecystitis with pus develops in patients whose condition is so severe that they are not able to describe the symptoms that bother them. The disease in this case progresses without visible signs and is detected only with a complete diagnostic examination.

The prevalence of purulent inflammation of the gallbladder is more common in women of retirement age.

How often does it occur?

According to statistics in the field of medicine, patients with purulent cholecystitis account for 2-3% of all cases of acute surgical diseases of the peritoneum. Women over 50 years of age are more prone to an inflammatory process with rotting on the gallbladder. It is extremely rare to diagnose a purulent form of cholecystitis in young patients.

Reasons for the appearance

Why does such a serious disease as purulent inflammation of the gallbladder appear? The root cause of the development of this disease is a decrease in the blood supply to the bladder walls, which occurs after heavy bleeding, dehydration of the body, shock shocks, and also as a result of heart failure (both acute and chronic forms). In addition, violations of the walls of the gallbladder occur due to compression by tumors, stone formation and nearby organs. Factors that provoke cholecystitis with suppuration are diseases such as diabetes mellitus and atherosclerosis, as well as drugs.

The above reasons become the reason for the formation of stagnation, thickening and violation of the outflow of bile, as well as improper functioning of the bladder. As a result, the walls of the organ are stretched and thereby progress ischemia, necrosis and perforation of the bladder. Cholecystitis can be caused by serious injuries, surgical interventions, to a greater extent on the organs of the abdominal cavity and the cardiovascular system, as well as pregnancy, severe burns, intestinal infection and prolonged food refusal.

Symptoms of the disease

It is not always possible to immediately identify a purulent lesion of the gallbladder, since the symptoms of this disease do not have a characteristic and pronounced picture. The patient is concerned about painful paroxysmal sensations in the right hypochondrium, often accompanied by high body temperature and jaundice. Pain can be given to the shoulder blade on the same side and the shoulder. On palpation of the abdomen, there are sharp, intensifying pains and severe tension in the abdominal muscles. In the future, painful symptoms are localized throughout the abdomen, which indicates the spread of inflammation over the surface of the abdominal cavity. Sometimes, when feeling the abdomen in patients, a large gallbladder can be distinguished, as well as the edge of an enlarged liver.

Abscesses, inflammation of the bile ducts and toxic hepatitis are capable of provoking an increase in the size of the largest digestive gland. Symptoms in the described pathology are reflex in nature and most often manifest as vomiting. However, the occurrence of vomiting is not always due to a reflex origin. In some cases, this symptom occurs as a result of the existing many coarse adhesions between the organs of the digestive system.

In addition, the patient is concerned about symptoms such as burning in the esophagus, involuntary discharge of gases through the oral cavity, nausea and constipation. The main distinguishing feature of purulent cholecystitis is an increase in body temperature to high marks on the thermometer. So, with the septic nature of the inflammatory process, the temperature rises to 40 degrees and above and the patient is shivering.

Diagnosis of purulent cholecystitis

If you suspect purulent cholecystitis, you will need to be examined by a doctor and tested.

Before starting treatment of an inflamed gallbladder with decay processes, it is imperative to conduct a diagnostic examination. The first step is to visit a specialized specialist, in this case a gastroenterologist and an endoscopist. Doctors, in turn, will collect all the necessary information about the disturbing symptoms, the general well-being of the patient. To make an accurate diagnosis, the doctor will need to palpate the abdomen.

Next, a patient with purulent cholecystitis is sent for testing. The results of a liver test and a blood test are needed to confirm the diagnosis. In addition, an ultrasound examination of the bladder is performed to detect thickening and doubling of the bladder walls, as well as to diagnose the accumulation of fluid in the gallbladder. An effective method for diagnosing the gallbladder is computed tomography of the bile ducts, which almost always reveals necrosis of the walls of the described organ and exfoliation of the mucosa.

In order for the doctor to be able to prescribe treatment correctly, in some cases, esophagogastroduodenoscopy, magnetic resonance imaging are required, and choledochoscopy with bile culture, ERCP and electrocardiography will not be out of place. The last diagnostic method is assigned to each patient in order to exclude myocardial infarction, which has a similar pain attack with biliary colic.

Treatment of the disease

When, with the help of diagnostics, the doctor has established an accurate diagnosis and selected a scheme, they begin to treat it. Patients with cholecystitis, accompanied by the process of decay, need to be in the surgical or gastroenterological department, since the patient is required to have an operation. Conservative treatment in most cases is intended to prepare the patient for surgery.

Treatment of purulent cholecystitis will occur with the use of antibacterial and analgesic drugs.

When a person reaches middle age, it will be useful to learn about the disease cholecystitis - what it is, what are its symptoms, prevention and treatment. According to medical statistics, women of middle age and older are more at risk of developing cholecystitis than men of the same age. Cholecystitis is an inflammatory process accompanied by irritation of the gallbladder. Classification of the disease - code according to ICD-10.

Causes of inflammatory processes

The cause of inflammatory processes in cholecystitis is a violation of the flow of bile from the gallbladder into the small intestine.

Bile plays an important role in the human digestive process. Excessive accumulation of bile in the gallbladder occurs due to problems with its removal through the bile ducts. All this is accompanied by severe pain and the risk of infection.

Women, especially middle-aged and older women, are more susceptible to this disease than men. This is due to the following reasons:

1. During pregnancy, there is a constant and long-term squeezing of the bladder, which lays the foundation for the subsequent violation of the flow of bile.
2. Female hormones during pregnancy negatively affect the production of bile and the functioning of the gallbladder.
3. The diets that women are fond of often not only contribute to weight loss, but also provoke disruption of the gallbladder.

There are certain causes of cholecystitis that can provoke bile flow disorders:

To determine which doctor treats a certain type of disease - a gastroenterologist or a surgeon, a comprehensive diagnosis of the patient is first carried out.

The first signs of inflammatory processes in the gallbladder are sharp pains in the lower ribs on the right side of the body. When the process provokes a deterioration in the flow of bile into the intestines, this is accompanied by the following external signs:

• the skin becomes bright yellow;
• pulse increases significantly.

The main cause of cholecystitis (international classification - ICD-10 code) is the process of accumulation of stones in the gallbladder. At first, an acute form of inflammation appears, which then develops into a chronic one. This changes the thickness of the walls of the gallbladder.

In the chronic course of the disease, these signs may not appear. Treatment is prescribed only by a doctor.

Types of cholecystitis, complications, its diagnosis

The gallbladder, which produces bile, plays an important role in the digestion of food. Bile helps to stimulate the secretion of mucus, which provides protective functions, activates enzymes, and supports the work of the small intestine. Let's take a closer look at what cholecystitis is.

The disease occurs for two main reasons:

• violation of the flow of bile;
• dysmotility of the gallbladder.

Depending on the cause of the disease, the disease is divided into two groups:

1. Calculous - the presence of stones, stretching of the walls of the gallbladder.
2. Non-calculous - a violation of the blood supply to the walls of the gallbladder.

The size and structure of gallstones can vary. The main composition of the stones is lime and cholesterol. Stones can be of different sizes. They can form both in the bladder and in the bile ducts.

By the nature of the process, there is chronic and acute cholecystitis.

By the nature of the inflammatory process, there are the following types of cholecystitis:

• purulent;
• mixed;
• gangrenous;
• catarrhal.

Complications of cholecystitis in the acute form of the disease, as a rule, are as follows:

• inflammatory process in the pancreas;
• rupture of the gallbladder;
• peritonitis;
• jaundice.

For the primary diagnosis of the disease, palpation of certain areas of the patient's body, light blows to provoke pain are used. After that, the presence and nature of these pains are analyzed.

The chronic form of the disease is characterized by the following symptoms:

• nausea;
• heaviness and bloating;
• bitterness in the mouth;
• on palpation, an increase in the liver is felt;
• elevated body temperature - up to 38 ° C;
• no sharp pain.

Diagnosis of the disease occurs with the help of ultrasound examination of the gallbladder and liver. Laboratory diagnostics includes analysis of blood, urine, duodenal contents. Probing and X-ray examination of the gallbladder are also actively used.

Disease in childhood

Cholecystitis in children has the same types as in adults. Older children are more susceptible to the disease than babies. At a younger age, boys are more likely to suffer from this disease, at an older age - girls. Acute cholecystitis in children with timely treatment is completely cured. If the treatment process is started, then the acute form can turn into a chronic one. Treatment of cholecystitis in children is tried to be carried out at home. Hospitalization is used only in severe cases. Treatment is complex and consists of the following:

1. The strictest observance of the regime.
2. Meals are strictly according to the recommendations of a dietitian.
3. Passing a course of medical treatment.
4. Phytotherapy.

A decrease in the child's motor activity in compliance with bed rest is prescribed only at a high temperature. It is not worth limiting the activity of the child for a long period, as this can cause stagnant processes in the movement of bile. Fatty, smoked, spicy, pickled, salty foods, chocolate, citrus and carbonated drinks must be completely excluded from the child's diet. Meals include low-fat broths, vegetables, fruits, salads, vegetable oils, cereals, steamed fish and poultry. Proper nutrition prevents the recurrence of the disease. Together with dietary nutrition, infusions of medicinal herbs are actively used: calendula, rosehip, corn stigmas, chamomile.

Parents need to exercise control over the child's compliance with the diet, physical exercises.

Treatment and prevention

When attacks occur, to relieve pain, you need to do the following:

• call a doctor;
• lie down in a horizontal position;
• apply cold to the abdomen;
• drink refreshing liquids to reduce nausea.

At the initial stage of the disease, a nutritionist takes an active part, who determines recommendations for adjusting food intake, recommends which foods to exclude from the diet. Treatment of the disease in the acute and chronic stages is carried out in a hospital.

In this case, the following methods of treatment are used:

1. Prescribing a course of antibiotics.
2. Antispasmodics - ensuring the passage of bile.
3. Cholagogue - stimulates the production of bile.
4. Surgical methods.

For dietary nutrition, cereals, steam cutlets, jelly, white bread, and plant foods without coarse fiber are used. Food must be broken into small portions. You need to take food often - up to 6 times a day.

You can't eat at night. It is forbidden to eat fatty, salty foods, canned foods, carbonated drinks, dairy products. Water of high mineralization is actively used as a drink. Consume them at room temperature before meals. Various herbal teas are useful, including chamomile, motherwort, valerian. To stimulate the tone of the gallbladder, use tea containing St. John's wort, corn stigmas, lemongrass. Non-hot and short coniferous baths are actively benefiting. Prevention of cholecystitis is to ensure a balanced diet.

What is calculous cholecystitis: ICD code 10, classification

Bile takes an active part in the process of splitting fats, and if its outflow is disturbed, then the gallbladder becomes inflamed and the normal functioning of the body is disrupted and cholecystitis develops. Sometimes the process of inflammation of the organ is associated with the formation of stones and then the gastroenterologist diagnoses chronic calculous cholecystitis.

If the system of normal bile release has gone astray, then the body not only disrupts the absorption of fats, but also the vitamins necessary for the body to function properly. In the article, we will take a closer look at what the disease is, what are the causes of its development and forecasts.

Calculous cholecystitis - what is it?

The calculous form of cholecystitis is diagnosed if, along with inflammation, during the diagnosis, stones in the gallbladder are found in the patient. These crystalline seals can also clog the bile ducts, preventing the release of bile, leading to intense pain. Stones are formed in different sizes and types.

Acute deposits, scratching the mucous membrane of the organ and ducts, help inflammation develop even more actively. Almost 70% of all cases of the disease develop against the background of cholelithiasis, and the presence of bacteria is also confirmed in the course of studies in the gallbladder, but gastroenterologists believe that the addition of a bacterial infection is a secondary condition.

The clinical picture of the disease: pain under the right rib, with exacerbation of pain can be very strong cramping, muscle tension in the anterior abdominal wall and on the right side.

ICD-10 codes

K80.0 Gallbladder stones with acute cholecystitis.

K80.1 - Gallbladder stones with other cholecystitis.

K80.4 - Stones of the bile duct with cholecystitis.

Etiology and pathogenesis

The root cause of the development of the disease is the formation of stones that block the possibility of a free release of bile.

Risk factors for developing this disease include:

• pregnancy;
• sudden weight gain or loss;
• age factor (with age, the risk of the disease increases);
• gender (in women, the diagnosis of calculous cholecystitis is much more common);
• regular intake of hormonal drugs;

The formation of stones leads to the fact that they block the possibility of outflow of bile, and the stagnation of bile leads to its thickening and the release of enzymes that cause the development of the inflammatory process. The inflamed mucosa of the bladder can exfoliate and produce additional fluid in which stones form. When they move, they damage the mucous membrane, activating inflammation.

With an increase in the volume of an organ, pressure rises in it, which leads to impaired blood supply to the tissues and can lead to their death, necrosis and perforation of the walls.

Causes of calculous cholecystitis

The main reason is the formation and growth of stones. But the following factors lead to sedimentation and crystallization of deposits: a change in the composition of bile, its thickening and stagnation, bacteria that cause inflammation.

In the normal state, bile should be liquid and homogeneous, if there is a violation of the ratio of bile acids to the amount of cholesterol, then the latter falls into the sediment. Over time, the sediment crystallizes and clumps into stones of various shapes and sizes.

This process awaits people who do not watch their diet. If you eat a lot of fatty foods, do not monitor the amount of cholesterol, then most likely risk stones form in the gallbladder very quickly. People with diabetes, hepatitis, obesity and chronic infectious diseases are also at risk. In the process of stagnation, bile thickens and creates favorable conditions for the penetration of infection from the blood, lymph or intestines.

Very often, calculous cholecystitis develops against the background of acalculous, which in turn appears when the dynamics of the gallbladder is disturbed, which leads to failures in its emptying. Also, the following diseases can be attributed to the causes:

• narrowing or deformation of the biliary tract,
• gastritis in a chronic form,
• hepatic disease,
• helminth attack,
• pancreatitis.

Classification

According to the clinical form of the development of the disease, it is divided into two types - acute and chronic. Each of them may show complications or the absence of additional diseases. We will talk about them in more detail below.

acute form

In this case, inflammation of the gallbladder occurs quickly with a pronounced pain syndrome. Most often, this form of the disease can be complicated by concomitant diseases and infection. Exacerbation of calculous cholecystitis just occurs after the penetration of pathogenic microorganisms from the intestine, lymph or liver into the gallbladder.

Acute obstructive calculous cholecystitis develops as a result of stones blocking the neck of the bladder or duct. In addition to pain, which has a cramping character, aggravated by physical exertion, and sometimes simply by changing the patient's position.

Chronic form

The case history of this form of calculous cholecystitis is characterized by an almost asymptomatic course of the disease at the initial stage of development, and a sluggish development of the inflammatory process. The diagnosis is made after several stopped exacerbations.

A person simply constantly experiences a feeling of heaviness, suffers from bloating and diarrhea. Belching is often noticed, after which a metallic aftertaste or bitterness is felt in the oral cavity. After overeating and breaking the diet, the symptoms may increase.

Catarrhal, purulent, phlegmonous, gangrenous forms and other complications

If the problems of the gallbladder are left to chance and not treated, then the organ increases in size, begins to swell, and its walls turn red, which leads to thickening and swelling of the tissue. At this stage, the catarrhal form is diagnosed.

Further, without the participation of the necessary medical care, pus begins to collect in the inflamed bile duct, which leads to the development of a purulent form of the disease. When the walls thicken, exfoliate, and the purulent contents do not find a way out, then we can say that phlegmonous calculous cholecystitis develops. In this case, the process of suppuration leads to the occurrence of irreversible changes in the gallbladder, which are no longer amenable to treatment.

The next stage, gangrenous, is the most severe and fatal for the patient's life. At the time of its onset, necrosis of the tissues of the organ occurs, the appearance of ulcers on the surface, which can provoke a rupture of the gallbladder. Inflamed bile with pus, getting through the ulcers into the abdominal cavity, spreads the inflammatory process and leads to peritonitis and abscess.

Forecast

If the course of cholecystitis with the presence of stones is not accompanied by complications and additional diseases, then we can say that the patient is lucky. In this case, a fatal outcome was recorded in a very small number of patients who were not even going to take care of their health.

If complications have already appeared, then the process of recovery and death is 50% more expensive. Here, even with proper treatment, the development of a gangrenous form of the disease is possible, which leads to epiema of the gallbladder, the formation of fistulas, ulcers, atrophy of the wall tissue, peritonitis, abscess and, as a result, death.

The most common questions from readers

Do they take in the army with calculous cholecystitis?

If cholecystitis occurs in a chronic form and exacerbations do not appear or occur less often than once a year, then most likely he will have to pay his debt to his homeland. If the conscript has frequent exacerbations of the disease in the medical record, during which hospitalization was carried out, then he is not suitable for military service. It is required to confirm the diagnosis with a gastroenterologist and undergo the necessary studies.

How does calculous cholecystitis progress?

In the chronic form, the disease can develop over many years, aggravating slightly, and then subsiding again. But at the same time, you need to understand that cholecystitis is progressing. Most often, the disease manifests itself in people after 45-50 years, but sometimes such a diagnosis occurs in children.

The main danger overtakes the patient when the stones begin to move. If they block the bile duct, then this leads to severe pain, yellowing of the skin and general intoxication of the whole organism.

What diet should be followed for calculous cholecystitis?

The daily diet should be rich in protein and fiber. It is recommended to eat at least 5-6 times a day and make sure that portions do not exceed 250-300 g. Completely eliminate junk food. Dishes should be warm, no boiling water or frozen ingredients.

Give preference to lean meat, fish, vegetables, fruits, low-fat dairy products. Porridges, soups, boiled dishes are only welcome. Tea compote, jelly, mineral water without gas. The liquid can be drunk in unlimited quantities. When the state has stabilized a little, you can diversify the menu with gourds and dried fruits. Learn more about the diet for cholecystitis.

How to behave when symptoms of calculous cholecystitis are detected?

In the end, I would like to say that even if you can apply some of the symptoms of calculous cholecystitis to yourself, then it makes sense to consult a doctor for diagnostic measures. Only after a consultation and a personal examination with a gastroenterologist, you can get answers to all your questions.

To understand whether your assumptions are true, you need to take a general and biochemical blood test and do an ultrasound scan. Such a minimum set of tests will allow the doctor to accurately make or refute the alleged diagnosis. Even if the diagnosis is confirmed, do not give up. While the disease proceeds without complications, you can fight it, the main thing is to follow the doctor's recommendations and understand that the quality of your life in this case is strained.

Be the first to comment!

With untimely diagnosis or treatment, acute cholecystitis leads to the development of a number of serious complications, which in some cases can lead to life-threatening consequences. Specialists classify them, taking into account the form of the course of the disease.

In this article, we will introduce you to the possible complications of acute cholecystitis. You will be able to understand what this ailment sometimes leads to and make the right decision about the need for a timely visit to the doctor with the development of this disease.

Why Complications Develop

The untimely appeal of the patient to the doctor is one of the most common causes of the development of complications of acute cholecystitis.

The following factors can lead to the development of complications arising from acute cholecystitis:

• untimely visit to the doctor;
• unprofessionalism of a specialist;
• the root cause of the development of acute cholecystitis is an infectious agent;
• development of peritonitis;
• the formation of an intestinal fistula;
• the presence of an inflammatory process in the pancreas.

With incorrect or untimely diagnosis of cholecystitis, the disease can become chronic. As a result, the patient may experience the following consequences of the disease:

• reactive hepatitis;
• reactive pancreatitis;
• pericholecystitis, etc.

Complications

Empyema of the gallbladder

With this consequence of the disease, purulent exudate accumulates in the cavity of the gallbladder due to blockage of the cystic duct and infection of bacterial origin. Due to such processes in the patient:

• the temperature rises to high levels;
• intense pain occurs;
• symptoms of intoxication develop.

Empyema of the gallbladder can be detected using the following studies:

• bacterial blood culture;
• Ultrasound of the liver and bile ducts.

To treat such a complication of acute cholecystitis, the patient is prescribed:

• antibacterial drugs before and after surgery for cholecystectomy, administered intravenously, and after stabilization of the condition - orally;
• detoxification therapy before surgery.

In some clinical cases, when the patient's condition is severe, the operation is postponed until the patient stabilizes, and as a temporary measure, decompression of the gallbladder is performed. This requires the installation of transhepatic drainage, which is performed under x-ray control.

Without timely surgical treatment, gallbladder empyema can be fatal. Such a prognosis largely depends on the presence of complications and the stage of the pathological process. In cases where this complication is detected on time and the patient does not show signs of perforation or blood poisoning, the outcome may be favorable.

To prevent the development of pleural empyema, timely treatment should be carried out or. Patients with immunodeficiency states, or hemoglobinopathies, should undergo regular preventive examinations, including studies such as ultrasound of the liver or abdominal organs.

Peripesical abscess

This complication of acute cholecystitis can develop 3-4 days after the onset of inflammation of the gallbladder. In a patient, an inflammatory infiltrate is formed around this organ, which at first looks like a conglomerate loosely adjacent to the tissues. At this stage of the pathological process, the abscess can be easily removed surgically. At more advanced stages, the formed infiltrate increases in size, grows into the surrounding tissues, and its treatment becomes more difficult.

When a perivesical abscess occurs, the patient experiences the following symptoms:

• stomach ache;
• vomiting and nausea;
• dry mouth;
• fever with chills;
• pain on movement.

If, against the background of the emerging complication, the patient takes antibacterial agents, then the abscess may not manifest itself with tangible symptoms. In such cases, a physical examination is not enough to identify the pathological process and a dynamic ultrasound examination is necessary.

Gallbladder perforation

With such a complication, a rupture of the organ wall occurs. The fluid contained in the gallbladder can enter the abdominal cavity. Subsequently, the patient may develop adhesions, subhepatic abscess and local peritonitis. In addition, intrahepatic abscesses and can develop.

The greatest likelihood of such a complication of acute cholecystitis is observed in elderly patients with gallstones with bouts of colic and patients with sickle cell and severe systemic diseases, diabetes mellitus.

With the development of perforation, the patient has the following symptoms:

• long-lasting pain syndrome in the right side, radiating to the scapula and right shoulder;
• the appearance of symptoms of an acute abdomen;
• high fever;
• vomiting of bile;
• nausea;
• signs of liver failure and hepatorenal syndrome;
• oppression of respiratory and cardiovascular activity;
• intestinal paresis and its obstruction.

If treatment is delayed, this complication can lead to death.

To detect perforation of the gallbladder, the doctor prescribes ultrasound studies to identify stones and effusion around the organ or the development of peritonitis, intrahepatic or interloop abscess. If it is necessary to obtain a more detailed clinical picture, CT or MSCT of the studied areas is performed.

For the treatment of perforation of the gallbladder, the patient is immediately transferred to the intensive care unit or operating room. At the stage of preparation for the upcoming surgical intervention, the patient is given antibacterial, infusion and analgesic therapy. Such measures are necessary to partially eliminate multiple organ failure, and after the stabilization of the patient's condition, the surgeon performs the operation.

Purulent diffuse peritonitis

With the initial development of this form of peritonitis, which occurs against the background of acute cholecystitis, serous-purulent exudate is formed in the abdominal cavity. Initially, almost all patients develop pain in the abdomen and vomiting and nausea occur. However, with a lightning-fast or uncharacteristic course of the disease, such patient complaints may be absent.

Due to severe pain, the patient has to take a forced position in bed, and some patients show signs of fever. On examination, the doctor may notice moderate tension in the abdomen and its non-participation in the breathing process. When probing the abdomen, a more active intestinal motility is initially determined, but over time it weakens.

After 1-3 days, the patient's condition worsens due to an increase in inflammation. He develops uncontrollable vomiting, leading to the appearance of fecal masses in the discharge from the oral cavity. The patient's breathing becomes superficial, the activity of blood vessels and the heart is disrupted, the abdomen swells, becomes moderately tense, the separation of gases and feces from the intestines stops.

At the irreversible stage of purulent peritonitis, the patient's skin acquires an earthy hue and becomes cold to the touch. Consciousness is disturbed to the manifestations of "travel fees" (the patient collects imaginary objects, does not react to the environment, catches midges in front of his eyes, etc.), and blood pressure and pulse indicators are almost not determined.

The transition to the stage of diffuse peritonitis can be lightning fast, and then it is impossible to separate one stage of the development of the pathological process from another.

To identify signs and symptoms of purulent peritonitis, the doctor prescribes blood tests, ultrasound, ECG and plain radiography. If difficulties arise in the diagnosis, the patient undergoes diagnostic laparoscopy. With such a study, the doctor can take an inflammatory exudate for seeding on the sensitivity of the pathogen to antibacterial drugs. If diagnostic laparoscopy is not performed, then the degree of intensity of inflammation is determined by the level of leukocytes in the blood.

To eliminate purulent peritonitis, only surgical treatment should be carried out. Before the intervention, medical preparation of the patient is carried out, aimed at eliminating anemia, electrolyte imbalance, detoxification and suppression of pathogenic flora.

To anesthetize operations, general anesthesia is performed, and the intervention itself can be performed according to classical methods or using video-laparoscopic surgery.

Gangrene of the gallbladder

With this complication, purulent contents accumulate in large quantities in the cavity of the gallbladder. This consequence of acute cholecystitis is caused by obstruction of the cystic lumen, which is provoked by an infectious process of a bacterial nature.

When such a complication occurs, pain occurs in the right hypochondrium, the temperature rises and intoxication develops. In addition, the patient may experience yellowness of the sclera.

When probing the abdomen, an enlarged gallbladder is determined, the size of which does not change with time. At any time, it can rupture and lead to peritonitis. In the future, if the infection has entered the bloodstream, then the patient develops sepsis, which can lead to severe outcomes.

To detect gangrene of the gallbladder, the doctor prescribes a series of examinations to the patient to assess the degree of the inflammatory process, intoxication of the body and obstruction of the organ. For this, the following studies are carried out: ultrasound, clinical tests and. In the future, to select the tactics of therapy after surgery, an analysis is prescribed to determine sensitivity to pathogenic microflora.

For the treatment of gangrene of the gallbladder, surgical treatment should be carried out, aimed at removing the organ affected by the purulent process. In addition, the patient is prescribed antibiotics that suppress bacterial inflammation. If a surgical intervention cannot be performed in the next few hours, then against the background of drug preparation, the patient is decompressed the gallbladder with a drain installed in the liver.

pancreatitis

Acute cholecystitis can lead to the development of inflammation in the pancreatic tissue.

Arising against the background of acute cholecystitis can be provoked by the activation of pancreatic enzymes. This process leads to inflammation of the tissues of the gland. With a mild process, the affected organ can be cured, and with a severe one, pronounced destructive processes or local complications occur in the gland, consisting in necrosis, infection or encapsulation. In severe cases of the disease, the tissues surrounding the gland are necrotic and encapsulated by an abscess.

With the development of acute pancreatitis, the patient develops pains of an intense nature, they are constant and become stronger when trying to lie on his back. In addition, the pain syndrome is more intense after eating (especially fatty, fried or spicy) and alcohol.

The patient experiences nausea and may experience uncontrollable vomiting. The body temperature rises, and the sclera and skin become icteric. Also, with acute pancreatitis, the patient may show signs of indigestion:

• bloating;
• heartburn;
• hemorrhages on the skin in the navel;
• bluish spots on the body.

To identify an acute inflammatory process in the pancreas, the patient undergoes a study of blood and urine parameters. To identify structural changes, instrumental studies are performed: ultrasound, MRI and MSCT.

Treatment of acute pancreatitis is pain relief and bed rest. To eliminate inflammatory processes are prescribed:

• bed rest and rest;
• hunger;
• enzyme deactivators;
• antibiotic therapy.

Pain can be eliminated by performing novocaine blockades and antispasmodic drugs. In addition, detoxification therapy is carried out. If necessary - the appearance of stones, the accumulation of fluid, necrotization and abscess formation - the patient undergoes a surgical operation.

The success of the treatment of pancreatitis depends on the severity of pathological changes in the tissues of the gland. The duration of therapy also depends on these indicators.

In some cases, acute pancreatitis can cause the following complications:

• shock reaction;
• gland necrosis;
• the appearance of abscesses;
• pseudocysts and subsequent ascites.

Biliary fistulas

A fistula of the gallbladder in acute cholecystitis can form in rare cases with a long course of cholelithiasis. Such a pathology occurs when a surgical operation is not performed in time and is detected in approximately 1.5% of patients with calculous cholecystitis and stones in the gallbladder.

Preoperative detection of fistulas is often difficult due to the absence of obvious clinical manifestations. Sometimes the first sign of such a pathological process is the appearance of large stones in the feces or vomit. More often, getting a calculus into the digestive organs leads to intestinal obstruction.

The development of cholangitis can be caused by the movement of infection through the fistula. Clinically, this pathology is accompanied by the occurrence of weakness, chills, diarrhea and increased pain. In the long term, symptoms are manifested by jaundice and toxic cholangitis.

With an external fistula of the gallbladder, an open fistulous tract appears on the anterior abdominal wall, from which bile, mucous secretions and small stones flow. In the expiration, pus, dyspepsia and steatorrhea can be observed, leading to emaciation.

In some cases, biliary fistulas cause acute pain, shock, respiratory distress, bleeding, and a persistent cough. If it is impossible to perform a surgical operation, such changes can lead to serious consequences and death.

Detection of the fistula is possible with the help of plain radiography and fistulography. In some cases, choledochoscopy is performed. Sometimes obstructive obstruction that occurs can be determined using contrast-enhanced radiography (EGDS). To obtain a more detailed clinical picture, tests are performed to detect hypoproteinemia, hyperbilirubinemia, and hypocoagulation.

Getting rid of the biliary fistula can only be achieved through surgery. To do this, the anastomosis between the gallbladder and adjacent tissues is eliminated, thereby ensuring a normal outflow of bile into the lumen of the duodenum. In addition, the doctor performs a cholecystectomy.

Cholangitis

With nonspecific inflammation of the bile ducts against the background of acute cholecystitis,

State budgetary educational institution of higher professional education

"Tyumen State Medical AcademyMinistry of Health of the Russian Federation"

DEPARTMENT OF FACULTY SURGERY WITH THE COURSE OF UROLOGY

ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS

Module 2. Diseases of the bile ducts and pancreas

Methodological guide for preparing for the exam in faculty surgery and the final state certification of students of the medical and pediatric faculty

Compiled by: DMN, prof. N. A. Borodin

Tyumen - 2013

ACUTE CHOLECYSTITIS

Questions that the student should know on the topic:

Acute cholecystitis. Etiology, classification, diagnosis, clinical picture Choice of treatment method. Methods of surgical and conservative treatment.

Acute obstructive cholecystitis, definition of the concept. Clinic, diagnosis, treatment.

Hepatic colic and acute cholecystitis, differential diagnosis, clinical picture, methods of laboratory and instrumental studies. Treatment.

Acute cholecystopancreatitis. Causes of occurrence, clinical picture, methods of laboratory and instrumental studies. Treatment.

Choledocholithiasis and its complications. Purulent cholangitis. Clinical picture, diagnosis and treatment.

Surgical complications of opisthorchiasis of the liver and gallbladder. Pathogenesis, clinic, treatment.

Acute cholecystitis this inflammation of the gallbladder from catarrhal to phlegmonous and gangrenous-perforative.

In emergency surgery, the concept of "chronic cholecystitis", "exacerbation of chronic cholecystitis" is usually not used, even if this attack was far from the first in the patient. This is due to the fact that in surgery any acute attack of cholecystitis is considered as a phase of a destructive process that can end in purulent peritonitis. The term "chronic calculous cholecystitis" is used practically only in one case, when the patient is admitted for planned surgical treatment in the "cold" period of the disease.

Acute cholecystitis is most often a complication of cholelithiasis (acute calculous cholecystitis). Often the trigger for the development of cholecystitis is a violation of the outflow of bile from the bladder under the influence of stones, then an infection joins. The stone can completely block the neck of the gallbladder and completely “turn off” the gallbladder; such cholecystitis is called “obstructive”.

Much less often, acute cholecystitis can develop without gallstones, in which case it is called acute acalculous cholecystitis. Most often, such cholecystitis develops against the background of impaired blood supply to the gallbladder (atherosclerosis or thrombosis a. cistici) in the elderly, the cause can also be reflux into the gallbladder of pancreatic juice - enzymatic cholecystitis.

Classification of acute cholecystitis.

Uncomplicated cholecystitis

1. Acute catarrhal cholecystitis

2. Acute phlegmonous cholecystitis

3. Acute gangrenous cholecystitis

Complicated cholecystitis

1. Peritonitis with perforation of the gallbladder.

2. Peritonitis without gallbladder perforation (blood bilious peritonitis).

3. Acute obstructive cholecystitis (cholecystitis against the background of obturation of the neck of the gallbladder in the area of ​​​​its neck, i.e. against the background of a “turned off” gallbladder. The usual cause of a stone is a wedged stone in the neck of the bladder. With catarrhal inflammation, this becomes dropsy of the gallbladder, with a purulent process occurs empyema of the gallbladder, i.e. accumulation of pus in the gallbladder.

4. Acute cholecysto-pancreatitis

5. Acute cholecystitis with obstructive jaundice (choledocholithiasis, strictures of the major duodenal papilla).

6. Purulent cholangitis (spread of a purulent process from the gallbladder to the extrahepatic and intrahepatic bile ducts)

7. Acute cholecystitis against the background of internal fistulas (fistula between gallbladder and intestines).

clinical picture.

The disease begins acutely as an attack of hepatic colic (hepatic colic is described in the manual on cholelithiasis), when an infection is attached, an inflammatory process, intoxication develops, a progressive disease leads to local and diffuse peritonitis.

The pain occurs suddenly, patients become restless, do not find a place for themselves. The pains themselves are permanent in nature, as the disease progresses, they increase. Localization of pain - right hypochondrium and epigastric region, the most severe pain in the projection of the gallbladder (Cera's point). Irradiation of pain is characteristic: lower back, under the angle of the right shoulder blade, in the supraclavicular region on the right, in the right shoulder. Often, a painful attack is accompanied by nausea and repeated vomiting, which does not bring relief. Subfibrile temperature appears, sometimes chills join. The last sign may indicate the addition of cholestasis and the spread of the inflammatory process to the bile ducts.

On examination: the tongue is lined and dry, the abdomen is painful in the right hypochondrium. The appearance of tension in the muscles of the anterior abdominal wall in the right hypochondrium (v. Kerte) and symptoms of peritoneal irritation (village of Shchetkina-Blumberg) speaks of the destructive nature of inflammation.

In some cases (with obstructive cholecystitis), an enlarged, tense and painful gallbladder can be felt.

Symptoms of acute cholecystitis

Symptom of Ortner-Grekov- pain when tapping with the edge of the palm along the right costal arch.

Symptom Zakharyin- pain when tapping the edge of the palm in the right hypochondrium.

Murphy's sign- when pressing on the gallbladder area with the fingers, the patient is asked to take a deep breath. At the same time, the diaphragm moves down, and the stomach rises, the bottom of the gallbladder runs into the fingers of the examiner, severe pain occurs and the breath is interrupted.

In modern conditions, Murphy's symptom can be checked during an ultrasound examination of the bladder, an ultrasound probe is used instead of a hand. The sensor needs to be pressed on the anterior abdominal wall and the patient is forced to take a breath, on the screen of the device you can see how the bubble approaches the sensor. At the moment of convergence of the apparatus with the bladder, severe pain occurs and the patient interrupts the breath.

Symptom Mussi-Georgievsky(phrenicus-symptom) - the occurrence of pain when pressed in the region of the sternocleidomastoid muscle, between its legs.

Ker's symptom- pain when pressing a finger into the corner formed by the edge of the right rectus abdominis muscle and costal arch.

Soreness on palpation of the right hypochondrium is called the Obraztsov symptom, but since it resembles other symptoms, this symptom is sometimes called the Ker-Obraztsev-Murphy symptom.

Soreness with pressure on the xiphoid process is called the phenomenon of the xiphoid process or Likhovitsky's symptom.

Laboratory research. Acute cholecystitis is characterized by an inflammatory reaction of the blood, primarily leukocytosis. With the development of peritonitis, leukocytosis becomes pronounced - 15-20 10 9 /l, the stab shift of the formula increases to 10-15%. Severe and advanced forms of peritonitis, as well as purulent cholangitis, are accompanied by a shift of the formula to the left with the appearance of young forms and myelocytes.

Other blood counts change as complications occur (see below).

Instrumental research methods.

There are several methods of instrumental diagnosis of diseases of the bile ducts, mainly ultrasound and radiological methods (ERCP, intraoperative cholangiography and postoperative fistulocholangiography). The method of computed tomography for the study of the bile ducts is rarely used. This is described in detail in the Guidelines on gallstone disease and methods for examining the bile ducts. It should be noted that for the diagnosis of cholelithiasis and diseases associated with a violation of the outflow of bile, both ultrasound and x-rays are usually used. methods, but for the diagnosis of inflammatory changes in the gallbladder and surrounding tissues - only ultrasound.

At acute cholecystitis The ultrasound picture is as follows. Most often, acute cholecystitis occurs against the background of cholelithiasis, therefore, in most cases, an indirect sign of cholecystitis is the presence of stones in the gallbladder, or bile sludge or pus, which are defined as suspended small particles without an acoustic shadow.

Often, acute cholecystitis occurs against the background of obstruction of the gallbladder neck, such cholecystitis is called obstructive, on ultrasound it can be seen as an increase in the longitudinal (more than 90-100 mm) and transverse direction (up to 30 mm or more). Finally straight Ultrasound signs of destructive cholecystitis is: thickening of the bladder wall (normally 3 mm) up to 5 mm or more, stratification (doubling) of the wall, the presence of a strip of fluid (effusion) near the gallbladder under the liver, signs of inflammatory infiltration of surrounding tissues.

Tactics and treatment:

When a patient with acute cholecystitis is admitted to the duty surgical hospital, the treatment of cholecystitis is reduced to 3 principles:

1. An emergency operation is performed in patients with signs of diffuse or diffuse peritonitis, as well as purulent cholangitis. With obvious signs of peritonitis, emergency surgery is indicated. Purulent cholangitis is also an indication for surgery, but this diagnosis requires some time, while purulent cholangitis itself is rare. As a result, the main indication for emergency surgery is cholecystitis, complicated by diffuse purulent peritonitis.

2. All other patients are treated conservatively, but only for 24 hours. Antispasmodics, analgesics, antibiotics, intravenous infusion of solutions in a volume of 1.5 liters are prescribed. If during this period the clinic of cholecystitis did not stop, or the symptoms of the disease increase, the patient is indicated for surgery.

3. If the clinic of cholecystitis stopped, the patient continues to be treated conservatively, while the issue of planned surgical treatment should be resolved. The presence of stones in the gallbladder + an attack of hepatic colic or acute cholecystitis (especially multiple attacks) is an absolute indication for performing planned cholecystectomy. Such an operation can be performed without discharge of the patient from the hospital, or the patient must be placed on the queue (waiting list).

Operation:

The most optimal variant of surgical treatment (operation of choice) is cholecystectomy. Performing this operation radically solves all issues. First, the source of inflammation and intoxication is removed - a phlegmonous or gangrenous gallbladder. Secondly, all stones are removed and subsequently new stones cannot form, since in most cases they form only in the gallbladder. All newly formed bile, as it is produced in the liver, continuously moves through the bile ducts to the duodenum. If cholecystectomy is performed within a reasonable time from the onset of cholelithiasis, i.e. until the moment when gross morphological changes (fibrosis, strictures, cysts) occur in the bile ducts and pancreas, then such a patient feels like a healthy person in the future and his dietary restrictions are minimal.

There are two types of cholecystectomy - from the neck and from the bottom. It is most correct to perform the operation “from the neck”.

Also allocate different accesses when performing an operation. Despite the fact that the purpose of the operation and its volume remain unchanged - cholecystectomy, reducing the trauma of the intervention itself greatly facilitates the postoperative period and reduces the rehabilitation period. There are 3 main accesses.

1. Traditional laparotomy, wide dissection of the tissues of the anterior abdominal wall - 15-18 cm, along the midline of the abdomen, or by oblique access (according to Kocher, according to Fedorov) in the right hypochondrium.

2. Mini-access using a special tool - "mini-assistant". Access 4-5 cm, through the rectus abdominis, in the projection of the gallbladder.

3. Videolaparoscopic cholecystectomy using a video camera, laparoscope, TV monitor and special power tools. The operation is performed through 3 punctures on the anterior abdominal wall.

Another option is surgery - Cholecystostomy. This is a palliative low-traumatic operation. It is performed in elderly, debilitated patients, in the presence of severe concomitant diseases, when a long and traumatic operation poses a significant risk for the patient. In other words, it relieves the patient of a specific attack of acute cholecystitis, but does not relieve such attacks in the future.

The essence of the operation is as follows: in the area of ​​the bottom of the gallbladder, a small incision is made on the skin - 3-5 cm. The bottom of the gallbladder is isolated through the incision and a puncture is made in it with a scalpel. Pus, bile, bile sludge and stones are sucked out through the puncture, then a drainage tube is inserted into the lumen of the gallbladder. The tube is fixed to the wall of the bladder with two purse-string sutures, the very bottom of the gallbladder is sutured to the edges of the wound, and the wound is sutured around the tube. In the postoperative period, pus, bile, and small stones are discharged through the tube. Usually this is enough to cure the patient even from destructive forms of cholecystitis. The method also helps if the patient has obstructive jaundice and purulent cholangitis, subject to the patency of the cystic duct. The only exception is gangrenous forms of cholecystitis with signs of deep necrotic disintegration of the walls of the gallbladder.

A similar amount of intervention can also be performed by puncture, under ultrasound guidance, or laparoscopically.

COMPLICATIONS OF ACUTE CHOLECYSTITIS

Gangrenous cholecystitis with the development of peritonitis in most cases, it is a consequence of the progression of the phlegmonous stage of inflammation of the bladder into the gangrenous stage with the development of necrosis and perforation of its wall. In addition, there is "Primary gangrenous cholecystitis" against the background of atherosclerosis and thrombosis of the cystic artery in elderly and senile people.

With the development of peritonitis, symptoms of intoxication come first with signs of local or widespread muscle tension of the anterior abdominal wall and symptoms of peritoneal irritation (Shchetkin-Blumberg).

With perforation of the bladder, symptoms of diffuse peritonitis quickly develop. The condition of the patients is severe. Body temperature is elevated. Tachycardia up to 120 beats per minute or more. Breathing is shallow, rapid. Dry tongue. The abdomen is swollen due to intestinal paresis, its right sections do not participate in the act of breathing. Intestinal peristalsis is reduced or absent. Symptoms of peritoneal irritation are positive. In the analyzes: high leukocytosis with a shift of the formula to the left, an increase in ESR, a violation of the electrolyte composition of the blood and an acid-base state, proteinuria and cylindruria. In elderly and senile people, the symptoms of the disease are not pronounced, which can make diagnosis difficult.

Peritonitis without gallbladder perforation or "Dropping" peritonitis is a special form of development of peritonitis that occurs in some patients with acute cholecystitis. One of the reasons for its occurrence is the reflux of pancreatic juice through the common ampulla of the major duodenal papilla into the bile ducts and bladder with the development of enzymatic cholecystitis. Another reason is the morphological features of the structure of the gallbladder: its thin-walled nature, the absence of a submucosal (the most durable) layer.

The clinical picture of acute cholecystitis in this case is transformed into a clinical picture of local and diffuse bile peritonitis. During the operation, a large amount of cloudy yellow effusion is found in the abdominal cavity, and the intestines and other organs of the abdominal cavity are colored bright yellow. On examination, the gallbladder is inflamed, but there are no obvious signs of necrosis of the bladder wall. At the same time, it can be seen that turbid bile is released (sweats) from the surface of the gallbladder into the abdominal cavity, which is the cause of bile peritonitis.

Treatment consists in emergency cholecystectomy and treatment of peritonitis in accordance with generally accepted standards: sanitation, drainage of the abdominal cavity. This is described in detail in the Guidelines "Peritonitis".

Acute obstructive cholecystitis is cholecystitis occurring against the background obstruction of the neck of the gallbladder stones and products of inflammation. Sometimes students call obturation of the bile ducts (choledochus) the cause of obstructive cholecystitis, but this is not correct, since in this case another complication occurs - obstructive jaundice. Obstructive cholecystitis proceeds without obstructive jaundice, its essence is different - inflammation occurs in a closed space, namely in the "disconnected" gallbladder.

If in the “disconnected” bladder the inflammation is catarrhal in nature, then the patient develops a “dropsy of the gallbladder”. New bile does not enter the bladder, and the existing bile pigments are gradually absorbed, the bladder is filled with serous effusion. As a result, when a puncture of the gallbladder is performed during the operation, I evacuate a light whitish liquid from the swollen bladder, resembling whey in appearance, the so-called “white bile”.

If the inflammation in the “disabled” bladder is purulent, an “empyema of the gallbladder” is formed and the bladder is filled with pus. When puncturing such a bladder, pus is pumped out in large quantities, sometimes with a fetid odor.

Clinically, the disease begins acutely, with the migration of a stone from the neck of the gallbladder back into the lumen of the gallbladder, the attack may end. If this does not happen, inflammatory changes progress. Clinically, this is similar to the clinic of ordinary cholecystitis, but there are also features. The main distinguishing feature of obstructive cholecystitis is a significant increase in the size of the bladder, as a result, it can be easily felt through the anterior abdominal wall in the form of a large pear-like, tense and painful formation. An enlarged gallbladder (more than 10-11 cm in length) can be seen on ultrasound; on ultrasound, you can also find a stone “hammered” into the neck of the bladder.

The remaining clinical signs correspond to the usual acute cholecystitis.

Tactics and methods of treatment are about the same as with ordinary cholecystitis. Namely: obstructive cholecystitis in itself is not an indication for emergency surgery, emergency intervention is performed only in the presence of peritonitis. If there is no peritonitis, then the patient is treated conservatively. But if, against the background of analgesics, antispasmodics, antibiotics, infusion therapy, the patient during the day didn't get better and the gallbladder did not shrink - an urgent operation is performed.

Cholecystopancreatitis. One of the options for the course of acute cholecystitis is its combination with the phenomena of acute pancreatitis. This course of the disease is due to the presence of common ampulla of the major duodenal papilla where the common bile duct and the main (Wirsung) duct of the pancreas merge. The presence of stones in the bile ducts and strictures of the major duodenal papilla can lead to the simultaneous development of both acute cholecystitis and acute pancreatitis. The disease begins as acute cholecystitis, but a violation of the outflow of pancreatic juice, or reflux of bile into the pancreas leads to the development of signs of pancreatitis.

As pancreatitis develops, the clinical picture changes, new signs appear, pain from the right hypochondrium spreads to the epigastric region, the left hypochondrium and becomes shingles. Pain radiates to the lower back. Vomiting intensifies, signs of intoxication increase.

Objectively, there are pains in the projection of the pancreas (p. Kerte), bloating of the upper half of the abdomen (p. Watchdog), pain in the left costovertebral angle (p. Mayo-Robson), the appearance of cyanosis spots on the side walls of the abdomen, near the umbilical region and face.

There may be a subicteric skin, darkening of urine and discoloration of feces due to swelling of the head of the gland and the occurrence of cholestasis on this background.

In a laboratory study, the presence of pancreatitis is confirmed by an increase in the content of amylase in the blood, and diastase in the urine.

Ultrasound examination shows an increase in the size of the transverse dimensions of the pancreas up to 4-5 cm, an increase in the distance between the posterior wall of the stomach and the anterior surface of the pancreas over 3 mm and reaching 10-20 mm, which characterizes the edema of the parapancreatic tissue.

In the absence of signs of pancreatic necrosis, the treatment of cholecystopancreatitis is the same as for acute cholecystitis and depends on changes in the bladder wall (see above for treatment of cholecystitis). Additionally, the appointment of drugs that reduce pancreatic secretion is required: sandostatin, octreotide; detoxification infusion therapy, prescription of antibiotics, analgesics and antispasmodics.

Purulent cholangitis - this is the spread of a purulent inflammatory process to the extrahepatic bile ducts: the common bile duct, the common hepatic duct, to the lobar, and then to the intrahepatic ducts. If left untreated, single or multiple liver abscesses form. Purulent cholangitis, as a complication of acute cholecystitis, is rare, but with its development, the patient's condition becomes severe and may result in death.

The peculiarity of this complication is that it is practically never develops in the backgroundunchanged bile ducts. Those. in order to develop purulent cholangitis, there must be stones of the common bile duct, or a stricture of the biliary tract or a large duodenal papilla. Against this background, bile stasis occurs in the ducts, then an infection joins.

Purulent cholangitis is characterized by increasing jaundice, an increase in body temperature to 39-40 0 C and above, pain in the right hypochondrium. All these features are called Charcot triad. A very characteristic sign of cholangitis are amazing chills, with temperature rises of 40 0 ​​and above, followed by a feeling of heat and heavy sweats.

The patient's condition is severe, they are lethargic and inhibited, the pulse is frequent, blood pressure is reduced. On palpation of the abdomen, along with symptoms of acute cholecystitis and pain in the right hypochondrium, an enlarged liver and spleen are determined (by palpation, percussion and ultrasound).

The progression of the disease leads to the development of liver abscesses and hepatic-renal failure. There are signs of sepsis and bacterial-toxic shock: high hyperthermia is replaced by hypothermia, jaundice increases, blood pressure drops, severe tachycardia, tachypnea, oliguria, confusion.

In the blood, pronounced leukocytosis, a shift of the L-formula to the left, a sharp increase in ESR, high bilirubinemia due to direct and indirect bilirubin, high activity of transaminases (AST, ALT) and alkaline phosphatase are determined. Nitrogenous slags of blood (residual nitrogen, urea, creatinine) increase.

Purulent cholangitis is an indication for emergency surgery .

If cholangitis has developed against the background of acute cholecystitis, the patient undergoes a cholecystectomy operation, but the treatment of purulent cholangitis itself requires external drainage of the bile ducts (see Fig.). Through the stump of the cystic duct or the holedochotomy opening, a plastic drainage is installed into the lumen of the common bile duct. Pus and bile flow through the drainage, which leads to the disappearance of jaundice and the relief of jaundice. The drainage itself can be T-shaped (Ker drainage), or it is a regular plastic tube with an additional side hole at the end (Vishnevsky drainage).

Another treatment for purulent cholangitis is endoscopic nasobiliary drainage of the common bile duct . With the help of an endoscopic apparatus - a fibrous duodenoscope, the patient is examined the duodenum, where they find a large duodenal papilla. In the presence of stricture of the papilla, the latter is dissected, stones are removed from the choledochus, and a thin tubular drainage is installed into the lumen of the choledochus from the side of the duodenum. After removal of the endoscope, the drainage remains in the bile ducts and is removed through the duodenum-stomach-esophagus-nose, therefore this type of drainage is called nasobiliary. This method is especially indicated for those patients who do not have a gallbladder (cholecystectomy was performed earlier).

mechanical jaundice. The complicated course of acute calculous cholecystitis can be manifested by the appearance of a clinic of obstructive jaundice that occurs when the bile ducts are obstructed by stones (choledocholithiasis) and the presence of stricture of the major duodenal papilla. Often, these bile duct stones and strictures coexist.

With a combination of cholecystitis and obstructive jaundice, signs of bladder inflammation and peritonitis occur against the background of cholestasis, which aggravates the patient's condition. Intense staining of the sclera and skin integuments in yellow color appears after one day or more from the onset of an acute attack of pain in the right hypochondrium, the appearance of a dark color of urine and discolored feces, skin itching, high levels of bilirubin (200-300 μmol / l) in mainly due to direct (conjugated) bilirubin. Details about these signs are written in the manual of the department "Mechanical jaundice".

Meanwhile, this combination of pathology greatly complicates the choice of tactics and methods of treating the patient. On the one hand, the patient must be relieved of the source of inflammation - the gallbladder, and on the other hand, bile hypertension must be eliminated in one way or another. The decision must be made quickly, since the presence of infection and cholestasis creates all the conditions for the development of another very serious complication - purulent cholangitis.