What threatens suppuration of the gallbladder. Acute cholecystitis. Causes of inflammatory processes

Purulent cholecystitis is an acute, purulent inflammatory process of the gallbladder, developing at a rapid speed and leading to serious complications. At the first signs, specialists prescribe laboratory and instrumental examination in order to detect the disease in time and prevent serious consequences.

As the disease develops, purulent substance accumulates in the cavity of the gallbladder. The insidiousness of the disease lies in the fact that it does not have clear, characteristic symptoms and there are no exact signs.

Mostly women over 50 years of age suffer from purulent cholecystitis, children - extremely rarely.

Doctors distinguish 3 exudative forms of cholecystitis:

• phlegmon - purulent inflammation spreads in the walls of the organ;
• abscess - pus is located on the inner wall of the bladder;
• empyema is an inflammation that covers all cavities of the gallbladder.

The clinical picture of purulent cholecystitis is determined by developing intoxication.

When collecting anamnesis, patients identify the following signs:

• paroxysmal pain with right side in the area of ​​the ribs;
• jaundice skin;
• heat bodies.

Diagnosis of the disease in the acute period is quite difficult, since the disease is often accompanied by additional factors (excess body weight, enterocolitis, etc.).

Symptoms of pathology are conventionally divided into 2 groups:

1. Local - constant, increasing pain. It is located in the upper abdomen. The most painful place is the location of the gallbladder. The pain may radiate to the shoulder area and under the right shoulder blade. When palpating the upper abdomen, the pain intensifies sharply, and the muscles of the abdominal wall are toned. After some time, it spreads throughout the abdomen. This suggests that inflammation has affected most of the peritoneum. When palpated, the size of the gallbladder and liver is significantly increased.
2. General - pain, yellow tint of the skin, bitter taste in the mouth, vomiting, nausea, diarrhea, increased body temperature, decreased appetite.

Liver enlargement occurs during stagnant processes, as well as with the development of poor bile outflow.

The main root cause of the development of purulent cholecystitis is the presence of stony tumors in the organ formed from cholesterol (calculous cholecystitis).

Inflammation and the appearance of pus occurs due to impaired organ motility, caused by several factors:

• infection of the body with worms;
• infectious diseases localized in the liver, gastrointestinal tract and gall bladder;
• blockage of the ducts leading to the organ with stony deposits.

Significant signs are those that contribute to insufficient blood supply to the cystic walls of the organ (ischemia):

• state of shock;
• increased level blood glucose;
• atherosclerosis;
• reception medicines, narcotic drugs;
• heart dysfunction, blood vessels.

For the above reasons, the functioning of the gallbladder is disrupted, as bile changes its chemical composition and stagnates in the organ, and peristalsis also worsens.

Stagnation increases the risk of ischemia, as a result of which necrotic processes spread faster - as a result, the organ wall becomes thinner, forming through holes.

Diagnostics

After collecting an anamnesis, the doctor prescribes a detailed examination of the patient in order to confirm or exclude the disease. Let's consider the basic diagnostic measures.

For more detailed confirmation of the acute inflammatory process of the gallbladder, the following are used:

• ultrasonography;
• CT scan;
• gastroduodenoscopy;
• dynamic hepatobiliscintigraphy.

Treatment methods and consequences

When acute pain appears in the abdominal area, most people ask the question: “Which doctor should I contact?” Basically, if you suspect cholecystitis, you should first visit a therapist. After the initial inspection and collection additional information the specialist sends the patient to a gastroenterologist or surgeon for further examination and proper treatment.

With a single diagnosis of cholecystitis and its successful treatment re-development of the inflammatory process is possible.

Only a doctor can eliminate the signs of purulent cholecystitis. Conservative methods V in this case ineffective. They are used to prepare the patient for surgery.

The development of pathology increases the risk of the formation of through holes in the organ. The phenomenon leads to additional infection of the abdominal cavity.

If you do not respond to the disease in a timely manner, the following adverse events may develop:

1. Sepsis occurs due to the penetration of toxic compounds and pathogenic microflora into the systemic bloodstream. The patient's body temperature sharply increases, chills appear, and the epidermis acquires a pale earthy color. The second name for the complication is blood poisoning.
2. Peritonitis is manifested by the entry of pus into the abdominal cavity through holes in the gallbladder. Clinical picture negative consequences- general intoxication of the body.
3. Reactive hepatitis is when inflammation moves from the gallbladder to the liver. The main symptom is yellow epidermis, a painful sensation in the area of ​​the right rib. A complication leads to liver cirrhosis.
4. Purulent cholangitis is the appearance of inflammation in the bile ducts. The main factor is their clogging with rocky growths.
5. Pancreatitis most often appears in patients with purulent cholecystitis. Formed due to changes in the functioning of the pancreas organ. The main symptom is pain in upper sections belly.

Despite the correct treatment, the gallbladder partially or completely loses functionality.

In the absence of emergency surgery, the following conservative treatment option is used:

• bed rest and hospitalization of the patient in surgery department;
• nutrition. On the 1st day - a complete hunger strike (you are allowed to drink clean water), on days 2 and 3 - the liquid part is applied dietary table №5;
• a dry, cold compress is placed on the right side in the area of ​​the ribs;
• antispasmodics (as prescribed by a doctor) within 5 days from the onset of the pathology;
• taking antibiotics.

Preparatory measures for surgery:

• normalization blood pressure;
• complete refusal to eat;
• cold compress on the sore area;
• before the operation, a cleansing enema is performed;
• compliance with bed rest.

Surgery

The main treatment for purulent cholecystitis is surgery, and in the shortest possible time. Exactly surgical intervention reduces the risk of serious complications.

Surgery is performed using 2 methods:

• cholecystostomy (a procedure in which surgeons create an opening to remove pus). This type is used extremely rarely due to the high risk of the disease forming again.
• cholecystectomy - complete removal gallbladder through an incision in the abdominal cavity.

After therapy, specialists prescribe medications aimed at eliminating pus and intoxication of the entire body.

An important point in postoperative period and in case of exacerbation of purulent cholecystitis, adherence to the following diet is considered:

1. For the first two days after the onset of purulent inflammation, you should go on a hunger strike; you are allowed to drink clean, filtered water without gas.
2. Then you should introduce food very carefully and in small portions. First of all, you should give preference to liquid or semi-liquid dishes.
3. In case of acute symptoms, food that is gentle for digestive system.
4. Drink plenty of fluids warm: diluted fruit or vegetable juice (1:1), infusion of rose hips, freshly brewed tea - black or green.
5. Food is used in pureed form: pureed soups, jelly, fruit mousses, jellies.
6. Gradually it is allowed to add low-fat varieties of fish, meat, and low-fat fermented milk drinks.
7. Heat treatment - boiling in water and steaming, baking without forming a crust, stewing.
8. The bread is used in dried form.

When a person recovers, the daily ration can be increased, but it is important to follow a dietary diet.

Prohibited foods include everything fatty, fried, spicy, salty, canned, and smoked. You should not drink alcoholic drinks, carbonated drinks, strong tea or coffee. During treatment, you should exclude legumes, radishes, garlic, onions, and natural milk.

Disease prevention

To prevent the development of pathologies, doctors recommend adhering to the following rules:

• promptly treat infectious and inflammatory diseases;
• conduct regular ultrasound examinations of the abdominal organs;
• stick to proper nutrition, excluding instant food, fast food, animal fats;
• maintain the correct daily routine;
• to live an active lifestyle;
• maintain weight without allowing it to increase;
• eliminate factors leading to the development of stressful and depressive conditions;
• eliminate physical and mental overload.

Cholecystitis with purulent contents is a serious disease accompanied by the accumulation of purulent bile in the organ cavity. If you ignore the signs, the disease can provoke a serious complication, which will ultimately lead to death. Compliance simple rules, will help the body quickly recover and prevent the recurrence of the disease.

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

General information

Ischemia of the wall causes disruption of the contractile activity of the gallbladder, stagnation and thickening of bile, and 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 aggravates pathological changes, therefore, the treatment of pathology is only surgical.

For department patients intensive care who are in an extremely serious condition, the mechanism of development of ischemia is somewhat different. The cholecystokinin pathway for stimulating gallbladder contraction does not function in them due to the inability to receive food and liquid through the digestive tract. In addition, such patients often develop dehydration and centralization of blood circulation. All this leads to primary thickening and stagnation of bile, overstretching of the gallbladder, obstruction and compression of the vessels of the cystic wall and its secondary ischemia against this background.

In the ischemic wall of the gallbladder, local immune mechanisms do not work, so most often colonization by bacteria occurs hematogenously (through the portal vein or hepatic artery). However, there are frequent cases of ascending infection, when pathogens enter the gallbladder from the intestine (if there is 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, progression of cystic hypertension and the formation of a pathogenetic vicious circle.

Symptoms of purulent cholecystitis

Detection 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 half of the abdomen, and is described as reminiscent of 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 excessive sweating, pallor of the skin, tachycardia, a pained grimace on the face. Pain may radiate to the right shoulder blade or shoulder.

The body temperature rises significantly, and hectic fever is characteristic. Most often, an increase in temperature is accompanied by severe chills and heavy sweat. In elderly and weakened patients, the temperature can only rise to low-grade levels (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 bile, an attack of acute pancreatitis. With obstruction of the biliary tract, jaundice may develop.

On palpation of the abdomen, there is 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 - the pain intensifies with tapping on the anterior abdominal wall (Mendel's method), percussion in the area of ​​the right costal arch (Ortner's method) ), palpation in the area of ​​the right hypochondrium while inhaling (with Kera). Sometimes Murphy's syndrome can be detected - when palpating the right hypochondrium, the patient involuntarily holds his breath; locally positive Shchetkin-Blumberg sign - when the palpating hand is abruptly removed from the anterior abdominal wall in the area of ​​the right hypochondrium, the pain increases significantly.

Diagnostics

Consultation with an abdominal surgeon and endoscopist is required for all patients with suspected purulent cholecystitis. TO diagnostic signs This disease includes: pain in the right hypochondrium, positive signs of peritoneal irritation and cystic symptoms, intoxication phenomena combined 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, increase in ESR, blood thickening or anemia); liver tests (increased levels of bilirubin, ALT, AST, alkaline phosphatase).

Ultrasound of the gallbladder reveals thickening and doubling of the contour of the bladder wall, inhomogeneity of its contents, and accumulation of fluid in the peri-vesicle. Computed tomography of the biliary tract in 95% of cases reveals necrosis of the gallbladder wall, desquamation of the mucosa, and peripysical inflammatory infiltrate. Dynamic scintigraphy of the hepatobiliary system allows you to evaluate the outflow of bile, the functioning of the gallbladder, and also detect its perforation (in this case, the isotope will accumulate in the peri-vesical space). Abdominal surgery. Conservative therapy usually used to prepare the patient for intervention. Surgical treatment should be carried out as soon as possible, since the risk of life-threatening complications with this disease is very high. Two methods are usually used: cholecystostomy (usually as an intermediate option in severely ill patients) and cholecystectomy using laparotomy or laparoscopic access.

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

Prognosis and prevention

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

State budgetary educational institution of higher professional education

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

DEPARTMENT OF FACULTY SURGERY WITH A 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 Faculty of Medicine and Pediatrics

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

Tyumen - 2013

ACUTE CHOLECYSTITIS

Questions that a student should know about 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 gall bladder. Pathogenesis, clinical picture, treatment.

Acute cholecystitis This is an inflammation of the gallbladder from catarrhal to phlegmonous and gangrenous-perforated.

In emergency surgery, the concept of “chronic cholecystitis” or “exacerbation of chronic cholecystitis” is usually not used, even if this was not the patient’s first attack. 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 result in purulent peritonitis. The term “chronic calculous cholecystitis” is used almost 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 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 occurs. A stone can completely block the neck of the gallbladder and completely “turn off” the gallbladder; this cholecystitis is called “obstructive”.

Much less often, acute cholecystitis can develop without gallstones - in this 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 elderly people; the cause may also be reflux of pancreatic juice into the gallbladder - 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 (sweaty biliary peritonitis).

3. Acute obstructive cholecystitis (cholecystitis against the background of obstruction of the neck of the gallbladder in the area of ​​its neck, i.e. against the background of a “switched off” gallbladder. The usual cause is a stone wedged into the area of ​​the neck of the bladder. With catarrhal inflammation this takes on the character hydrocele of the gallbladder, with a purulent process occurs gallbladder empyema, i.e. accumulation of pus in the disabled gallbladder.

4. Acute cholecysto-pancreatitis

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

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

7. Acute cholecystitis against the background of internal fistulas (fistulas between the 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 occurs, a clinical picture of the inflammatory process and intoxication develops, and the progressive disease leads to local and diffuse peritonitis.

The pain occurs suddenly, patients become restless and do not find rest. The pain itself is constant and increases as the disease progresses. Localization of pain is the right hypochondrium and epigastric region, the most severe pain is in the projection of the gallbladder (Ker's point). Irradiation of pain is typical: in the 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. A subfibrile temperature appears, sometimes accompanied by chills. 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 coated 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 (village Kerte) and symptoms of peritoneal irritation (Shchetkina-Blumberga village) speaks of the destructive nature of inflammation.

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

Symptoms of acute cholecystitis

Ortner-Grekov symptom– pain when tapping the edge of the palm on the right costal arch.

Zakharyin's symptom– pain when tapping the edge of the palm in the right hypochondrium.

Murphy's sign– when pressing on the area of ​​the gallbladder with the fingers, the patient is asked to take a deep breath. In this case, the diaphragm moves down and the stomach rises, the bottom of the gallbladder collides with the examiner’s fingers, severe pain occurs and breathing is interrupted.

In modern conditions, Murphy's symptom can be checked during an ultrasound examination of the bladder; an ultrasound sensor is used instead of a hand. You need to press the sensor on the anterior abdominal wall and force the patient to take a breath; the device screen shows how the bubble approaches the sensor. When the device approaches the bladder, severe pain occurs and the patient interrupts his breath.

Mussi-Georgievsky's sign(phrenicus symptom) - the occurrence of painful sensations when pressing in the area of ​​the sternocleidomastoid muscle, between its legs.

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

Pain on palpation of the right hypochondrium is called Obraztsov's symptom, but since it resembles other symptoms, sometimes this sign is called the Kera-Obraztsev-Murphy symptom.

Pain when pressing on the xiphoid process is called the xiphoid process phenomenon 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 band 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 when complications occur (see below).

Instrumental research methods.

There are several methods for instrumental diagnosis of bile duct diseases, mainly ultrasound and radiological methods (ERCP, intraoperative cholangiography and postoperative fistulocholangiography). Method computed tomography It is rarely used to study the bile ducts. This is written in detail in the Guidelines on cholelithiasis and methods for studying the bile ducts. It should be noted that for the diagnosis of cholelithiasis and diseases associated with impaired bile outflow, both ultrasound and x-rays are usually used. methods, but for diagnosing inflammatory changes in 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 gall bladder, or bile sludge or pus, which are determined in the form of suspended small particles without an acoustic shadow.

Often acute cholecystitis occurs against the background of obstruction of the neck of the gallbladder; this cholecystitis is called Obstructive; on ultrasound it is visible 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) to 5 mm or more, stratification (doubling) of the wall, the presence of a strip of liquid (effusion) next to the gallbladder under the liver, signs of inflammatory infiltration of surrounding tissues.

Tactics and treatment:

When a patient with acute cholecystitis is admitted to an emergency surgical hospital, treatment of cholecystitis comes down to 3 principles:

1. Emergency surgery is performed on patients with signs of diffuse or diffuse peritonitis, as well as purulent cholangitis. At obvious signs peritonitis, emergency surgery is indicated. Purulent cholangitis is also an indication for surgery, but it takes some time to make this diagnosis, 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, IV infusion of solutions in a volume of 1.5 liters are prescribed. If during this period the clinical picture of cholecystitis is not relieved, or the symptoms of the disease increase, the patient is indicated for surgery.

3. If the clinical picture of cholecystitis has stopped, the patient continues to be treated conservatively, and the issue of planned surgical treatment. The presence of stones in the gall bladder + a previous attack of hepatic colic or acute cholecystitis (especially multiple attacks) are an absolute indication for performing planned cholecystectomy. Such an operation can be performed without discharging the patient from the hospital, or the patient must be put on a waiting list.

Operation:

The most optimal surgical treatment option (operation of choice) is cholecystectomy. Performing this operation radically solves all issues. Firstly, the source of inflammation and intoxication is removed - the 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 into 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 himself to be a healthy person in the future and his dietary restrictions are minimal.

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

There are also different accesses when performing an operation. Despite the fact that the purpose of the operation and its scope remain unchanged - cholecystectomy, reducing the invasiveness of the intervention itself significantly facilitates the course of the postoperative period and reduces rehabilitation time. 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 through an oblique approach (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 muscle, in the projection of the gallbladder.

3. Video laparoscopic cholecystectomy using a video camera, laparoscope, television 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, weakened 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 from a specific attack of acute cholecystitis, but does not relieve him from similar 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. Through the incision, the bottom of the gallbladder is isolated 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 installed into the lumen of the gallbladder. The tube is fixed to the wall of the bladder with two purse-string sutures, the bottom of the gallbladder itself 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 drain 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, provided the cystic duct is patent. The only exceptions are gangrenous forms of cholecystitis with signs of deep necrotic decay of the gallbladder walls.

A similar amount of intervention can also be performed by puncture, under ultrasound control, 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, “Primary gangrenous cholecystitis” occurs against the background of atherosclerosis and thrombosis of the cystic artery in elderly and senile people.

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

When the bladder is perforated, symptoms of diffuse peritonitis quickly develop. The condition of the patients is serious. Body temperature is increased. Tachycardia up to 120 beats per minute or more. Breathing is shallow and rapid. The tongue is dry. The abdomen is swollen due to intestinal paresis; its right parts do not participate in the act of breathing. Intestinal motility is reduced or absent. Symptoms of peritoneal irritation are positive. In the tests: high leukocytosis with a shift of the formula to the left, an increase in ESR, disturbances in the electrolyte composition of the blood and the acid-base state, proteinuria and cylindruria. In elderly and senile people, the symptoms of the disease are not clearly expressed, which can complicate diagnosis.

Peritonitis without gallbladder perforation or "sweating" 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 strongest) layer.

The clinical picture of acute cholecystitis in this case is transformed into the 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 abdominal organs are colored bright yellow. On examination, the gallbladder is inflamed, but there are no obvious signs of necrosis of the bladder wall. In this case, it is clear that cloudy bile is secreted (sweats) from the surface of the gallbladder into the abdominal cavity, which is the cause of biliary peritonitis.

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

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

If the inflammation in the “disabled” bladder is catarrhal in nature, then the patient develops “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, a light whitish liquid is evacuated from the swollen bladder, resembling whey in appearance, the so-called “white bile”.

If the inflammation in the “disconnected” bladder is purulent in nature, “gallbladder empyema” is formed and the bladder is filled with pus. During puncture, a large amount of pus is pumped out of such a bladder, sometimes with a foul odor.

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

Other clinical signs correspond to ordinary acute cholecystitis.

The tactics and methods of treatment are approximately the same as for 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 within 24 hours it didn't get better and the gallbladder has not contracted - urgent surgery is performed.

Cholecystopancreatitis. One of the variants of the course of acute cholecystitis is its combination with the phenomena of acute pancreatitis. This course of the disease is due to the presence common ampulla of the major duodenal papilla, where the common bile duct and the main (Wirsung) pancreatic duct 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 encircling in nature. The pain radiates to the lower back. Vomiting intensifies, signs of intoxication increase.

Objectively, pain is noted in the projection of the pancreas (Kerte p.), bloating of the upper half of the abdomen (Sentry Loop p.), pain in the left costovertebral angle (Mayo-Robson p.), the appearance of spots of cyanosis on the lateral walls of the abdomen, near the umbilical region and face.

Subicteric skin, darkening of urine and discoloration of feces may be noted due to swelling of the head of the gland and the occurrence of cholestasis against this background.

Laboratory testing confirms the presence of pancreatitis by an increase in amylase in the blood and diastase in the urine.

Ultrasound examination reveals an increase in 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 by over 3 mm and reaching 10 - 20 mm, which characterizes swelling of the parapancreatic tissue.

In the absence of signs of pancreatic necrosis, 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 prescription 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: common bile duct, 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 when it develops, the patient’s condition becomes severe and can result in death.

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

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

The patient's condition is serious, they are lethargic and lethargic, 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).

Progression of the disease leads to the development of liver abscesses and hepatic-renal failure. Signs of sepsis and bacterial toxic shock appear: high hyperthermia is replaced by hypothermia, jaundice increases, a drop in blood pressure, sharp tachycardia, tachypnea, oliguria, confusion.

The blood shows 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. Nitrogenous wastes in the blood (residual nitrogen, urea, creatinine) increase.

Purulent cholangitis is an indication for emergency surgery .

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

Another method of treating purulent cholangitis is endoscopic nasobiliary drainage of the common bile duct . Using an endoscopic device - a fiber duodenoscope, the patient is examined at the duodenum, where the large duodenal papilla is found. If there is a stricture of the papilla, the latter is dissected, stones are removed from the common bile duct, and a thin tubular drainage is installed into the lumen of the common bile duct from the side of the duodenum. After removing the endoscope, the drainage remains in the bile ducts and is discharged 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. A complicated course of acute calculous cholecystitis can manifest itself as a clinical manifestation of obstructive jaundice, which occurs when the bile ducts are obstructed by stones (choledocholithiasis) and the presence of a stricture of the major duodenal papilla. Often these bile duct stones and stricture occur together.

When cholecystitis and obstructive jaundice are combined, signs of inflammation of the bladder and peritonitis occur against the background of cholestasis, which aggravates the patient’s condition. Intense yellow staining of the sclera and skin appears one day or more after the onset of an acute attack of pain in the right hypochondrium, the appearance of dark colored urine and discolored feces, skin itching, high levels of bilirubin (200-300 µmol/l) in mainly due to direct (conjugated) bilirubin. These signs are described in detail in the manual of the department “Obstructive jaundice”.

Meanwhile, this combination of pathology significantly complicates the choice of tactics and methods of treating the patient. On the one hand, the patient must be freed from the source of inflammation - the gallbladder, and on the other hand, biliary 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.

Cholecystitis is an inflammation of the gallbladder. Cholecystitis is a very common disease, more common in women. According to the course, cholecystitis is divided into acute and chronic; calculous and stoneless.

Etiology and pathogenesis. In the occurrence of cholecystitis, the following is important: a variety of infections (viruses, E. coli, cocci, etc.), helminthic infestation(roundworms), giardiasis, damage to the mucous membrane of the gallbladder when pancreatic juice is thrown into it. The infection can penetrate the gallbladder hematogenously, enterogenously (from the intestines) and lymphogenous route.

However, infection alone is not enough to cause cholecystitis. A factor contributing to its development is stagnation of bile in the gallbladder, which occurs due to the presence of stones in it (calculous cholecystitis), disruption of its motor activity (dyskinesia), long breaks in food intake and a sedentary lifestyle. Besides, motor function the gallbladder can change under the influence of numerous reflexes from other pathologically altered organs (visceral-visceral reflexes).

Pathological anatomy . According to the nature of the inflammatory process in acute cholecystitis, forms are distinguished: catarrhal, purulent, phlegmonous and gangrenous. In chronic cholecystitis, the wall of the gallbladder gradually becomes sclerotic. The resulting (pericholecystitis) deforms the gallbladder, and thereby creates conditions for stagnation of bile and periodic exacerbations of the chronic inflammatory process. Typically, inflammation of the gallbladder is combined with inflammation of the bile ducts (see).

Clinical picture (symptoms and signs). Acute cholecystitis. The leading symptom is sudden pain in the right hypochondrium, epigastric region, less often around. The pain radiates to the right supraclavicular region, to the right scapula and sometimes to the heart area. An attack of pain is usually accompanied by bitterness in the mouth, vomiting, moderate fever (t 38-39°); Sometimes jaundice occurs as a result of pressure from an enlarged and tense gallbladder on the common bile duct or blockage by a stone, or when changes occur in the liver cells. The liver is enlarged, especially with purulent cholecystitis. The gallbladder is not always palpable. In acute cholecystitis, tapping on the abdominal wall and in the right hypochondrium is sharply painful, here there is usually muscle tension, Ortner's symptom is positive - pain when tapping with the edge of the hand on the right costal arch.

On palpation between the legs of the right sternocleidomastoid muscle, the Mussi-Georgievsky symptom is detected. When the peritoneum is involved in the inflammatory process, the Shchetkin-Blumberg symptom appears - the appearance of sharp pain in the abdomen after the rapid cessation of finger pressure on the anterior wall of the abdominal cavity. A blood test reveals neutrophilic leukocytosis (8000-10,000 leukocytes in 1 mm 3 of blood) with a slight shift to the left. All patients with acute cholecystitis should be hospitalized in the surgical department, since based on the clinical picture it is impossible to accurately judge the nature of the pathological changes in the gallbladder. Only the surgeon, based on an analysis of the symptoms of the disease and their changes during the observation process, determines the indications for conservative or surgical treatment and the degree of urgency of the operation.

Acute cholecystitis can be complicated by diffuse or limited purulent peritonitis (see), perforation of the gallbladder with the development of bile peritonitis (see), obstructive jaundice and purulent cholangitis (see). Any of these complications can develop both during the first and each subsequent attack; with stone (calculous) cholecystitis - more often, acalculous cholecystitis - less often.

Acute cholecystitis must be differentiated from acute appendicitis(see), hepatic colic (see), perforated ulcer duodenum(see), myocardial infarction (see), diaphragmatic (see).

Chronic cholecystitis may develop after an acute episode, but more often develops gradually. Patients feel dull aching pain in the right hypochondrium, under the right shoulder blade and in the right shoulder. Chronic cholecystitis can occur without pain, manifested only by a feeling of heaviness in the epigastric region, bloating, nausea 1-3 hours after eating, especially fatty foods, and a feeling of bitterness in the mouth. When palpated, pain is detected in the area of ​​the right hypochondrium. There is no muscle tension. Ortner's and Mussi-Georgievsky's symptoms may be negative. An enlarged liver is observed as a complication of chronic cholecystitis with cholangitis. In portions B and C of the duodenal contents, signs of inflammation are detected (see Duodenal intubation). At x-ray examination gallbladder (see) you can detect a violation of its functional ability, shape, as well as the presence of stones in it. In uncomplicated chronic cholecystitis, it is often found low-grade fever, somewhat accelerated. Periodically, exacerbations may occur, reminiscent of clinical picture acute cholecystitis.

Chronic cholecystitis should be differentiated from duodenal ulcer, colitis,.

Forecast in acute cholecystitis depends on timely hospitalization and early initiation of indicated treatment. Chronic calculous cholecystitis requires surgical treatment, since with long-term conservative treatment it is possible to develop a number of severe complications(acute cholecystitis and, acute and, obstructive jaundice and cholangitis, gall bladder cancer).

Cholecystitis (cholecystitis; from the Greek chole - bile and kystis - bladder) - inflammation of the gallbladder. Relatively frequent illness; women get sick more often than men.

Classification. In the USSR, the classification of S. P. Fedorov, with some modifications, is most commonly used, distinguishing: 1) acute primary cholecystitis (catarrhal, phlegmonous, gangrenous); 2) chronic recurrent; 3) chronic complicated (purulent, ulcerative); 4) sclerosis of the gallbladder; 5) hydrocele of the gallbladder.

Etiology and pathogenesis. In most cases, the cause of cholecystitis is an infection, most often Escherichia coli, paracoliforms and coccal flora (strepto- and staphylococci), less often anaerobes. IN last years The possibility of a viral nature of the disease (a virus that causes epidemic hepatitis) has been proven. In some cases, intoxication, irritation of the mucous membrane of the gallbladder by pancreatic juice thrown into it, as well as infestation by helminths (roundworms) are important; The etiological significance of Giardia is controversial.

The etiological role of the infection is proven by the detection as a result of bacteriological research microbial flora in cystic bile obtained on the operating table, as well as in bile obtained during duodenal intubation of patients with chronic cholecystitis (normally, bile is sterile).

Penetration of microbial flora or other pathogens (virus, helminths, protozoa) into the gallbladder can occur in three ways: hematogenous, enterogenous and lymphogenous, of which, apparently, the first two are the most common. On this basis, cholecystitis can be classified as a group of autoinfections.

An indispensable condition for the development of cholecystitis is stagnation of bile, without which inflammation does not occur, despite the microflora already nesting in the gallbladder. The role of gallstones is also known. In acalculous cholecystitis, bile stasis is facilitated by dyskinesia of the biliary tract, long breaks in food intake, a sedentary lifestyle, as well as numerous and varied interoceptive effects on the biliary system from pathologically altered abdominal organs. The allergic factor is known to be important in some cases.

Pathological anatomy. Cholecystitis, according to the nature of the inflammatory process, is divided into catarrhal, purulent, diphtheritic, and gangrenous.

In acute catarrhal cholecystitis, the gallbladder is slightly enlarged, its mucous membrane is hyperemic, swollen, the bile in the bladder cavity is watery, cloudy from an admixture of mucoserous or mucopurulent exudate. Microscopically, the wall of the gallbladder is full-blooded, swollen, infiltration of leukocytes, lymphoid cells, macrophages is observed in the mucous and submucous membranes, and desquamation of epithelial cells is noted. Acute cholecystitis can occur with acute infections ( typhoid fever, paratyphoid), with cholelithiasis, is often a consequence of an autoinfectious process (coli-infection).

Catarrhal cholecystitis can take a chronic, relapsing course. In this case, the wall of the gallbladder becomes denser, sclerosed, the mucous membrane atrophies, and in some places polypous growths form. A large number of macrophages containing cholesterol (xanthoma cells) appear under the epithelium - cholesterosis of the gallbladder (color table, Fig. 2 and 4). Microscopically, lymphocytic and plasmacytic infiltrates are observed in the sclerotic wall of the gallbladder; during the period of relapse, against the background of chronic changes, hyperemia, edema, and infiltration of leukocytes develop.

Rice. 1. Acute hemorrhagic cholecystitis. Rice. 2. Cholesterosis of the gallbladder. Rice. 3. Purulent-hemorrhagic cholecystitis. Rice. 4. Chronic cholecystitis. Rice. 5. Purulent cholangitis, which arose as a complication of cholecystitis.

Purulent cholecystitis most often develops with stones in the gall bladder (calculous cholecystitis). The gallbladder is enlarged and tense; the serous covers are dull, covered with fibrinous deposits (pericholecystitis), the wall of the gallbladder is sharply thickened (up to 0.5-1 cm). The mucous membrane is swollen, congested, with erosions and ulcerations. Purulent exudate, colored by bile, accumulates in the lumen of the gallbladder. Purulent cholecystitis often occurs as a phlegmonous cholecystitis, with abundant diffuse infiltration of the gallbladder wall with segmented leukocytes (phlegmonous cholecystitis). Acute cholecystitis can be accompanied by massive hemorrhages into the wall and lumen of the bladder, and then the process takes on the character of purulent-hemorrhagic inflammation - purulent-hemorrhagic cholecystitis (color table, Fig. 1 and 3). Often, with purulent cholecystitis, necrosis of the mucous membrane occurs with the formation of more or less extensive ulcers (phlegmonous-ulcerative cholecystitis); sometimes necrotic tissues of the mucous membrane are abundantly saturated with fibrinous exudate and take on the appearance of dirty green films. These films are rejected, and in their place deep ulcers form (diphtheritic cholecystitis) or the necrotic process spreads to the entire thickness of the gallbladder wall, which becomes black-brown, dull, and flabby (gangrenous cholecystitis). In the pathogenesis of this form of cholecystitis, hemodynamic disorders associated with damage to intramural blood vessels are important, in which, in acute purulent cholecystitis, inflammatory changes usually occur - purulent vasculitis, thrombovasculitis, as well as fibrinoid vascular necrosis.

The gangrenous process in the gallbladder can also result from primary damage to the blood vessels when hypertension(see), periarteritis nodosa (see Periarteritis nodosa; R. A. Khurgina, G. A. Kirillov).

Chronic purulent cholecystitis is morphologically characterized primarily by deformation of the gallbladder. It is reduced in size and fused with coarse adhesions to neighboring organs - the transverse colon, omentum, and stomach. In places free from adhesions, the outer surface of the gallbladder has a “glaze” appearance. Its wall is significantly thickened, dense due to sclerosis and sometimes petrification. The inner surface of the gallbladder has fibrous cords that are visible through the atrophic mucous membrane. There are ulcers of the mucous membrane of varying depths, made of granulation tissue. Microscopically, against the background of sclerosis, infiltrates of lymphoid and plasma cells, a small number of macrophages, and eosinophilic leukocytes are found in the wall of the gallbladder. Reparation processes in chronic cholecystitis are expressed in the form of granulation of ulcers followed by scarring and epithelization, the latter occurring due to the remaining cells of Luschka's ducts. Lushka's passages grow, branch, and reach the subserous layer; in some places they are cystically dilated and filled with mucin; Among the granulation tissue one can see the formation of adenomatous structures.

The most serious complications of acute purulent, phlegmonous with suppuration and gangrenous cholecystitis are perforations (sometimes microperforations) of the gallbladder wall with the subsequent development of bile or bile-purulent diffuse peritonitis; less commonly, encysted pericholecystitis or subphrenic abscess. Purulent inflammation may spread to the retroperitoneal tissue. With a prolonged course, fistula tracts sometimes form, opening into the lumen of the intestine, stomach, or through the abdominal wall to the outside.

When the mouth of the cystic duct is closed by a stone, thickened exudate or obliterated by chronic course In case of cholecystitis, a large amount of pus accumulates in the gallbladder, significantly stretching its cavity - the so-called gallbladder empyema. When the inflammatory process subsides, the leukocyte exudate is replaced by serous fluid, and hydrocele of the gallbladder develops.

The inflammatory process that occurs primarily in the gallbladder often spreads along the bile ducts. Therefore, in some cases, cholecystitis is combined with inflammation of the intra- and extrahepatic bile ducts - cholangitis (color table, Fig. 5), pericholangitis, which in turn can be complicated by liver abscesses, and with a long course - biliary cirrhosis. In addition, inflammation from the wall of the gallbladder through contact in the area of ​​its bed can spread to the liver tissue, where focal fibrinous perihepatitis and interstitial hepatitis develop.

With cholecystitis, damage to the pancreas sometimes develops in the form of acute hemorrhagic necrosis when infected bile enters the pancreatic duct or in the form of chronic pancreatitis (see) in case of infection of the gland by the lymphogenous route. Occasionally, specific inflammation occurs in the gallbladder during tuberculosis and syphilis; cholecystitis has been described in giardiasis, ascariasis, opisthorchiasis and echinococcosis.