Purulent cholangitis is most often the result. Diagnosis and treatment of cholangitis

Cholangitis is an inflammation of the bile ducts that occurs as a result of infection through the blood or lymph coming from the gallbladder or intestines. The syndrome rarely develops on its own, most often occurring as a complication of hepatitis, pancreatitis, gallstone formation, gastroduodenitis, if the patient ignored their symptoms and was not treated.

Classification

Determining the type of disease plays an important role in the preparation of a treatment regimen. Cholangitis is classified into several groups of signs. According to the nature of the course, acute and chronic forms are distinguished. According to pathomorphological changes, the acute form is divided into subtypes:

• purulent - characterized by the melting of the walls of the bile ducts and the formation of many internal abscesses;
• catarrhal - it is characterized by swelling of the mucous membranes lining inner surface bile ducts, excessive blood flow to them and oversaturation with leukocytes with further exfoliation of epithelial cells;
• diphtheritic - begins with the appearance of ulcers on the mucous membranes, desquamation of the epithelium and leukocyte infiltration walls with subsequent tissue death;
• necrotic - passes with the formation of dead areas that occur under the influence of aggressive enzymatic activity of the pancreas.

Chronic cholangitis is divided into the following forms:

• sclerosing (with proliferation of connective tissue);
• latent;
• recurrent;
• septic for a long time;
• abscessing.

According to the location of the inflammatory process, there are:

• choledochitis (inflamed common duct);
• angiocholitis (affected intra- and extrahepatic bile ducts);
• papillitis (inflamed large duodenal papilla).

By origin, cholangitis happens:

The chronic form of the disease is more common than the acute form and develops after an exacerbation of the disease and as independent disease, initially taking a protracted course.

Sclerosing type cholangitis is a special form of the disease. Initially having a chronic form of the course, inflammation in the bile ducts occurs without prior infection. The inflammatory process leads to tissue sclerosis - hardening, they completely block the lumen of the ducts, thereby causing cirrhosis of the liver. This disease is not treatable, slow progress (about 10 years) ends with the formation severe violations followed by death.

Main reasons

In most cases, cholangitis occurs as a result of an infection in the bile ducts. The most common infectious agents are:

• coli;
• staphylococcus;
• enterococcus;
• non-clostridial anaerobic infection;
• pale spirochete;
• typhoid stick.

The infection can spread upward. Wherein pathogenic bacteria enter the bile ducts:

• from duodenum;
• through the blood through the portal vein;
• through the lymph (as a complication of pancreatitis, enteritis, cholecystitis).

The main prerequisite for the formation of a pathological condition of the bile ducts is their impaired patency, which contributes to stagnation of bile and is unfavorable factor upon infection. The patency of the biliary tract is impaired in such diseases:

• choledocholithiasis - stone formation in the biliary system;
• chronic cholecystitis, accompanied by narrowing of the lumen of the ducts as a result of tissue scarring;
• postcholecystectomy syndrome - pathological condition coming after excision of the gallbladder;
• cystosis or tumor process of another etiology with localization in the bile duct;
• stenosis of the duodenal papilla;
• cholestasis - obstructed bile secretion, occurring with biliary dyskinesia.

With the development of infection in a descending type, microorganisms affect extra- and intrahepatic bile ducts, penetrating from the affected organs abdominal cavity above the gallbladder.

Cholangitis can also be provoked by endoscopic manipulations for the treatment or examination of the bile ducts, as a result of which the integrity of the walls was violated: choledochal stenting, retrograde cholangiopancreatography, sphincterotomy. Damaged mucous membranes become especially vulnerable to bacteriological infections, therefore, after any invasive examination or operation, you should regularly visit a doctor in order to control the healing process.

Symptoms

In adults and children early age cholangitis develops in different ways. Adult patients rarely complain of pain in acute stage. Their primary symptoms are mild, but if left untreated, the disease progresses rapidly, turning into a purulent complicated form, with extensive internal inflammation fraught with general sepsis.

In children, the acute form of cholangitis practically does not occur. Most often it begins after the attachment of the secondary streptococcal infection. The signs of the disease are nonspecific, the symptoms largely coincide with other diseases of the gastrointestinal tract, so if they occur, you should consult a doctor who will differential diagnosis on the basis of which an effective treatment regimen will be drawn up.

The following signs indicate the development of acute cholangitis:

• pain in the right hypochondrium of a aching nature, radiating to shoulder joint or in the region of the scapula;
• fever, accompanied by chills and intense sweating;
• bouts of nausea leading to vomiting;
• jaundice with the addition of severe skin itching.

In the absence of adequate measures for the treatment of acute cholangitis, the pathology becomes chronic, which is characterized by the following manifestations:

• decreased performance, constant weakness;
• hyperemic and itchy skin (most often on the palms);
• an increase in body temperature outside of colds;
• thickening of the distal (nail) phalanges of the fingers.

AT childhood cholangitis leads to weight loss because the child is constantly sick and refuses to eat. Intoxication caused by the activity of microorganisms and decay products formed during extensive purulent inflammation leading to the development of an anemic state. The patient's skin is pale, the sclera are colored in yellow. The child may complain of constant headaches. If at this stage of cholangitis is not treated, the progress of the disease can lead to a slowdown in physical development.

Diagnosis of the disease

Since this disease is recognized by outward signs is not possible, on the basis of a physical examination only a presumptive diagnosis is made. Its refinement is based on comprehensive survey patient, including the following laboratory and hardware examinations:

1. Liver tests will allow you to determine the biochemical composition of the blood (to draw up a treatment plan, the doctor will need information about the level of bilirubin, transaminases, alkaline phosphatase, alpha-amylase).
2. Examination of the contents of the duodenum by the method duodenal sounding and bacteriological culture bile will help identify the type of microorganisms that caused cholangitis.
3. Analysis for helminthic invasions (ascaris, lamblia, etc.).
4. On ultrasound, CT, ultrasonography, the nature of pathological changes in the biliary tract, their narrowing or expansion, the localization of inflamed areas and the nature of local blood circulation are determined. Hardware examination will make it possible to assess the condition of the bile ducts and liver themselves.
5. In combination with hardware methods, endoscopic research methods are used in the diagnosis: transhepatic cholangiography, retrograde pancreatocholangiography.

Diagnosis begins with delivery laboratory tests, according to the results of which the doctor will determine the necessary additional research he needs to formulate a treatment plan.

Complications

If you ignore the first signs of cholangitis and do not diagnose and treat this disease in time, inflammatory process in the biliary tract can lead to the following serious conditions:

• Crohn's disease;
• cirrhosis of the liver;
• the development of hepatic coma;
• acute liver or kidney failure;
• hepatitis;
• blood poisoning;
• peritonitis;
• infectious-toxic shock.

Treatment

When the diagnosis of cholangitis is confirmed, the main vector of treatment is the removal of the internal inflammatory process. At the same time, intoxication of the body is eliminated and measures are taken to stop the processes that cause compression of the bile ducts. In the presence of concomitant diseases of the biliary system, gastrointestinal tract, liver or kidneys, a medication course is required to correct them.

To suppress pathogenic microflora, combinatorial drug treatment antibiotics a wide range actions (cephalosporins, metronidazole, aminoglycazides). In order to remove intoxication as soon as possible, purification of blood plasma (plasmapheresis) is carried out. To consolidate the result of treatment outside the acute stage of cholangitis, stabilization of the patient's condition is facilitated by physiotherapeutic procedures.

The general well-being of the patient during this period is well affected by the use of therapeutic mud, treatment with paraffin applications, sodium chloride baths with high concentration, physiotherapy with the use of high-frequency magnetic fields, drug electrophoresis, deep heating with currents.

Running cholangitis in chronic form is not amenable to conservative treatment. At this stage, the ducts are often so deformed that it is no longer possible to restore their patency with a course of antibiotics.

Surgery recommended when all methods conservative therapy have already been applied, but it was not possible to normalize the outflow of bile. by the most effective method surgical treatment running forms cholangitis are considered endoscopic procedures - minimally invasive and having a brief rehabilitation period. Endoscopic techniques are contraindicated in necrotic and purulent processes, and are also excluded in the presence of multiple abscesses in the lumen of the biliary tract.

Surgical interventions are carried out in order to eliminate the decompression of the affected pathways. Their format is determined by the prevalence of the inflammatory process and the nature of pathological changes. So, as part of the surgical treatment of sclerosing type cholangitis, doctors recommend a liver transplant.

Diet

Diet therapy is an integral part of the treatment of all diseases associated with impaired functionality of the organs responsible for digestion. Nutrition during inflammatory processes in the bile ducts should be organized in such a way as to normalize the functioning of the biliary system and reduce the load on the liver.

For this, fasting is prescribed in the first 2 days of treatment of acute cholangitis. After that, easily digestible foods are gradually introduced into the diet. At the time of treatment, foods high in fat, smoked meats, salted, spicy and fried foods are completely excluded.

• wholemeal bread;
• dairy products with minimal fat content;
• vegetables - it is allowed to take it raw, but preference is given to stewed or boiled, as well as steamed vegetable dishes;
• eggs;
• pasta;
• porridge.

If the patient feels well, boiled or baked meat of low-fat diet varieties (rabbit, turkey, veal) can be added to the diet.

To avoid intense bile formation, throughout the course of treatment, you need to eat fractionally, in small portions, taking breaks between meals at 2-3 hours.

Of particular importance in the treatment of cholangitis is the drinking regimen. Drinking up to 1.5 liters per day clean water without gas, the patient will provide favorable conditions for the elimination of toxins. Instead of water, you can drink a decoction of wild rose or dried fruits, ginger or green tea- they well relieve nausea and promote detoxification of the body.

Eating food from the list of prohibited foods will reduce the effectiveness of treatment and may cause a recurrence of cholangitis even during a period of long-term remission.

Prevention and prognosis

With timely treatment of the acute form of the disease, not complicated by sepsis, abscess formation or functional insufficiency of the liver or kidneys, the pathology is cured by conservative methods. Factors that worsen the prognosis are elderly age, chronic course illness, fever persisting for 14 days or longer, anemia, female sex.

Chronic forms of cholangitis often occur with complications that require surgical intervention. An inflammatory process that lasts for years can lead to disability, and in this case there is a high probability lethal outcome. The cause of death becomes septic shock, which occurs as a result of systemic blood poisoning and occurs when the patient refuses treatment.

• Medical treatment

  In conditions of biliary hypertension with cholangitis, independent significance drug therapy relatively small. It is advisable to consider it only as an intensive short-term preparation of the patient for urgent decompression of the bile ducts. In a threatened state intensive care should be combined with immediate decompression.

  • Pain therapy.

    Scopolamine IV or IM 20 mg 4 r / day or metamizole sodium (Analgin, Baralgin M) 2.5 g 4 r / day or pentazocine IV or IM 30 mg 4 r / day day or pethidine in / in - 25-150 mg / day.

  • Antibacterial therapy.

    It includes the appointment of cephalosporins, as well as ureidopenicillins, which, if necessary, are prescribed with aminoglycazides.

    Cefotaxime (Claforan, Cefotaxime por.d / in.) IM 2 g 2p / day or ceftriaxone (Rocefin , Ceftriaxone por.d / in.) IM 2g 2r / day + piperacillin PO or IM 100-300 mg/kg/day or azlocillin po or IM 12–15 g/day +/- tobramycin IM 3–5 mg/kg/day or metronidazole (400 ml/day or Hemodez 200 ml/day or 10–20 % Albumin solution 100 ml/day.

• Surgical treatments

  Urgent decompression of the bile ducts is required. Decompression means surgical intervention aimed at creating conditions for a normal outflow of bile by external or internal drainage of the bile ducts. Surgical treatment is also used to remove gallstones, as one of the main causes of cholangitis.

  Methods of decompression of the biliary tract:

  • Endoscopic papillosphincterotomy.
  • Introduction of an endoprosthesis into the common bile duct.
  • Percutaneous transhepatic cholangiostomy.

  After surgery for chronic cholangitis it is advisable to repeat courses of antibiotic therapy and carry out tubazh with a choleretic purpose.

• Treatment tactics

  The tactics of managing patients with cholangitis presents significant difficulties, which are due to the presence of purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these moments requires an early resolution, however, patients with obstructive jaundice do not tolerate long and traumatic surgical interventions.

  Therefore, first of all, it is advisable to ensure an adequate outflow of bile, which at the same time reduces clinical manifestations cholangitis, intoxication.

  The second stage is a radical intervention aimed at eliminating the cause of cholangitis.

  In order to decompress the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual choledochal stones after papillosphincterotomy, the discharge of calculi from the biliary tract is sometimes noted, the phenomena of cholangitis are stopped and the question of the need for a second operation disappears.

• Further management of patients

  All patients with cholangitis, including after surgery, are recommended diet therapy, which excludes spicy and fatty foods, smoked meats, spices. Food should contain many vitamins, vegetable fats.

  shown Spa treatment in sanatoriums of a gastroenterological profile.

Filtering toxins, storing vitamins, producing glycogen - these are the main tasks that the liver performs in the body of every person. If for some reason these functions cannot be full degree be executed, then . Yellowing of the skin or sclera of the eyes are clear signs that the liver is starting to fail.

What is it - cholangitis?

What is it - cholangitis? This is inflammation of the bile ducts. Their obstruction with the addition of infection is a sure sign of the disease.

Types and forms

Cholangitis has its own types and forms of development. The forms are divided into:

1. Spicy. By inflammatory nature acute cholangitis divided into types:

• Catarrhal - swelling of the bile ducts with their further scarring and narrowing.
• Purulent - affects the liver and gallbladder, characterized by the accumulation of pus and bile in the bile ducts.
• Necrotic - the formation of necrosis of sections of the bile duct after the ingestion of pancreatic enzymes.
• Diphtheritic - manifestations and necrosis of the mucosa, destruction of the walls of the bile duct, purulent fusion of the surrounding tissue.

1. Chronic. According to the inflammatory nature, they are divided into types:
   • Hidden (latent).
   • Septic.
   • Recurrent.
   • Abscessing.
2. Sclerosing (autoimmune) cholangitis - it is assumed that it develops as a result of autoimmune reaction organism on itself. Hardening, narrowing and overgrowth of the bile ducts occurs, which leads to cirrhosis of the liver.
3. Bacterial.

Causes

What could be the causes of such an unpleasant disease as cholangitis? Consider the most common:

• Gallstone disease in the bile ducts (choledocholithiasis).
• Scarring and narrowing of the bile duct due to removal of a cyst, tumor, or chronic cholecystitis.
• Roundworm, helminthic invasion.
• Hepatitis.
• Penetration of infection from the intestines, through the flow of lymph or blood. A favorable environment for her becomes a violation of the outflow (stagnation) of bile.

Predisposing factors for these anomalies are:

1. genetic predisposition.
2. psychogenic factor.
3. congenital anomalies.
4. Giardiasis.
5. Dyskenesia.
6. endocrine disorders.
7. immunological reactions.
8. Pancreatobiliary reflux.
9. Dyscholia, which develops for the following reasons:
   • Eating disorder.
   • Obesity.
   • Overweight.
   • Hormonal disruptions.
   • Taking hormonal medications.
   • Violation of the blood supply to the liver and gallbladder.
   • Dishormonal disorders.
   • Alcoholism, smoking.

Symptoms and signs of cholangitis of the bile ducts

Symptoms and signs of cholangitis of the bile ducts should be considered in the form of their course:

1. Spicy:
   • Attack of pain in right side chest(shoulder, shoulder blade) and abdomen.
   • Raising the temperature to 40ºС.
   • Nausea.
   • Lowering blood pressure.
   • Weakness.
   • Vomit.
   • Skin itching.
   • Chills.
   • Yellowness skin, mucous membranes, sclera.
   • Violation of consciousness.
   • Perhaps the development of hepatic coma.
2. Chronic:
   • Pain is mild, but intense in the presence of stones.
   • Skin itching.
   • Bursting or squeezing in the right hypochondrium.
   • Weakness.
   • Intermittent high fever.
   • fatigue.
   • Thickening of the fingers, redness of the palms.
3. Sclerosing:

• Pain in the upper abdomen and right hypochondrium.
• Violation of the stool, as in ulcerative colitis or Crohn's disease.
• Jaundice and pruritus.
• Temperature up to 38ºС.

Cholangitis in children

In children, cholangitis occurs mainly due to genetic or innate character. In other cases, the disease is not observed in children.

Cholangitis in adults

In adults, cholangitis develops due to genetic, congenital and in women, it occurs when hormonal disruptions during pregnancy or childbirth. It occurs in men due to the presence bad habits or untreated diseases. An unhealthy lifestyle and poor-quality nutrition are the main factors of cholangitis in adults.

Diagnostics

Diagnosis of inflammation of the bile ducts begins with a general examination and collection of complaints. According to some external signs, the doctor has reasons for the following procedures:

• Ultrasound of the liver.
• Blood test.
• Magnetic resonance cholangiography.
• Analysis of feces for eggs of worms.
• Endoscopic retrograde cholangipancreatography.
• Analysis of urine.
• duodenal sounding.
• X-ray cholegraphy.
• Cholangiomanometry.
• Choledochoscopy.
• Liver biopsy.
• Radioisotope examination of the bile ducts.

Treatment

Treatment of cholangitis is carried out only in a hospital. Folk remedies, which a person wants to spend at home, do not contribute to recovery. This requires medical, therapeutic and sometimes surgical treatment.

What is the treatment for cholangitis? The doctor prescribes medications if there is a normal outflow of bile:

• Antibiotics.
• Antispasmodics.
• Sulfonamides.
• Drugs that reduce toxicity.
• Medications that improve the outflow of bile.
• Anthelmintic drugs.

In case of ineffectiveness of conservative treatment, surgical treatment is resorted to. Endoscopy is performed with drainage of the bile ducts, elimination of narrowing, removal of stones. With purulent inflammation, abdominal operation to remove purulent or necrotic areas. Sometimes a cholecystectomy is performed - the removal of the gallbladder or a complete liver transplant.

In the treatment of cholangitis, a rigid diet is actively used:

1. Small meals at least 5 times.
2. Avoid eating before bed.
3. Exclusion from the menu of fresh bread, spicy, fried, spicy, onions, lard, sour berries and fruits, garlic, strong tea, alcohol.
4. Included in the menu are lean fish, cottage cheese, buckwheat, oatmeal, warm milk, egg whites, boiled meat, vegetables, milk soups, kefir, stale bread, honey, jam.
5. Prohibition on hunger strike.
6. tea drinking special charges herbs. Compotes, jelly, mineral waters.

Sclerosing cholangitis is treated as follows:

• Vitamin therapy.
• Antihistamines.
• Ursodeoxysolic acid.
• Sedative drugs.

Physiotherapy procedures are used:

1. Amplipulse therapy.
2. Diathermy.
3. microwave therapy.
4. Paraffin and mud applications.
5. Sanatorium treatment.
6. Physiotherapy.

Lifespan

How long do people live with cholangitis? The disease itself does not affect life expectancy, but provokes such complications that lead to death:

• Peritonitis.
• Abscess of the abdomen.
• Liver failure.
• Intrahepatic abscesses.
• Sepsis.
• biliary cirrhosis.
• Cholangiocarcinoma.

Here you should not delay treatment and do not self-medicate. Contact for medical assistance at the first symptoms.

The liver is one of the most important organs human body along with the heart, brain, lungs. There are a lot of tasks that the liver performs: this is filtering all kinds of toxins, and the production of glycogen, and the storage of some vitamins (A, D, B12). Refers to the functions of the liver and the synthesis of bile. First, bile is collected in the hepatic bile ducts, and then goes through the common bile duct to gallbladder. Inflammation of these bile ducts is the main feature of a fairly common disease - cholangitis.

Causes

Two factors contribute to the occurrence and development of cholangitis: stagnation of bile and the presence of infection. This set of circumstances can be caused by the following reasons:

In addition to these reasons, some viruses can provoke inflammation of the bile ducts - for example,.

Classification of varieties of the disease

In the previous section, we discussed different kinds cholangitis, which differed disease-causing reasons. So, for example, there are bacterial, viral, autoimmune and helminthic types of the disease. However, cholangitis is also divided according to other features. The main types will be discussed below.

Primary sclerosing type

About what constitutes primary sclerosing cholangitis, it was said a little above, but it would be useful to consider this issue in more detail. It’s worth starting with the fact that this is chronic cholangitis, in which biliary tract scars are formed. As a result, bile cannot move normally through the channels, which means that the liver does not work as it should.

The causes contributing to the development of a disease such as primary sclerosing cholangitis are not fully understood, but it is assumed that this is due to autoimmune diseases. People whose relatives were ill with this disease fall into the risk category. Also, primary sclerosing cholangitis occurs somewhat more often in men than in women.

Purulent type of disease

Purulent cholangitis is usually bacterial in nature and is characterized by the presence of wounds on the walls of the bile ducts. Wounds begin to fester over time, in some cases tissue necrosis may even begin. This type of disease sometimes behaves like acute cholangitis, and sometimes takes a chronic form.

The purulent type of cholangitis is dangerous, first of all, because its picture of the disease is similar to other varieties of this disease, and the wrong and untimely treatment can lead to severe complications: liver failure, the occurrence of many abscesses in the liver, purulent intoxication etc.

Cholecystocholangitis

Manifestations of the disease

Despite the fact that different types There are several cholangitis (including the already mentioned primary sclerosing cholangitis, cholecystocholangitis, etc.), their symptoms are quite similar. These characteristic signs of cholangitis will be listed below.

• Yellowing of the skin and whites of the eyes. Occurs due to stagnation of bile.
• Severe fever, chills. Especially such symptoms are characteristic if acute cholangitis occurs.
• Pain in the right hypochondrium.
• Bitterness in the mouth, nausea, strong vomiting.
• Enlargement of the liver in size.
• Weakness, lethargy.

At acute form diseases, all these symptoms will be very pronounced, so it will be difficult not to notice them. But in the chronic form, all the symptoms are somewhat muffled: instead of fever, subfebrile condition is observed, instead of constant vomiting - slight nausea, pain in the hypochondrium is not so strong. One side, chronic form disease is less painful for the patient, on the other hand, a person often decides to endure not too much severe pain, and in the case of cholangitis, this can have disastrous consequences.

Diagnostic methods

Symptoms of cholangitis, especially acute cholangitis, are pronounced and indicate liver problems, but a number of additional tests are needed in order to make an accurate diagnosis and prescribe treatment for cholangitis. Here are the main ones:

Treatment for cholangitis

Treatment of cholangitis can be done both in the outpatient clinic and in the hospital department. The patient must be released from physical activity. Treatment methods work in a complex, therefore it is important not to miss any of its sides.

Feeding method

The diet for cholangitis involves the rejection of fatty foods, alcohol, fried foods, dishes with an abundance of spices, smoked meats, and canned food. Don't eat garlic or onions either. You need to eat often and little by little so as not to overload the liver. The following products will also benefit:

• Low-fat meats (veal, chicken fillet, rabbit meat) and fish (hake, pike perch).
• Low-fat dairy products (kefir, fermented baked milk, fat-free cottage cheese).
• Kashi, especially buckwheat and oatmeal.
• Vegetables - boiled or steamed.

Also, with cholangitis, the drinking regimen is important - at least 1.5–2 liters of pure water should be consumed per day.

Medical treatment

During the period acute attacks treatment of cholangitis involves taking drugs that can reduce inflammation. Usually these are broad-spectrum antibiotics, such as tetracycline, biomycin. For removal pain sedatives and painkillers are prescribed.

Conservative therapy

When acute inflammation has been removed, general methods of treatment are used to improve the patient's condition. Good results in this respect gives a stay in the resorts mineral waters, also shows some physiotherapy (diathermy, UHF), special sets of exercises, mud and paraffin applications.

In conclusion, it can be noted that the symptoms of cholangitis are sometimes not too noticeable, but it is important to pay attention to them in time. The treatment of cholangitis at the present time is not too difficult, especially on early stages, but if you start the disease, then the complications can be very serious - up to cirrhosis of the liver.

Nonspecific inflammation of the bile ducts, which occurs as a result of impaired patency of the biliary tract and infection of the bile. Most often, with cholangitis, E. coli is sown from bile. Most often combined with choledocholithiasis, cysts of the common bile duct, bile duct cancer. In most cases, cholangitis occurs when pathogens of a bacterial infection enter the bile ducts from the lumen of the duodenum (ascending infection), hematogenous (through the portal vein system) or lymphogenous (in diseases of the gallbladder, pancreas or colon) by. According to the nature of the course, acute and chronic cholangitis are distinguished. Acute cholangitis, depending on the severity of inflammatory changes in the wall of the bile ducts, can be catarrhal, purulent, diphtheritic and necrotic. Among the forms of chronic cholangitis, latent, recurrent, long-term septic, abscessing and sclerosing are distinguished. Symptoms, course. The clinical picture depends on the presence or absence of acute destructive cholecystitis, often complicated by cholangitis. The disease usually begins with a painful attack resembling hepatic colic (a manifestation of choledocholithiasis), after which obstructive jaundice, fever, and pruritus quickly appear. On examination, icterus of the skin, traces of scratching on the skin, the tongue is wet, lined, the abdomen is not swollen. On palpation of the abdomen, some stiffness of the muscles in the right hypochondrium, pain, with deep palpation, an increase in the size of the liver is determined, its edge is rounded. Temperature sometimes hectic type, chills. In the blood - leukocytosis with a shift to the left. Hyperbilirubinemia is mainly due to direct bilirubin, an increase in alkaline phosphatase, a moderate increase in liver enzymes (ALT, ACT) due to toxic damage to the hepatic parenchyma. An ultrasound examination of the liver and biliary tract can provide significant assistance in establishing the diagnosis of cholangitis. In the absence of timely treatment, inflammation from the wall of the bile ducts passes to the surrounding tissues and can cause impregnation of the hepatoduodenal ligament with bile and peritonitis, the formation of intrahepatic abscesses, the development of sclerotic changes in the liver tissue and secondary biliary cirrhosis. Complications. Formation of multiple liver abscesses, sepsis, hepatic-renal insufficiency. Obstructive jaundice often develops in elderly and old age, the compensatory capabilities of the organism of which are very limited, and surgical intervention against the background of acute cholecystitis is a great risk. In this situation, urgent endoscopic papillotomy is promising. Through the biopsy channel of the duodenoscope, a thin cannula is inserted into the major duodenal papilla, after which it is dissected using a special papillotome upper wall. In this case, the calculi from the ducts either move away on their own, or they are removed with special tweezers using a Dormia loop (basket) or a Fogarty probe. This manipulation allows you to eliminate biliary and pancreatic hypertension, reduce jaundice and intoxication. Subsequently, an operation on the gallbladder is performed in a planned manner. A patient with suspected cholangitis needs urgent hospitalization, since the treatment is predominantly surgical. At the pre-medical stage, antispasmodic and anti-inflammatory drugs, broad-spectrum antibiotics that do not have hepatotoxic properties are prescribed. The tactics of managing patients with cholangitis presents significant difficulties, they are due to the presence of a purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these moments requires an early resolution, however, patients with obstructive jaundice do not tolerate long-term and traumatic surgical interventions. Therefore, it is advisable first of all to ensure an adequate outflow of bile, which at the same time reduces the clinical manifestations of cholangitis, intoxication. The second stage is a radical intervention aimed at eliminating the cause of cholangitis. In the hospital, detoxification and antibiotic therapy and prepare the patient for surgery. The most widely used in acute cholangitis are endoscopic methods for draining the bile ducts, which ensures a normal outflow of bile. The prognosis of catarrhal cholangitis with timely treatment is favorable. With purulent, diphtheritic and necrotic cholangitis, the prognosis is more serious and depends on the severity of morfol. changes, the general condition of the patient, as well as the factor that caused cholangitis. With long-term chronic cholangitis, biliary cirrhosis of the liver or abscess cholangitis may develop, the prognosis of which is unfavorable. Prevention consists in the timely detection and treatment of diseases of the biliary tract and the region of the major duodenal papilla. In order to decompress the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual choledochal stones after papillosphincterotomy, the discharge of calculi from the biliary tract is sometimes noted, the phenomena of cholangitis are stopped and the question of the need for a second operation disappears. The prognosis is serious. Cholecystectomy is the main surgical intervention performed in acute cholecystitis. Removal of the gallbladder can present significant difficulties due to severe inflammatory changes in the surrounding tissues. Therefore, it is recommended to remove the bubble "from the bottom". Cholecystectomy, if indicated, should be supplemented by intraoperative examination of the extrahepatic bile ducts (cholangiography). When choledocholithiasis or stenosis of the terminal section of the common bile duct is detected, the same manipulations are performed that are customary to do in similar cases during planned operations in patients with chronic calculous cholecystitis (choledochectomy, T-shaped drainage, etc.). Drainage is left in the abdominal cavity to control blood and bile leakage. Mortality after cholecystectomy performed for acute cholecystitis is 6-8%, reaching the streets of elderly and senile age 15-20%. Tom and I with the removal of calculi and infected contents of the gallbladder is indicated in rare cases, as a necessary measure in the general serious condition of the patient and massive inflammatory infiltrate around the gallbladder, especially in elderly and senile patients. This operation allows only to eliminate acute inflammatory changes in the wall of the gallbladder. In the long term after the operation, as a rule, stones form again in the gallbladder and patients have to be operated on again.