Typical clinical symptoms of cholangitis. Purulent cholangitis

Date: 19.07.2019

Cholangitis is a malfunction of the liver in which the bile ducts become inflamed.

All people are at risk. A similar violation of the gastrointestinal tract occurs in men and women of different age categories. However, most often the disease is diagnosed in the fairer sex at the age of 50-60 years. Doctors attribute this to what is changing hormonal background, the metabolism slows down, the level of immunity decreases.

What it is?

Cholangitis - infection biliary tract. Occurs due to bacterial infection... There are acute and chronic forms. Sometimes it develops as an independent disease, more often it is a consequence of other diseases internal organs... It usually occurs in women in old age.

This article will tell you what cholangitis is, what the symptoms are, and how to treat it in adults.

Classification

Determining the type of disease plays an important role in the design of the treatment regimen. Cholangitis is classified according to several groups of characteristics. By the nature of the course, acute and chronic forms are distinguished. According to pathomorphological changes, the acute form is subdivided into subtypes:

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

Chronic cholangitis is divided into the following forms:

sclerosing (with overgrowth connective tissue);
latent;
recurrent;
septic long-running;
abscessing.

By the location of the inflammatory process, there are:

choledochitis (common duct is inflamed);
angiocholitis (intra- and extrahepatic biliary tract is affected);
papillitis (large duodenal papilla is inflamed).

By origin, cholangitis is:

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

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

Reasons for development

The main cause of cholangitis is a violation of the patency of the bile ducts and the addition of infection. Violation of the patency of the bile ducts often occurs with choledocholithiasis - the formation gallstones in the biliary tract. Other causes of impaired bile outflow can be cicatricial narrowing of the biliary tract due to chronic cholecystitis, removal of the gallbladder (postcholecystectomy syndrome), cysts or tumors of the common bile duct.

Infection in the biliary tract mainly comes from the intestines, since with stagnation of bile, the mechanism is disrupted that prevents the penetration of intestinal contents into the upper parts of the gastrointestinal tract. In addition to the ascending (intestinal) route of infection, there is also a descending route when the infection enters the biliary tract with the flow of blood or lymph from another inflammatory focus v abdominal cavity.

Symptoms

Acute disease occurs suddenly. But like any disease, cholangitis also has symptoms and signs:

Highly heat up to 40 ° C.
Characteristic pains on the right in the ribs.
Yellowness skin and the mucous membrane of the eyes.
Chills, intense sweating.
General intoxication of the body, which is characterized by diarrhea, general weakness, vomiting and loss of appetite.
Itching of the skin appears due to jaundice.
If the form of the disease is severe, the patient may faint.

In the chronic form of cholangitis, the symptoms are not so pronounced, the pain is dull, the temperature is low, closer to normal. The patient gets tired quickly, feels general weakness. If the disease is not treated, a number of dangerous complications can appear.

Sclerosing primary cholangitis (PSC)

A few statistical facts about this form:

55% of people this disease proceeds without symptoms or with minimal manifestations;
In 20-60% of cases, the disease is detected only at the stage of the appearance of liver cirrhosis;
Up to 20% of patients with PSC suffer from cholangiocarcinoma ( malignant tumor), which developed as a result of pathology.
These moments clearly demonstrate how difficult the diagnosis is. On the one hand, patients often do not pay attention to "minor" symptoms, which leads to late referral for medical help... On the other hand, not every city has a specialist who will suspect this rare but dangerous pathology.

What solution can be found in this case? First of all, you need to be wary of your health. The table below will provide the necessary information that will allow you to suspect PSC. The main thing is not to neglect it and objectively analyze the state of your body. This will prevent the progression of PSC and avoid dangerous complications.

Diagnostics

Based clinical picture, in diagnostics acute cholangitis you should be guided by the Charcot triad or the Reynolds pentad. But in general for making a diagnosis this disease it is also necessary to involve additional diagnostic methods - physical (examination, probing, tapping and listening to the abdomen with a phonendoscope), instrumental and laboratory.

Examination of such a patient reveals:

yellowness of the skin, sclera and visible mucous membranes;
tongue dry, covered with yellow bloom;
traces of scratching are visible on the skin, sometimes quite pronounced, up to blood (with severe itching).

With the symptoms of jaundice, examination of feces and urine will also be informative:

feces are characterized by a lighter shade than usual (but in general it is not white, as it can be with jaundice due to blockage of the biliary tract);
due to the ingress of bile pigments into the blood, and then into the kidneys, urine may darken ( characteristic symptom"Beer color").

On palpation at the peak of the pain attack, there is strong pain in the right hypochondrium. With percussion (tapping with the edge of the palm on the right costal arch), the patient reacts very painfully.

Instrumental methods that are used to diagnose cholangitis are:

Ultrasound diagnostics of the liver (ultrasound) and ultrasonography (ultrasound) of the biliary tract - these methods allow you to evaluate the biliary tract, determine pathological changes in them - in particular, their expansion, as well as changes in the liver, which occur due to a violation of the flow of bile in the biliary tract ;
Computed tomography of the bile ducts (CT) - an assessment of the very parameters that are assessed using ultrasound, will help to conduct computed sections biliary tract;
Endoscopic retrograde cholangiopancreatography (ERPCG) - using an endoscope inserted into the gastrointestinal tract, a contrast agent is injected into the biliary tract, an X-ray is taken and evaluated;
Magnetic resonance cholangiopancreatography (MRPCG) - bile ducts with injected contrast are examined using magnetic resonance imaging;
Percutaneous transhepatic cholangiography - contrast is injected into the bile ducts not through the digestive tract, but by puncturing (piercing) the skin and liver;
Duodenal intubation - with its help, bile is taken with subsequent bacteriological inoculation on nutrient media.

In the diagnosis of cholangitis, such laboratory methods, how:

Complete blood count - its data are not specific, but are important for assessing the progression of inflammation. So, an increase in the number of leukocytes and an increase in ESR will be revealed;
Biochemical liver tests - determine an increase in the amount of bilirubin, alkaline phosphatase, as well as transaminases and alpha-amylase. Such data indirectly indicate cholestasis (stagnation of bile), which is observed with cholangitis;
Bacteriological culture of bile obtained with duodenal intubation- thanks to him, the causative agent of cholangitis is identified;
Stool analysis - thanks to it, the presence of helminths or protozoa in the body, which can cause inflammation of the biliary tract, is confirmed or excluded.

Effects

If timely treatment is absent, the inflammatory process may become more serious. Gradually, it spreads to the peritoneum, because of this, the development of peritonitis is possible. Pathology is capable of "spreading" to the surrounding tissues. As a result, subphrenic and intrahepatic abscesses begin to form. Sepsis and toxic shock are common. The last complication develops against the background of the bacterial form of cholangitis.

The patient's condition becomes extremely difficult. Sometimes it's impossible to do without resuscitation measures... The inflammatory process for a long time can lead to sclerotic changes. As a result, the disease takes on a chronic form and leads to the development of biliary cirrhosis.

Self-medication and attempts to eliminate pathology folk remedies on the contrary, it will aggravate the situation. In general, such interference is unacceptable. After all, time may be lost, and the pathology will take on a more serious character. In the later stages, the prognosis is far from the most favorable.

Cholangitis treatment

There are several fundamental points in the cholangitis treatment regimen that every patient should know:

If an acute process is suspected, hospitalization in a surgical hospital is necessary. This tactical nuance is explained by the unpredictable course of the disease - at any time, inflammation of the duct system can cause blood poisoning (sepsis) or disturbances in the work of other organs;
Every patient with acute process potentially requires surgery to restore outflow from the biliary tract. Doctors try to choose the most gentle method for the body and try to avoid a large amount of intervention and incisions in the skin. If possible, surgeons perform all interventions using an endoscope, passing it through the mouth to the end of the common bile duct. This allows you not to injure excess tissue and reduce the risk of complications.
The patient should be aware of the possibility surgical intervention and not be afraid of this method of treatment;
Almost always, chronic forms of the disease are treated on an outpatient basis - hospitalization, like an operation, with a prolonged course is not necessary, since the pathology is relatively predictable in its development.

Treatment of the acute process

As mentioned above, almost every patient with this form is a potential "candidate" for surgery. The time it takes is determined by the patient's condition. With a relatively mild course of the disease and preserved functions of all organs, it is possible to carry out surgical intervention on the first day after hospitalization.

A severe variant of the disease or the development of sepsis requires preliminary preparation of the body with the help of medications. In order to improve a person's condition, the surgeon may prescribe the following therapy:

Intravenous infusion of solutions that improve metabolism in tissues and reduce the concentration of blood toxins: glucose or sodium chloride solutions, Ringer's solution, Disol or Trisol preparations, etc.;
A combination of antimicrobial drugs;
Hepatoprotectors, to maintain the functioning of liver cells: Essentiale, ademetionine, ursodeoxycholic acid and others;
If necessary, drugs are used to relieve pain and to eliminate spasms in the digestive tract (antispasmodics).

After the operation to restore the outflow from the common bile duct, drug treatment continues. The time of taking the drugs is determined in each case individually and depends only on the state of the body and the characteristics of the course of the pathology.

Treatment of the chronic form

When this type of disease is detected, the doctor first of all tries to deduce the cause chronic inflammation... It is this nuance that determines the further treatment tactics. There may be several options:

In addition to specific treatment, all patients with chronic forms of the disease are advised to:

Adhere to a diet (table number 5 according to Pevzner), which implies frequent fractional meals 5-6 times a day, in a small amount, with the exception of fatty foods;
If possible, exclude physical and psychological stress;
Quit smoking, drinking alcoholic and caffeinated beverages;
Take multivitamin complexes with the presence of vitamins K, D, E and A. Absorption of these particular substances is impaired with prolonged inflammation of the biliary system.

Prophylaxis

The disease is much easier to prevent than to deal with its consequences in the future. To prevent the development of primary or recurrent cholangitis, it is necessary to observe simple principles healthy lifestyle:

to give up smoking;
refusal to drink alcoholic beverages;
regular sports;
daily walks in the fresh air;
full sleep;
healthy eating;
avoidance of stressful situations.

In addition, it is recommended to systematically undergo complete medical examination... This will detect chronic diseases on early stages. Preventive examination in no way should be neglected. Better to spend a little free time consulting a doctor than a long and tedious treatment neglected form pathology.

Forecast for life

The prognosis for cholangitis is different.

With the catarrhal form of cholangitis, it is satisfactory, with purulent, diphtheritic and necrotic forms it is more serious: in this case, the outcome can be favorable for the patient only in the case of verified prescriptions and scrupulously adhered to treatment. If the inflammation of the biliary tract passes with complications, then the prognosis is unsatisfactory. This is especially stated in diseases such as:

the formation of abscesses in the biliary tract;
cirrhosis of the liver;
hepatic renal failure;
septic damage to the body.

What is Cholangitis
What provokes Cholangitis
Cholangitis symptoms
Cholangitis diagnostics
Cholangitis Treatment
Which doctors should you contact if you have Cholangitis?

What is Cholangitis

Cholangitis- a syndrome characterizing a nonspecific inflammatory process with damage to the extra- and / or intrahepatic bile ducts.

Prevalence. In recent years, there has been an increase in the incidence of this pathology by 40%.

What provokes Cholangitis

The condition for cholangitis is stagnation of bile and the presence of infection. There are many reasons that prevent the flow of bile. Obturation of the bile ducts, as a result of the primary pathological process, contributes to the emergence of bile hypertension, a change in the physicochemical properties of bile, which is a prerequisite for its infection. The most common causes of obstruction of the bile outflow tract are choledocholithiasis, benign strictures of the bile ducts, diseases of the duodenum, pancreas, common bile duct cysts, Caroli's disease, dyskinesia of the sphincter of Oddi, cystic duct stump syndrome, invasions of Clonorchissinenschia, Fasciolahistus. to predispose the throwing of the contents of the small intestine into the biliary tract, complications after reconstructive operations on the bile ducts.There are several ways of introducing infection into the bile ducts.More often, pathogenic pathogens enter the biliary system by enterogenic, hematogenous, lymphogenous pathways. The causative agents that lead to the development of cholangitis are microorganisms intestinal microflora found in associations. Most often, cholangitis is of a bacterial nature, among the pathogens are representatives of the enterobacteriaceae family (E. coli, Klebsiellaspp., Serratiespp., Proteusspp., Enterobacterspp., Acinetobacterspp.), Gram-positive microorganisms (Streptococcus, Enterococcus), non-spore-forming anaerobes (Cloppi. , fusobacteria, Pseudomonasspp., etc.).

Bacterial cholangitis tends to rise and spread to the intrahepatic ducts. At severe course the disease can develop empyema of the gallbladder, hepatitis, liver abscesses, septicemia, pylephlebitis, subdiaphragmatic abscess, peritonitis, cicatricial-inflammatory stenosis of large bile ducts.

Classification of cholangitis. Topically distinguish between cholangitis or angiocholitis - the defeat of large intra- and extrahepatic bile ducts; choledochitis - damage to the common bile duct; papillitis - a lesion in the area of the Vater nipple. There are aseptic and induced infectious factors cholangitis. Aseptic cholangitis includes autoimmune in primary biliary cirrhosis, autoimmune cholangiopathies, sclerosing (primary and secondary sclerosing) forms. According to the clinical picture, acute, chronic, stenosing and septic cholangitis are distinguished. Cholangitis caused by infectious agents is acute obstructive, recurrent, bacterial, secondary sclerosing.

Cholangitis symptoms

Features of clinical manifestations. Acute cholangitis occurs as a complication of choledocholithiasis with total or subtotal obstruction of the bile duct, less often it develops as a complication of cholangiography or after arthroplasty of the common bile duct, endoscopic papillosphincterotomy. Clinical symptoms acute cholangitis includes malaise, jaundice, pain in the right hypochondrium with irradiation in right shoulder, forearm, shoulder blade, intermittent fever with chills and profuse sweat, nausea, vomiting, confusion, arterial hypotension (infectious toxic shock), making up the so-called Reynolds pentad. Patients often develop thrombocytopenia as a manifestation of intravascular coagulopathy, signs of hepatocellular failure.

Acute recurrent cholangitis is characterized by a less severe course and occurs against the background of cholelithiasis, Caroli's disease. The Sarco triad is inherent in recurrent cholangitis. In some cases, patients have undefined dyspeptic disorders without fever, jaundice, pain syndrome. In the intervals between obosfeniye, in the absence of liver disease, symptoms of cholangitis may be absent or manifest as mild biliary dyspepsia. Jaundice with cholangitis can have a combined character, it is usually mechanical, due to the obstruction of the outflow of bile. In cases of concomitant liver damage, signs of parenchymal jaundice are added. Sometimes the disease begins like sepsis, with intermittent fever and chills. Severe forms diseases are accompanied by the development of sepsis, complicated septic shock, oliguria and renal failure.

The frequency of fever, the nature of the course of the disease in bacterial cholangitis depends on the pathogen and the degree of obstruction of the bile ducts. Pneumococcal cholangitis is especially difficult, which, as a rule, is complicated by the development of liver abscesses. Reduction of biliary hypertension leads to the disappearance of clinical manifestations. During an exacerbation of the disease, the liver increases in size due to overstretching of the hepatic capsule, becomes painful on palpation. The liver edge is usually smooth. It should be noted that, since the leading link in the pathogenesis of cholangitis is temporary obstruction of the bile ducts, obstructive jaundice has a variable character and depends, similarly to temperature, on the degree of obstruction of the biliary tract. The clinical manifestations of cholangitis in chronic course can be characterized by a feeling of pressure or dull pains in the right hypochondrium, weakness, rapid fatigue, often mild yellowness of visible mucous membranes, skin, itchy skin Frequent symptom are long periods of unmotivated subfebrile condition, accompanied by chills. Features of the course of the disease in the elderly - pronounced asthenic syndrome, confusion in the absence of fever and pain. In making the diagnosis, along with the described clinical picture, laboratory and instrumental methods research.

Cholangitis diagnostics

Features of diagnostics. V clinical analysis blood neutrophilic leukocytosis with a shift to the left, an increase in CO total protein and albumin, a relative increase in the amount of γ-globulins. It is advisable to study the activity of amylase, lipase, trypsin and its inhibitors, as well as blood for sterility. V general analysis urine there is an increase in the level of urobilin, bile pigments. Duodenal fractional intubation with bacteriological examination portions B, C and determination of the sensitivity to antibiotics of the duodenal contents, ultrasound of the abdominal cavity provide reliable information about the nature of the existing disorders. Ultrasound reveals signs of biliary hypertension, expansion of the intra- and extrahepatic bile ducts, signs of damage to the pancreas, which caused the development of cholangitis. Echographically, with cholangitis, the ducts are unevenly linearly expanded, the walls are homogeneously thickened, weakly echogenic (edematous). During effective treatment there is a narrowing of their lumen, thinning of the wall until it completely merges with the liver parenchyma.

In some cases, according to echography, the diameter of the bile ducts may not change, which requires computed tomography. It is advisable to carry out intravenous cholangiography or endoscopic retrograde cholangiopancreatography, which can be used to identify the expansion of the bile ducts. If it is impossible to carry out these studies, percutaneous transhepatic cholangiography (PTCCG) is performed.

When diagnosing cholangitis, it is advisable to find out whether it occurs in isolation or in combination with damage to the gallbladder, liver, pancreas, etc. As already mentioned, in many cases cholangitis is a concomitant disease. It is also important to identify the leading etiological factor and the relationship Of this process with the presence of calculi in gallbladder and bile ducts.

At differential diagnosis it is necessary to keep in mind such diseases as malaria, pyelonephritis, paranephritis, subphrenic abscess, sepsis, lymphogranulomatosis, infectious endocarditis.

Cholangitis Treatment

Features of treatment. Cholangitis treatment should primarily focus on eliminating bile stagnation and fighting infection.

Antibiotics are advisable for acute obstructive cholangitis wide range to influence the family of enterobacteria and anaerobes. Currently, there is no single, well-developed approach to the use of antibacterial drugs for ascending cholangitis.

The most commonly used penicillins

ampicillin possesses bactericidal effect against E. coli
ampicillin with sulbactam affects gtenicillinase-producing strains of staphylococci, Bacteroides and Klebsiellaspp
ureidopenicillin (mezlocillin) is effective against enterococci

Aminoglycosides have bactericidal action on bacteria of the enterobacteriaceae family.

Cephalosporins, broad-spectrum antibiotics, have a bactericidal effect, quickly accumulate in the foci of inflammation. Of the drugs in this group, ceftriaxone and cefoperazone are excreted mainly in the bile.

Drugs of choice in the treatment of severe cholangitis caused by microorganisms resistant to most antibacterial agents are fluoroquinolones.

In severe cholangitis, it is recommended that ureidopenicillin / piperacillin 3-4 g 4-6 times a day IV or meslocillin 3 g after 4 hours IV in combination with metronidazole at a dose of 0.5 g after 8 hours IV v. Instead of metronidazole, amikacin 0.5 g can be used after 12 hours IV.

An expedient scheme, including an aminoglycoside (amikacin 0.5 g after 12 hours IV in combination with ampicillin 1.0 g after 6 hours intramuscularly and metronidazole 0.5 g after 8 hours IV).

The use of third-generation cephalosporins is effective: ceftriaxone 1-2 g once i.v. or cefoxitin 2 g after 4 hours i.v. in combination with metronidazole 0.5 g every 8 hours i.v. or clindamycin at 0.15-0, 45 g after 6 hours i.v. Clindamycin can be replaced with aminoglycoside amikacin 0.5 g every 12 hours IV.

With a mild process, it is possible to use antibiotics in the form of monotherapy piperacillin / tazobactam at 4.5 g after 8 hours IV, ampicillin / sulbactam at 1.5-5 g after 6 hours IV, third-fourth generation cephalosporins (ceftriaxone 1 -2 g per day or 0.5-1 g every 12 hours i.v.).

Reserve antibiotics are carbapenems (imipenem-cilastatin 0.5 g every 6 hours IV or meropenem 1 g every 8 hours IV). These drugs are used as empirical therapy in patients who are in critical condition in the presence of E. coli, Acinetobacterspp, Paeruginosa.

Fluoroquinolones (ciprofloxacin, ofloxacin, mefloxacin) are also used to isolate strains resistant to most antibiotics or in case of their intolerance, at a dose of 0.2-0.4 g after 12 hours IV.

High antibacterial sensitivity is possessed by nitro-furan compounds, primarily furazolin, furazolidone, furadonin (0.1 g 4 times a day with meals).

In some cases, 5-hydroxyquinoline derivatives (5-NOC, nitroxoline) are effective. Nigroxoline is prescribed 0.1 g 4 times a day with meals for 3 weeks.

With complete insensitivity of microflora to all antibiotics or their intolerance, sulfonamides etazole, phthalazole, sulfadimethoxine are prescribed for 1 week.

In the case of effective treatment, the improvement of the condition occurs within 6-12 hours. The duration of antibiotic therapy is 14-21 days. The clinical effectiveness of the scheme used (even empirical) or an individual drug indicates the appropriateness of its use during the entire period of treatment. If the fever persists, it is necessary to revise the drainage for its patency, as well as to exclude the possibility of complications.

For patients with cholangitis, it is advisable to carry out detoxification therapy according to the generally accepted rules for the treatment of a septic condition.

for ascariasis, Helmex is used at 10 mg / kg per day once, or Vermox 100 mg 2 times a day for 3 days, or levamisole 150 mg once,
clonarchosis and opisthorchiasis can be treated with biltricide at a dose of 25 mg / kg 3 times a day for 1-3 days,
with fascioliasis, a 2-week course of bitional is carried out at a dose of 1 g 3 times a day

For patients with primary sclerosing cholangitis, it is advisable to carry out symptomatic therapy of digestive disorders with enzyme preparations (Creon, pancreoflat, mesimfort, etc.).

Severe cholangitis is an indication for emergency ERCP, which takes precedence over emergency surgery.

The main methods of physiotherapeutic treatment of cholangitis are fresh and sodium chloride baths and mud therapy on the right hypochondrium in combination with the intake of antibiotics secreted through bile and B vitamins for 7-10 days. A good effect is noted when applying galvanic mud to the area of the right hypochondrium, as well as mud inductothermy to the area of the right hypochondrium. It should be remembered that before physiotherapy, it is necessary to carry out antibacterial treatment aimed at suppressing infection in the bile ducts, as well as stimulating the outflow of bile.

Forecast. The prognosis is determined by the main suffering, leading to a violation of the outflow of bile. Timely treatment, especially surgery, can lead to significant improvement or recovery. In the later stages of cholangitis, the prognosis is usually poor. Multivariate analysis revealed the main signs associated with a poor prognosis of cholangitis:

acute liver failure;
cholangitis complicated by liver abscess;
secondary biliary cirrhosis of the liver;
cholangitis, which developed against the background of malignant strictures of the high parts of the biliary tree or after CCH;
female;
age over 50.

Cholangitis is a disease in which an inflammatory process develops in the intrahepatic and extrahepatic bile ducts. The disease rarely occurs on its own, and is often a consequence of gallbladder disease ( cholelithiasis, oncological diseases biliary tract and gallbladder). Cholangitis must be treated, because in the absence of adequate therapy, the disease can lead to severe complications and even death.

Treatment of an exacerbation of the disease should be carried out in a hospital under the constant supervision of a doctor, since at any time you may need an emergency surgery... Depending on the degree of impairment of the outflow of bile through the biliary tract, the doctor chooses a therapeutic tactic (conservative or surgical treatment).

Cholangitis conservative treatment

A patient with cholangitis can be assigned antibacterial drugs, antispasmodics, choleretic agents, and enzymes.

Drug treatment cholangitis is possible only in cases where there is no mechanical obstruction to the outflow of bile from the gallbladder.

To stop the inflammatory process, it is prescribed antibiotic therapy... The doctor chooses drugs with a wide spectrum of action from the tetracycline series or the group of sulfonamides. The drug is administered intravenously or intramuscularly, the course of antibiotic treatment lasts at least 10 days.

Detoxification therapy is necessary to remove from the body toxins that are produced during inflammatory process... For this purpose, intravenous administration of 5% glucose solution, physiological saline, rheopolyglucin is recommended.

In the acute stage of cholangitis, in no case should bile stagnation in the gallbladder and its ducts be allowed. Choleretic drugs (allochol) and antispasmodics (papaverine, no-shpa) are prescribed. Enzyme preparations (Creon, Pancreatin, Mezim) will help improve digestion.

In cases where patients are worried about an intense pain syndrome, it is possible to prescribe analgesics. Pain relievers are used only as directed by a doctor after the diagnosis has been verified. Pain syndrome with cholangitis, it can mimic hepatic or renal colic, and analgesics can mask the symptoms of these diseases.

For the treatment of chronic cholangitis without exacerbation, as prescribed by a doctor, physiotherapeutic procedures (diathermy, UHF therapy), thermal procedures (ozokerite, paraffin, mud applications on the liver area) are used. Also, patients are shown physiotherapy exercises and Spa treatment(Truskavets, Caucasian Mineral water and etc.)

Surgical treatment of cholangitis

In cases where conservative therapy it turns out to be ineffective or the normal outflow of bile is impaired, surgical treatment is indicated. Today, the endoscopic technique is the most preferable for surgical treatment cholangitis.

This surgical method has many advantages over abdominal surgery... This method allows you to drain and eliminate the narrowing of the bile ducts, remove stones from them without making a large incision on the patient's body. Blood loss during laparoscopic biliary tract surgery is minimal, and the recovery period is shortened. With development purulent complications nevertheless, an abdominal operation is necessary.

Diet therapy

As with any other disease digestive system, with cholangitis, diet is necessary.

In the acute stage of the disease, hunger is shown. After the exacerbation subsides, the diet gradually expands. The diet is fractional, food should be taken 5-6 times a day in small portions. Cold food and drinks are excluded. All dishes are steamed, boiled, baked in the oven.

It is allowed to eat low-fat meat, fish and poultry, soups should be cooked in secondary broth, vegetable broths or milk. You can eat cereal porridge, pasta, wheat and black bread (better dried). It is allowed to eat dairy and dairy products low fat, vegetables (excluding legumes, onions and garlic), fruits and berries (not sour), honey. The eggs should be limited to 1 piece. a day, it is better to make an omelet from them. Sugar is limited to 70 g per day. From sweets, it is best to choose marmalade, marshmallow, jam, caramel candies. You should drink juices (freshly squeezed ones are best diluted with water), weak tea with milk, compotes.

Patients with cholangitis should exclude fresh bread and pastries from the diet. It is not recommended to eat fatty meats and fish, canned food, smoked sausages, mushroom broths. Mustard, pepper, horseradish and other hot spices should be removed from the diet. You will also have to remove chocolate, ice cream, pastries with fat creams, coffee, cocoa, carbonated drinks from the table.

People with chronic cholangitis should not be allowed to stagnate bile in the gallbladder and its ducts. To do this, you should constantly adhere to a diet, the interval between meals should be no more than 4 hours. Regular bowel activity must be maintained physical exercise(hiking, gymnastics), it is necessary to combat constipation. You should also promptly treat diseases such as colitis, cholecystitis, and other diseases of the digestive system.

Which doctor to contact

A patient with cholangitis must follow a diet, giving preference to boiled, steamed or baked dishes.

Cholangitis is treated by a gastroenterologist. In addition, a consultation with a nutritionist will help, if necessary, the help of a surgeon, physiotherapist. An ultrasound diagnostic doctor, often an endoscopist, is involved in the diagnosis.

Cholangitis is an inflammatory lesion of the biliary tract, which is most often of a nonspecific nature - that is, it is caused by nonspecific pathogens that can cause other inflammatory diseases.

This is a common disease that often goes hand in hand with other disorders of the gastrointestinal tract. Cholangitis is a problem in gastroenterology, but in case of complications it requires surgery.

Table of contents:

Total information

The bile ducts can equally often be affected by cholangitis along their entire length - both small intra- and large extrahepatic ones.

note

The disease is most often diagnosed in the older age group - from 50 to 60 years, but in recent years there has been a tendency towards rejuvenation of cholangitis, and more and more 40-year-old patients are admitted to the clinic with signs of this disease. Mainly women of the specified age group suffer.

Isolated cholangitis is less common than combined - therefore, if it is detected, other diseases of the gastrointestinal tract should be diagnosed, which may or may not appear, or their symptoms may be lost against the background of signs of cholangitis. Most often, an inflammatory lesion of the bile ducts is combined with acute or chronic forms of such acute and chronic diseases of the digestive tract as:

gastroduodenitis;
in some cases - violations from the Vater papilla (places where the common bile duct and pancreatic duct flow into the duodenum 12).

Causes

Inflammatory changes in the biliary tract are directly caused by an infectious agent that has entered them in various ways. Most often these are:

different shapes;
enterococci;
anaerobic infection of the non-clostridial series.

Defeat with an infectious agent that causes specific infectious diseases, passes quite rarely - but it should also be remembered about it (in particular, if typical cholangitis does not respond classic treatment). These can be the following pathogens:

Koch's bacillus (mycobacteria);
pale spirochete (pathogen).

note

Often the symptoms of such cholangitis, provoked specific infection, may not be noticed, since they are lost against the background of the main symptoms caused by this infectious agent. This is especially true for latent (hidden) and sluggish forms of inflammatory lesions of the biliary tract.

The infectious agent most often enters the bile ducts:

by usual migration, being next to the duodenum and getting out of it through the papilla of the Vaters;
hematogenous - with blood flow through the portal vein (central vein of the liver);
by the lymphogenous route - with lymph flow (mainly with inflammatory lesions of the gallbladder, pancreas or small intestine).

Also, a viral agent can play a role in the development of cholangitis - mainly with such a lesion, small bile ducts are involved, which pass inside the liver (in particular, this is observed in viral hepatitis).

But inflammation of the biliary tract can develop without the participation of any pathogens. This is the so-called aseptic (literally sterile) cholangitis. Basically, it happens:

enzymatic nature, when activated pancreatic juice irritates the wall of the biliary tract from the inside (this is observed in the so-called pancreatobiliary reflux, when the secret of the pancreas is "poured" into the biliary tract, which normally should not be). Initially, inflammation occurs without the participation of an infectious agent, but it can join later at different stages of the disease;
sclerosing cholangitis - occurs due to autoimmune inflammation of the bile ducts (when the body reacts to own fabrics as strangers).

The suspicion that cholangitis is of an autoimmune nature should appear if, in parallel, the patient has signs of immune diseases such as:

(the formation of ulceration of the mucous membrane of the large intestine along its entire length);
(formation of granulomas throughout gastrointestinal tract);
(inflammation and subsequent destruction of the walls blood vessels);
(connective tissue disease that goes away with deformity of the joints);
thyroiditis (inflammation of the thyroid gland)
and some other diseases.

The penetration of infection into the biliary tract is facilitated by cholestasis - stagnation of bile. It is mainly found in pathologies such as:

(violation of their motor skills);
congenital anomalies of the biliary tract (kinks, squeezing);
common bile duct cyst;
cancer of the biliary tract;
choledocholithiasis (stones in the common bile duct);
stenosis (narrowing) of the Vater papilla.

The trigger for the onset of cholangitis can also serve as damage to the walls of the bile ducts during endoscopic manipulations - most often such as:

retrograde cholangiopancreatography (introduction of a contrast medium with a probe through the duodenum into the bile ducts);
stenting (installation of special frames that support the normal shape of the bile ducts);
sphincterotomy (dissection of the sphincter of Oddi - muscles at the confluence of the common bile duct and pancreatic duct into the duodenum);
surgical treatment of diseases of the biliary system of the liver.

Flow

Downstream cholangitis can be:

sharp;
chronic.

Depending on what pathological changes occur in the wall of the bile ducts, acute cholangitis is:

catarrhal;
purulent;
diphtheria;
necrotic.

At catarrhal cholangitis in the walls of the biliary tract, the usual uncomplicated inflammation in its classic manifestation is observed - this is redness and swelling of the mucous membrane, exfoliation of its surface layer.

Purulent form cholangitis is characterized by the formation of multiple small abscesses (limited abscesses) and further purulent fusion of the bile ducts.

At diphtheria cholangitis in the walls of the biliary tract, multiple ulcerations are formed, which lead to the gradual destruction of the walls. Also a characteristic feature - the walls of the biliary tract are covered from the inside with a fibrous film.

For necrotic the formation of foci of necrosis (necrosis) of the wall of the biliary tract is characteristic.

Chronic cholangitis is more common. It can develop:

as a primary process with a protracted course;
as a consequence of acute inflammation.

There are such forms of chronic cholangitis as:

latent - this is a latent form, during which there are morphological changes in the bile ducts, but the symptoms do not appear;
recurrent - a form with alternating exacerbations and periods of calm;
long-term septic - lingering form with infectious lesion the whole organism;
abscess - with this form, abscesses form in the bile duct system;
sclerosing - in the walls of the bile ducts, a pronounced proliferation of connective tissue occurs, which causes their narrowing and deformation.

Cholangitis can take the form of such varieties as:

choledochitis - inflammation of the choledoch (common bile duct);
angiocholitis - defeat of the smaller bile ducts;
papillitis - an inflammatory lesion of the Vater papilla (the place where the common bile duct flows into the duodenum);
total defeat of the entire biliary tract system.

Cholangitis symptoms

The signs of cholangitis depend on its form.

Acute cholangitis always begins suddenly. Its symptoms are:

fever and hyperthermia;
signs of intoxication;
dyspeptic symptoms;

Hyperthermia and fever are the symptoms with which acute cholangitis usually begins:

body temperature rises to 39-40 degrees Celsius;
observed;
sweating is expressed.

Pain characteristics:

begin almost simultaneously with the fever;
by localization - in;
by irradiation (spreading) - given to right hand, shoulder, right half of the neck;
by nature - cramping, reminiscent of hepatic colic;
in intensity - strong.

Signs of intoxication are:

progressive weakness;
loss of appetite;
decreased performance.

Dyspeptic symptoms soon develop:

that does not bring relief;

Jaundice occurs most recently - yellowing of the skin, sclera and visible mucous membranes. Due to the accumulation of bile pigments and their irritation of the nerve endings, jaundice provokes itching.

Increased itching at night is characteristic, which interferes with the patient's sleep.

The main signs of acute cholangitis are three symptoms that make up the so-called Charcot triad:

significant hyperthermia (rise in body temperature);

If the course of acute cholangitis is especially difficult, then disturbances from consciousness and manifestations of shock join - these five most important symptoms of this disease are called Reynolds pentad. We can say that this is the main reference point, thanks to which clinicians diagnose acute cholangitis.

Signs chronic form cholangitis similar to symptoms acute form, but erased - on the other hand, with the progression of the disease, they gradually increase . In this case, abdominal pain:

stupid;
weak;
in some cases, this is not pain, but a feeling of discomfort and bursting in upper divisions belly.

Jaundice with chronic cholangitis is present, but arises rather late, when inflammation has long arisen and aggravated in the bile ducts - in fact, these are far-reaching pathological changes.

Common signs in chronic cholangitis are also present, but they are not as pronounced as in acute cholangitis. In particular, the following are observed:

an increase in body temperature to subfebrile numbers;
fatigue, but not critically affecting performance;
feeling of weakness.

Complications

If cholecystitis is not diagnosed and stopped in time, the following complications may occur:

Diagnostics

Based on the clinical picture, in the diagnosis of acute cholangitis, one should focus on the Charcot triad or Reynolds pentad. But in general, for the diagnosis of this disease, it is also necessary to involve additional diagnostic methods - physical (examination, probing, tapping and listening to the abdomen with a phonendoscope), instrumental and laboratory ones.

Examination of such a patient reveals:

yellowness of the skin, sclera and visible mucous membranes;
tongue dry, covered with yellow bloom;
traces of scratching are visible on the skin, sometimes quite pronounced, up to blood (with severe itching).

With the symptoms of jaundice, examination of feces and urine will also be informative:

feces are characterized by a lighter shade than usual (but in general it is not white, as it may be with jaundice);
due to the ingress of bile pigments into the bloodstream, and then into the kidneys, urine may darken (a characteristic symptom of "beer color").

On palpation at the peak of a painful attack, there is severe pain in the right hypochondrium.

With percussion (tapping with the edge of the palm on the right costal arch), the patient reacts very painfully.

Auscultation is not informative.

Instrumental methods that are used to diagnose cholangitis are:

In the diagnosis of cholangitis, laboratory methods are used, such as:

- its data are not specific, but are important for assessing the progression of inflammation. So, an increase in the number of leukocytes and an increase in ESR will be revealed;
biochemical- determine the increase in the amount of alkaline phosphatase, as well as transaminases and alpha-amylase. Such data indirectly indicate cholestasis (stagnation of bile), which is observed with cholangitis;
bacteriological culture of bile obtained with duodenal intubation - thanks to it, the causative agent of cholangitis is identified;
- thanks to him, they confirm or exclude the presence in the body or protozoa that can cause inflammation of the biliary tract.

Differential diagnosis

Differential (distinctive) diagnosis of cholangitis should be carried out with diseases such as:

Cholangitis treatment

Cholangitis is treated conservatively or surgical method... The choice of method depends on:

causes of the disease;
degree of manifestation;
complications.

The most important tasks that are pursued in the treatment of this disease are:

elimination of inflammation;
detoxification;
decompression (unloading) of the biliary tract.

At the heart of conservative treatment there are such appointments:

If acute events managed to overcome, then during the period of remission, physiotherapeutic methods of treatment are successfully practiced, such as:

inductothermy;
microwave therapy;
electrophoresis;
diathermy;
mud applications (applying therapeutic mud);
ozokeritotherapy;
paraffin therapy;
salt baths (in particular, sodium chloride).

All these methods can be carried out in the conditions of the physiotherapy room of the clinic or during the spa treatment, which is recommended for a patient in remission.

If necessary, they resort to surgical correction of disorders of the biliary tract - these are:

endoscopic papilosphincterotomy - dissection of the narrowed vater of the papilla;
endoscopic extraction of stones from the bile ducts;
endoscopic stenting of the common bile duct - the introduction of a framework into it, which will help maintain the normal lumen of the common bile duct;
percutaneous transhepatic drainage of the bile ducts - the diversion of bile from the duct system by puncturing the skin and liver.

In the case of sclerosing cholangitis, the most effective way is a liver transplant (transplant).

Prophylaxis

The activities that will help prevent inflammatory damage to the biliary tract are based on the following:

Forecast

The prognosis for cholangitis is different. With the catarrhal form of cholangitis, it is satisfactory, with purulent, diphtheritic and necrotic forms it is more serious: in this case, the outcome can be favorable for the patient only in the case of verified prescriptions and scrupulously adhered to treatment.

If the inflammation of the biliary tract passes with complications, then the prognosis is unsatisfactory. This is especially stated in diseases such as:

the formation of abscesses in the biliary tract;
cirrhosis of the liver;
hepatic renal failure;
septic damage to the body.

Oksana Vladimirovna Kovtonyuk, medical commentator, surgeon, consultant physician