Cholangit - syndrome characterizing a non-specific inflammatory process with the lesion of out and / or intrahepatic bile ducts.
Prevalence.IN last years There is an increase in the incidence of this pathology by 40%.
What provokes / causes of cholangitis:
The condition for the occurrence of cholangitis is stagnant bile and the presence of infection. There are many reasons to prevent bile outflows. The obturation of bile ducts, being the result of the primary pathological process, contributes to the occurrence of bile hypertension, changing the physicochemical properties of bile, which serves as a prerequisite for infection. The most common causes of obstruction of boring paths - choledocholithiasis, benign strictures of bile ducts, duodo disease "tupest intestine, pancreatic glands, choledoch's cysts, caroli disease, dyskinesia of the Sphinteer Oddi, Bubble Culting Syndrome, Clean Culti Syndrome, invasion Preprip out the contents of the contents of a small intestine in biliary paths, complications after reconstructive operations on bile ducts. There are several ways to introduce infection into bile ducts. More often pathogenic pathogens enter the biliary system by enterogenic, hematogenic, lymphogenic paths. Pathways leading to the development of chorelgites are intestinal microorganisms Microflora, found in associations. Most often, cholants have a bacterial nature, among the pathogens, representatives of the Enterobacteria family (E. coli, Klebsiellaspp, Serratiespp, Proteuspp, Enterobacterspp., AC inetobacterspp.), gram-positive microorganisms (Streptococcus, Enterococcus), Unfortunate Anaerobes (Bacteroidesspp., Clostridiumspp., Fuzobacteria, pseudomonasspp., etc.).
Bacterial cholangitis tends to rising flow and spread to intrahepatic ducts. With a serious course of the disease, the development of an empiemy of the gallbladder, hepatitis, liver abscesses, septicemia, pylephlegitis, subdia-fragmal abscess, peritonitis, cetting-inflammatory walls of large bile ducts can be observed.
Classification of cholangitis.Topically distinguish with cholangitis or angiiology - the defeat of large intra and extrahepatic bile ducts; Kledochit - the defeat of the total gall duct; Papillitis is the defeat of the region of the Nipple Fatera. Septic and caused by cholangitis infectious factors. Aseptic cholangitis includes autoimmune with primary biliary cirrhosis, autoimmune cholangiopathy, sclerosing (primary and secondary sclerosing) forms. By clinical picture Allocate sharp, chronic, stenosing and septic cholangitis. The cholangitis caused by infectious agents is acute obstructive, recurrent, bacterial, secondary sclerosing.
Symptoms of cholangitis:
Features of clinical manifestations.Acute cholangitis occurs as a complication of choledocholiticiasis with a total or subtotal obstruction of the bile duct, less often it develops as a complication of cholangiography or after choledoch's endoprosthetics, conducting endoscopic papillosphinclineotomy. Clinical symptoms of acute cholangitis includes malaise, jaundice, pain in the right hypochondrium with irradiation in right shoulder, forearm, blade, intermittent fever with chills and abundant, nausea, vomiting, confusion, arterial hypotension (infectious-toxic shock), which constitute the so-called Pentad Reynolds. Patients often develop thrombocytopenia as a manifestation of intravascular coagulopathy, signs of hepatic cellular insufficiency.
Acute recurrent cholangitis is characterized by a less severe flow and arises against the background of a gall-eyed illness, Caroli disease. The recurrent cholant is inherent in the triad Charcot. In some cases, patients have uncertain dyspeptic disorders without fever, jaundice, painful syndrome. In the intervals between the sneakers, in the absence of liver disease, the symptoms of cholangitis may be absent or manifested by a light biliary dyspepsia. Jaundice under cholangitis may have a combined character, usually it is mechanical, due to the obstacle to the ottok of bile. In cases of concomitant liver damage, signs of parenchymal jaundice are joined. Sometimes the disease begins like sepsis: with intermittent fever and chills. Heavy forms Diseases are accompanied by the development of sepsis, complicating with septic shock, oliguria and renal failure.
The frequency of fever, the nature of the course of the disease in bacterial cholangitis depend on the causative agent and the degree of obturation of bile ducts. Pneumococcal cholangitis, which, as a rule, are complicated by the development of liver abscesses. Reducing bile hypertension leads to the disappearance of clinical manifestations. During the exacerbation of the disease, the liver increases in size due to polishing the hepatic capsule, becomes painful when palpation. The edge of the liver usually has a smooth surface. It should be noted that, since the leading link in the pathogenesis of cholangitis is the temporal obturation of bile ducts, mechanical jaundice has variable character and depends, similarly to temperature, on the degree of oration of biliary tract. Clinical manifestations of cholangitis in chronic flow can be characterized by a sense of pressure or stupid pain in the right hypochondrium, weakness, fast fatigue, often the light yellowness of visible mucous membranes, leather, the skin of the skin is frequent symptoms are long periods of unmotivated subfebilite, accompanied by chills. Features of the course of the disease in the elderly - pronounced asthenic syndrome confusion confusion in the absence of fever and pain. In diagnosis, along with the described clinical picture, laboratory and instrumental research methods help.
Diagnosis of cholangitis:
Features of diagnostics.IN clinical analysis The blood is determined by neutrophilic leukocytosis with a shift to the left, an increase in biochemical study shows an increase in the level of biliary bin, triglycerides, alkaline phosphatase activity, asate, ALGGTP, decrease in content general protein and albumin, relative increase in the number of U-globulins. It is advisable to study the activity of amylase, lipase, trypsin and its inhibitors, as well as blood for sterility. IN general Analysis urine is observed an increase in the level of urobilin, bile pigments. Duodenal fractional sensing with bacteriological research Portions B, C and Definition of Sensitivity to Duodenal Content Antibiotics, Ultrasound abdominal cavity Give reliable information about the nature of the existing disorders. With ultrasound, signs of biliary hypertension, expansion of intra and extrahepatic bile ducts are detected, signs of pancreatic damage caused by the development of cholangitis. Echographically under the cholants, the docks are unevenly linearly expanded, the walls are homogeneously thickened, weaklyogenne (edema). In the process of effective treatment, there is a narrowing of their lumen, the wall thinning to a complete merger with the parenchy liver.
In some cases, according to the echography, the diameter of bile ducts may not change, which requires computed tomography. It is advisable to conduct intravenous cholangiography or endoscopic retrograde pancreaticolangiography, with which you can reveal the expansion of bile ducts. If it is impossible to conduct these studies, percutaneous chrsecheny cholangiography is performed (CCHG).
When establishing the diagnosis of "cholangitis" it is advisable to find out whether it is isolated or combined with the damage to the gallbladder, liver, pancreas, etc. As already mentioned, in many cases, the 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 concrections in bile bubble and bile ducts.
In differential diagnosis, it is necessary to keep in mind diseases such as malaria, pyelonephritis, paranefritis, subadiaphragmal abscess, sepsis, lymphogranulomatosis, infectious ENKOROCARD.
Treatment of cholangitis:
Features of treatment.The treatment of cholangitis primarily should be aimed at eliminating the stagnation of bile and fighting infection.
With acute obstructive cholangitis, it is advisable to use antibiotics wide spectrum For influence on the family of enterobacteria and anaerobes. Currently there is no single constructed approach to apply antibacterial drugs With ascending cholangitis.
Penicillins are most often used
- ampicillin has a bactericidal effect in relation to E. Soli
- ampicillin with Sulbactam affects the production of GTU-Nicyllinase strains of staphylococci, Bacteroides klebsiellaspp
- ureidopenicillin (Meslo Cyllain) is effective for enterococci
Aminoglycosides are provided bactericidal action On the bacteria of the Enterobacteria family.
Cephalosporins, antibiotics of a wide range of action, have a bactericidal effect, quickly accumulate in foci of inflammation. From the drugs of this group, ceftriaxone and cefoperason are excreted primarily with bile.
Preparations of choice in the treatment of heavy cholangitis caused by microorganisms that are resistant to most antibacterial agents are fluoroquinolones.
With a serious flow of cholangitis, ureidopenicyl-lin / pepperillalin is recommended for 3-4 g 4-6 times a day in / B or Meslocillin 3 g after 4 h in / in combination with metronidazole in a dose of 0.5 g after 8 h in / in. Instead of metronidazole, an amikacin of 0.5 g can be used after 12 h in / c.
It is advisable to the scheme comprising aminoglycoside (amikacin of 0.5 g after 12 h in / c in combination with ampicillin 1.0 g after 6 hours intramuscularly and metronidazole 0.5 g after 8 h in / c).
The use of cephalosporins of the third generation Ceftriaxone 1-2 g is once in / B or cefoxitin 2 g after 4 h in / in in combination with metronidazole 0.5 g after 8 h in / in or clindamy at 0.15-0, 45 g after 6 h in / c. Clindamycin can be replaced by Ami-Nogilikoside amikacin at 0.5 g after 12 h in / c.
With a non-heavy process, it is possible to use antibiotics in the form of monotherapy Piperillalin / Tazobaktam 4.5 g after 8 h in / s, ampicillin / sulbactam for 1.5-5 g after 6 h in / c, the cephalosporins of the third-fourth generations (Ceftriaxone 1 -2 g per day or 0.5-1 g after 12 h in / c).
The antibiotics of the reserve are carbapenes (imipenem-cilastatin at 0.5 g after 6 h in / in or Meropene 1 g after 8 h in / c). These drugs are used as empirical therapy in patients in critical state in the presence of E. coli, Acinetobacterspp, Paeruginosa.
Fluoroquinolones (Ciprofloxacin, Offlsacin, Mesfoxacin) and enjoy the selection of strains resistant to most antibiotics or during their intolerance, at a dose of 0.2-0.4 g after 12 hours in / c.
Nitro-furanovy compounds are highly antibacterial sensitivity, primarily Frazolin, Furazolidon, Furadonin (0.1 g 4 times a day during meals).
In some cases, 5-oxychinoline derivatives (5-nct, nitroxyoline) nigroxoline are appointed 0.1 g 4 times a day during meals for 3 weeks.
With complete insensitivity of microflora to all antibiotics or their intolerances, sulfonamides are prescribed etazol, phthalazole, sulfadimetoxine for 1 week.
In case of effective treatment, the improvement of the state occurs after 6-12 hours. The duration of antibacterial therapy is 14-21 days. The clinical effectiveness of the scheme used (even empirical) or a separate preparation indicates the expediency of its use during the entire period of treatment. When preserving the fever requires a drainage revision on its permeability, as well as the elimination of the possibility of developing complications.
Patients with cholangitis should be carried out for disinfecting therapy for generally accepted rules for the treatment of septic state.
- in ascariasis, Helmex is used for 10 mg / kg per day once, or vermocus 100 mg 2 times a day for 3 days, or levamizol 150 mg once,
- clonarhoz and opistorhosis are amenable to therapy with biltricide at a dose of 25 mg / kg 3 times a day for 1-3 days,
- with a fasciolese, a 2-week bitional rate is carried out in a dose of 1 g 3 times a day.
Patients with primary sclerosing cholangitis it is advisable to conduct symptomatic therapy of digestion disorders of the drugs of enzymes (Creon, pancreatophold, Mesform, and T P).
Heavy cholangitis is an indication for urgent ERCHP, which has an advantage over the emergency operation.
The main methods of the physiotherapeutic treatment of cholangitis are fresh and chloride-sodium baths and mud at the area of \u200b\u200bthe right hypochondrium in combination with the intake of antibiotics that are distinguished through bile and vitamins of the group in for 7-10 days. A good effect is noted when applying Galvanogryazhi to the area of \u200b\u200bthe right hypochondrium, as well as mudducotothermia to the area of \u200b\u200bthe right hypochondrium. At the same time, it must be remembered that before the physiologicalness, it is necessary to carry out antibacterial treatment aimed at suppressing infection in bile stocks, as well as a stimulating bile outflow.
Forecast.The forecast is determined by the basic suffering leading to a violation of bile outflow. Timely treatment, primarily operational, can lead to a significant improvement or recovery. In the later stages of cholangitis, the forecast is usually unfavorable. In multivariate analysis, the main features associated with the unfavorable Halgitis forecast are established:
- acute hepatic insufficiency;
- cholangitis complicated with liver abscess;
- secondary biliary cirrhosis of the liver;
- cholangitis, developed against the background of malignant strictures of high departments of biliary wood or after CHCh;
- female;
- age older than 50 years.
What doctors should contact if you have cholangitis:
Gastroenterologist
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Other diseases from the disease group of the gastrointestinal tract:
| Cultivation (abrasion) teeth |
| Abdominal injury |
| Abdominal surgical infection |
| Abscess cavity of the mouth |
| Adenity |
| Alcoholic liver disease |
| Alcoholic cirrhosis of the liver |
| Alveolit |
| Nihina of the Wantilya - Ludwig |
| Anesthetics and intensive therapy |
| Ankylosis of teeth |
| Anomalies of dental ranks |
| Anomalies position of teeth |
| Anomalies of the development of the esophagus |
| Size Anomalies and Shapes |
| Atresia |
| Autimmune hepatitis |
| Ahalasia Cardia |
| Ahalasia Foods |
| Burnt of stomach |
| Disease and Badda Kiari Syndrome |
| Viooclusive biennial disease |
| Viral hepatitis in patients with CPNs located on chronic hemodialysis |
| Viral hepatitis G. |
| Viral hepatitis TTV. |
| Outdoor Ployer Fibrosis (PTT Oral Fibrosis) |
| Hairy leukoplakia |
| Gastroduodenal bleeding |
| Gemohromatosis |
| Geographical language |
| Hepatolenticular degeneration (Vilson-Konovalov Wilson's disease) |
| Hepatolyenal syndrome (hepatic spleen syndrome) |
| Hepatorenal syndrome (functional renal failure) |
| Hepatocellular carcinoma (ICC) |
| Gingivitis |
| Hyperplane |
| GUN hypertrophy (fibromatosis of adhesion) |
| Hypercitenosis (periodontitis assimicing) |
| Food Food Diverticulus |
| The hernia of the esophageal hole of the diaphragm (under) |
| Diverticulous esophagus purchased |
| Diverticula stomach |
| Diverticulus of the lower third of the esophagus |
| Diverticulus of esophagus |
| Diverticulus of esophagus |
| Diverticulus of the middle third of the esophagus |
| Discower of the esophagus |
| Dyskinesia (dysfunction) of biliary tract |
| Dystrophy liver |
| Sphynuncter dysbe dysfunction (postcholecistectomic syndrome) |
| Benign ne imitation tumors |
| Big bubble benign neoplasms |
| Benign liver tumors |
| Benign tumors of esophagus |
| Benign epithelial tumors |
| Cholelithiasis |
| Grease hepatosis (steatosis) liver |
| Malignant gallbladder neoplasms |
| Malignant tumors of bile ducts |
| Stomach foreign bodies |
| Candidose Stomatitis (thrush) |
| Caries |
| Carcinoid |
| Cysts and aberrant fabrics in the esophagus |
| Pickled teeth |
| Bleeding of the upper digestive tract |
| XantrNeleumatous cholecystitis |
| Leukoplakia mucous membrane |
| Medicinal lesions of the liver |
| Medicinal ulcers |
| Mukobovysidosis |
| Mukocele salivary gland |
| Violation of bite |
| Violation of the development and teething |
| Disorders of the formation of teeth |
| Inheritance coil apipaffia |
| Healthy violation of the structure of Enamel and Dentin (Stantona Capedeppon syndrome) |
| Non alcoholic steatohepatitis |
| Necrosis of the liver |
| Necrosis pulp |
| Urgent States in Mountains |
| Food obstruction |
| Imperfect osteogenesis of teeth |
| Survey of patients in extension surgery |
| Acute delta-superinfection in hepatitis viruses in |
| Acute intestinal obstruction |
| Acute intermittent (intermitting) porphyria |
| Acute disruption of mesenteric blood circulation |
| Acute gynecological diseases in the practice of surgeon |
| Acute bleeding from the organs of the digestive tract |
| Acute Ezophagitis |
| Acute alcoholic hepatitis |
| Acute apendescit |
| Acute apical periodontitis |
| Acute breedless cholecystitis |
| Acute viral hepatitis A (OWGA) |
| Acute viral hepatitis B (OVGV) |
| Acute viral hepatitis in a delta agent |
| Acute viral hepatitis E (OVGA) |
| Acute viral hepatitis with |
| Acute gastritis |
| Acute gingivit |
| Acute belly |
| Acute pericoronite |
| Separate types of intestinal obstruction |
| Even-ascitic syndrome |
| Perodontosis |
| Pathological resorption of teeth |
| Peptic ulcer of unspecified localization |
Among the diseases of the digestive tract, the cholangitis is one of the most complex pathologies in terms of diagnosis and treatment. There are several different forms of this disease that differ from each other in symptoms and causes of occurrence. Some of them proceed hidden and do not have a specific reason. All these factors make it difficult to determine the disease and "move" the time of the start of therapy.
What can it lead to? Here is a far incomplete list of complications: sepsis (blood infection), liver cirrhosis, bile duct cancer or bubble, infectious toxic shock, etc. Each of these states arises either due to the lightning flow of pathology, or when it untimely diagnosis. About how to suspect the disease on initial stages and start proper treatmentYou can learn from this article.
What is cholangitis and the basics of anatomy
The literal translation of the word "HALLGIO" from the Latin language is a "bile vessel". Accordingly, cholangitis is an inflammatory process in any of these vessels. In person, there is a complex network of ducts of various sizes for which bile. This network begins on the liver, and ends in the intestine, where it occurs to digest the fats and the destruction of malicious microbes.
Simplified, the path of this biological fluid can be described in the following steps:
- During the intake of food or special medicines, bile in the slices of the liver begins to form. Further, it falls into intracranue bile capillaries;
- From the entire liver, the capillaries gather in two large duct - one for each share of the organ (right and left);
- From these formations is formed common liver duct.To which the gallbladder is joined through bubble duct. Together, these two structures form a large "collector" of bile - choledoch (synonymous overall bile duct);
- The cholester is opened in the 12th pans and allocates the required amount of bile. Unused residues are returned to the bubble on the same path.
Symptoms of cholangitis occur during the damage to intrahepatic or extrahepatic structures that are involved in the allocation of bile components.
Types of disease
As we have already spoken, signs of cholangitis can differ significantly in various forms of illness. For convenience, the doctors share this pathology for two main criteria - the duration of the flow and type of inflammation. These nuances are fundamentally important, as they determine the optimal assistance time (urgent / planned), the doctor's tactics and the need for operation.
Depending on the duration of the flow, the following pathology options are allocated:
- Fulminant or fulminant. The most severe and dangerous form at which all signs of the disease and blood infection appear suddenly and quickly progress (within a few hours). Fulminant ends with death in 90-100% of cases, even despite timely and qualified medical care;
- Acute. The most common option at which they manifest typical symptomsdeveloping within 1-2 days;
- Chronic. The most difficult option for diagnostics. It can occur independently or in the outcome acute form. The clinical picture is often erased - often the only complaint of patients is a liquid chair or periodic abdominal pain.
The second principal moment in determining the form of pathology is the type of inflammatory process. In any diagnosis, this nuance is defined, since further depends on it medical tactics. Currently, the doctors allocate the following options:
| Form of the disease | a brief description of | Acute or chronic? |
| Serous | The most favorable pathology option, in which blood is extremely rarely developing. In the cavity of the ducts there is no pus - inflammation is manifested by the increase in the production of serous fluid. |
May be sharp and chronic, however, more often the first option. |
| Fibrino-serous | Proceeds by analogy with the serous form. The main difference is due to the inflammatory process - in the organ, in addition to the liquid, there are protein (fibrinous) overlays. |
|
| Purulent | A severe form in which a large number of bacteria is in the cavity of the organ and is aggressively proceeding. It often marks the development of sepsis and the occurrence of infectious-toxic shock is possible. |
As a rule, sharp. |
| Necrotic | It is the final stage of purulent cholangitis, in which the walls of the organ begin to die. The greatest danger is the possibility of penetrating the particles of dead tissues, bile and pus in the blood. The natural result of this is the development of infection of blood and shock. |
Only sharp. |
| Sclerosing | Hidden a slow-ending form of pathology at which there are practically no characteristic features. It is dangerous by the development of severe irreversible damage to the liver, right up to biliary cirrhosis. | Only chronic. |
Causes of occurrence
The greatest role in the occurrence of cholangitis (all except for the sclerosing) plays the presence of two factors - malicious microorganism and stagnation of bile. What leads to their occurrence? Bacteria causing an inflammatory process can penetrate the ducts from the gallbladder or from the intestinal cavity. That is why there are often cholangitis after acute cholecystitis, in the presence of intestinal (fine-turn) deficiency or biliodyagisal reflux - cast intestinal content into the duct system.
Stagnation bile appears when it is violated her outflow. Such a situation may occur in the following states:
- Blockage of duct by stone against the background of bile-named disease;
- The development of acute pancreatitis and the edema of the pancreas head;
- The presence of a tumor, squeezing choledo or preventing bile outflow;
- Stricking (pronounced narrowing) of the biliary tract;
- The defeat of the header nipple is the place where the clearance of choledoch and pancreatic duct opens.
Separately, it must be said about the causes of sclerosed cholangitis. This form differs from all others. It is unambiguous to determine the cause of its development is not possible, even at the modern level of medicine. Most doctors believe that the disease arises in the development of an autoimmune process.
Because of the "error" of immunity, in which the protector cells begin to produce antibodies against healthy tissues, the tissue of the protocal system is affected. Prolonged sluggish inflammation leads to the growth of connective tissue, narrowing the lumen and violation of the outflow of bile. A frequent "target" of this disease is intrahepatic bile capillaries, which often leads to the formation of the liver cirrhosis.
Symptoms
As already mentioned, this disease is quite complicated in terms of diagnosis. One form can manifest themselves in different ways in two identical patients, disguised as a different pathology or is hidden at all. However, there are certain signs that suggest the correct diagnosis.
At the same time, it is necessary to remember that the symptoms that disturbing a person can differ significantly in acute and chronic flow. Its characteristic features has a sclerosing primary cholangitis, which will be described below.
Acute option
The treatment of cholangitis, in this case, is carried out only under the conditions of a surgical hospital. it threatening Life A condition that, with untimely treatment for medical care or in inadequate therapy, can lead to blood infection and even death. That is why, in the presence of typical signs, it is strongly recommended to consult a doctor, and not try to get rid of the disease independently.
Unlike most other pathologies, with inflammation of the doctor's joyful pathways, not separate symptoms, but their specific combination. For this state, the most characteristic of the appearance of the following set of features:
- Increased body temperature. As a rule, fever increases in several hours and remains at a sufficiently high level (38-40 o C). Patients feel pronounced weakness, chills and headaches. Often, a person is celebrated strong sweatingBecause of what it can lose a large amount of fluid per day. Some patients fever may have a "jump-shaking" current and change to 1-2 ° C throughout the day. Such temperature fluctuations are exacerbated by a person, his well-being worsens so much that he is hard to get out of bed. Consciousness is bold, there is no appetite, fainting may occur;
- Jaundice / intrusive itching. These two symptoms have the same origin and are associated with a delay in bilirubin in the body. Bilirubin - toxic substance formed after decay blood cells and outlined with urine and bile. Since the inflammation of the biliary system leads to a violation of this process, bilirubin compounds are beginning to be deposited in various tissues. The session in the skin leads first to a strong obsessive ferry, and then to change its color. The bilirubin hit in the sclera explains the yellow shade of the eyes (around the iris). Attempting the body to remove the toxic substance with urine manifested by its darkening - up to the color of "dark beer";
- Pain in the right half of the abdomen (directly under the ribs). This place corresponds to the approximate location of the bubble and choledoch. If a person makes it difficult to determine the area where there are easy sensations, You can spend a simple test - the edge of the palm of the palm of the lower edge of the rib arc on the right and left. With cholegite / cholecystitis, the pain increases when the right is tight.
The following complaints can be complemented by a number of other pathological signs: a decrease in blood pressure less than 90/60 mm. the appearance of feelings of heartbeat; Pulse increases more than 90 UD / min, etc. However, the combination of the three above mentioned diseases is specific for this disease.
Chronic form
To suspect and confirm the presence of this form is much more complicated than diagnosing a sharp cholangitis in humans. The fact is that during chronic flow, pathology can slightly disturbing human well-being, and it does not appeal for medical help. Additional difficulty represents the diversity of manifestations of pathology - for this form, the characteristic combination of symptoms has not been detected. Each patient has a disease individually.
The only significant tip can be the past patient, and more precisely transferred operations and associated diseases:
- After the removal of the gallbladder (the operation is called "cholecissectomy") of each third patient there is chronic cholangitis;
- The presence of gallposted disease significantly increases the risk of this disease;
- The acute process transferred in the past may result in the occurrence of a chronic disease.
People with listed risk factors are most susceptible to this pathology. To suspect the protracted inflammatory process in the ducts in the presence of the following complaints:
- Stool violation. The appearance of a liquid / cascidular chair with a bright color having a brilliant surface is difficult to flush from the walls of the toilet;
- Jaundice or skin itchthat appear mainly in the evening and night time;
- Pain in the upper half of the abdomen. In most cases, unpleasant sensations are located in the right hypochondrium, but they can be left or in the middle between the ribs (in the epigastric region);
- Development of asthenovegetative syndrome - constant weakness, reduction of working capacity, reducing body weight;
- The appearance of fever is obscurely;
- The feeling of "breakdown", in the afternoon;
- The taste of bitterness in the mouth, mainly after meals.
Sclerosing primary cholangitis (PSH)
Several statistical facts about this form:
- In 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 liver cirrhosis;
- Up to 20% of PSX patients suffer from cholangiocarcinoma (malignant tumor), which developed in the outcome of pathology.
These moments vividly indicate how difficult the diagnosis is complex. On the one hand, patients often do not pay attention to "insignificant" symptoms, which leads to late appealing for medical assistance. On the other hand, not in every city there is a specialist who will suspect this rare, but dangerous pathology.
What way to find in this case? First of all, it is necessary to treat your health with cautiousness. The table below will provide the necessary information that will allow PSX to suspect. The main thing is not to neglect her and objectively analyze the state of your body. This will prevent PSH progression and avoid dangerous complications.
| Risk group |
|
| Diseases - "Satellites" PSX In 60-70% of patients, the inflammation of the ducts is combined with other chronic lesions of the digestive tract. |
|
| Symptoms of the disease at an early stage |
|
| Symptoms of late Stage | Any symptoms characteristic of classical chronic form. |
| Possible complications |
|
Diagnostics
To confirm the diagnosis, a whole complex of laboratory and instrumental research is needed. Most of them can be carried out in any multidisciplinary clinic with a standard equipment of the laboratory.
But, unfortunately, in most provincial cities medical institutions Do not even be equipped with a standard minimum. In this case, the doctor cannot appoint the necessary surveys, so patients often have to contact private clinics / laboratories.
Laboratory diagnostics
| Type of research | Normal indicators | Possible changes | |
| Clinical blood test | Soe | Up to 15 mm / hour | In the acute process there is an increase in all listed indicators. On the background chronic flow Clinical blood test may remain within the norm (with the exception of the ESP). |
| Leukocytes | 4,1-9.0 * 10 9 CL / l | ||
| Neutrophila |
or 2.0-5.4 * 10 9 kl / l |
||
| General urine analysis | Bilirubin | Negative | |
| Blood chemistry | C-reactive protein | Up to 5 mg / l | |
| Common Bilirubin | 5.1-17 μmol / l | ||
| Direct (related) Bilirubin | 1.7-5.0 μmol / l | ||
| GGTP |
Men 10-50 E / L; Women 7-31 E / L |
||
| Alkaline phosphatase |
Or 0.5-2.0 μcat / l |
||
| Immunological analysis of blood serum (for PSH diagnostics only) | Antinuclear antibodies | Titre less than 1/160 | With a sclerosing version of pathology, an increase in the titer listed antibodies occurs. |
| Anti-thunder autoantibodes | Titre less than 1/40. | ||
| Analysis on Panca. | |||
Instrumental examinations
MRHP
On this momentThe "Gold Standard" among the hardware research methods is considered to be MRHP - magnetic resonance cholangiopancratography. Despite the complex name, the principle of this survey is quite simple. A special substance is introduced into the blood of a person, the staining ducts of the biliary system and the gallbladder are studied on the MRI apparatus.
It should be noted that this method Safe for a person, does not irradiate his body with X-rays and requires the use of special surgical instruments. It does not need hospitalization for it - the procedure itself takes 15-30 minutes and can be performed outpatient. Contraindications to MRHP are not so much, they include:
- Allergy to a contrast agent;
- The presence of some implants in the body: pacemakers, cochlear implants, intravascular stents and metal clips in the brain. In the presence of other artificial devices in the body, it is necessary to first consult with the doctor performing a survey. He will analyze the situation and determine the possibility of diagnostics.
Preparation for the examination includes a refusal to eat and fluid a few hours before the procedure. Also immediately before the examination, it is necessary to remove all metal accessories and clothing items. If necessary, additional training, the attending physician individually advises the patient before the study.
Other research methods
Despite the fact that the MRHA is recommended as the main diagnostic method, far from each hospital has an MRI apparatus and trained specialists in his staff. As alternative methods Detection of disease, doctors can recommend the following instrumental examinations:
| Name of the procedure | Principle of conduct | Preparation for the examination |
| Abdominal ultrasound | Using an ultrasonic sensor, the doctor examines the gallbladder and choledo. The study is fully safe and does not bring significant discomfort to a person. Lack of methodology - the inability to inspect small bile ducts. In pathology, the doctor may detect the presence of a stone in the lumen of the biliary tract or the extension of the choledoch (more than 6 mm). |
|
| Endoscopic retrograde pancreato-cholangiography (abbreviated ERHP) | In the recent past, this method was the main in the diagnosis of diseases of the biliary system. It is performed as follows:
Main flaw - High probability of developing complications after the procedure. The most frequent of them is damage to the final choledoch (fabric chipboard) and the development of pancreatitis. |
|
| Percutaneous chrsecheny cholangiography (abbreviated CCH) | The method, according to its own principle, similar to ERCP. The gallways are filled with contrast after which radiography is performed. The main difference in the method of delivery of a contrast substance - with CCH, the doctor introduces it directly into the duct, conducting a needle through the skin and the liver under the control of the ultrasound. Chief flaw - The ability to injure the internal organs. |
Treatment
In the therapy of this disease there are several fundamental moments that each patient should know:
- In suspected acute process, hospitalization is needed to surgical hospital. This tactical nuance is explained by the unpredictable course of the disease - at any moment the inflammation of the duct system may cause blood infect (sepsis) or violations in the work of other bodies;
- Each patient S. acute process Potentially requires an operation to restore the outflow from the biliary tract. Doctors try to choose the most gentle technique for the body and are trying to avoid large volume of interference and cuts on the skin. If possible, the surgeons perform all interference with the help of an endoscope, by conducting it through the mouth to the final choledoch. This allows not to injury extra tissues and reduce the risk of complications.
The patient must be aware of the possibility of surgical intervention and not be afraid of this treatment method; - Almost always chronic forms of the disease are treated outpatient - hospitalization, as well as an operation, with a protracted flow is not required, since pathology is relatively predictable in its development.
Treatment of acute cholangitis
As mentioned above, almost every patient with this form is a potential "candidate" to conduct an operation. Its time is determined by the patient's condition. At relatively easy course Diseases and preserved functions of all organs, it is possible to carry out surgical intervention in the first day after hospitalization.
The heavy version of the disease or the development of sepsis requires preliminary training of the body with medicines. In order to improve the condition of a person, the surgeon may assign the following therapy:
- Intravenous infusion of solutions that improve the metabolism in tissues and reduce blood toxins concentration: solutions of glucose or sodium chloride, ringer solution, dish and trisole preparations, etc.;
- Combination of antimicrobial drugs;
- Hepatoprotectors, to maintain the work of hepatic cells: essential, admethionine, ursodeoxycholic acid and others;
- If necessary, preparations are used for anesthesia and to eliminate spasms in the digestive tract (spasmolytics).
After the operation to restore the outflow from Kolado, medical treatment continues. The time of reception of drugs is determined in each case individually and depends only on the state of the body and the characteristics of the pathology.
Therapy of chronic form
When identifying this type of disease, the doctor first is trying to identify the cause of chronic inflammation. It is this nuance that determines the further tactics of treatment. There may be several options:
In addition to specific treatmentAll patients with chronic disease forms are recommended:
- Stick to the diet (table number 5 by svnery), which implies frequent fractional power 5-6 times a day, in a small amount, with the exception of oily food;
- If possible, eliminate physical and psychological loads;
- Refuse smoking, drinking alcoholic and caffean-containing drinks;
- Take multivitamin complexes with the presence of vitamins K, D, E and A. The absorption of these substances is broken during the protracted inflammation of the biliary system.
Disability time
Since the vast majority of patients with cholangitis students or able-bodied people, this issue needs to pay attention. With an acute version, the period of stay in the hospital is 10-30 days, depending on the state of the person and the activity of the disease. After discharge, the sick leave / certificate is extended for 20-30 days to continue treatment at home and the restoration of the body.
As for chronic cholangitis, at the moment there are no unambiguous recommendations. In each case, the doctor itself determines the duration of the patient's disability, depending on its well-being and the possibility of conducting therapy.
FAQ
Question:
How dangerous for life is this disease?
Inflammation of the duct system is a life-degrading state at which there is always the likelihood of sepsis, irreversible liver damage and other organs.
Question:
What diseases can flow under the "mask" of cholangitis?
In some cases, similar symptoms can be detected in acute pancreatitis, against the background of acute / exacerbation of chronic cholecystitis. To properly make a diagnosis, it suffices to use laboratory and instrumental research methods described above.
Question:
Is it possible to diagnose "acute cholangitis" only in symptoms and data ultrasound?
With a combination of typical signs of pathology (fever, jaundice, pain) and extension of Kolado, more than 6 mm according to the results of the ultrasound, the diagnosis is considered justified.
Question:
What operation can do the doctor, when acute flow Diseases?
The main goal of surgical intervention is to restore the normal outflow from the choledoch and reduce the pressure in the biliary system. There are several basic options for performing this operation:
- Endoscopic method. With the help of an endoscope, which is introduced into the oral cavity and moves along digestive tractThe doctor penetrates himself in Kaldo, through his mouth in a 12-risen intestine;
- Expressive christsect drainage. Ultrasound under control of the ultrasound, the surgeon through the skin and the hepatic tissue penetrates the needle in the choledoch and sets drainage - a thin tube to create bile outflow;
- Open method. It is extremely rare. The doctor dissects the fabric, starting with the skin in the upper part of the abdomen, after which it highlights a large bull duct and sets drainage. There is a variant of this operation, in which, instead of a large section, the surgeon makes only 2-3 small wounds, for endoscopic tools. It is with the help of them and drainage is carried out.
Primary sclerosing cholangitis, bacterial cholangitis
Version: MedElement disease reference
Cholant (K83.0)
Gastroenterology
general information
Short description
Cholangit- inflammatory disease of outside and intrahepatic bile ducts having an acute or chronic recurrent course. It occurs significantly less frequently inflammatory diseases of the gallbladder.
Notes
1. In this subhead included:
1.1 Bacterial cholangitis.
1.2 Primary sclerosing cholangitis (PSX) - chronic cholestatic disease characterized by inflammation and progressive fibrosis Fibrosis is the growth of fibrous connective tissue, occurring, for example, in the outcome of inflammation.
In- and extrahepatic bile ducts, which consistently leads to their narrowing, obliteration, duktopenia Duktopenia - disappearing bile duct syndrome.
And, as a result, to the development of liver cirrhosis and cholangiocellular carcinoma.
2. From this subhead excludeds:
- cholangitis with liver abscess ();
- cholangitis and choledocholithiasis (K80.3 -, K80.4);
- chronic destructive non-resident cholangitis with primary biliary cirrhosis ().
Progressive cholangitis;
Cholant is unspecified;
Primary cholangitis;
Periodic cholangitis;
Sclerosing cholangitis;
- secondary cholangitis;
Stenosing cholangitis;
4. Synonyms:
Bacterial cholangitis;
Bacterial cholangitis;
- Primary sclerosing cholangitis.
Classification
A clear comprehensive cholangita classification currently does not exist. Approximately allocate the types of cholangitis listed below. Some forms of cholangitis (cholangitis with HCB, ischemic cholangitis and others) are classified in other categories.
I. By clinical flow:acute and chronic cholangitis (some authors also identify recurrent cholangitis).
II. Primary and secondary (as complications of diseases, manipulations).
III. By the nature of the process:
2. Sclerosing:
2.1 Primary sclerosing cholangitis (PSX):
- in combination with nonspecific ulcerative colitis (Nyak);
- Without a nic.
2.2 Secondary sclerosing cholangitis:
2.2.1 Toxic damage:
- with the introduction of formaldehyde and absolute alcohol in echinococcal cysts;
- Taking Tobendazole.
2.2.2 Ischemic damage:
- during thrombosis of the hepatic artery after the liver transplantation;
- with a transplant reaction reaction;
- when introduced into the hepatic artery of 5-fluorouracil during tumor chemotherapy;
- with operations on bile ducts.
2.2.3 Stones of bile ducts, including choledocholithiasis.
2.2.4 Congenital abnormalities of bile ducts:
- Kist Kolado;
- Karoli's disease.
2.2.5 Cytomegalovirus infection or cryptosporidia with AIDS.
2.2.6 Gisticiocytosis.
2.2.7 cholangiocarcinoma.
Primary sclerosing cholangitis is also classified by stages (severity of damage to bile ducts and fibrosis):
- Stage 1 (early changes) - damage to the bile ducts inflammation, limited area of \u200b\u200bthe portal path;
- Stage 2 - the scene of inflammation and fibrosis beyond the portal path;
- Stage 3 - Reducing the number of bile ducts and bridge-shaped fibrosis;
- Stage 4 (terminal) - the development of the liver cirrhosis.
Etiology and pathogenesis
Bacterial cholangit
Etiology
Spectrum of pathogens bacterial infection At cholangitis corresponds to the intestinal microflora spectrum (Escherichia coli, Proteus vulgaris, Enterococcus). With purulent cholangitis, more than 90% of patients in bile detect several pathogens at the same time and, moreover, register positive results Sowing blood for sterility.
Pathogenesis
Microorganisms can fall into bile ducts as a result of the violation of the function of a duodenal nipple (condition after the endoscopic retrograde cholangiopancratography, ERCP) or can be entered into bile ducts with hematogenic or lymphogenic.
(PSH)
Ethiopathogenesis of PSS is unknown. As possible etiological factors, toxins, infectious agents and immune disorders are considered.
In patients with PSX, excessive copper deposition was found in the liver tissue. However, the chelating therapy in these patients was ineffective, which indicates the secondary nature of the overload with copper (in particular, it is characteristic of patients with primary biliary cirrhosis).
The epithelium of intrahepatic bile ducts amazed cytomegalovirus and the 3rd type response, but the probability of detecting these viruses in all patients with PSH remains hypothetical.
The possibility of genetic predisposition to the disease indicates the high frequency of the occurrence of various autoimmune disorders (including liver - autoimmune cross-syndrome) in patients with PSX. Locuses HLA-B8 and HLA-DR3, which are often determined in patients autoimmune diseasesAlso found in patients with PSX.
With PSH in damage to the bile ducts, T-lymphocytes and immuno-mediated mechanisms are actively involved, the effect of which is manifested by lymphoplasmocyte infiltration, by the accumulation of eosinophils and obliterating phleets.
Pathogenesis of duktopenia and housing with PSX:
Reduction of secretion as a result of pro-inflammatory cytokines;
Violation of the expression and functional activity of molecules;
Blockade of the patency of bile ducts as a result of chronic inflammation and fibrosis;
Delay of bile acids and the activation of apoptosis Apoptosis is a programmed cell death using internal mechanisms.
hepatocytes.
Epidemiology
Cholangit
Mortality varies within 13-88%.
Geography. There is an increase in frequency in Southeast Asia.
Floor. No differences
Age. Basically meets in adults, the average age of the origin of 50-60 years.
Primary sclerosing cholangitis
Prevalence is estimated on average as 6.3 cases per 100,000 population.
Paul and age. The disease usually begins at the age of 20-30, although it may appear in childhood. About 70% of patients with PSX make up men. The average age of diagnosis for them is about 40 years.
Patients with PSX, but without inflammatory diseases of the intestine, at the time of the diagnosis most likely, will be women older age.
The true frequency of PSX in the population is unknown, but it increases every year due to the improvement of diagnostic methods. It is assumed that in individual countries, the underestimation of the prevalence of the disease is significant figures (understated 3-4 times).
Risk factors and groups
- Men of young age (25-45 years);
- Patients with nonspecific ulcerative colitis of any age and gender;
- Patients with and diabetes first type;
- Patients with a burdened family history.
Cymptoms, flow
Bacterial cholangit
Classic symptoms cholangita: Pain in the right hypochondrium, chills, fever, Triad Sharko (combination of fever, chills and jaundice).
Pain is usually localized in the epigastric area, is intensive and behavior character.
Fever, as a rule, has an intermitting character, but the elderly patients and persons in the state of immunosuppression may be subfebrile.
In the case when the symptoms described are attached signs of sepsis in the form of arterial hypotension and psyche disorders, this symptom complex is called pentada Reynold.
Primary sclerosing cholangitis
In patients with primary sclerosing cholangitis (PSS), many clinical signs are detected, characteristic of primary biliary cirrhosis (PBC). The disease usually begins imperceptibly and retrospectively difficult to fix the temporal interval of the Debut of the disease.
Separate signs of illness may appear in 75% of PSX patients within 1-2 years before diagnosis.
Main complaints associated with increasing general weakness and skin itch, which subsequently joins jaundice. This symptom triad is characteristic of 2/3 patients.
With the appearance of clinical signs of cholangitis (pain in the right hypochondrium, fever and jaundice), it is necessary to exclude the possibility of developing complications (choledocholithiasis and other). At the stage of clinical manifestations, 75% of patients detect jaundice in combination with hepatosplegegaly. Melanomy and Xantellasma (Xantomians) are less common than in patients with PBC.
Primary symptoms In 29 patients with PSH (by Sh. Sherlock, J. Duli, 1999)
| Symptom | Number of patients | % |
| Jaundice | 21 | 72 |
| Itch | 20 | 69 |
| Reducing body weight | 23 | 79 |
| Pain in the right upper belly quadrant | 21 | 72 |
| Acute cholangit | 13 | 45 |
| Bleeding from varicosely extended veins of the esophagus | 4 | 14 |
| Malaise | 1 | 3 |
| Asymptomatic flow | 2 | 7 |
| Total | 29 |
PSX is often combined with defeats of other organs and systems. Diseases associated with PSX:
Chronic inflammatory gut diseases (nyak, crooh disease);
Pancreatitis;
Joint diseases;
Sarcoidosis;
Celiac disease;
Thyroiditis;
Autoimmune hepatitis of the first type.
Always, even in the absence of symptoms of the intestinal disease, the nap should be excluded (and in rare cases of Crohn's disease) by carrying out the rectoromanoscopy and biopsy of the rectal mucosa. PSH can be detected earlier or later than colitis. Colitis usually happens chronic, diffuse, light or moderate severity. The activity of cholangitis is inversely proportional to the activity of colitis. Remissions are usually long.
Diagnostics
The basis for the diagnosis of any cholangitis is the study of clinical symptoms of the disease.
Bacterial cholangit
1. Ultrasound. In acute cholangitis, it is often detected: thickening of the walls of biliary ducts, increasing their echogenicity, the presence of gas bubbles in bile ducts, sometimes some expansion of the ducts and inquisitive visualization of the lumen.
Cholant often can often lead to the development of acute cholecystitis or develop in parallel with it. After clinical recovery from cholangitis in the echographic painting of the liver, multiple hyperheogenic point and small-scale inclusions in a parenchym can be detected. Parenchima - a set of basic functioning elements internal organbounded by a connective tissue stroma and capsule.
In the location zones of intrahepatic ducts.
One of the frequent causes of cholangitis and cholecystocholangitis in some regions can serve as opistorhosis Opistorhoz - Helmintosis from a group of trematodosis caused by a feline duxtile (opisthorchis felineus) or a squirrel duxtile (opisthorchis viverrini); manifests itself in the early phase of cholangitis phenomena, pancreatitis and allergies; Man infection occurs when eating invasive fish
.
2. CT scan Also allows you to see the expansion of intra and extrahepatic bile ducts.
3. If suspicion of the obstruction of raging strokes perform ERCP ERHPG - endoscopic retrograde cholangiopancratography
.
Primary sclerosing cholangitis
1. EPHE - The method of choice, also with success can be used by CRessechen cholangiography. Diagnostic criterion - identification of areas of uneven narrowing and expansion (clearness) of intra and extrahepatic biliary tract.
2. Ultrasoundremoves thickening of the walls of bile ducts and signs of portal hypertension Portal hypertension is venous hypertension (increased hydrostatic pressure in veins) in the system of the portal vein.
.
3. CT scanallows you to visualize the minimal expanded areas throughout the bile ducts.
Laboratory diagnostics
Bacterial cholangit
1. Signs of inflammation:
- leukocytosis with the shift of the formula to the left;
- an increase in SEE SE - Erythrocyte sedimentation rate (nonspecific laboratory blood indicator, reflecting the relationship of plasma proteins fractions)
.
2. Cholestasis: Improving alkaline phosphatase activity, GGT Gamma-GlutamylTranspend of Gamma (GGT) - an enzyme involved in the exchange of amino acids
, Bilirubin concentration.
3. Cytolysis (rarely): increasing serum transaminase activity.
Notes:
1. High levels of bilirubin are found mainly in patients with malignant obstruction.
2. Simultaneous increase in amylase speaks of possible obstruction in the area of \u200b\u200bthe packer.
3. The results of the sowing of blood are positive almost in 50% of patients. The results of sowing bile positive almost in all patients.
Several organisms are defined as the most common (approximately 60% of patients): Escherichia Coli, Klebsiella, Enterococcus Species. From the anaerobic pathogens, the culture of Bacteroides Fragilis most often highlighted.
Primary sclerosing cholangitis (PSH)
1. Cholestasis:
- improving alkaline phosphatase activity 3 times higher than the norm Attention!
;
The level of bilirubin will significantly fluctuate and in rare cases exceeds 170 μmol / l;
- In all patients with heavy and long-lasting cholestasis, the content of ceruloplasmin and copper in serum can increase.
2. Levels of gamma-globulin and Igm increase 30 and 50% of cases, respectively.
3. Low antibody titers to smooth muscles (SMA), P-ANCA are present in serum, 84% of patients may be detected. Anticardolypin (ACL) antibodies - in 66% of cases; Antinuclear antibodies (ANA) - in 53% of cases. Antimitochondrial antibodies (AMA) are usually absent.
4. Eosinophilia (rarely).
Notes:
1. In some patients with hypothyroidism, hypophosphatems, magnesium or zinc deficiency, the normal level of alkaline phosphatase can be marked.
2. Sometimes hypoalbuminimia, which arises either in the later stages of the disease, or in the presence of an active stage of inflammatory bowel diseases.
Biopsy and morphological examination of liver tissue
Morphological studies of the liver tissue are carried out to confirm the diagnosis of PSX (morphological data is especially valuable in the damage to small bile ducts).
Stage 1.The early stage of damage to the biliary canal does not have specific signs. Typical focal atrophy and violation of robes of the epithelium. Not characterized by hyperplasia Hyperplasia is an increase in the number of cells, intracellular structures, intercellular fibrous formations due to the enhanced function of the organ or as a result of the pathological tissue formation.
Gall epithelium peculiar to patients with primary biliary cirrhosis. Possible focal oblostuity Oblotia is an infection of the cavity of the internal organ, a channel, a circulatory or lymphatic vessel.
and dividing bile ducts. In portal paths, signs of moderate lymphocytic inflammatory infiltration are visible. Sometimes the lymphoid follicles are visible without germinative centers, rarely granules.
Stage 2.Characterized signs of lobular hepatitis, often resembling autoimmune hepatitis or chronic hepatitis C. Typichna proliferation of bile ducts (usually has focal nature). Moderate fibrosis of portal paths is possible. At this stage, the signs of hepatitis have a more serious prognostic value than the defeat of bile ducts.
Stage 3. Typical (not pathogenic Pathognomonic - characteristic of this disease (on the sign).
) Sign of PSX - Peridectural Fibrosis ("Symptom low husk"). It is very characteristic of the presence of duktopenia and fibrous fields in the loss of bile canalis.
In portal paths, only the branches of the portal vein and the hepatic artery are visible (bile ducts are obliged). Parenchima disseminate portal fibrous septa, the inflammatory infiltrate is less pronounced Infiltrate is a piece of fabric characterized by the accumulation of the usually non-peculiar cell elements, an increased volume and increased density.
. In the perportal zones, copper deposits, intra-robber cholestasis, in some cases - Taurus Mulletri.
Stage 4.It is characterized by the common bilro-type fibrosis with signs of biliary liver cirrhosis. This fact may complicate the differential diagnosis between PSX and primary biliary cirrhosis.
Differential diagnosis
Bacterial cholangitit should be differentiated with infectious hepatitis, as well as with infectious and noncommunicable lesions of other departments of the biliary tract, gallbladder, pancreas.
Primary sclerosing cholangitisdifferentiate with the cholestatic shape of sarcoidosis (granulomatous lesion of the biliary tubules is uncharacteristic for sarcoidosis).
Primary biliary cirrhosis is another, developing more often, a cholestatic disease, in which the bright canals are affected as a result of immune inflammation. In diagnostically obscure cases, the definition of antimitucleonial antibodies is shown.
Complications
Bacterial cholangit
The main complication is the "septic" or "acute biliary septic" shock, which is hemodynamic disorders that develop as a result of penetration of microorganisms from bile in systemic blood flow. Such shock is diagnosed in 10-30% of patients with infections of biliary tract; Its development is accompanied by high mortality.
Abspessa is possible Abscess - cavity filled with pus and delivered from the surrounding tissues and organs of the pyrogen membrane
Liver, Flebita Flebit - inflammation of the wall of the vein
Relight veins and other purulent-septic complications.
Primary sclerosing cholangitis:
- bacterial cholangitis;
- cholangicarcinoma (10-30%);
- increase risk of colorectal cancer.
Treatment abroad
Non-specific inflammation of gall ducts resulting from a violation of the patency of biliary tract and infection of yellow. Most often, by cholangitis, E. coli is seeded from Hall. Most often combined with choledocholiticiasis, common bile duct cysts, bile duct cancer. In most cases, the cholangitis occurs when the causative agents of a bacterial infection in bile ducts from the lumen of the duodenum (ascending infection), hematogenic (through a portal vein system) or lymphogenic (for gallbladder diseases, pancreas or colon) by. By the nature of the flow, acute and chronic cholangitis are isolated. Acute cholangitis Depending on the severity of inflammatory changes in the wall of bile ducts, it may be a catarrhal, purulent, diphtheritic and necrotic. Among the forms of chronic cholangitis, latent, recurrent, long-term septic, abscessive and sclerosing is isolated. Symptoms, flow. The clinical picture depends on the presence or absence of acute destructive cholecystitis, quite often complicating cholangitis. The disease usually begins with a painful attack resembling a hepatic colic (manifestation of choledocholithiasis), after which mechanical jaundice, temperature rise, skin itching is quickly manifested. When examining the image of the skin, on the skin, traces of combs, the language is wet, covered, the stomach does not go. With the palpation of the belly, some muscle rigidity in the right hypochondrium, soreness, with deep palpation, the increase in the size of the liver is determined, its edge is rounded. Temperature Sometimes hectic type, chills. In blood leukocytosis with a shift to the left. Hyperbilirubinemia mainly due to direct Bilirin, increasing alkaline phosphatase, moderate increase in hepatic enzymes (ALT, ACT) due to toxic damage to hepatic parenchyma. Substantial assistance in establishing a diagnosis of cholangitis can have an ultrasound study of the liver and biliary tract. In the absence of timely treatment, inflammation from the wall of bile ducts passes to the surrounding fabrics and can cause impregnation of the hepatic and duodenal bunch of 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 failure. Obstructive jaundice develops in the elderly and senile ages, the compensatory possibilities of the organism of which are very limited, and surgical intervention against the background of acute cholecystitis is a big risk. In this situation, the urgent endoscopic papillotomy is promising. The biopsy canal of the Duodenoscope in a large duodenal duodenal ducts are injected with a thin cannula, after which it disseminate it with a special papillotoma upper wall. At the same time, the accretions from the ducts are either separated independently, or they are removed by special tweezers with a loop (baskets) of Dormia or Fogarrty probe. Such manipulation allows you to eliminate bile and pancreatic hypertension, reduce jaundice and intoxication. Subsequently perform an operation on the bustling bubble in a planned manner. Bolon with suspicion of cholangitis needs urgent hospitalization, since treatment is predominantly operational. A pre-deployed stage is prescribed antibiotic and antibiotics of a wide range of action that do not have hepatotoxic properties. The tactics of conducting patients with cholangitis represents significant difficulties, they are due to the presence of a purulent process, mechanical jaundice and acute destructive cholecystitis. Each of these moments requires a speedy resolution, however, patients with mechanical jaundice do not tolerate long and traumatic surgical interventions. Therefore, it is advisable primarily to ensure adequate bile outflow, which simultaneously reduces the clinical manifestations of cholangitis, intoxication. The second stage is carried out by radical intervention, aimed at eliminating the cause of the occurrence of cholangitis. In the hospital, disintellation and antibacterial therapy are carried out and a patient is prepared for surgical intervention. Endoscopic methods for draining bile ducts, providing normal bile outflows obtained the greatest propagation in acute cholangitis. The output of catarrhal cholangitis with timely treatment is favorable. With purulent, diphtheric and necrotic cholangitis, the forecast is more serious and depends on the severity of morphol. Changes, the overall condition of the patient, as well as from the factor that caused the cholangitis. With a long-term chronic chronicle, biliary cirrhosis of the liver or an abscessive cholangitis can develop, which is unfavorable. Prevention lies in the timely detection and treatment of diseases of the biliary tract and the region of a large duodenal papilla. With the purpose of decompression of the biliary tract, endoscopic papillosphincterotomy is carried out after preliminary retrograde cholangiography. With the residual choledoch stones after papilosophynetotomy, there is sometimes the destruction of the biliary paths, the phenomena of cholangitis will be stopped and the question of the need for a repeated operation disappears. Forecast serious. X o l e c and with t e to about m and i - the main operational intervention performed at acute cholecystitis. The removal of the gallbladder can represent considerable difficulties in connection with expressed inflammatory changes in the cloth surrounding it. Therefore, it is recommended to remove a bubble "from the bottom". Cholecystectomy in the presence of testimony should be supplemented with an intraoperative study of extrahepatic bile ducts (cholangiography). When the choledocholithiasis or stenosis of the terminal department of the total bile duct produces the same manipulations that it is customary to do in similar cases in planned operations in patients with chronic calculose cholecystitis (choledochotomy, T-shaped drainage, etc.). In the abdominal cavity, the drainage is left to control blood and bore exhibition. The delicacy after cholecystectomy, made about acute cholecystitis, is 6-8%, reaching the streets of the elderly and senile age 15-20%. T about M and I, with the removal of the concrections and the infected contents of the gallbladder, is shown in rare cases, as a forcediment with a general serious condition of the patient and a massive inflammatory infiltrate around the gallbladder, especially in elderly and senile people. This operation allows only to eliminate acute inflammatory changes in the wall of the gallbladder. In a long time after surgery, as a rule, the bustling bubble reappears the concrections and patients have to operate again.
The inflammatory disease of hepatic and extrahepatic biliary ducts is called cholangitis. The disease may develop independently or be the complication of inflammatory processes in the liver and the bustling bubble. Depending on the rate of occurrence and flow of the disease, acute and chronic cholangitis are isolated. It is possible to treat this pathology by surgical intervention or conservative method.
Show all
Causes
Cholant refers to the pathologies of the hepatobiliary system. Women are more susceptible to the disease. The greatest increase in morbidity is celebrated in patients over the age of 50. In children, this ailment occurs only against the background of congenital abnormalities of biliary ducts.
The main reason for the occurrence of cholangitis is infection.
Most often, intestinal wand, protea and enterococcus become pathogens.For purulent process Practically, 90% of patients in the analysis of bile on sterility are revealed simultaneously several pathogens. It is extremely important to determine them to appoint effective antibacterial therapy.
There are several ways to penetrate the infection in the gallways:
- 1. Ascending. Microorganisms penetrate the biliary pathways from the lumen of the duodenal intestine along the walls of the ducts.
- 2. Hematogenic. The causative agent enters the ducts through mortal veinwhich collects blood from everything gastrointestinal tract.
- 3. Lymphogenic. In this embodiment, microorganisms fall into the ducts from the gallbladder, the pancreas or intestines on the lymphatic vessels.
With aseptic cholangitis, the inflammatory process develops as a result of the cast of pancreatic enzymes in bile ducts. Due to the fact that the pancreas is distinguished by an aggressive action, he corps the wall of the ducts, leading to their necrosis.
Sclerosing cholangitis develops as a result of autoimmune processes in the body - the immune system Begins to produce antibodies to the mucous membrane of biliary tract.
The predisposing factors in the development of cholangitis are:
- bile stagnation resulting from dyskinesia of biliary tract;
- congenital abnormal bile ducts;
- cystic education choledoch;
- khdocholithiasis (stone in the choleret);
- nipple stenosis.
The appearance of cholangitis also contributes to mechanical damage to the mucous membranes of the ducts at diagnostic events (Installation of stents, retrograde pancreaticolangiography) and carrying out surgical operations on bile ducts.
Obstructive jaundice
Classification
The structure of the biliary system
The inflammatory process in biliary tracts are divided into forms depending on the course of the disease, etiology and type of pathological reaction.
For course, the disease happens:
- Sharp.
- Chronic.
Due to the occurrence of cholangitis:
- Primary.
- Secondary (due to other diseases of the hepatobiliary system or transferred surgical interventions).
Depending on the type of inflammatory process, cholangitis distinguish:
- Bacterial.
- Sclerosing.
The localization of the inflammatory process is distinguished:
- Kaldochit - Inflammation of Kolado.
- Angocholite is the defeat of intrahepatic and extrahepatic bile ducts.
- Papillitis is an inflammatory process in a fare nipple.
Chronic cholecystopancatitis
Acute cholangit
Symptoms of cholangitis
Acute cholangitis is an infectious disease form with a sudden beginning. It is characterized by inflammatory processes in bile ducts with further development of stagnation of bile - right up to blockage of biliary tract. Most often develops on the background:
- gallway disease;
- cystic formations of intrahepatic tract;
- gallbladder cancer;
- chronic sclerosing cholangitis.
Patients with cholangitis are mild are subject to conservative treatment, and with complicated forms - operational intervention.
The following types of acute cholangitis are distinguished:
- Purulent. At the same time, the type of disease in biliary ducts begins to accumulate the pus. This state is dangerous in that inflammation has the ability to quickly spread the arranged organs and tissues.
- Catarial. Most light form, It is characterized by redness and swelling of the mucous membrane of biliary tract. This type of illness often develops in chronic formSince symptomatics in this case is less pronounced.
- Necrotic. In this case, there are foci of necrosis in the ducts due to the pancreatic enzymes in them, which corrode the walls of biliary tract. It is the most severe form, a dangerous development of serious complications, such as peritonitis and hepatitis.
- Difteric. This form is characterized by the formation of ulcerative processes in the mucous membranes of the ducts. The ulcers are covered with dense films, under which the necrosis zones extend even faster. Quite often inflammation goes to the liver cloth.
Symptoms of acute process
Signs of acute cholangitis appear suddenly. Basic symptoms:
- increasing body temperature;
- yellowing scler, mucous membranes and skin;
- the appearance of pain in the right hypochondrium.
This symptom complex is called Triah Charcot. These are the most typical signs of acute cholangitis. The body temperature rises to high digits - 39-40 degrees, sweating and chills occur. The temperature during the day can fluctuate (with a peak in the evening) or be constant. With her arises strong pain On the right in the hypotherapy, which gives to the neck, right blade, clavicle and hand.
After 1-2 days, the painting of the scler and skin begins to change in patients. This is due to the increase in bilirubin in the blood. The most sensitive to changes in its level is the mucosa of the occasion of the eyelids and the eye scler. Due to the deposit of bilirubin in the skin, an intensive itch begins to appear, which is not eliminated by antihistamine.
If at this stage the patient does not assist, the disease can grow into infectious-toxic shock. It is manifested by a violation of consciousness, the appearance of nausea and vomiting. In clinical analysis of blood, the level of bilirubin continues to increase, the concentration of hepatic enzymes is growing and the platelet content is reduced.
The presence of a large number of toxins in the blood leads to the defeat and appearance renal failure. The diuresis decreases, the concentration of creatinine and urea increases. In the future, there is a violation of the heart, the heart rate is expected, arrhythmia occurs and blood pressure decreases.
Infectious-toxic shocks in the end leads to polyorgan deficiency, so it is extremely important to begin treatment of acute cholangitis in the early stages: this condition carries a threat to human life.
Chronic cholangit
Sclerosing cholangitis
Chronic cholangitis meets much less often in contrast to other diseases of the hepatobiliary system. It is mainly happening again, that is, against the background of the existing pathologies of the gallbladder or the liver. In one third part of the cases, this state appears after removal of the gallbladder.
Highlight The following forms of chronic inflammation of bile ducts:
- Septic. It is characterized by grinding changes in the ducts.
- Latent. It has a hidden course and may not be manifested for many years.
- Recurrent. It is characterized by the emergence of periodic exacerbations of the disease.
- Abscessant. With this form of illness in biliary tracts, limited purulent foci (abscesses) are formed.
A separate type is. With this pathology, the inflammatory response in the ducts appears without the presence of infection. In the future, this leads to the sclerosis of the paths and disturbance of the outflow of bile. At the last stages of the disease, there is a complete infection of biliary ducts, which, in turn, provokes the appearance of a liver cirrhosis. This disease relates to extremely heavy and cannot be treated. Most patients for 10 years this species Cholant leads to irreversible changes in the liver.
Symptoms of chronic inflammation
At the initial stages, chronic cholangitis may not have symptoms (or they will be expressed extremely weak). For this state, Characc Triad is also characterized, but the signs appear to a lesser extent. The patient is concerned about moderate pain in the right hypochondrium. Body temperature rises to 37-38 degrees. Jaundice appears in exacerbation of the disease, there is no remission during the remission.
At the initial stages of patients concerned:
- general weakness;
- disgraceability;
- headaches;
- severity after meals;
- nausea.
Especially often symptoms appear in the error in the diet - the use of a large number of fatty products or overeating.
The aggravation of chronic cholangitis has the same manifestations as acute inflammation of biliary ducts.
Diagnostics
The diagnosis of cholangitis is primarily based on a characteristic clinical picture - Charcot Triad. Often, patients come to the doctor to do with these symptoms, and in the future, the diagnosis is helped by laboratory and instrumental research.
Find out the prevalence of the process using ultrasonic research Liver and biliary ducts. In suspected oncological disease, it is recommended to carry out computer tomography - it will help to identify the prevalence of the inflammatory process and the presence of metastases.
To date, endoscopic diagnostic methods are widely used. Among them are distinguished:
- Magnetic resonance pancreatocholangiography.
- Expressive and cheap cholangography.
- Retrograde pancreatocholangiography.
These methods allow you to analyze the state of the internal shells of biliary tract, establish the prevalence of processes and their stage.
Treatment
First of all, the cholangitis is important to reduce the manifestation of inflammation. To this end, antibacterial therapy is prescribed. The following combination of funds are most often used: the cephalosporins of the 2nd and 3rd generation are combined with metronidazole and aminoglycosides.
- To reduce pain syndrome, antispasmodics (but-shpa, balallgan) are prescribed and painkillers (analgin and ketonal).
- To improve the liver condition, hepatoprotectors are written - heptral, essential (only when normal level Alkaline phosphatases), Hep-Merz and others.
- In order to reduce intoxication, infusion therapy with saline, reosorbilakt, glucose solution, reopolyglucin, etc. is prescribed.
In the case of infectious and toxic shock, plasmapheresis is carried out. It allows you to clear the blood from toxins in a short time and warns the development of polyorgan deficiency.
With complicated cholangitis, the following operational interventions are carried out:
- Endoscopic papillosphincterotomy. Used to eliminate the stenosis of the packer.
- Extraction of biliary ducts by endoscopic methods (with stones).
- Endoscopic stenting of choledoch - in case of its significant damage.
- For purulent complications Set percutaneous transcript drainage of bile ducts or conduct outer drainage of biliary tract.
Often, cholangitis is combined with cholecystitis, in which case the operation is carried out in two stages. Initially, they produce cholecystectomy (removal of the gallbladder), then apply one of the above techniques for the operational treatment of the disease.
For the treatment of sclerosing cholangitis, the best method is recognized as a liver transplantation.
Chronic cholangitis during the remission is treated using physiotherapy techniques. Patients are prescribed:
- electrophoresis;
- ozkeritotherapy;
- medical baths;
- diathermy.
It is important to stick to the diet and normalize lifestyle. This will significantly improve the condition of the patients and extends remission.
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