Cholangitis is an inflammatory lesion of both the intrahepatic and extrahepatic bile ducts. In most cases, this disease is diagnosed in women, men suffer from the disease less often. The main risk group is made up of older people - from fifty to sixty years old. It is extremely rare that the disease develops in children.
The main prerequisites for the development of inflammation are the infection of the body with pathological bacteria, as well as the course of other pathologies of the liver or gallbladder.
Cholangitis has no specific symptoms, which is why a wide range of laboratory and instrumental examinations will be required to establish the correct diagnosis. The most characteristic clinical manifestations can be considered the development of jaundice, the appearance of severe pain under the right ribs, as well as an increase in body temperature.
In the treatment of the disease, conservative methods prevail, however, in case of severe course, surgical intervention may be required.
V International classification diseases ICD-10 of such a pathology is assigned a code value - K83.0.
Etiology
The source of any inflammatory process is the penetration into the body and reproduction of pathogenic microflora. In most cases, the causative agents of this disease are:
- staphylococci;
- Escherichia coli;
- enterococci;
- proteas;
- non-clostridial anaerobic infection.
Disease-causing bacteria can enter the biliary tract in several ways:
- ascending - from the lumen of the duodenum;
- hematogenous - through portal vein;
- lymphogenous - with the flow of lymph through the lymphatic vessels.
Other predisposing factors for the appearance of a similar disease in adults may be:
Cholangitis in children is rarely an independent disease, and often acts as a secondary infection in the course of other ailments.
Classification
In gastroenterology, there are several classifications of this disease. The first classifies the disease according to the cause of cholangitis. Thus, it happens:
- bacterial;
- viral;
- helminthic;
- autoimmune;
- oncological.
By the nature of the course, there are two forms of the disease:
- acute cholangitis- characterized by a vivid expression of clinical signs and a sharp deterioration in the human condition;
- chronic cholangitis - characterized by the alternation of remission and relapse phases. In the first case, the symptoms may not appear at all, and in the second, a similar picture is observed as in the previous form of the disease.
The acute form of the inflammatory process in the bile ducts can take the following forms:
- catarrhal - while there is swelling of the mucous membrane biliary tract... In the absence of therapy, the disease becomes chronic and eventually becomes the cause of cicatricial narrowing of the ducts;
- purulent - characterized by the fact that the bile ducts are filled with purulent fluid mixed with bile. The onset of purulent cholangitis is most often associated with a violation or complete blockage of the outflow of bile - which occurs against the background of closure of the ducts by calculi or cancerous tumor... Purulent cholangitis often spreads to nearby organs, such as gall bladder or liver;
- diphtheria - ulceration and necrosis of the mucous membrane of the ducts occurs. This leads to complete destruction their walls, which often causes purulent fusion of the surrounding tissues;
- necrotic - develops as a result of the influence on the biliary tract of aggressive pancreatic enzymes. The result of this process is mucosal necrosis.
The chronic form of the course of such an ailment also has its own classification and is divided into:
- latent or hidden - this course is characterized by a complete absence of symptoms;
- recurrent - characterized by alternating periods of retreat and exacerbation of symptoms. The first phase is expressed in the unchanged state of a person, as in the latent form, and during the second, the expression of clinical signs occurs, as in acute cholangitis;
- septic is the most severe course chronic inflammation which can be fatal;
- abscess - characterized by the formation of abscesses in the bile ducts.
We should also highlight autoimmune cholangitis, which is formed due to the production of antibodies by the body against its own healthy tissues and cells. In such cases, they talk about sclerosing cholangitis. This type of disease is characterized by slow progression and within ten years leads to irreversible changes. Inflammation leads to hardening of the ducts and overgrowth of the lumen, which, in turn, acts as a predisposing factor for the development of liver cirrhosis.
Symptoms
A wide variety of varieties and forms of the disease have the same clinical signs. The main symptoms of an acute course of such a disease and an exacerbation of a chronic course will be:
- emergence of a strong pain syndrome in the projection of the affected organ, i.e. in the area of the right hypochondrium;
- significant increase in body temperature;
- chills;
- the acquisition of a yellowish tint by the skin and mucous membranes;
- bouts of nausea, accompanied by severe vomiting;
- the appearance of a bitter taste in the mouth;
- hepatomegaly - an increase in the volume of the liver, which is very well felt on palpation;
- weakness, lethargy and rapid fatigability of the body;
- spread of pain to the area of the right scapula, shoulder and neck;
- intense headaches;
- violation of the stool;
- redness of the skin of the palms;
- itchy skin, which is characterized by an increase at night, which leads to sleep disturbance;
- fainting.
In acute cholangitis, the symptoms will be so pronounced that it cannot be ignored, but in the chronic course of the disease, the symptoms will be erased. The temperature will rise slightly, instead of severe vomiting - nausea, and the pain syndrome will not be so intense.
In addition, the clinical picture will differ in children and the elderly. Cholangitis in a child develops very quickly and, in addition to the above symptoms, may join:
- decreased or complete lack of appetite;
- signs of body intoxication;
- pallor of the skin;
- anemia;
- chronic headaches;
- slowdown in physical and general development.
Cholangitis in elderly people will be expressed in severe fatigue, rapid fatigue and an unreasonable increase in temperature, which returns to normal on its own.
Diagnostics
In order to make the correct diagnosis, the doctor relies on the symptoms of the disease and the data of laboratory and instrumental examinations.
Primary diagnosis of cholangitis includes:
- conducting a detailed survey of the patient - to find out the presence, the first time of onset and the severity of the symptoms of the disease;
- the study by the clinician of the patient's medical history and anamnesis is necessary to search for etiological factors;
- a thorough physical examination, which is aimed at examining the condition of the skin and sclera, measuring body temperature and palpating the entire surface of the anterior abdominal wall, but special attention is paid to the area under the right ribs.
Among laboratory research worth highlighting:
Instrumental diagnostic methods involve the implementation of:
- Abdominal ultrasound;
- CT - to obtain a clearer image of the problem area and identify their expansion, as well as to identify changes in the liver;
- ultrasonography of the bile ducts;
- cholecystography;
- electronic cholegraphy;
- MRPHG - to identify the causes of obstruction of the biliary tract.
Cholangitis should be differentiated from:
- cholecystitis of non-calculous form;
- viral hepatitis;
- primary biliary cirrhosis;
- empyema of the pleura;
- right-sided pneumonia.
Treatment
Therapy of such a disease is aimed at solving several problems, including:
- relief of the inflammatory process;
- detoxification of the body;
- decompression of the bile ducts.
Depending on the predisposing factors and the presence of complications, the elimination of the disease can be conservative or surgical.
The disease can be treated with the following physiotherapy procedures:
- mud applications;
- electrophoresis;
- exposure to current or magnetic field;
- ozokeritotherapy;
- paraffin therapy;
- taking sodium chloride baths.
Diet for cholangitis implies adherence to the following rules:
- frequent and fractional food intake;
- complete rejection of fatty and spicy foods, smoked meats and preservatives;
- chopping and thoroughly chewing food;
- eating only warm food;
- enrichment of the diet with dietary meats, fish and poultry, cereals, especially buckwheat and oatmeal, low-fat fermented milk products, fruits and vegetables after they undergo heat treatment;
- cooking should be carried out only by boiling, stewing, steaming or baking without adding fat;
- plentiful drinking regime - you need to drink at least two liters of liquid. All drinks are allowed except strong coffee and soda.
Cholangitis therapy will not be complete without restoring normal bile flow. This will require the following surgical operations:
- removal of calculi;
- endoscopic papillosphincterotomy or duct stenting;
- percutaneous transhepatic or external drainage of the biliary tract;
- cholecystectomy.
Complications
Cholangitis is dangerous disease leading to the development of complications, many of which pose a threat to the patient's life. Among the consequences of ignoring symptoms or untimely initiation of treatment, it is worth highlighting:
- liver failure;
- biliary cirrhosis;
- the formation of liver abscesses;
- development of peritonitis and sepsis;
- infectious toxic shock;
- cholecystopancreatitis.
Prevention and prognosis
There are no special preventive measures to prevent the appearance of angiocholitis, people just need to adhere to the general rules:
- completely abandon drinking alcoholic beverages and smoking;
- eat rationally and balanced;
- timely treat diseases that can lead to the development of the underlying ailment;
- pass regularly preventive examinations at the gastroenterologist.
Only early diagnosis and therapy of cholangitis provides a favorable prognosis for such a disease. In cases of complications, the outcome is unfavorable - very often the death of the patient occurs. The prolonged course of the chronic form of cholangitis leads to disability.
Nonspecific inflammation of the bile ducts, resulting from a violation of the patency of the biliary tract and infection of the bile. Most often, in cholangitis, E. coli is sown from bile. Most often combined with choledocholithiasis, common bile duct cysts, bile duct cancer. In most cases, cholangitis occurs when bacterial pathogens enter the bile ducts from the lumen duodenum(ascending infection), hematogenous (through the portal vein system) or lymphogenous (in diseases of the gallbladder, pancreas or colon) by. By the nature of the course, acute and chronic cholangitis are distinguished. Acute cholangitis, depending on the severity of inflammatory changes in the wall of the bile ducts, can be catarrhal, purulent, diphtheritic and necrotic. Among the forms of chronic cholangitis, there are latent, recurrent, long-term septic, abscess and sclerosing. Symptoms for. Clinical picture depends on the presence or absence of acute destructive cholecystitis, quite often complicated by cholangitis. The disease usually begins with a painful attack resembling hepatic colic (a manifestation of choledocholithiasis), after which it quickly manifests itself obstructive jaundice, fever, itchy skin. On examination, the skin is icterus, there are traces of scratching on the skin, the tongue is moist, coated, the stomach is not swollen. On palpation of the abdomen, some muscle rigidity in the right hypochondrium, soreness, with deep palpation, an increase in the size of the liver is determined, its edge is rounded. Temperature is sometimes of a hectic type, chills. In the blood, leukocytosis with a shift to the left. Hyperbilirubinemia is mainly due to direct bilirubin, an increase in alkaline phosphatase, a moderate increase in liver enzymes (ALT, ACT) due to toxic damage to the hepatic parenchyma. Ultrasound examination of the liver and biliary tract can provide essential assistance in establishing the diagnosis of cholangitis. In the absence of timely treatment, inflammation from the wall of the bile ducts passes to the surrounding tissues and can cause impregnation of the hepato-duodenal ligament with bile and peritonitis, the formation of intrahepatic abscesses, the development of sclerotic changes in the liver tissue and secondary biliary cirrhosis... Complications. Formation of multiple liver abscesses, sepsis, hepatic renal failure... Obstructive jaundice often develops in elderly and old age, the compensatory capabilities of the organism of which are very limited, and surgical intervention against the background acute cholecystitis poses a great risk. In this situation, an urgent endoscopic papillotomy is promising. A thin cannula is inserted through the biopsy canal of the duodenoscope into the large papilla of the duodenum, after which its upper wall is dissected using a special papillotome. In this case, calculi from the ducts either leave on their own, or they are removed with special forceps using a loop (basket) of Dormia or a Fogarty probe. This manipulation allows you to eliminate biliary and pancreatic hypertension, reduce jaundice and intoxication. Subsequently, surgery on the gallbladder is performed in a planned manner. A patient with suspected cholangitis needs urgent hospitalization, since the treatment is mainly surgical. At the pre-medical stage, antispasmodic and anti-inflammatory drugs, broad-spectrum antibiotics that do not have hepatotoxic properties are prescribed. The tactics of managing patients with cholangitis presents significant difficulties, they are due to the presence of a purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these moments requires prompt resolution, however, patients with obstructive jaundice do not tolerate long-term and traumatic surgical interventions. Therefore, it is advisable, first of all, to ensure an adequate outflow of bile, which simultaneously reduces the clinical manifestations of cholangitis, intoxication. The second stage is a radical intervention aimed at eliminating the cause of cholangitis. In the hospital, detoxification and antibacterial therapy is carried out and the patient is prepared for surgery. The most widespread in acute cholangitis are endoscopic methods of drainage of the bile ducts, which ensure the normal outflow of bile. The prognosis of catarrhal cholangitis with timely treatment is favorable. With purulent, diphtheritic and necrotizing cholangitis, the prognosis is more serious and depends on the severity of morfol. changes, the general condition of the patient, as well as from the factor that caused the cholangitis. With long-term chronic cholangitis, biliary cirrhosis of the liver or abscessed cholangitis may develop, the prognosis of which is poor. Prevention consists in the timely detection and treatment of diseases of the biliary tract and the area of the large duodenal papilla. For the purpose of decompression of the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual stones of the common bile duct after papillosphincterotomy, the discharge of calculi from the biliary tract is sometimes noted, the phenomena of cholangitis are stopped and the question of the need for a second operation disappears. The prognosis is serious. Cholecystitis is the main surgical intervention performed for acute cholecystitis. Removal of the gallbladder can present significant difficulties due to severe inflammatory changes in the surrounding tissues. Therefore, it is recommended to remove the bubble "from the bottom". Cholecystectomy, if indicated, should be supplemented with intraoperative examination of the extrahepatic bile ducts (cholangiography). When choledocholithiasis or stenosis of the terminal section of the common bile duct is detected, the same manipulations are performed that are usually done in similar cases during planned operations in patients with chronic calculous cholecystitis (choledochotomy, T-shaped drainage, etc.). A drainage is left in the abdominal cavity to control blood and bile leakage. The fatality rate after cholecystectomy performed for acute cholecystitis is 6-8%, reaching the streets of elderly and senile age 15-20%. tom and I with the removal of calculi and infected contents of the gallbladder is indicated in rare cases, as a forced measure in the general serious condition of the patient and massive inflammatory infiltration 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 the long term after the operation, as a rule, calculi form again in the gallbladder and the patients have to be operated on again.
Cholangitis- inflammatory process in the bile ducts (cholangiolitis - lesion of small bile ducts; cholangitis or angiocholitis - lesion of larger intra- and extrahepatic bile ducts; choledochitis - lesion of the common bile duct; papillitis - lesion of the Vater's nipple region).
Cholangitis classification(Yu.I. Fishzon-Ryss, I.A.Postrelov, 1985)
1. By etiology:
- 1.1. Bacterial.
- 1.2. Helminthic.
- 1.3. Toxic and toxic-allergic.
- 1.4. Viral.
- 1.5. Autoimmune.
2. Downstream:
- 2.1. Spicy.
- 2.2. Chronic.
3. By pathogenesis:
3.1. Primary (bacterial, helminthic, autoimmune).
3.2. Secondary and symptomatic:
3.2.1. On the basis of subhepatic cholestasis:
- 3.2.1.1. Stones of hepato-choledochus.
- 3.2.1.2. Cicatricial and inflammatory strictures of the main bile ducts and the greater duodenal nipple.
- 3.2.1.3. Malignant and benign tumors with occlusion of hepatocholedochus or large duodenal papilla.
- 3.2.1.4. Pancreatitis with compression of the common bile duct.
3.2.2. Due to diseases without subhepatic cholestasis:
- 3.2.2.1. Biliodigestive anastomoses and fistulas.
- 3.2.2.2. Insufficiency of the sphincter of Oddi.
- 3.2.2.3. Postoperative cholangitis.
- 3.2.2.4. Cholestatic hepatitis and biliary cirrhosis of the liver.
4. By the type of inflammation and morphological changes:
- 4.1. Catarrhal.
- 4.2. Purulent.
- 4.3. Obstructive.
- 4.4. Destructive, non-purulent.
5. By the nature of complications:
- 5.1. Liver abscesses.
- 5.2. Necrosis and perforation of hepatocholedochus.
- 5.3. Sepsis with extrahepatic purulent foci.
- 5.4. Bacterial toxic shock.
- 5.5. Sharp renal failure.
Most often, cholangitis is of a bacterial nature, the causative agents are most often Escherichia coli, enterococci, Friedlander's bacillus, pneumococci, streptococci.
HOLANGITIS ACUTE
Clinical symptoms. In the first stage, the main symptom is heat bodies with tremendous repetitive chills. The beginning is sudden, stormy. The body temperature rises daily or once every 2 to 3 days. Cramping pains in the right hypochondrium, vomiting are also characteristic. Severe weakness develops, blood pressure decreases. In the second stage, an enlargement of the liver joins the above symptoms, it is sharply painful, hepatic functional tests are disturbed, subictericity occurs, and then a slight jaundice. By the end of the first week, the spleen is enlarged. Pneumococcal cholangitis is especially difficult, most often complicated by the development of liver abscesses. In the third stage, if there is no improvement, a picture of liver failure with severe jaundice develops, at the same time pronounced changes in urine appear, urea and creatinine in the blood increase (hepatorenal syndrome), cardiac activity is significantly impaired (tachycardia, muffled heart sounds, arrhythmia, dystrophic changes myocardium on ECG), collapses are possible, pancreatitis often occurs. In the fourth, final, stage, severe hepatic-renal failure, coma, develops.
Acute catarrhal cholangitis is manifested by an increase in body temperature, chills, an increase and soreness of the liver, but the severity of intoxication does not reach a very severe degree. Purulent cholangitis is very difficult, characterized by severe intoxication up to the development of bacterial-toxic shock. Often the central nervous system in the form of prostration, confusion. Purulent cholangitis is often complicated by subphrenic, intrahepatic abscess, reactive exudative pleurisy and pleural empyema, lung abscess, peritonitis, endocarditis, pancreatitis.
Laboratory data.
- 1. OAK: moderate or high (more than 1.5-109 / l) leukocytosis, shift of the blood count to the left, toxic granularity of neutrophils, increased ESR.
- 2. LHC: an increase in the content of bilirubin with a predominance of the conjugated fraction, α2- and γ-globulins, transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, sialic acids, fibrin, seromucoid.
- 3. OA of urine: the appearance of protein, casts, bilirubin.
Chromatic fractional duodenal intubation... Serving B: large number of small columnar epithelium. Portion C: a decrease in the concentration of the lipid complex, an increase in the content of sialic acids, fibrin, transaminases, sowing of abundant bacterial flora, it is possible to detect a large number of leukocytes. Ultrasound examination - an increase in the size of the liver, heterogeneity of the acoustic picture, expansion of the intrahepatic bile ducts.
Examination program
1. OA of blood, urine, feces. Examination of urine for bile pigments. 2. LHC: total protein and its fractions, sialic acids, fibrin, seromucoid, transaminases, aldolase, alkaline phosphatase, bilirubin, γ-glutamyl transpeptidase, urea, creatinine. 3. Blood test for sterility. 4. Duodenal fractional probing with bacteriological examination of portions B and C and determination of the sensitivity of flora to antibiotics. 5. Ultrasound examination of the liver and biliary tract.
CHRONIC HOLANGITIS
Chronic cholangitis- chronic bacterial inflammation of the bile ducts (extrahepatic and intrahepatic).
Clinical symptoms. Latent form: pain and soreness in the right hypochondrium, blurred or absent, weakness, chills, subfebrile temperature body, occasionally itching, icterus of the skin and visible mucous membranes, gradual enlargement of the liver. Recurrent form: pain and soreness in the right hypochondrium on palpation, nausea, bitterness in the mouth, itching; in the period of exacerbation - jaundice, fever, prolonged subfebrile condition is possible; with prolonged course - thickening of the terminal phalanges in the form drum sticks and nails in the form of watch glasses, the liver and spleen are enlarged, dense. Prolonged septic form: severe course with fever, chills, pain in the right hypochondrium, enlarged liver, spleen, severe intoxication, kidney damage, jaundice. Resembles septic endocarditis. Sclerosing (stenosing) form: general weakness, malaise, fever, chills, pruritus, jaundice, enlarged liver, spleen; frequent combination with ulcerative colitis, Crohn's disease, vasculitis, thyroiditis.
In the late stages of chronic cholangitis, the development of biliary cirrhosis of the liver is possible.
Laboratory data the same as in acute cholangitis, but for chronic cholangitis, anemia is more natural.
Instrumental research the same as in acute cholangitis. Intravenous cholangiography or endoscopic retrograde pancreatocholangiography reveals dilated bile ducts (extra- and intrahepatic), with sclerosing cholangitis - intrahepatic ducts in the form of beads, often sharply narrowed with reduced branching, narrowing in some parts or throughout the common bile duct.
Examination program the same as in acute cholangitis. In addition, in difficult differential diagnostic cases, laparoscopy with cholangiography and targeted liver biopsy is necessary.
Diagnosis formulation
The diagnosis is formulated on the basis of the etiological and pathogenetic characteristics of cholangitis and its role in a number of other manifestations of the pathological process.
Primary cholangitis develop as an independent disease. Among them, primary sclerosing cholangitis should be distinguished - a disease of a presumably autoimmune nature. Eastern cholangitis, an insufficiently studied form endemic to some regions of Asia and possibly associated with clonorchiasis, is also described as the primary one. With secondary symptomatic cholangitis, the disease that served as a prerequisite for its development or is associated with it comes to the fore. True, with cholestatic hepatitis and primary biliary cirrhosis, it is not customary to stipulate the participation of cholangitis in the formation of the pathological process, but it is appropriate to imply. If cholangitis acts as an independent disease, it is advisable to reflect its primacy in the diagnosis. Thus, the isolation of such rare forms from the absolutely prevailing cases of secondary cholangitis is emphasized. Examples of wording a diagnosis
- 1. Acute primary bacterial cholangitis, sepsis, liver abscesses.
- 2. Gallstone disease (choledocholithiasis), exacerbation of secondary bacterial cholangitis.
CHOLANGITIS PRIMARY SCLEROSING
Primary sclerosing cholangitis (CPC) - chronic inflammatory disease liver, accompanied by fibrous obliteration of part of the bile ducts.
Etiology and pathogenesis of chronic heart disease not definitively established. Hypotheses are put forward about the connection of the disease with bacterial, viral, toxic factors, with thrombosis of the branches of the cystic artery. In recent years, much attention has been paid to the role of immune mechanisms and genetic factors in the development of CIL. In general, two concepts are being discussed. According to the first, CHD refers to autoimmune diseases, according to the second, it develops in individuals with a genetic predisposition, when the triggering factor is any infection or a toxic process. In CHD patients, the HLA Be, DR3 haplotype is more often found and, very rarely, B12.
Clinical symptoms
Mostly young men are ill. Patients complain of weakness, fatigue, pain in the right hypochondrium, epigastrium, nausea, weight loss, fever up to low-grade fever, jaundice, itching of the skin. On examination, icterus is found, with severe portal hypertension - varicose veins of the anterior abdominal wall, ascites, edema. Hepatomegaly is determined. A sharp deterioration in the course of the disease in the form of clear signs of obstructive cholangitis (increased cholemia, fever with chills, severe pain in the right hypochondrium) indicates the development of complications of the disease: choledocholithiasis, acute bacterial cholangitis, carcinoma of the bile ducts.
ChPS is often combined with ulcerative colitis, severe fibrosis of the mediastinum, retroperitoneal space, thyroid gland(Riedel's thyroiditis), pancreas (chronic pancreatitis, diabetes mellitus), less often with Crohn's disease, autoimmune thyroiditis, thyrotoxicosis, hypothyroidism, SLE, rheumatoid arthritis, ankylosing spondylitis, Sjogren's disease.
Diagnostic criteria
The presence of obstructive jaundice of the progressive type; absence of stones in the biliary tract (previously no operations were performed in the hepatobiliary zone); detection of widespread thickening and narrowing of the extrahepatic bile ducts during laparotomy, the patency of their intrahepatic sections is confirmed by operating cholangiography; absence of malignant neoplasms; exclusion of primary biliary cirrhosis of the liver, filed by morphological examination of liver biopsy.
Laboratory data
- 1. OAK: increased ESR, signs of anemia, leukocytosis.
- 2. Urine analysis - positive reaction for bilirubin.
- 3. BAC: increased blood levels of alkaline phosphatase, bilirubin (mainly conjugated), alanine amine transferase.
Instrumental research
Laparoscopy: liver in initial stages may look unchanged, subsequently cirrhosis is formed. Its color is from dark cherry to green, but less intensity than with subhepatic cholestasis. On the surface of the liver, stellate retractions are detected, combined with pronounced fibrosis, small nodes of purple-red or black color, resembling metastases. In advanced stages, a "large green liver" is observed macroscopically due to chronic cholestasis, but on its surface there are no dilated bile capillaries characteristic of obstructive jaundice. Retrograde endoscopic cholangiopancreatography: the simplest and most convenient type of examination to confirm the diagnosis. Cholangiograms show bead-like changes in large intrahepatic bile ducts, combined with depletion of small intrahepatic ducts (a picture resembling a "dead" tree). Described are characteristic, chaotically scattered, short finger-like constrictions, replaced by bile ducts of normal size and combined with common strictures, diverticulum-like protrusions and microectases, which causes unevenness of the walls of the ducts. In addition to the intrahepatic biliary tract, the extrahepatic biliary tract is also affected. Absence of supra-stenotic expansion - important sign CHD, distinguishing it from secondary cholangitis. Liver biopsy: fibrotic inflammation of the bile ducts.
Examination program
1. OA of blood, urine, urinalysis for urobilin, bilirubin. 2. BAC: bilirubin, transaminases, alkaline phosphatase, total protein and protein fractions, cholesterol. 3. II blood: T- and B-lymphocytes, immunoglobulins, CEC. 4. Laparoscopy with targeted liver biopsy. 5. Retrograde endoscopic cholangiopancreatography (if it is impossible to perform laparoscopy with targeted liver biopsy).
Diagnostic reference book of the therapist. Chirkin A.A., Okorokov A.N., 1991
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 / Causes of Cholangitis:
The condition for cholangitis is stagnation of bile and the presence of infection. There are many reasons that prevent the flow of bile. Obstruction of the bile ducts, as a result of the primary pathological process, contributes to the occurrence of biliary hypertension, a change physical and chemical properties 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. 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. microflora found in associations Most often cholangitis is of bacterial nature, among the pathogens representatives of the enterobacteriaceae family are found (E. coli, Klebsiellaspp., Serratiespp., Proteusspp., Enterobacterspp., Ac inetobacterspp.), gram-positive microorganisms (Streptococcus, Enterococcus), non-spore-forming anaerobes (Bacteroidesspp., Clostridiumspp., fusobacteria, Pseudomonasspp., etc.).
Bacterial cholangitis tends to rise and spread to the intrahepatic ducts. In a severe course of the disease, the development of empyema of the gallbladder, hepatitis, liver abscesses, septicemia, pylephlebitis, subdiaphragmatic abscess, peritonitis, cicatricial-inflammatory stenosis of large bile ducts can be observed.
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 Charcot 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 of the disease are accompanied by the development of sepsis, complicated by 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 is variable 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 - severe 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. In the clinical analysis of blood, neutrophilic leukocytosis with a left shift, an increase in CO is determined. Biochemical research shows an increase in the level of bilirubin, triglycerides, the activity of alkaline phosphatase, AST, ALGHTP, a decrease in the content of total protein and albumin, and 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. In the general analysis of urine, there is an increase in the level of urobilin, bile pigments. Duodenal fractional probing with bacteriological examination of portions B, C and determination of the antibiotic sensitivity 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). In the process of effective treatment, their lumen narrows, the wall becomes thinner 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 perform intravenous cholangiography or endoscopic retrograde cholangiopancreatography, which can be used to identify the expansion of the bile ducts. If it is impossible to conduct these studies, percutaneous transhepatic cholangiography (PTCC) 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 leader etiological factor and the relationship of this process with the presence of calculi in the gallbladder and bile ducts.
In 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 the treatment. Cholangitis treatment should primarily focus on eliminating bile stagnation and fighting infection.
In acute obstructive cholangitis, it is advisable to use broad-spectrum antibiotics to target the family of enterobacteriaceae 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 has a 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 a bactericidal effect 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.
Fluoroquinolones are the drugs of choice in the treatment of severe cholangitis caused by microorganisms resistant to most antibacterial agents.
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.
It is advisable to have a scheme including an aminoglycoside (amikacin 0.5 g every 12 hours intravenously in combination with 1.0 g ampicillin every 6 hours intramuscularly and metronidazole 0.5 g every 8 hours intravenously).
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 4.5 g after 8 hours IV, ampicillin / sulbactam 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 i.v. or meropenem 1 g every 8 h i.v.). These drugs are used as empiric therapy in patients who are in critical condition in the presence of E. coli, Acinetobacterspp, Paeruginosa.
Fluoroquinolones (ciprofloxacin, ofloxacin, mefloxacin) are also used for the isolation of strains resistant to most antibiotics or for 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-NOK, 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. Duration antibacterial 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,
- for 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 underlying 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.
Which doctors should you contact if you have Cholangitis:
Gastroenterologist
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Other diseases from the group Diseases of the gastrointestinal tract:
| Grinding (abrasion) of teeth |
| Abdominal trauma |
| Abdominal surgical infection |
| Oral abscess |
| Adentia |
| Alcoholic liver disease |
| Alcoholic cirrhosis of the liver |
| Alveolitis |
| Angina Jensul - Ludwig |
| Anesthetic management and intensive care |
| Ankylosis of teeth |
| Anomalies of the dentition |
| Tooth position anomalies |
| Developmental anomalies of the esophagus |
| Tooth size and shape abnormalities |
| Atresia |
| Autoimmune hepatitis |
| Achalasia cardia |
| Achalasia of the esophagus |
| Stomach bezoars |
| Disease and Budd-Chiari Syndrome |
| Veno-occlusive liver disease |
| Viral hepatitis in chronic hemodialysis patients with chronic renal failure |
| Viral hepatitis G |
| Viral hepatitis TTV |
| Intraoral submucosal fibrosis (oral submucosal fibrosis) |
| Hairy leukoplakia |
| Gastroduodenal bleeding |
| Hemochromatosis |
| Geographic language |
| Hepatolenticular degeneration (Westphal-Wilson-Konovalov disease) |
| Hepatolienal syndrome (hepato-splenic syndrome) |
| Hepatorenal syndrome (functional renal failure) |
| Hepatocellular carcinoma (HCC) |
| Gingivitis |
| Hypersplenism |
| Gingival hypertrophy (gingival fibromatosis) |
| Hypercementosis (ossifying periodontitis) |
| Pharyngeal-esophageal diverticula |
| Hernia of the esophageal opening of the diaphragm (POD) |
| Acquired esophageal diverticulum |
| Stomach diverticula |
| Diverticula of the lower third of the esophagus |
| Diverticula of the esophagus |
| Diverticula of the esophagus |
| Diverticula of the middle third of the esophagus |
| Dyskinesia of the esophagus |
| Dyskinesia (dysfunction) of the biliary tract |
| Liver dystrophies |
| Sphincter of Oddi dysfunction (postcholecystectomy syndrome) |
| Benign non-epithelial tumors |
| Benign neoplasms of the gallbladder |
| Benign liver tumors |
| Benign tumors of the esophagus |
| Benign epithelial tumors |
| Cholelithiasis |
| Fatty hepatosis (steatosis) of the liver |
| Malignant neoplasms of the gallbladder |
| Malignant tumors of the bile duct |
| Foreign bodies of the stomach |
| Candidal stomatitis (thrush) |
| Caries |
| Carcinoid |
| Cysts and aberrant tissues in the esophagus |
| Speckled teeth |
| Upper digestive tract bleeding |
| Xanthogranulomatous cholecystitis |
| Leukoplakia of the oral mucosa |
| Medicinal liver damage |
| Medicinal ulcers |
| Cystic fibrosis |
| Mucocele of the salivary gland |
| Malocclusion |
| Development and eruption of teeth |
| Tooth formation disorders |
| Hereditary coproporphyria |
| Hereditary violation of the structure of enamel and dentin (Stanton-Capdepon syndrome) |
| Non-alcoholic steatohepatitis |
| Liver necrosis |
| Pulp necrosis |
| Emergencies in gastroenterology |
| Obstruction of the esophagus |
| Osteogenesis imperfecta of teeth |
| Examination of patients in emergency surgery |
| Acute delta superinfection in hepatitis B virus carriers |
| Acute intestinal obstruction |
| Acute intermittent porphyria |
| Acute violation of mesenteric circulation |
| Acute gynecological diseases in the practice of a surgeon |
| Acute bleeding from the digestive tract |
| Acute esophagitis |
| Acute alcoholic hepatitis |
| Acute appendicitis |
| Acute apical periodontitis |
| Acute acalculous cholecystitis |
| Acute viral hepatitis A (AHVA) |
| Acute viral hepatitis B (AVHV) |
| Acute viral hepatitis B with delta agent |
| Acute viral hepatitis E (OVHE) |
| Acute viral hepatitis C |
| Acute gastritis |
| Acute gingivitis |
| Sharp belly |
| Acute pericoronitis |
| Certain types of intestinal obstruction |
| Edematous ascites syndrome |
| Periodontal disease |
| Pathological resorption of teeth |
| Peptic ulcer, unspecified |
Among diseases of the digestive tract, cholangitis is one of the most difficult pathologies in terms of diagnosis and treatment. There are several different forms of this disease, which differ in symptoms and causes. Some of them run latently and do not have a specific reason. All these factors complicate the definition of the disease and "postpone" the time of initiation of therapy.
What can this lead to? Here is an incomplete list of complications: sepsis (blood poisoning), cirrhosis of the liver, cancer of the bile duct or bladder, infectious toxic shock, etc. Each of these conditions arises either due to the lightning-fast course of the pathology, or when it is untimely diagnosed. How to suspect a disease in the initial stages and start correct treatment, you can find out from this article.
What is cholangitis and the basics of anatomy
The literal translation of the word "Cholangio" from the Latin language is "bile vessel". Accordingly, cholangitis is an inflammatory process in any of these vessels. A person has a complex network of ducts of various sizes through which bile flows. This network begins with the liver and ends in the intestines, where fats are digested and harmful microbes are destroyed.
Simplified, the path of this biological fluid can be described by the following stages:
- While eating or special medicines, bile begins to form in the lobules of the liver. Then it enters the intrahepatic bile capillaries;
- From all over the liver, capillaries collect in two large ducts - one for each organ lobe (right and left);
- From these formations, a common hepatic duct, to which the gallbladder joins through the cystic duct. Together, these two structures form a large "collector" of bile - Choledoch (synonymous with common bile duct);
- The common bile duct opens into the duodenum and secretes the required amount of bile. Unused leftovers return to the bubble along the same path.
Cholangitis symptoms occur when intrahepatic or extrahepatic structures are involved, which are involved in the release of bile components.
Disease types
As we have said, the signs of cholangitis can differ significantly in different forms of the disease. For convenience, doctors share this pathology according to two main criteria - the duration of the course and the type of inflammation. These nuances are fundamentally important, since they determine the optimal time for the provision of care (emergency / planned), the doctor's tactics and the need for surgery.
Depending on the duration of the course, the following pathology options are distinguished:
- Fulminant or fulminant. The most severe and dangerous form, in which all signs of the disease and blood poisoning appear suddenly and rapidly progress (within a few hours). Fulminant ends in death in 90-100% of cases, even despite timely and qualified medical assistance;
- Spicy... The most common option in which typical symptoms developing within 1-2 days;
- Chronic... The most difficult option to diagnose. It can arise on its own or in the outcome of an acute form. In this case, the clinical picture is often erased - often the only complaint of patients is loose stools or recurrent abdominal pain.
The second fundamental point in determining the form of pathology is the type of inflammatory process. In any diagnosis, this nuance is necessarily indicated, since further treatment tactics depend on it. Currently, doctors identify the following options:
| Disease form | a brief description of | Acute or Chronic? |
| Serous | The most favorable variant of pathology, in which blood poisoning is extremely rare. There is no pus in the duct cavity - inflammation is manifested by an increase in the production of serous fluid. |
It can be acute and chronic, but the first option is more common. |
| Fibrinous-serous | It proceeds by analogy with the serous form. The main difference lies in the course of the inflammatory process - in addition to fluid, protein (fibrinous) overlays are present in the organ. |
|
| Purulent | Severe form, in which there is a large number of bacteria and inflammation proceeds aggressively. With it, the development of sepsis is often noted and an infectious-toxic shock may occur. |
Typically spicy. |
| Necrotic | It is the final stage of purulent cholangitis, in which the walls of the organ begin to die off. The greatest danger is the possibility of penetration of particles of dead tissue, bile and pus into the blood. The natural result of this is the development of blood poisoning and shock. |
Only spicy. |
| Sclerosing | A latent, slowly progressive form of pathology, in which there are practically no characteristic signs. Dangerous by the development of severe irreversible liver damage, up to biliary cirrhosis. | Only chronic. |
Causes of occurrence
The greatest role in the occurrence of cholangitis (all except for sclerosing) is played by the presence of two factors - a harmful microorganism and stagnation of bile. What leads to their occurrence? The bacterium that causes the inflammatory process can enter the ducts from the gallbladder or from the intestinal cavity. That is why cholangitis is often found after acute cholecystitis, in the presence of intestinal (small intestinal) insufficiency or biliodhistivny reflux - the reflux of intestinal contents into the duct system.
Stagnation of bile appears when its outflow is disturbed. This situation can occur under the following conditions:
- Blockage of the duct with a stone against the background of gallstone disease;
- Development of acute pancreatitis and edema of the head of the pancreas;
- The presence of a tumor compressing the common bile duct or preventing the outflow of bile;
- Strictures (pronounced narrowing) of the biliary tract;
- The defeat of the Fatter nipple - the place where the lumen of the common bile duct and pancreatic duct opens.
Separately, it is necessary to say about the causes of sclerosed cholangitis. This form is different from all the others. It is not possible to unequivocally determine the cause of its development, even at the modern level of medicine. Most doctors believe that the disease occurs when an autoimmune process develops.
Due to the "error" of immunity, in which the protective cells begin to produce antibodies against healthy tissues, the tissue of the ductal system is affected. Prolonged sluggish inflammation leads to overgrowth connective tissue, narrowing of the lumen and impaired outflow of bile. Intrahepatic bile capillaries are a frequent "target" of this disease, which often leads to the formation of cirrhosis of the liver.
Symptoms
As already mentioned, this disease is quite difficult to diagnose. One form can manifest itself in different ways in two identical patients, disguise itself as another pathology, or even proceed latently. However, there are certain signs that suggest a correct diagnosis.
It should be remembered that the symptoms that bother a person can differ significantly in acute and chronic course. Sclerosing primary cholangitis also has its characteristic features, which will be described below.
Sharp option
Cholangitis treatment, in this case, is carried out only in a surgical hospital. This is a life-threatening condition, which, if untimely treatment for medical help or inadequate therapy can lead to blood poisoning 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 manifestations of the disease on your own.
Unlike most other pathologies, with inflammation of the biliary tract, doctors are not looking for individual symptoms, but their specific combination. For this condition, the appearance of the following complex of signs in a person is most characteristic:
- Increased body temperature... As a rule, the fever builds up in a few hours and lasts for enough high level(38-40 about C). Patients experience severe weakness, chills and headache. Often a person has heavy sweating, because of which he can lose a large amount of fluid per day. In some patients, fever can have a "spasmodic" course and change by 1-2 ° C throughout the day. Such temperature fluctuations exhaust a person, his health deteriorates so much that it is difficult for him to get out of bed. Consciousness is clouded, there is no appetite, fainting may occur;
- Jaundice / compulsive itching of the skin... These two symptoms have the same origin and are associated with the retention of bilirubin in the body. Bilirubin is a toxic substance formed after the breakdown of blood cells and excreted along with urine and bile. Since inflammation of the biliary system leads to a violation of this process, bilirubin compounds begin to be deposited in various tissues. Their deposition in the skin leads first to severe obsessive itching, and then to a change in its color. The ingestion of bilirubin in the sclera explains the yellow tinge of the eyes (around the iris). An attempt by the body to remove a toxic substance with urine is manifested by its darkening - up to the color of "dark beer";
- Pain in the right side of the abdomen(directly under the ribs). This place corresponds to the approximate location of the bladder and common bile duct. If a person finds it difficult to determine the area where the discomfort is located, a simple test can be carried out - with the edge of the palm, knock on the lower edge of the costal arches on the right and left. With cholangitis / cholecystitis, the pain intensifies with tapping on the right.
The listed complaints can be supplemented by a number of other pathological signs: a decrease in blood pressure of less than 90/60 mm Hg; the appearance of a feeling of palpitations; an increase in the pulse rate of more than 90 beats / min, etc. However, a combination of the above three manifestations of the disease is specific for this disease.
Chronic form
It is much more difficult to suspect and confirm the presence of this form than to diagnose acute cholangitis in a person. The fact is that in a chronic course, pathology can slightly disrupt a person's well-being, and he does not seek medical help. An additional difficulty is the variety of manifestations of pathology - for this form, no characteristic combination of symptoms was found. Each patient has an individual course of the disease.
The only meaningful clue can be the patient's past, or rather, the operations carried out and concomitant diseases:
- After removal of the gallbladder (an operation called "cholecisectomy"), every third patient develops chronic cholangitis;
- The presence of gallstone disease significantly increases the risk of this disease;
- An acute process transferred in the past can lead to the emergence of a chronic variant of the disease.
People with the listed risk factors are most susceptible to this pathology. It is possible to suspect they have a lingering inflammatory process in the ducts if you have the following complaints:
- Stool disorder. Characterized by the appearance of a liquid / mushy stool with a light color, having a shiny surface, it is difficult to wash off from the walls of the toilet bowl;
- Jaundice or itching of the skin, which occurs mainly in the evening and at night;
- Pain in the upper abdomen. In most cases, discomfort is located in the right hypochondrium, however, they can be located on the left or in the middle between the ribs (in the epigastric region);
- Development of asthenovegetative syndrome - constant weakness, decreased performance, weight loss;
- The appearance of fever for an unknown reason;
- Feeling "overwhelmed", chills in the afternoon;
- Bitter taste in the mouth, mainly after eating.
Sclerosing primary cholangitis (PSC)
A few statistical facts about this form:
- In 55% of people, this disease occurs without symptoms or with minimal manifestations;
- In 20-60% of cases, the disease is detected only at the stage of the onset of liver cirrhosis;
- Up to 20% of patients with PSC suffer from cholangiocarcinoma (malignant tumor), which developed as a result of the 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 seeking 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.
| Risk group |
|
| Diseases - "satellites" of PSC In 60-70% of patients, inflammation of the ducts is combined with other chronic lesions of the digestive tract. |
|
| Early symptoms of the disease |
|
| Late stage symptoms | Any symptoms characteristic of the classic chronic form. |
| Possible complications |
|
Diagnostics
To confirm the diagnosis, a whole complex of laboratory and instrumental research... Most of them can be performed in any multidisciplinary clinic with standard laboratory equipment.
But, unfortunately, in most provincial cities medical institutions not even equipped to the standard minimum. In this case, the doctor cannot prescribe necessary examinations therefore patients often have to go to private clinics / laboratories.
Laboratory diagnostics
| Study type | Normal indicators | Possible changes | |
| Clinical blood test | ESR | Up to 15 mm / hour | In an acute process, an increase in all of the listed indicators occurs. Against the background of a chronic course clinical analysis blood may remain within normal limits (with the exception of ESR). |
| Leukocytes | 4.1-9.0 * 10 9 cells / l | ||
| Neutrophils |
or 2.0-5.4 * 10 9 cells / l |
||
| General urine analysis | Bilirubin | Negatively | |
| Blood chemistry | C-reactive protein | Up to 5 mg / l | |
| Total bilirubin | 5.1-17 μmol / l | ||
| Direct (linked) bilirubin | 1.7-5.0 μmol / l | ||
| GGTP |
Men 10-50 U / l; Women 7-31 U / l |
||
| Alkaline phosphatase |
Or 0.5-2.0 μkat / l |
||
| Serum immunoassay (for PSC diagnostics only) | Antinuclear antibodies | Titre less than 1/160 | With a sclerosing variant of the pathology, an increase in the titer of the listed antibodies occurs. |
| Anti-smooth muscle autoantibodies | Titre less than 1/40 | ||
| PANCA analysis | |||
Instrumental examinations
MRCP
At the moment, MRCP - magnetic resonance cholangiopancreatography - is considered the "gold standard" among hardware research methods. Despite the complex name, the principle of this survey is quite simple. A special substance is injected into the blood of a person that stains the ducts of the biliary system and the gallbladder, they are studied on an MRI machine.
It should be noted that this method is safe for a person, does not irradiate his body with X-rays and requires the use of special surgical instruments. It does not require hospitalization - the procedure itself takes 15-30 minutes and can be performed on an outpatient basis. There are not so many contraindications to MRCP, these include:
- Allergy to contrast agent;
- The presence of certain implants in the body: pacemakers, cochlear implants, intravascular stents and metal clips in the brain. If there are other artificial devices in the body, you must first consult with the doctor performing the examination. He will analyze the situation and determine the possibility of diagnostics.
Preparation for the examination includes refusing to eat and drink a few hours before the procedure. Also, immediately before the examination, you must remove all metal accessories and clothing items. If additional training is required, the attending physician advises the patient individually before the examination.
Other research methods
Despite the fact that MRCP is recommended as the main diagnostic method, not every hospital has an MRI machine and trained specialists in its state. As alternative methods detecting the disease, doctors may recommend the following instrumental examinations:
| Procedure name | Principle of carrying out | Preparation for the examination |
| Abdominal ultrasound | Using an ultrasound probe, the doctor examines the gallbladder and common bile duct. The study is completely safe and does not bring significant discomfort to a person. Lack of technique- inability to inspect small bile ducts. In case of pathology, the doctor can detect the presence of a stone in the lumen of the biliary tract or an expansion of the common bile duct (more than 6 mm). |
|
| Endoscopic retrograde pancreato-cholangiography (abbreviated ERCP) | In the recent past, this method was the main one in the diagnosis of diseases of the biliary system. It is performed as follows:
The main disadvantage- high likelihood of complications after the procedure. The most common of them is damage to the end section of the common bile duct (Vater's papilla) and the development of pancreatitis. |
|
| Percutaneous transhepatic cholangiography (abbreviated as PTC) | The method is similar in principle to ERCP. The biliary tract is filled with contrast and an x-ray is taken. The main difference is in the method of delivery of the contrast medium - with the frequency response, the doctor injects it directly into the duct, passing the needle through the skin and liver under ultrasound control. The main disadvantage- the ability to injure internal organs. |
Treatment
In the treatment of this disease, there are several fundamental points 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;
- Each patient with an acute process potentially requires surgery to restore the 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 of 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.
Acute cholangitis treatment
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, continues drug treatment... 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.
Chronic therapy
When detecting this type of disease, the doctor first of all tries to deduce the cause of chronic inflammation. It is this nuance that determines the further treatment tactics. There may be several options:
In addition to specific treatment, to all patients with chronic forms diseases are recommended:
- 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 during prolonged inflammation of the biliary system.
Time of incapacity for work
Since the vast majority of patients with cholangitis are students or able-bodied people, this issue needs to be addressed. At spicy version, the length of stay in the hospital is 10-30 days, depending on the condition 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 restore the body.
As for chronic cholangitis, at the moment, there are no unequivocal recommendations. In each case, the doctor himself determines the duration of the patient's disability, depending on his health and the possibility of therapy.
FAQ
Question:
How life-threatening is this disease?
Inflammation of the duct system is a life-threatening condition in which there is always the possibility of developing sepsis, irreversible damage to the liver and other organs.
Question:
What diseases can occur under the “mask” of cholangitis?
In some cases, similar symptoms can be found in acute pancreatitis, against the background of acute / exacerbation of chronic cholecystitis. To correctly diagnose, it is enough to use laboratory and instrumental research methods described above.
Question:
Is it possible to diagnose "acute cholangitis" only by symptoms and ultrasound data?
With a combination of typical signs of pathology (fever, jaundice, pain) and expansion of the common bile duct by more than 6 mm according to the results of ultrasound, the diagnosis is considered justified.
Question:
What kind of operation can a doctor perform in case of an acute course of the disease?
The main goal of surgery is to restore the normal outflow from the common bile duct 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 inserted into the oral cavity and moves along the digestive tract, the doctor enters the common bile duct, through its mouth in the duodenum;
- Percutaneous transhepatic drainage... Under the control of an ultrasound machine, the surgeon penetrates the common bile duct with a needle through the skin and liver tissue and installs a drainage - a thin tube to create an outflow of bile;
- Open way... It is used extremely rarely. The doctor cuts the tissue in layers, starting with the skin in the upper abdomen, and then secretes a large bile duct and installs drainage. There is a variant of this operation, in which, instead of a large incision, the surgeon makes only 2-3 small wounds for endoscopic instruments. It is with the help of them that drainage is carried out.
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