Methods and methods for the diagnosis of acute cholecystitis. Acute cholecystitis and acute pancreatitis: differential diagnosis Acute cholecystitis differential diagnosis table

Date: 26.06.2020

Differential diagnosis of gallstone disease should be carried out with acute appendicitis, gastric ulcer and duodenal ulcer, biliary dyskinesia, pancreatitis.

1. Acute appendicitis.

In acute appendicitis, the pain is sudden, constant, dull, often occurs in the evening and night hours, of moderate intensity, localized at the onset of the disease in the epigastric region (Kocher's symptom), less often in the peri-umbilical region (Kummel's symptom) or throughout the abdomen. Subsequently, within 2 - 12 hours, it moves to the right iliac region (Volkovich's symptom). Characterized by the absence of pain irradiation (except for the pelvic, retrocecal and subhepatic location of the appendix), wavy nausea and at least two vomiting after the onset of pain, stool retention, increased heart rate. Positive symptoms of Rovzing, Razdolsky, Sitkovsky, Voskresensky, Obraztsov, Krymov. The patient's pain is inconsistent, cutting in nature, localized in the right hypochondrium and radiating to the lower back. Symptoms of acute appendicitis are negative, which makes it possible to exclude this pathology.

2. Duodenal ulcer.

Pain in duodenal ulcer disease is of a daily and rhythmic nature (hungry, night pain), during an exacerbation, prolonged pain lasting 3-4 weeks is characteristic. This patient is characterized by pain associated with the intake of fatty, "heavy" food, are of short duration. Soreness is localized in the right hypochondrium. The secretory function of the stomach, as a rule, remains normal, and with duodenal ulcer, a hyperacid state is usually observed. Bleeding in duodenal ulcer disease has, as a rule, characteristic manifestations: vomiting in the form of "coffee grounds", melena, blanching of the skin, and in this patient these manifestations are not observed. Vomiting and bleeding are absent. Based on the above phenomena, data from instrumental studies, the diagnosis of duodenal ulcer is excluded.

3. Stomach ulcer.

With gastric ulcer, pain occurs immediately after eating or 15-45 minutes after eating. Relief in this condition can be brought about by evacuation of gastric contents. This patient is characterized by pain associated with the intake of fatty, "heavy" food, physical exertion, psycho-emotional stress. Localization of pain in peptic ulcer disease, as a rule, between the xiphoid process and the umbilicus, more often to the left of the midline, irradiation to the left half of the chest, to the interscapular region. In this patient, the pain is localized in the right hypochondrium. Soreness is located at a characteristic point - the projection point of the gallbladder, Ortner's symptom is also positive. Consequently, this patient has no characteristic signs for gastric ulcer, which is confirmed by the data of esophagogastroduodenoscopy.

4. Dyskinesia of the biliary tract.

Dyskinesias of the biliary tract combine a variety of functional disorders of the biliary system, in which signs of organic lesions (inflammation or stone formation) are not clinically established. The development of dyskinesia is based on violations of the complex innervation of the biliary tract sphincters. Clinically, biliary dyskinesias are characterized by recurrent biliary colic, which can be significant and mimic cholelithiasis. Painful attacks often occur in connection with strong emotions and other neuropsychic moments; less often they appear under the influence of significant physical exertion. With dyskinesias of the biliary tract, the connection between the occurrence of pain syndrome and negative emotions, the absence of tension of the abdominal wall during biliary colic, negative results of duodenal intubation, and mainly the data of contrast cholecystography, which does not reveal calculi, stand out more clearly.

5. Pancreatitis.

Pancreatitis is an inflammation of the pancreas. Pancreatitis is characterized by attacks of pain, which may be preceded by dyspeptic symptoms. Pain can have different localization depending on which part of the organ is involved in the pathological process. When the head of the gland is damaged, they are localized in the epigastric region or in the right hypochondrium, when the body of the gland is damaged in the epigastric region, with diffuse damage - throughout the upper abdomen. Pain usually radiates posteriorly to the lumbar region, scapula. On external examination, jaundice may be detected. Differential diagnosis is facilitated by a peculiar localization of pain in the left side of the epigastric region, to the left of the navel, radiating to the back, to the left side of the spine, which is characteristic of pancreatic diseases and is usually not observed in cholelithiasis. The high content of diastase in the urine in acute pancreatitis is also important.

Etiology and pathogenesis.

Gallstone disease is considered as a polyetiological disease. The question of the cause of stone formation is currently not fully understood.

Most authors attribute the following to the main causes of stone formation:

Violation of the physical and chemical composition of bile.

With gallstone disease, there is a change in the normal composition of bile - cholesterol, lecithin, bile salts. Micellar structures, consisting of bile acids and lecithin, contribute to the dissolution of cholesterol in bile, which is part of the micelles. In micellar structures, there is always a certain limit of cholesterol solubility. When the amount of cholesterol in bile exceeds the limits of its solubility, bile becomes oversaturated with cholesterol, and cholesterol precipitates. The lithogenicity of bile is characterized by the lithogenicity index, which is determined by the ratio of the amount of cholesterol (IL) in the bile under study to the amount of cholesterol that can be dissolved at a given ratio of bile acids, lecithin, and cholesterol. Silt, equal to one, shows the normal saturation of bile, above one - its oversaturation, below one - its unsaturation. Bile becomes lithogenic with the following ratio changes:

- an increase in cholesterol concentration (hypercholesterolemia);
- a decrease in the concentration of phospholipids;
- a decrease in the concentration of bile acids.

It has been established that in the body of patients with a significant degree of obesity, bile oversaturated with cholesterol is produced. The secretion of bile acids and phospholipids in obese patients is greater than in healthy individuals with normal body weight, but their concentration is insufficient to keep cholesterol in a dissolved state. The amount of secreted cholesterol is directly proportional to body weight and its excess, while the amount of bile acids largely depends on the state of enterohepatic circulation and does not depend on body weight. The consequence of this imbalance is oversaturation with bile in obese people.

J. Deaver (1930) described the principle of five F, according to which one can suspect patients with gallstones: female (woman), fat (full), forty (40 years and older), fertile (had pregnancy), fair (blonde). As can be seen from the above, this principle is not devoid of pathogenetic foundations.

The reasons leading to a decrease in the flow of bile acids into bile can be divided into the following groups:

- primary impairment (decrease) in the synthesis of bile acids and impaired feedback mechanisms regulating the synthesis of bile acids: impaired liver function, poisoning with hepatotropic poisons, taking hormonal contraceptives, chronic hepatitis, various forms of liver cirrhosis, pregnancy, increased levels of estrogen hormones;
- violation of enterohepatic circulation of bile acids (significant losses of bile acids occur during resection of the distal small intestine, diseases of the small intestine); another mechanism for excluding bile acids from the circulation - their deposition in the gallbladder - is observed with atony of the gallbladder, prolonged starvation.

Stagnation of bile.

By itself, the presence of a gallbladder ("bile sediment") in the biliary system is a predisposing factor for bile stagnation. In addition to this, in case of gallstone disease, it is often (in 65 - 80%) that it is possible to reveal a dysfunction of the gallbladder. Disruption of the coordinated work of the sphincters causes dyskinesias of various types. Allocate hypertensive and hypotonic (atonic) dyskinesias of the bile ducts and gallbladder. With hypertensive forms of dyskinesia, an increase in the tone of the sphincters occurs. So, a spasm of the common part of the sphincter of Oddi (Westphal fibers) causes hypertension in the ducts and gallbladder. An increase in pressure is associated with the entry of bile and pancreatic juice into the ducts and gallbladder, while the latter can cause a picture of enzymatic cholecystitis. A spasm of the cystic duct sphincter is possible, which also causes congestion in the bladder. In hypotonic (atonic) forms of dyskinesia, the sphincter of Oddi relaxes, followed by reflux of the contents of the duodenum into the bile ducts (duct infection occurs). At the same time, against the background of atony and poor emptying of the gallbladder, congestion and an inflammatory process develop in it. In both hypertensive and hypotonic form of dyskenisia, there is a violation of the evacuation of bile from the gallbladder and ducts, which is a favorable factor for stone formation in the biliary system.

Biliary tract infections.

In addition to increasing the lithogenicity of bile, the initiating factor in the formation of gallstones is the inflammatory process in the mucous membrane of the gallbladder. As a result of inflammation, microparticles enter the lumen of the bladder, which are a matrix for the deposition of crystals of a substance in a supersaturated state on them. Inflammation of the gallbladder can be the result of bacteriocholia against the background of various forms of dyskinesia of the biliary tract and gallbladder, which cause stagnation of bile. Bile does not possess bactericidal properties, which is explained by its alkaline reaction. Inflammation can be aseptic in nature - with various allergic, autoimmune reactions, as well as when pancreatic juice is thrown into the bile ducts and gallbladder.

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Acute cholecystitis is an inflammation of the gallbladder that occurs when the normal movement of bile is suddenly disrupted when its outflow is blocked. In this condition, pathological violations of the walls of the organ may also occur.

Very often, in almost 90% of cases, the disease is combined with stones in the gallbladder (calculi), and in 60% of patients, bile is also infected with various pathogenic bacteria.

Methods for the diagnosis of acute cholecystitis

Many methods are used to accurately diagnose the disease. Diagnostics is always carried out in a comprehensive manner, since only in this case it is possible to accurately identify the disease, because its symptoms almost completely coincide with other ailments of the digestive system.

First of all, the doctor conducts a detailed conversation with the patient., during which he finds out the specifics of the existing symptoms, the peculiarities of the person's lifestyle, specific complaints and everything that worries the patient. After that, the doctor directs the patient for additional examinations, as well as for consultations with some specialists, in particular, a surgeon.

Each patient receives a referral to a surgeon's consultation if there is a suspicion of cholecystitis.

The doctor can also refer the patient to consultations with related specialists, such as an infectious disease specialist, a pulmonologist, a gastroenterologist and a cardiologist. Consultations of related specialists in most cases are necessary in cases where difficulties arise in making a certain diagnosis.

Also, the patient is sent for laboratory diagnostics, analyzes and hardware diagnostics by various methods.

Laboratory research

If there is a suspicion of cholecystitis in a patient, the doctor necessarily directs him to take tests and conduct certain studies, since one conversation with the patient and identifying the existing symptoms will not be enough to make an accurate diagnosis.

In addition to basic tests, the doctor may prescribe additional studies, for example, determining the level of glucose in the blood, the amount of bilirubin and its fractions, the level of alkaline phosphatase, protein fractions and total protein, the amount of cholesterol and amylase in the blood serum.

Instrumental diagnosis of acute cholecystitis

Instrumental diagnostics includes several different procedures at once, allowing you to accurately identify the presence of the disease and the features of its course.

If a patient suspects cholecystitis, it is mandatory to carry out:

Ultrasound examination of the abdominal organs, which allows you to determine the presence of thickening of the wall of the gallbladder and doubling of its contour, as well as to identify the accumulation of fluid near the organ and stones in it. Also, with the help of ultrasound, you can identify other pathological conditions, for example, those associated with inflammation.
FEGDS(fibroesophagogastroduodenoscopy). This research procedure is carried out in order to exclude a possible peptic ulcer, since it is this ailment that often causes pain in the patient.
Chest x-ray and. Such a study is necessary to exclude the possible presence of diseases and pathologies of the pleura or lungs.

Additional diagnostic methods can also be prescribed, in particular, computed tomography, which is often performed as an alternative to ultrasound examination. The patient can be referred for MRI of the biliary tract, as well as for endoscopic retrograde cholangiopancreatography, if there is a suspicion that the lesion of the biliary tract is of a tumor nature.

Ultrasound procedure

Ultrasound can be called practically the leading diagnostic method, since it can detect many types of diseases and determine their features.

Conducting an ultrasound examination if you suspect cholecystitis allows you to establish the presence or absence of stones in the gallbladder and its ducts, as well as other organs, and determine their number, size, shape.

When conducting an ultrasound scan, the doctor has the opportunity to accurately assess the existing scale of the problem and outline adequate treatment options in order to help the patient as much as possible. Such a method of diagnosis is carried out strictly on an empty stomach so that the food masses do not create obstacles to the study of the state of internal organs.

With the help of an ultrasound examination, the doctor can also determine the chronic form of the disease, which has certain signs:

Deformation of the organ, which often occurs with the development of the disease;
Changes in the size of the organ, since with cholecystitis, the gallbladder can greatly increase or decrease;
The presence of heterogeneity in the structure of the gallbladder cavity when it is affected by a disease;
Thickening of the walls of the organ, which can be more than 3 mm.

With the help of ultrasound, it is possible to establish not only the presence of the disease itself, but also all the features of its course, as well as existing complications, but in some cases it may be necessary to carry out other diagnostic methods.

Laparoscopy

When conducting ultrasound, it is far from always possible to give clear characteristics of the state of the affected gallbladder, in particular, changes in the organ itself, its hepatoduodenal ligament and the neck area that have arisen during the development of the disease, since such changes create difficulties for ultrasound.

Indications for diagnostic laparoscopy are mainly situations with the development of the disease, changes in the organ itself, its hepatoduodenal ligament and the neck region, as well as the need to differentiate cholecystitis from other pathologies in an acute form

When conducting a survey diagnostic laparoscopy, the doctor has the opportunity to carefully examine all internal organs and accurately assess their condition. Also, during laparoscopy, the cavity is examined in order to determine the presence of a pathological effusion and its nature. Such a violation is localized in most cases under the liver, as well as along the lateral canal on the right side. An assessment is also made of the general condition of the liver and the relationship to its edge of the gallbladder.

Endoscopic retrograde cholangiopancreatography

If cholecystitis in an acute form is complicated by obstructive jaundice, then an ERCP procedure is prescribed for diagnostic purposes. This diagnostic method allows you to identify the exact causes of extrahepatic biliary stasis, as well as the location of the occlusion of the bile duct. If a stricture of the distal duct is found, then its length is calculated during the procedure.

ERCP is both a therapeutic and diagnostic procedure that combines radiography with endoscopy. Such a study is carried out if it is necessary to study the bile ducts and determine their condition.

Also, this type of diagnosis is used to remove tumors, gallstones. With the help of this procedure, the expansion of the bile ducts is also carried out, if there are areas of narrowing in them.

Before starting the procedure, the patient is given certain sedatives by intravenous route so that he is completely relaxed. In addition, throat treatment is carried out, for which local anesthetics are used, and a special mouth guard is placed in the patient's mouth, designed to protect his teeth.

After that, an endoscope is inserted through the patient's mouth into his digestive system, which is slowly advanced along the esophagus into the stomach and, then, to the duodenum. Then a special thin catheter is passed through the endoscope, which is inserted into the ducts of the gallbladder and pancreas.

The ducts of the gallbladder and pancreas are filled with a radiopaque contrast agent, which is carried out through the catheter, after which a picture is taken immediately. In the course of such a procedure, it is usually possible to expand the ducts when they narrow, as well as wash out small stones from them, and diagnose the state of the gallbladder. If necessary, during the procedure, the tissues of the bladder, pancreas and their ducts are also taken for further research.

Such a procedure is necessarily carried out on an empty stomach, while it is important to temporarily stop taking medications, since many of them can cause complications.

X-ray

When diagnosing the condition of the gallbladder and its ducts, along with various procedures, X-ray studies are also used, such as an overview X-ray, cholegraphy, cholecystography and cholangiography.

When conducting a survey X-ray, the doctor can detect many pathologies of the gallbladder, in particular, the presence of stones inside the organ and in its ducts, changes in the walls.

Quite often, when examining the gallbladder during an overview X-ray, the doctor also discovers pathologies of other organs, as well as some related diseases, often occurring under the symptoms of cholecystitis.

To conduct an X-ray and obtain the most informative results, it is necessary to introduce special contrast agents into the cavity of the organs under study and their ducts.

The introduction of contrast agents can be carried out in various ways., but most often the patient is given a special drug in the required dosage, in particular, Holevid in the amount of 4 - 6 grams or Bilitrast in the amount of 3 - 3.5 grams, which are absorbed into the bloodstream in the intestine and enter the organs under investigation. In this case, the procedure is carried out 14-16 hours after the introduction of funds.

Now you know all the methods for diagnosing acute cholecystitis, you will learn more about the symptoms of the disease and methods of treatment.

Varieties of cholecystitis

The wording of the diagnosis of acute cholecystitis can be as follows:

Acute cholecystitis acalculous type in a chronic form, with a mild course.
Acute cholecystitis acalculous type in a chronic form, with an average severity of the course. The presence of gallbladder dysfunction of the secondary category of hyperkinetic type.
Acute cholecystitis acalculous type in a chronic form, with a severe course. The presence of gallbladder dysfunction of the secondary category of hypotonic and hypokinetic type.

Gallstone disease (gallstone disease). Cholecystitis of calculous type with attacks of biliary colic, mild, moderate or severe.
Acute calculous cholecystitis of the destructive category.
Acute calculous cholecystitis of the catarrhal category. Choledocholithiasis.

Differential diagnosis of acute cholecystitis

If the patient has a suspicion of acute cholecystitis, differential diagnosis is carried out for other acute inflammatory diseases of the abdominal organs.

In particular, the underlying disease must be differentiated from liver abscess, acute cholangitis, pancreatitis, acute appendicitis, perforated duodenal ulcer or stomach. In addition, the disease should be isolated and an attack of right-sided pleurisy, pyelonephritis or urolithiasis should be excluded.

Acute cholangitis is characterized by symptoms called the Charcot triad, which includes pain in the right hypochondrium, jaundice, and fever.

In some cases, the Charcot triad can be supplemented by impaired consciousness, as well as arterial hypotension. This combination of symptoms is called the Reino pentad.

If the cecum is high, then in the presence of symptoms of cholecystitis, the first step is to exclude possible inflammation of appendicitis.

Acute pancreatitis is characterized by the presence of nausea and bouts of vomiting., pain in the epigastric region, which can be given to the back, as well as an increase in the activity of lipase and amylase in the blood.

With pyelonephritis of the right-sided type, pain is usually observed during palpation examination, as well as signs of the presence of an inflammatory process in the urinary tract.

With a peptic ulcer, in most cases pain is observed in the area of the right hypochondrium, as well as in the epigastric region, while if the ulcer is complicated by perforation, then the symptoms of this condition strongly resemble signs of an acute form of cholecystitis

Cholecystitis should be differentiated from other ailments, for example, from myocardial infarction of a lower diaphragmatic nature, acute viral hepatitis, pathologies of the pleura and lungs, vascular ischemia, liver tumors, gonococcal perihepatitis.

The human body is an intelligent and fairly balanced mechanism.

Among all infectious diseases known to science, infectious mononucleosis has a special place ...

The world has known about the disease, which official medicine calls "angina pectoris" for a long time.

Mumps (scientific name - mumps) is an infectious disease ...

Hepatic colic is a typical manifestation of gallstone disease.

Cerebral edema is a consequence of excessive stress on the body.

There are no people in the world who have never had ARVI (acute respiratory viral diseases) ...

A healthy human body is able to assimilate so many salts obtained with water and food ...

Knee bursitis is a common condition among athletes ...

Differential diagnosis

Recognition of the classic forms of acute cholecystitis, especially with timely hospitalization of patients, is not difficult. Difficulties in diagnosis arise in the atypical course of the disease, when there is no parallelism between pathomorphological changes in the gallbladder and clinical manifestations, as well as in the complication of acute cholecystitis with unbounded peritonitis, when, due to severe intoxication and the diffuse nature of abdominal pain, it is impossible to find out the source of peritonitis.

Diagnostic errors in acute cholecystitis occur in 12-17% of cases. Erroneous diagnoses can be such diagnoses of acute diseases of the abdominal organs as acute appendicitis, perforated stomach or duodenal ulcer, acute pancreatitis, intestinal obstruction and others. Sometimes the diagnosis of acute cholecystitis is made with right-sided pleuropneumonia, paranephritis, pyelonephritis. Errors in diagnosis lead to the wrong choice of treatment method and delayed surgical intervention.

Most often, at the prehospital stage, acute appendicitis, intestinal obstruction and acute pancreatitis are diagnosed instead of acute cholecystitis. Attention is drawn to the fact that when referring patients to a hospital, diagnostic errors are more common in the older age group (10.8%) compared with the group of patients under 60 years of age.

Errors of this kind, made at the prehospital stage, as a rule, do not entail special consequences, since each of the diagnoses listed above is an absolute indication for emergency hospitalization of patients in a surgical hospital. However, if such an erroneous diagnosis is confirmed in the hospital as well, this may be the cause of serious tactical and technical miscalculations (incorrectly chosen surgical access, erroneous removal of the secondarily changed appendix, etc.). That is why the differential diagnosis between acute cholecystitis and clinically similar diseases is of particular practical importance.

To distinguish acute cholecystitis from acute appendicitis in some cases is a rather difficult clinical task. Differential diagnosis is especially difficult when the gallbladder is located low and its inflammation simulates acute appendicitis or, conversely, with a high (subhepatic) location of the appendix, acute appendicitis is in many ways similar to acute cholecystitis clinically.

When examining patients, it should be borne in mind that patients of the older age group most often suffer from acute cholecystitis. Patients with acute cholecystitis have a history of repeated attacks of pain in the right hypochondrium with characteristic irradiation, and in some cases direct indications of cholelithiasis. Pain in acute appendicitis is not as intense as in acute cholecystitis and does not radiate to the right shoulder girdle, shoulder and scapula. The general condition of patients with acute cholecystitis, other things being equal, is usually more severe. Vomiting in acute appendicitis - single, in acute cholecystitis - repeated. Palpation of the abdomen allows you to identify the localization of pain and tension in the muscles of the abdominal wall characteristic of each of these diseases. The presence of an enlarged and painful gallbladder finally excludes diagnostic doubts.

There are many similarities in the clinical manifestations of acute cholecystitis and acute pancreatitis: anamnestic indications of cholelithiasis, acute onset of the disease after an error in the diet, localization of pain in the upper abdomen, repeated vomiting. Distinctive features of acute pancreatitis are: girdle pain, sharp pain in the epigastric region and much less pronounced in the right hypochondrium, no enlargement of the gallbladder, diastasuria, the severity of the general condition of the patient, which is especially characteristic of pancreatonecrosis.

Since in acute cholecystitis, repeated vomiting is observed, and there are often phenomena of intestinal paresis with bloating and stool retention, a suspicion of acute obstructive intestinal obstruction may arise. The latter is distinguished by the cramping nature of pain with localization uncharacteristic for acute cholecystitis, resonating peristalsis, "splash noise", a positive Valya symptom and other specific signs of acute intestinal obstruction. Plain fluoroscopy of the abdominal cavity is of decisive importance in differential diagnosis, allowing to detect swelling of intestinal loops (symptom of "organ pipes") and fluid levels (Kloyber's cup).

The clinical picture of perforated gastric ulcer and duodenal ulcer is so characteristic that it rarely has to be differentiated from acute cholecystitis. An exception is covered perforation, especially if it is complicated by the formation of a subhepatic abscess. In such cases, you should take into account the history of ulcers, the acute onset of the disease with "dagger" pain in the epigastrium, the absence of vomiting. Essential diagnostic assistance is provided by an X-ray study, which makes it possible to identify the presence of free gas in the abdominal cavity.

Renal colic, as well as inflammatory diseases of the right kidney and perirenal tissue (pyelonephritis, paranephritis, etc.) may be accompanied by pain in the right hypochondrium and therefore simulate the clinical picture of acute cholecystitis. In this regard, when examining patients, it is imperative to pay attention to the urological history, carefully examine the kidney area, and in some cases it becomes necessary to use a targeted study of the urinary system (urinalysis, excretory urography, chromocystoscopy, etc.).

Instrumental diagnosis of acute cholecystitis

Reducing the incidence of misdiagnosis in acute cholecystitis is an important task in practical surgery. It can be successfully solved only with the widespread use of such modern diagnostic methods as ultrasound, laparoscopy, retrograde cholangiopancreatography (RPCH).

Echoes of acute cholecystitis include a thickening of the wall of the gallbladder and an echo-negative rim around it (doubling of the wall) (Fig. 9).

Rice. 9. Ultrasound picture of acute cholecystitis. There is a thickening of the gallbladder wall (between the black and white arrow) and a small amount of fluid around it (single white arrow)

The high diagnostic accuracy of laparoscopy in acute abdomen allows the method to be widely used for differential diagnostic purposes. The indications for laparoscopy in acute cholecystitis are as follows:

1. Ambiguity of the diagnosis due to the unconvincing clinical picture of acute cholecystitis and the inability to establish the cause of the "acute abdomen" by other diagnostic methods.

2. Difficulties in determining by clinical methods the severity of inflammatory changes in the gallbladder and abdominal cavity in patients with a high degree of operational risk.

3. Difficulties in choosing a method of treatment (conservative or operative) with "blurred" clinical picture of acute "cholecystitis.

According to the indications, laparoscopy in patients with acute cholecystitis allows not only to clarify the diagnosis and the depth of pathomorphological changes in the gallbladder and the prevalence of peritonitis, but also to correctly solve treatment and tactical issues. Complications with laparoscopy are extremely rare.

In case of complications of acute cholecystitis with obstructive jaundice or cholangitis, it is important to have accurate information about the causes of their development and the level of obstruction of the bile ducts before the operation. To obtain this information, RPHG is performed by cannulating the large duodenal nipple under the control of the duodenoscope (Fig. 10, 11). RPHG should be performed in each case of acute cholecystitis, occurring with severe clinical signs of impaired outflow of bile into the intestine. With a successful contrast study, it is possible to identify stones in the bile duct, to determine their localization and the level of blockage in the duct, to establish the length of the narrowing of the bile duct. Determination of the nature of the pathology in the bile ducts using the endoscopic method allows you to correctly solve questions about the timing of the operation, the amount of surgery on the extrahepatic bile ducts, as well as the possibility of performing endoscopic papillotomy to eliminate the causes. causing obstructive jaundice and cholangitis.

When analyzing cholangiopancreatograms, it is most difficult to correctly interpret the state of the terminal section of the common bile duct due to the possibility of false signs of its lesion appearing on radiographs. The most common misdiagnosis is cicatricial stenosis of the large duodenal nipple, while the X-ray picture of stenosis may be caused by functional reasons "(swelling of the nipple, persistent sphincterospasm). According to our data, the wrong diagnosis of organic stenosis of the large duodenal papilla is made in 13% of cases. Misdiagnosis of nipple stenosis may lead to incorrect "tactical actions. In order to avoid unnecessary surgical interventions on the duodenal papilla, the endoscopic diagnosis of stenosis should be verified during the operation using an optimal set of intraoperative studies.

Rice. 10. RPHG is normal. PP - pancreatic duct; F - gallbladder; О - common hepatic duct

Rice. 11. RPHG. A common bile duct stone is visualized (marked with an arrow).

In order to shorten the preoperative period in patients with obstructive jaundice and cholangitis, endoscopic retrograde cholangiopancreatography is performed on the first day after admission of patients to the hospital.

Therapeutic tactics for acute cholecystitis

The main provisions on therapeutic tactics for acute cholecystitis were developed at the 6th and supplemented at the 15th plenary sessions of the Board of the All-Union Society of Surgeons (Leningrad, 1956 and Kishinev, 1976). According to these provisions, the tactics of the surgeon in acute cholecystitis should be actively expectant. A wait-and-see tactic is recognized as vicious, because the desire to resolve the inflammatory process by conservative measures leads to serious complications and belated operations.

The principles of active-expectant treatment tactics are as follows.

1. Indications for emergency surgery, which is performed in the first 2-3 hours after hospitalization of the patient, are gangrenous and perforated cholecystitis, as well as cholecystitis complicated by diffuse or diffuse peritonitis.

2. Indications for urgent surgery, which is performed 24-48 hours after the patient is admitted to the hospital, are the lack of effect of conservative treatment while the symptoms of intoxication and local peritoneal phenomena persist, as well as cases of an increase in general intoxication and the appearance of symptoms of peritoneal irritation, which indicates about the progression of inflammatory changes in the gallbladder and abdominal cavity.

3. In the absence of symptoms of intoxication and local peritoneal phenomena, patients undergo conservative treatment. If, as a result of conservative measures, it is possible to stop the inflammation in the gallbladder, the question of surgery in these patients is decided individually after a comprehensive clinical examination, including X-ray examination of the bile ducts and gastrointestinal tract. Surgical intervention in this category of patients is performed in the "cold" period (not earlier than 14 days from the onset of the disease), as a rule, without discharging patients from the hospital.

From the listed indications, it follows that a conservative method of treatment can be used only in the catarrhal form of cholecystitis and in cases of phlegmonous cholecystitis, proceeding without peritonitis or with mild signs of local peritonitis. In all other cases, patients with acute cholecystitis should be operated on urgently or urgently.

The success of the operation in acute cholecystitis largely depends on the quality of the preoperative preparation and the correct organization of the operation itself. In an emergency operation, patients need short-term intensive therapy aimed at detoxifying the body and correcting metabolic disorders. Preoperative preparation should not take more than 2-3 hours.

An emergency operation performed for acute cholecystitis has its shadow sides, which are associated with insufficient examination of the patient before the operation and with the impossibility, especially at night, to conduct a full study of the bile ducts. As a result of incomplete examination of the bile ducts, stones and strictures of the large duodenal nipple are viewed, which subsequently leads to a relapse of the disease. In this regard, it is advisable to perform emergency operations for acute cholecystitis in the morning and afternoon, when it is possible for a qualified surgeon to participate in the operation and use special methods for diagnosing lesions of the bile ducts during its operation. When patients are admitted at night, who do not need urgent surgery, they need to carry out intensive infusion therapy during the remaining night hours.

Conservative treatment of acute cholecystitis

Conservative therapy in full and in the early stages of the disease usually allows to stop the inflammatory process in the gallbladder and thereby eliminate the need for urgent surgical intervention, and with a long period of the disease - to prepare the patient for surgery.

Conservative therapy, based on pathogenetic principles, includes a set of therapeutic measures that are aimed at improving the outflow of bile into the intestine, normalizing disturbed metabolic processes and restoring the normal activity of other body systems. The complex of therapeutic measures must include:

hunger for 2-3 days;

local hypothermia - application of an ice bubble to the right hypochondrium;

gastric lavage while maintaining nausea and vomiting;

the appointment of antispasmodics in injections (atropine, platifillin, no-shpa, or papaverine);

antihistamine therapy (diphenhydramine, pipolfen or suprastin);

antibiotic therapy. For antibiotic therapy, drugs should be used that are able to act against etiologically significant microorganisms and penetrate well into bile.

Drugs of choice:

Ceftriaxone 1-2 g / day + metronidazole 1.5-2 g / day;

Cefopyrazone 2-4 g / day + metronidazole 1.5-2 g / day;

Ampicillin / sulbactam 6 g / day;

Amoxicillin / clavulanate 3.6-4.8 g / day;

Alternative mode:

Gentamicin or tobramycin 3 mg / kg per day + ampicillin 4 g / day + metronidazole 1.5-2 g / day;

Netilmicin 4-6 mg / kg + metronidazole 1.5-2 g / day;

Cefepime 4 g / day + metronidazole 1.5-2 g / day;

Fluoroquinolones (ciprofloxacin 400-800 mg intravenously) + metronidazole 1.5-2 g / day;

to correct disturbed metabolic processes and detoxification, 1.5-2 liters of infusion media are injected intravenously: Ringer-Locke's solution or lactasol - 500 ml, glucose-novocaine mixture - 500 ml (novocaine solution 0.25% - 250 ml and 5% glucose solution - 250 ml), hemodez - 250 ml, 5% glucose solution - 300 ml together with 2% potassium chloride solution - 200 ml, protein preparations - casein hydrolyzate, aminopeptide, alvezin and others;

prescribe vitamins of group B, C, calcium preparations;

taking into account the indications, glycosides, cocarboxylase, panangin, euphyllin and antihypertensive drugs are used.

The appointment of anesthetic drugs (promedol, pantopon, morphine) for acute cholecystitis is considered unacceptable, since pain relief often smoothes the picture of the disease and leads to viewing the moment of perforation of the gallbladder.

An important component of therapeutic measures for acute cholecystitis is the blockade of the round ligament of the liver with a 0.25% solution of novocaine in an amount of 200-250 ml. It not only relieves pain, but also improves the outflow of infected bile from the gallbladder and bile ducts due to "enhancing the contractility of the bladder and relieving spasm of the sphincter of Oddi. Restoration of the drainage function of the gallbladder and emptying it from purulent bile contribute to the rapid subsiding of the inflammatory process.

Surgical treatment of acute cholecystitis

Surgical approaches. For access to the gallbladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the most widespread incisions are Kocher, Fedorov, Cherni, and the upper midline laparotomy.

The amount of surgery. With the remaining cholecystitis, it is determined by the general condition of the patient, the severity of the underlying disease and the presence of concomitant changes in the extrahepatic bile ducts. Depending on these circumstances, the nature of the operation may consist in cholecystostomy or cholecystectomy, which, if indicated, is supplemented by choledochotomy and external drainage of the bile ducts or the creation of a biliodigestive anastomosis.

The final decision on the scope of surgery is made after a thorough revision of the extrahepatic bile ducts, which is carried out using simple and accessible research methods (examination, palpation, probing through the cystic duct stump or open common bile duct), including intraoperative cholangiography. Intraoperative cholangiography can reliably judge the state of the bile ducts, their location, width, presence or absence of stones and strictures. On the basis of cholangiographic data, an intervention on the common bile duct and the choice of a method for correcting its lesion are argued.

Cholecystectomy. Removal of the gallbladder is the main intervention for acute cholecystitis, leading to a complete recovery of the patient. This operation was first performed by K. Langenbuch in 1882. Two methods of cholecystectomy are used - "from the neck" and "from the bottom". The method of removing the gallbladder “from the neck” has undoubted advantages (Fig. 12).

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Differential diagnosis of acute cholecystitis

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Acute cholecystitis is distinguished from acute inflammation of the pancreas, renal colic, perforated gastric and duodenal ulcers, or appendicitis.

Renal colic differs from acute cholecystitis in that it feels acute pain in the lumbar region. This pain radiates to the genital area and thighs. At the same time, there is a violation of urination. With renal colic, the temperature does not rise, leukocytosis is not fixed. Analysis of urine shows the presence of uniform blood components and salts. There are no symptoms of peritoneal irritation, but Pasternatsky's symptom is found.

Acute appendicitis with a high location of the appendix can provoke acute cholecystitis. The difference between acute cholecystitis and acute appendicitis is that it has vomiting with bile, and the pain radiates to the right shoulder blade and shoulder area. In addition, with appendicitis, the Mussey-Georgievsky symptom is not detected. Diagnosis is facilitated by the presence of information in the medical history that the patient has gallstones. Unlike acute cholecystitis, acute appendicitis is more severe, with rapid development of peritonitis.

In some cases, a perforated stomach and duodenal ulcer is masked as acute cholecystitis. However, in acute cholecystitis, unlike ulcers, there is usually a history of gallstones.

Acute cholecystitis is characterized by vomiting with bile and pain that radiates to other parts of the body. Initially, pain is localized in the right hypochondrium, gradually increases, and fever begins.

Hidden perforated ulcers begin acutely. In the first few hours of the disease, the muscles of the anterior abdominal wall are strongly strained. The patient complains of localized pain in the right ileum due to the contents of the stomach leaking into the cavity. Similar phenomena are not observed in acute cholecystitis. In addition, hepatic dullness persists in acute cholecystitis.

Acute pancreatitis is characterized by increasing intoxication, palpitations, intestinal paresis - this is its main difference from acute cholecystitis. Pain sensations are observed mainly in the left hypochondrium or above the stomach, have a shingles in nature. Pain with inflammation of the pancreas is often accompanied by severe vomiting. Distinguishing between acute pancreatitis and acute cholecystitis is very difficult, so the diagnosis has to be carried out in stationary conditions.

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Differential diagnosis

Acute cholecystitis is differentiated from the following diseases:

1) Acute appendicitis. In acute appendicitis, the pain is not so intense, and, most importantly, it does not radiate to the right shoulder, right scapula, etc. Also, acute appendicitis is characterized by the migration of pain from the epigastrium to the right iliac region or throughout the abdomen; with cholecystitis, the pain is precisely localized in the right hypochondrium ; vomiting with appendicitis, single. Usually, palpation reveals a compaction of the consistency of the gallbladder and local tension of the muscles of the abdominal wall. Ortner's and Murphy's symptoms are often positive.

2) Acute pancreatitis. This disease is characterized by the encircling nature of the pain, sharp soreness in the epigastrium. Mayo-Robson's symptom is positive. The patient is in a difficult condition, he takes a forced position. The level of diastase in urine and blood serum is of decisive importance in the diagnosis; figures over 512 units are evidence-based. (in urine).

With stones in the pancreatic duct, pain is usually localized in the left hypochondrium.

3) Acute intestinal obstruction. In acute intestinal obstruction, the pain is cramping, non-localized. There is no rise in temperature. Increased peristalsis, sound phenomena (“splash noise”), radiological signs of obstruction (Kloyber's bowls, arcades, feathering symptom) are absent in acute cholecystitis.

4) Acute obstruction of the mesenteric arteries. With this pathology, severe pains of a constant nature arise, but usually with distinct intensifications, are less diffuse in nature than with cholecystitis (more diffuse). Be sure to have a history of pathology from the cardiovascular system. The abdomen is well accessible for palpation, without pronounced symptoms of peritoneal irritation. Fluoroscopy and angiography are decisive.

5) Perforated ulcer of the stomach and duodenum. More often men suffer from this, while women suffer more often from cholecystitis. With cholecystitis, intolerance to fatty foods is characteristic, nausea and malaise are frequent, which does not happen with a perforated ulcer of the stomach and duodenum; pains are localized in the right hypochondrium and radiate to the right scapula, etc., with an ulcer, the pain radiates mainly to the back. Erythrocyte sedimentation is accelerated (in case of an ulcer - vice versa). The presence of an ulcer history and tarry stools clarify the picture. Radiographically, free gas is found in the abdominal cavity.

6) Renal colic. Pay attention to the urological history. The kidney area is carefully examined, Pasternatsky's symptom is positive, urine analysis, excretory urography, chromocystography are performed to clarify the diagnosis, since renal colic often provokes biliary colic.

Clinical diagnosis:

Cholelithiasis, chronic calculous cholecystitis.

Rationale for the diagnosis:

The diagnosis is based on:

Complaints provided by the patient about discomfort and recurrent dull pains of a girdle nature, appearing after taking any kind of food, in the right hypochondrium, spreading to the epigastric region;

Anamnesis of the disease: the appearance of such pains about 1 year ago, in September 2015, after taking mostly fatty foods that were not stopped by painkillers. As a result of inpatient treatment in the Central Regional Hospital of Ussuriysk for acute cholecystitis, she was admitted for planned surgical treatment;

Objective examination data:

1.the general condition of the patient is satisfactory, the skin and visible mucous membranes are pink, clean,

2.peripheral lymph nodes are not enlarged,

3. vesicular breathing is heard in the lungs, wheezing is absent,

4. heart sounds are clear, rhythmic, blood pressure 120/80 mm Hg, pulse 76 beats per minute,

5. the tongue is moist, the abdomen is not swollen, soft, painless in all parts, the liver is not enlarged, stool and diuresis are regular (normal);

Instrumental studies: ultrasound of the abdominal organs - the presence of calculi up to 2-3 cm, enlargement and diffuse changes in the liver;

Laboratory research:; an increase in the level of bilirubin in the blood, to a greater extent due to direct; the presence of leukocytosis, a sharp shift of the leukocyte formula to the left, an increase in ESR.

All of the above is in favor of the diagnosis: gallstone disease. Chronic calculous cholecystitis.

Differential diagnosis.

The differential diagnosis should be carried out with those nosological units that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis.

Pain syndrome:

With gallstones, chronic calculous cholecystitis - pain in the right hypochondrium at the Kera point, there is also moderate resistance of the muscles of the anterior abdominal wall, painful symptoms of Murphy, Georgievsky-Mussey, Ortner-Grekov. Increased pain, worsening of the condition are associated with errors in the diet, intake of fatty foods.

In case of peptic ulcer, duodenal ulcer, the daily circadian rhythm of pain, hunger - pain, food intake - pain subsides, hunger - pain. On palpation, tenderness in the right upper quadrant of the abdomen. The condition worsens significantly in the spring and autumn periods.

In chronic pancreatitis - pains are localized in the epigastric region, are dull in nature and radiate to the back. The pain is worse after eating or drinking. Palpation of the abdomen usually reveals its swelling, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation soreness is noted at the Desjardins point or in the Shoffard zone. Often, a painful point is detected in the left cost-vertebral angle (Mayo-Robson symptom). Sometimes the zone of cutaneous hyperesthesia is determined according to the innervation zone of the 8-10 thoracic segment on the left (Kacha's symptom) and some atrophy of the subcutaneous fat layer in the area of the pancreas projection onto the anterior abdominal wall (Groot sign).

With choledocholithiasis - pain in the upper abdomen, more on the right, radiating to the back.

Dyspeptic syndrome:

With gallstones, chronic calculous cholecystitis - dryness, bitterness in the mouth, nausea, sometimes vomiting, stool disorders (more often diarrhea), there is a natural connection with the intake of fatty foods. Patients usually have adequate nutrition.

With peptic ulcer of the duodenum - a similar symptomatology. Vomiting relieves and worsens with fasting. Patients are more often asthenic.

In chronic pancreatitis - a characteristic symptomatology, there is a natural relationship with the intake of alcohol, spicy, fried foods. Stool disorders - diarrhea, steato-amylo-creatorrhea. Patients are asthenic.

With gallstones, choledocholithiasis - dyspeptic syndrome is similar to chronic cholecystitis.

Laboratory data:

With gallstones, chronic calculous cholecystitis - normal blood counts, urine, there may be a slight leukocytosis, increased ESR. In blood biochemistry - transaminases slightly increase, hepatic fraction of alkaline phosphatase, amylase, total bilirubin may increase (due to direct) - cholestatic syndrome is slightly expressed.

In case of duodenal ulcer disease - iron deficiency, normal urine parameters, with exacerbation of the disease, slight leukocytosis in the KLA, transaminases within normal limits, bilirubin is normal. Cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase, alkaline phosphatase increase, transaminases, dysproteinemia may increase, urine is normal, calorrhea, creatorrhea, amilorrhea. Coagulogram without features.

In case of gallstones, choledocholithiasis, slight leukocytosis is possible in the KLA, ESR rises, in urine - bilirubin, urobilin will be absent, in feces - stercobilin will also be absent. Feces of the type of white clay. Biochemistry - transaminases rise sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Expressed cholestatic syndrome. In the coagulogram changes - an increase in bleeding time, a decrease in the prothrombin index (the lower limit of the norm), an increase in INR.

Instrumental methods: ultrasound, FGDS.

With gallstones, chronic calculous cholecystitis - the gallbladder is enlarged, the wall of the bladder is compacted, in the lumen there is hyperechoic bile (suspension), calculi. Diffuse changes in the parenchyma of the liver and pancreas are possible. On X-ray-positive calculi, with cholecystography - calculi (filling defects), enlargement, possible dystopia of the gallbladder. Duodenal intubation - inflammatory changes in bile (portion B).

In the case of duodenal ulcer disease, EGDS is used (ulcerative defect, cicatricial changes, stenosis), pH-metry, urease test are also performed in parallel. With duodenal intubation, the inflammatory altered bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to carry out EGD - X-ray with barium - a niche symptom is found.

In chronic pancreatitis - on ultrasound, diffuse changes in the gland, calcification, fibrosis, cystic changes, reduction of the gland in size, decreases the patency of the Wirsung duct (inflammatory changes in the wall, possible calcifications in the duct).

With gallstones, choledocholithiasis on ultrasound - a diffusely altered liver, expansion of the intrahepatic ducts, calculi in the common bile duct. With duodenography in conditions of artificial controlled hypotension, pathology of the organs of the pancreatoduodenal zone is revealed. RPHG - the ability to see the external and internal hepatic ducts, as well as the ducts of the pancreas. CRCP - it is possible to determine both the nature and the localization of the obstruction in the hepatoduodenal zone.

Etiology and pathogenesis of the underlying disease.

Calculous cholecystitis is a disease caused by the presence of stones in the gallbladder and bile ducts. Distinguish between cholesterol, pigmented and mixed stones (calculi).

Etiology There are the following main groups of etiological factors leading to the development of calculous cholecystitis: 1. Inflammatory process in the wall of the gallbladder of bacterial, viral (hepatitis virus), toxic or allergic etiology. 2. Cholestasis. 3. Disorders of lipid, electrolyte or pigment metabolism in the body. 4. Dyskinesia of the gallbladder and biliary tract, which is often caused by impaired neuroendocrine regulation of the motility of the biliary tract and gallbladder, hypodynamia. 5. Nutritional factor (unbalanced nutrition with a predominance of coarse animal fats in the diet to the detriment of vegetable fats). 6. Congenital anatomical features of the structure of the gallbladder and biliary tract, anomalies of their development. 7. Parenchymal liver disease.

Pathogenesis There are two main concepts of the pathogenesis of calculous cholecystitis: 1) the concept of metabolic disorders; 2) inflammatory concept.

Today, these two concepts are considered as possible pathogenetic variants (mechanisms) of the development of calculous cholecystitis - hepatic-metabolic (the concept of metabolic disorders) and gallbladder-inflammatory (inflammatory concept). According to the concept of metabolic disorders, the main mechanism for the formation of gallstones is associated with a decrease in the cholato-cholesterol ratio (bile acids / cholesterol), i.e. with a decrease in the content of bile acids in bile and an increase in cholesterol. Lipid metabolism disorders (general obesity, hypercholesterolemia), alimentary factors (excess of animal fats in food), lesions of the hepatic parenchyma of toxic and infectious genesis can lead to a decrease in the cholato-cholesterol ratio. A decrease in the cholato-cholesterol ratio leads to a violation of the colloidal properties of bile and to the formation of cholesterol or mixed stones. According to the inflammatory concept, gallstones are formed under the influence of an inflammatory process in the gallbladder, leading to physicochemical changes in the composition of bile. A change in the pH of bile to the acidic side, characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular - protein fractions of bile, the transition of the bilirubin micelle from a suspended state to a crystalline state. In this case, a primary crystallization center is formed, on which exfoliated epithelial cells, microorganisms, mucus, and other bile components are layered. According to modern concepts, at the initial stage of the development of calculous cholecystitis, one of these mechanisms may dominate. However, in the later stages of the disease, both mechanisms function. The formation of stones initiates stagnation of bile, an inflammatory process, stones serve as centers of crystallization of bile. Thus, the vicious circle is closed and the disease progresses.

Dyskinesia of the gallbladder what is it

Cholelithiasis, chronic calculous cholecystitis.

Rationale for the diagnosis:

The diagnosis is based on:

Objective examination data:

1.the general condition of the patient is satisfactory, the skin and visible mucous membranes are pink, clean,

2.peripheral lymph nodes are not enlarged,

3. vesicular breathing is heard in the lungs, wheezing is absent,

4. heart sounds are clear, rhythmic, blood pressure 120/80 mm Hg, pulse 76 beats per minute,

5. the tongue is moist, the abdomen is not swollen, soft, painless in all parts, the liver is not enlarged, stool and diuresis are regular (normal);

Instrumental studies: ultrasound of the abdominal organs - the presence of calculi up to 2-3 cm, enlargement and diffuse changes in the liver;

All of the above is in favor of the diagnosis: gallstone disease. Chronic calculous cholecystitis.

Differential diagnosis.

The differential diagnosis should be carried out with those nosological units that have similar clinical manifestations. These are duodenal ulcer, chronic pancreatitis, choledocholithiasis.

Pain syndrome:

In chronic pancreatitis, pains are localized in the epigastric region, are dull in nature and radiate to the back. The pain is worse after eating or drinking. Palpation of the abdomen usually reveals its swelling, pain in the epigastric region and in the left hypochondrium. When the head of the pancreas is affected, local palpation soreness is noted at the Desjardins point or in the Shoffard zone. Often, a painful point is detected in the left cost-vertebral angle (Mayo-Robson symptom). Sometimes the zone of cutaneous hyperesthesia is determined according to the innervation zone of the 8-10 thoracic segment on the left (Kacha's symptom) and some atrophy of the subcutaneous fat layer in the area of the pancreas projection onto the anterior abdominal wall (Groot sign).

With choledocholithiasis - pain in the upper abdomen, more on the right, radiating to the back.

Dyspeptic syndrome:

With peptic ulcer of the duodenum - a similar symptomatology. Vomiting relieves and worsens with fasting. Patients are more often asthenic.

With gallstones, choledocholithiasis - dyspeptic syndrome is similar to chronic cholecystitis.

Laboratory data:

With peptic ulcer of the duodenum - iron deficiency, normal urine parameters, with an exacerbation of the disease, slight leukocytosis in the UAC is possible, transaminases are within normal limits, bilirubin is normal. Cholestasis syndrome is not typical. Coagulogram without features.

In chronic pancreatitis - anemia, slight leukocytosis is possible, amylase, alkaline phosphatase increase, transaminases, dysproteinemia can increase, urine is normal, calorrhea, creatorrhea, amilorrhea. Coagulogram without features.

In case of cholelithiasis, choledocholithiasis, slight leukocytosis is possible in the KLA, ESR rises, in urine - bilirubin, urobilin will be absent, in feces - stercobilin will also be absent. Feces of the type of white clay. Biochemistry - transaminases rise sharply, alkaline phosphatase is very active, bilirubin increases significantly due to the direct fraction. Expressed cholestatic syndrome. In the coagulogram changes - an increase in bleeding time, a decrease in the prothrombin index (the lower limit of the norm), an increase in INR.

Instrumental methods: ultrasound, FGDS.

In the case of duodenal ulcer disease, EGDS is used (ulcerative defect, cicatricial changes, stenosis), pH-metry, urease test are also carried out in parallel. With duodenal intubation, the inflammatory altered bile in portion A will indicate the localization of the process in the duodenum. If it is impossible to conduct EGD - X-ray with barium - a niche symptom is found.

With gallstone disease, choledocholithiasis on ultrasound - diffusely altered liver, expansion of the intrahepatic ducts, calculi in the common bile duct. With duodenography in conditions of artificial controlled hypotension, pathology of the organs of the pancreatoduodenal zone is revealed. RPHG - the ability to see the external and internal hepatic ducts, as well as the ducts of the pancreas. CRCP - it is possible to determine both the nature and the localization of obstruction in the hepatoduodenal zone.

Etiology and pathogenesis of the underlying disease.

Calculous cholecystitis- a disease caused by the presence of stones in the gallbladder and bile ducts. Distinguish between cholesterol, pigmented and mixed stones (calculi).

Pathogenesis There are two main concepts of the pathogenesis of calculous cholecystitis: 1) the concept of metabolic disorders; 2) inflammatory concept.

Today, these two concepts are considered as possible pathogenetic variants (mechanisms) of the development of calculous cholecystitis - hepatic-metabolic (the concept of metabolic disorders) and gallbladder-inflammatory (inflammatory concept). According to the concept of metabolic disorders, the main mechanism of gallstone formation is associated with a decrease in the cholato-cholesterol ratio (bile acids / cholesterol), i.e. with a decrease in the content of bile acids in bile and an increase in cholesterol. Lipid metabolism disorders (general obesity, hypercholesterolemia), alimentary factors (excess of animal fats in food), lesions of the hepatic parenchyma of toxic and infectious genesis can lead to a decrease in the cholato-cholesterol ratio. A decrease in the cholato-cholesterol ratio leads to a violation of the colloidal properties of bile and to the formation of cholesterol or mixed stones. According to the inflammatory concept, gallstones are formed under the influence of an inflammatory process in the gallbladder, leading to physicochemical changes in the composition of bile. A change in the pH of bile to the acidic side, characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular - protein fractions of bile, the transition of the bilirubin micelle from a suspended state to a crystalline state. In this case, a primary crystallization center is formed, on which exfoliated epithelial cells, microorganisms, mucus, and other bile components are layered. According to modern concepts, at the initial stage of the development of calculous cholecystitis, one of these mechanisms may dominate. However, in the later stages of the disease, both mechanisms function. The formation of stones initiates stagnation of bile, an inflammatory process, stones serve as centers of crystallization of bile. Thus, the vicious circle is closed and the disease progresses.

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Moscow State University of Medicine and Dentistry

Department of Faculty Surgery No. 2

Head department: doctor of medical sciences, prof. I. E. Khatkov

Lecturer: ass. Zhdanov Alexander Vladimirovich

Disease history

Head Chair

Doctor of medical sciences, prof. I. E. Khatkov

Teacher

ass. Zhdanov Alexander Vladimirovich

Moscow 2010

PASSPORT DATA

Surname, name, patronymic of the patient

Age: 62 years old

Marital status: Married

Education: specialized secondary

Profession, position, place of work: pensioner

Place of residence

Time of admission to the clinic: 11/21/2010

COMPLAINTS ON ADMISSION

Complaints of a sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, double vomiting - not bringing relief, dry mouth, weakness, subfebrile temperature.

History of the present disease ANAMNESIS MORBI

He considers himself ill since 1990, when an attack of acute pain in the right hypochondrium first occurred. Was diagnosed with acute cholecystitis. Until now, the patient was hospitalized 4 times due to an exacerbation of the disease. In 2005, based on the results of an ultrasound scan, a diagnosis of cholelithiasis was made. They were treated conservatively. A few days after the onset of the attack, under the influence of treatment, the pain subsided.

The onset of this attack is acute. On November 20, 2010, the patient felt a sharp intense pain in the right hypochondrium, radiating to the lumbar region, which appeared several hours after eating a fatty meal. Vomiting did not bring relief. I tried to stop the pain on my own by taking no-shpa - without effect. After 16 hours from the onset of the attack, the patient was hospitalized by ambulance at City Clinical Hospital No. 68.

Life story (Anamnesis vitae)

Brief biographical information: born in 1947, in Moscow, in a family of employees, the first child. He grew and developed, keeping up with his peers.

Education: specialized secondary.

Family and sex history: Married since 1969, two children.

Employment history: He started working at the age of 20 as an adjuster at a factory.

Working conditions: work daily, 8 hours a day, with a break for lunch, indoors.

Occupational hazards: not noted.

Household history: Lives in a panel house in a two-room apartment with an area of 47 m2, with his wife. Has a separate bathroom, centralized water supply; did not stay in the zones of ecological disasters.

Meals: regular, 3 times a day, varied, medium-calorie. There are addictions to salty, fatty foods.

Bad habits: does not smoke, does not abuse alcohol, does not use drugs, is not a drug addict.

Past diseases: arterial hypertension since 2002.

In childhood, he suffered from acute respiratory viral infections, acute respiratory infections, chickenpox.

Postponed operations: tonsillectomy 1971, appendectomy 1976.

Sexually transmitted diseases, jaundice denies. Blood and blood substitutes were not transfused.

Allergic history: not burdened. Denies drug intolerance and food allergies.

Insurance history: for the last calendar year, he did not take a sick leave for this disease.

Heredity: mother died at 82 years old (suffered from cholelithiasis). My father died at the age of 47 from cancer.

The present state of the patient (Status praesens)

The general condition of the patient: satisfactory

State of consciousness: clear

Patient position: active

Body type: correct

Constitution: hypersthenic

Posture: correct

Gait: fast

Height - 167 cm

Weight - 95 kg

Body temperature: 36.7 C

Face examination:

Facial expression is calm, there is no pathological mask; the shape of the nose is correct; nasolabial folds are symmetrical.

Examination of the eyes and eyelids:

Swelling, dark color, ptosis was not noted; exophthalmos, enophthalmos were not found.

Conjunctiva pale pink; sclera white; the shape of the pupils is correct, symmetrical, the reaction to light is preserved; pulsation of the pupils, rings around the pupil were not detected.

Head and Neck Examination:

Musset's symptom is not identified; the size and shape of the head are correct; curvature and deformation of the neck in the anterior section associated with an enlargement of the thyroid gland, no lymph nodes were found; the pulsation of the carotid arteries is moderate; pulsations and swelling of the jugular veins, Stokes collar were not identified.

Skin integuments:

The skin is flesh-colored, the moisture of the skin is moderate, the turgor and elasticity of the skin are preserved, no pathological elements have been identified.

Skin appendages:

Male-type hair growth, corresponding to gender and age; the hair is brown, not brittle, not dry, no thinning or premature hair loss. The shape of the nails is correct, pink in color, longitudinal striation is revealed, there is no transverse striation; Quincke's pulse is not detected; the symptom of drumsticks and watch glasses is absent.

Visible mucous membranes:

The conjunctiva is pale pink in color, of moderate humidity, the vascular pattern is not pronounced, no pathological elements have been identified.

The mucous membrane of the nose is pale pink, moderate moisture.

The mucous membrane of the oral cavity is pale pink, moist, the vascular pattern is moderately pronounced, no pathological elements were found.

Subcutaneous fat:

Overdeveloped, the places of the greatest fat deposition are on the abdomen. The thickness of the skin fold on the abdomen near the navel is 4.5 cm, on the back at the angle of the scapula 3.5 cm. No edema was found.

The lymph nodes:

The occipital, parotid, submandibular, anterior cervical, posterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal are not palpable.

Muscular system:

Muscles are developed satisfactorily; muscle tone is preserved. Muscle strength is preserved, symmetrical throughout the limb. Soreness and seals on palpation were not noted.

Skeletal system:

When examining the bones of the correct shape, pain on palpation and beating of the bones of the skeleton was not noted. The symptom of "drumsticks" has not been identified.

The joints are of the correct shape, painless on palpation. The skin color and local temperature of the skin above the joints correspond to the skin color and the temperature of the surrounding tissues; active and passive movements in the joints are performed in full, painlessly.

Examination of the hands and feet:

The brushes are regular, pale pink, no edema, no muscle atrophy, no drumstick syndrome, Bouchard, Heberden nodules, tofuses, no hepatic palms symptom.

The feet were of the correct shape, pale pink in color, no edema was detected, no tofuses were found.

RESPIRATORY EXAMINATION INSPECTION

Chest shape:

The shape of the chest is hypersthenic: the supraclavicular and subclavian fossa are poorly expressed, the intercostal spaces are smoothed, the epigastric angle is obtuse, the scapula and clavicle are moderately prominent; Breathing tours are symmetrical on both sides.

Curvature of the spine: absent

Chest circumference at the level of IV ribs: 101 cm., On inhalation-104 cm, on exhalation-100 cm.

Chest excursion: 4 cm.

Breathing: Breathing freely, through the nose.

Breathing type - abdominal. Respiratory movements are symmetrical, the abdominal muscles are involved in the act of breathing. The number of respiratory movements per minute is 19. Breathing is shallow, rhythmic.

PALPATION

Determination of painful areas:

No painful areas were found on palpation of the chest.

Determination of resistance:

The rib cage is resistant.

PERCUSSION

Comparative percussion: A clear lung sound is detected over the entire lung surface during percussion.

Topographic percussion.


Height of standing of the apexes of the lung:
	4 cm above the clavicle	4 cm above the clavicle
		At the level of the spinous process of the VII vertebra
Kroenig field width
Lower lung border:
along the sternal line
along the mid-clavicular line
along the anterior axillary line
along the mid-axillary line
on the posterior axillary line
along the scapular line
along the paravertebral line
Respiratory excursion of the lower edge of the lungs 5 cm 5 cm
along the mid-axillary line

LUNG AUSCULTATION

Basic breathing sounds:

Vesicular breathing is heard over the entire surface of the lungs, except for the interscapular space from the VII cervical to IV thoracic vertebrae - in this area, bronchial breathing.

Adverse breathing sounds:

no side respiratory sounds were detected.

Bronchophonia:

Bronchophonia over symmetrical areas of the chest is not changed over the entire surface of the lungs.

EXAMINATION OF THE CARDIOVASCULAR SYSTEM

Examination of the heart area:

Protrusion of the region of the heart, apical impulse, cardiac impulse, pulsation in the II intercostal space near the sternum, pulsation of the arteries and veins of the neck, pathological pericardial pulsation, epigastric pulsation, and varicose veins in the epigastric region were not detected.

PALPATION OF THE HEART

The apical impulse is localized 1.5 cm outward from the left mid-clavicular line along the V intercostal space, the area is 1.5 cm, the strength, height and resistance are moderate. Cardiac impulse, tremors in the region of the heart are not detected by palpation.

PERCUSSION OF THE HEART

The boundaries of the relative dullness of the heart:

Right: IV intercostal space, 1 cm outward from the right edge of the sternum

Left: V intercostal space 1.5 cm medially from the left mid-clavicular line

Upper: along the upper border of the III rib along the left edge of the sternum.

The diameter of the relative dullness of the heart is 11 cm.

Vascular bundle width 5 cm

The configuration of the heart is normal.

The boundaries of the absolute dullness of the heart:

Right - on the left edge of the sternum

Left - 2 cm inward from the left border of the relative dullness of the heart

The upper one is at the level of the IV rib.

HEART AUSCULTATION

Heart sounds are rhythmic, muffled. Heart rate 80 in 1 minute.

Auscultation of the heart at the 1st point:

Auscultation of the heart at the 2nd point:

A melody of two tones is heard: 1 and 2 tones. 1 tone follows after a long pause. The tone ratio is correct: 2 tones are louder than 1, but no more than 2 times. No splitting or bifurcation of the 2nd tone was found. Accent 2 tone over the aorta was not revealed.

Auscultation of the heart at the 3rd point:

Auscultation of the heart at the 4th point:

A melody of two tones is heard: 1 and 2 tones. 1 tone follows after a long pause, coincides with the pulsation of the carotid artery. The tone ratio is correct: 1 tone is louder than 2, but no more than 2 times. Bifurcation and splitting of 1 tone was not revealed.

Auscultation of the heart at the 5th point (Botkin-Erb point): A melody of 2 tones is heard: 1 and 2 tones. 1 and 2 tones are approximately equal in volume to each other.

No additional tones and noises were detected.

Pericardial friction noise was not detected.

RESEARCH OF VESSELS

Examination of the arteries: no pulsations of the carotid arteries, no Quincke's capillary pulse were detected during examination. Palpation of the carotid, temporal, radial, brachial, ulnar, femoral, popliteal arteries and arteries of the rear of the foot - no local enlargements, contractions, tortuosity, seals were found; the ripple is moderate; the arterial wall is elastic and smooth.

When listening to the carotid and femoral arteries, Traube's double tone, Vinogradov-Durozier's double murmur were not detected.

Arterial pulse on the radial arteries: synchronous on both radial arteries, rhythmic, tense (hard), moderate filling, large, regular shape, uniform, frequency 68 beats per minute. Pulse deficiency was not identified.

Blood pressure (BP): systolic 135 mm Hg, diastolic 80 mm Hg

Study of veins. On examination, swelling and pulsation of the cervical veins were not detected, no visible pattern of the veins of the chest and abdominal wall was found, varicose veins of the lower extremities were not found.

On palpation, swelling and pulsation of the cervical veins were not detected. The "whirring of the top" in the jugular veins was not detected. No thickening or soreness of the veins was found.

RESEARCH OF THE DIGESTIVE ORGANS

Gastrointestinal tract

INSPECTION

At the time of examination, complaints of heaviness in the right hypochondrium.

Oral cavity:

The tongue is pink, moderately moist, coated with a gray bloom, the papillary layer is normal. There are no cracks or ulcers. Gums, soft and hard palate pink; no hemorrhages, no ulceration.

Belly:

The abdomen is symmetrical, regular in shape, participates in the act of breathing. There is no visible peristalsis of the stomach and intestines. Venous collaterals and striae are absent. The navel is retracted. There are no hernial protrusions.

The circumference of the abdomen at the level of the navel is 113 cm.

PERCUSSION

A tympanic percussion sound is heard over the entire surface of the abdomen. Free or lumpy fluid in the abdominal cavity is not detected. The fluctuation symptom is negative.

PALPATION

Superficial approximate palpation: The abdomen is soft, slight pain in the right hypochondrium. The muscles of the abdominal wall are not tense. Discrepancy of the rectus abdominis muscles is not observed. Superficial tumor-like formations, inflammatory infiltrate, umbilical hernia and hernia of the white line were not revealed. Symptom Shchetkin - Blumberg was not identified.

Methodical deep sliding palpation (according to Obraztsov-Strazhesko):

The sigmoid colon is palpable as a painless cylinder, 2 cm in diameter, moderately mobile, does not rumbling.

The cecum is palpable as a painless cylinder, 2 cm in diameter, moderately mobile, hums.

The ascending colon is palpable as a painless cylinder, 3 cm in diameter, moderately mobile, does not rumbling.

The descending colon is palpable as a painless cylinder, 3 cm in diameter, moderately mobile, does not rumbling.

The greater curvature of the stomach is palpable as a soft, painless cushion.

The pyloric region of the stomach is not palpable.

AUSCULTATION

Intestinal noises are heard. In the projection of the abdominal part of the aorta and renal arteries, tones and noises are not heard. There is no peritoneal rubbing noise.

surgical calculous cholecystitis

STUDY OF LIVER AND GALL BLADDER

Inspection:

There is no protrusion in the right hypochondrium and epigastric region, there is no breathing restriction in this area.

Liver percussion:

The upper bound of absolute dullness:

along the right midclavicular line - 6th rib.

along the anterior median line - 6 rib.

The lower bound of absolute dullness:

along the right mid-clavicular line - 1 cm below the edge of the costal arch.

along the anterior midline - on the border between the upper and middle third line drawn from the xiphoid process to the navel.

along the left costal arch - at the level of 8 ribs.

Liver size according to Kurlov:

on the right mid-clavicular line - 9 cm.

along the anterior median line - 7 cm.

along the left costal arch - 6 cm.

Palpation:

The edge of the liver is even, painful. The gallbladder is not palpable. Symptoms of Ortner, Murphy are positive, Mussey's symptom (phrenicus symptom) is negative.

Auscultation:

Friction noise the peritoneum in the right hypochondrium is absent.

EXAMINATION OF THE Spleen

Inspection:

There is no protrusion in the left hypochondrium. There is no breathing restriction in this area.

Percussion:

Length - 7 cm

Diameter - 5 cm

Palpation:

The spleen is not palpable.

Auscultation:

No friction noise was found in the left hypochondrium.

Pancreas examination

Palpation:

The pancreas is not palpable.

URINE SYSTEM

Dysuric disorders:

Difficulty urinating, the presence of involuntary urination, false urge to urinate, cramps, burning, pain during urination, frequent urination, no nighttime urination.

Lumbar region:

There is no protrusion in the lumbar region. The halves of the lumbar region are symmetrical.

Percussion:

The tapping symptom is negative on both sides.

Palpation:

The kidneys are not palpable.

Bladder:

The bladder is not palpable.

NEURO-PSYCHIC SPHERE

Consciousness is clear, easily comes into contact, the mood is calm, speech is unchanged. Sensitivity is preserved, vision, hearing, sense of smell are normal. The motor sphere is unchanged.

RECTAL EXAMINATION

The sphincter tone was preserved, the ampulla was empty, the walls were painless, no organic pathologies were found at the height of the finger, brown feces on the glove.

PRELIMINARY DIAGNOSIS

On the basis of complaints, examination, anamnesis, the patient was diagnosed with acute calculous cholecystitis.

SURVEY PLAN

1) Complete blood count

2) General urine analysis

3) Blood test: determine the blood group, Rh factor. serological tests: RW, HIV, HbsAg

4) Biochemical blood test for:

- total protein and its fractions

- bilirubin and its fractions

- cholesterol

- urea

- creatinine

- AST, ALT

- blood glucose

5) ultrasound of the abdominal organs

6) X-ray of the chest and abdomen

7) ECG

8) EGDS

9) Intravenous cholangiography

10) Fibrocholedochoscopy

11) Endoscopic retrograde cholangiopancreatography

12) Hepatocholescintigraphy

DATA OF LABORATORY AND INSTRUMENTAL RESEARCH METHODS

General blood analysis:

Hemoglobin - 138 g / l

Erythrocytes - 5.28 * 1012 / l

Leukocytes - 7.8 * 109 / l

Platelets - 248 * 109 / l

General urine analysis:

Color - straw yellow

Transparency is transparent

Relative density - 1010

Reaction - acidic

Leukocytes - 1-0-2 in the field of view

Erythrocytes - 1-0-2 in the field of view

Blood chemistry:

Abdominal ultrasound:

Gallbladder measuring 10 * 4 cm, wall 0.5 cm, contents: calculus 1.5 cm.

Choledoch 0.5 cm

Pancreas with clear, uneven contours, medium size, homogeneous structure, increased echogenicity.

The liver is not enlarged, homogeneous structure.

The spleen measures 4 * 4 cm of a homogeneous structure.

The kidneys are located symmetrically, with clear, even contours, of medium size, the renal sinuses are not dilated, normal echogenicity, the parenchyma thickness is 1.8 cm, the structure is homogeneous

Conclusion: acute calculous cholecystitis

The electrical axis of the heart in a semi-horizontal position. Sinus rhythm, correct. No pathological changes were found.

X-ray of the abdominal organs:

Signs of intestinal obstruction and violation of the integrity of the hollow abdominal organ were not revealed.

JUSTIFICATION OF DIAGNOSIS

The diagnosis of acute calculous cholecystitis is based on:

Complaints of the patient about a sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, double vomiting - not bringing relief, weakness, subfebrile temperature.

Anamnesis data. Addiction to fatty and salty foods. The pain appeared after eating fatty foods. It was not stopped by the No-shpa reception.

In 1990 he was diagnosed with acute cholecystitis, in 2005 he was diagnosed with acute calculous cholecystitis.

The patient's mother suffered from cholelithiasis.

Objective examination data: the presence of pain in the right hypochondrium; wet, gray-coated tongue; positive symptoms Ortner, Murphy.

Additional instrumental research data. Ultrasound: gallbladder measuring 10 * 4 cm, wall 0.5 cm, contents: calculus 1.5 cm.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis of acute calculous cholecystitis should be carried out with acute pancreatitis, peptic ulcer disease, acute appendicitis and an attack of renal colic.

1) With acute appendicitis:

With appendicitis, young people most often get sick. With cholecystitis, the elderly and more often women get sick. An attack of cholecystitis is caused by an error in the diet, the use of fatty, abundant food. Appendicitis begins for no apparent reason. However, the irradiation of pain in cholecystitis and appendicitis is of a different nature. With cholecystitis, irradiation to the lumbar region. Soreness at the point of the gallbladder can exclude appendicitis.

For acute appendicitis, it is characteristic: it begins with acute pain in the epigastric region - for a short time, after 2-4 hours the pain moves to the right iliac region (Kocher-Volkovich symptom), combined with tension of the abdominal wall. Symptoms of Rovzing, Sitkovsky, Voskresensky, Bartomier-Michelson are positive. These signs were not found in this patient.

2) With acute pancreatitis:

There are a number of common symptoms between acute pancreatitis and cholecystitis: sudden onset of the disease, acute pain, repeated vomiting, which does not bring relief. But unlike acute pancreatitis, where the irradiation of pain under the left scapula, the epigastric region, into the left hypochondrium, with acute cholecystitis, the pains are localized in the right hypochondrium and do not have a shingles in nature. Body temperature is subfebrile. In this patient, ultrasound did not reveal changes in the pancreas; the symptoms of Ortner-Grekov, Murphy are positive; Negative symptoms of Kerte, Voskresensky, Mayo-Robson, specific for acute pancreatitis. Thus, the diagnosis of acute pancreatitis can be excluded.

3) with peptic ulcer:

Pain in the epigastric region, of varying intensity, associated with food intake, stopped by taking antacids. Pain in cholecystitis does not have the same pattern as in peptic ulcer disease, and vomiting and bleeding are frequent symptoms of an ulcer. Pain and vomiting, occurring at the height of a painful attack, are characteristic of an ulcer. Diseases of the gallbladder lead to an increase in temperature, and peptic ulcer disease proceeds with a normal temperature. With an ulcer, dyspeptic disorders are manifested - constipation, diarrhea, as well as the presence of an ulcer history and a chronic course.

4) with renal colic

Stones of the right kidney give attacks of pain - renal colic. Low back pain, paroxysmal, extremely intense, relieved by the use of antispasmodics. The pain radiates down to the thigh, pubis, testicle. With cholecystitis, pain radiates upward: to the shoulder, scapula, neck. The behavior of patients with cholecystitis and renal colic is different. Patients with renal colic are usually restless, trying to change their position, which is not typical for cholecystitis. The study of urine is of great importance. In renal colic, we often find blood in the urine. Dysuria is possible. History of urolithiasis.

Treatment

An urgent hospitalization of a patient with suspected acute cholecystitis in a surgical hospital is mandatory.

In acute calculous cholecystitis, it makes sense to carry out conservative treatment. When complications appear, surgical treatment is indicated.

Bed mode, locally on the area of the right hypochondrium, put an ice pack.

Food - restriction of food (hunger), only alkaline drinks are allowed. When the process subsides, table number 5.

Pain relief:

1) Non-narcotic analgesics:

Rp: Sol. Analgini 50% - 2 ml

Sol. Dimedroli 1% - 1ml

S. i / m

2) If the pain does not subside, narcotic analgesics are used:

Rp: Sol. Morphini hydrochloridi 1% - 1 ml

Sol. Natrii chloridi 0.9% - 20 ml

M.D.S. Every 10-15 minutes until a positive effect is obtained, inject 4-10 ml of the resulting solution.

3) Antispasmodics:

Rp: Sol. Papaverini Hydrohloridi 2% - 2 ml

S. i / m, 3 times a day

Relief of the inflammatory process (antibiotic therapy):

Rp: Sol. Ampicillini 0.5

S. i / m, 4 times a day

Rp: Sol. Imipenemi

S. IM, 500 mg every 12 hours. Use with cilastatin.

Detoxification therapy:

Rp: Sol. Glukozi 5% -200 ml

Sol. KCl-3% -30 ml

S. i.v.

Rp: Sol. Natrii Chloridi 0.9% - 400 ml

Sol. Euphyllini 2,4% - 10 ml

S. in / in, drip

After the acute attack subsides, the patient must be operated in a planned manner in 2-3 weeks. If, against the background of the ongoing treatment of acute cholecystitis for 48-72 hours, the patient's condition does not improve, abdominal pain persists or intensifies, the protective tension of the muscles of the anterior abdominal wall persists or increases, the pulse quickens, remains at a high level or rises in body temperature, leukocytosis increases , urgent surgical intervention is indicated.

Surgical treatment of calculous cholecystitis

Early laparoscopic cholecystectomy is the main treatment.

The surgery is usually performed as soon as the symptoms of the disease have subsided. With such an operation, the mortality and frequency of complications are lower than with a planned operation carried out after 6-8 weeks of conservative treatment.

Patients with acute cholecystitis complicated by peritonitis, gangrenous cholecystitis, perforation of the gallbladder wall are subject to emergency cholecystectomy.

Percutaneous cholecystostomy in combination with antibiotic therapy is the method of choice in the treatment of severely ill and elderly patients with complications of acute cholecystitis.

Contraindications to laparoscopic cholecystectomy are:

* High risk of poor tolerance to general anesthesia.

* Obesity that interferes with the normal functioning of the body.

* Signs of perforation of the gallbladder (abscess, peritonitis, formation of a fistulous tract).

* Giant gallstones or suspicion of a malignant process.

* Severe liver damage with portal hypertension and severe coagulopathy.

In these cases, it is recommended to carry out an abdominal operation - cholecystectomy.

It consists in removing the gallbladder to prevent recurrence of gallstone disease.

The standard operation is performed through four very small punctures located on the anterior abdominal wall.

Positive aspects of cholecystectomy:

Due to a more uniform flow of bile into the intestine after surgery, an increase in the rate of enterohepatic circulation of bile acids, the lithogenicity of bile decreases;

Removal of the gallbladder - places where bile can crystallize;

A functionally defective organ is removed, which can become a source of serious complications;

The source of infection is removed.

The advantage of laparoscopic surgery is immeasurably less surgical trauma compared to the standard wide incision. This made it possible not only to activate patients earlier and shorten their stay in the hospital. It is much more important to reduce the number of general complications caused by volumetric surgery (pneumonia, thromboembolism, heart failure), which in turn makes it possible to improve the results of treatment of elderly and debilitated patients.

An important role is also played by the fact that postoperative hernias are immeasurably less common after laparoscopic surgery.

It is desirable to carry out cholecystectomy by the laparoscopic method, the advantages of this method are:

Low invasiveness;

The diameter of the stones is more than 2 cm;

Reducing the length of stay of the patient in the hospital;

A significant decrease in the need for narcotic analgesics in the postoperative period;

Reducing mortality in the group of elderly patients with severe concomitant diseases.

Performing cholecystectomy from a minilaparotomic approach, 4-5 cm long. This technology arose in parallel with laparoscopy and consists in performing the operation with modified instruments using a specially developed system of retractors. Cholecystectomy from a minilaparotomic approach is slightly inferior to laparoscopy in terms of the volume of surgical trauma inflicted, but it is cheaper and allows a more extensive intervention to be performed while maintaining the cosmetic effect.

Diary: (from 24.11.2010 Time: 11.30)

Complaints of aching, low intensity pain in the right hypochondrium, without irradiation, weakness. Nausea, vomiting is absent. The condition is satisfactory, the consciousness is clear, the patient is adequate. Skin and visible mucous membranes of normal color and moisture. The sclera are of normal color. In the lungs, vesicular breathing is carried out in all departments, there is no wheezing. NPV 19 per minute. The heart sounds are muffled, the pulse on the radial arteries is the same, the frequency is 80 to 1, rhythmic, satisfactory filling and tension. HELL 130/80 mm Hg The tongue is moderately moist, with a gray coating. The abdomen of the usual form, not swollen, participates in the act of breathing. On palpation, soft, moderately painful in the right hypochondrium. Symptoms of Shchetkin-Blumberg are negative, Ortner's, Murphy's symptoms are positive. With percussion, there are no dulls in the sloping places of the abdomen. During auscultation, intestinal noises are heard, active. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination is independent, painless. Diuresis is adequate. Straw-yellow urine, transparent. Physiological functions are normal.

Diary: (from 25.11.2010 Time: 12.00)

Complaints of slight pain in the right hypochondrium, without irradiation. Nausea, vomiting is absent. The condition is satisfactory, the consciousness is clear, the patient is adequate. Skin and visible mucous membranes of normal color and moisture. The sclera are of normal color. In the lungs, vesicular breathing is carried out in all departments, there is no wheezing. NPV 18 per minute. The heart sounds are muffled, the pulse on the radial arteries is the same, the frequency is 78 in 1, rhythmic, satisfactory filling and tension. HELL 140/70 mm Hg The tongue is moderately moist and clean. The abdomen of the usual form, not swollen, participates in the act of breathing. On palpation, it was soft, moderately painful in the right hypochondrium. Symptoms of Shchetkin-Blumberg, Ortner, Murphy are negative. With percussion, there are no dulls in the sloping places of the abdomen. During auscultation, intestinal noises are heard, active. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination is independent, painless. Diuresis is adequate. Straw-yellow urine, transparent. Physiological functions are normal.

Epicrisis

Patient Viktor Georgievich Latyshev, 62 years old, was admitted to the surgical department on 11/21/2010 with complaints of sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, double vomiting - not bringing relief, dry mouth, weakness, low-grade fever. The real deterioration occurred within 17 hours. From the anamnesis it was established that these symptoms appeared after ingestion of fatty foods. I tried to stop the painful attack by No-shpa on my own, but to no avail.

On examination at the time of admission - general condition of moderate severity, clear consciousness, active position, temperature 37.8 ° C; breathing is rhythmic, with a frequency of 20 per minute, with auscultation - vesicular breathing, there are no side respiratory noises; heart sounds are muffled, rhythmic, blood pressure 130/85 mm Hg, rhythmic pulse with a frequency of 80 beats / min; the tongue is moist, coated with a gray bloom, the abdomen is not swollen, soft, painful in the right hypochondrium, the symptoms of Ortner-Grekov, Murphy are positive.

Ultrasound of the abdominal cavity and kidneys - chronic calculous cholecystitis.

Based on the data obtained, the diagnosis was made - acute calculous cholecystitis. Conservative therapy was started, with pronounced positive dynamics (pain syndrome decreased, temperature dropped, according to ultrasound data - a decrease in the thickness of the gallbladder wall).

With the complete cessation of pain, a planned radical operation is indicated - cholecystectomy.

Forecast:

For life - favorable, with the preservation of working capacity. Relapses of the disease are possible, while maintaining the gallbladder.

Prevention of acute cholecystitis consists in adherence to a rational diet, exercise, prevention of fat metabolism disorders, and elimination of foci of infection.