Acute cholangitis clinic diagnosis treatment. Infections in abdominal surgery

- It is non-specific inflammation of intrahepatic or extrahepatic biliary ducts. It is characterized by three symptoms - a rapid increase in temperature to febrile numbers, strong pain under the right hypochine, jaundice. In order to diagnose acute cholangitis, the ultrasound of the liver and gallbladder is performed, computed tomography of biliary tract, biochemical liver samples. Also, the diagnosis is clarified by ERPHG, percutaneous christsechen cholangiography. Conservative treatment, only in severe cases resort to surgical interference with the purpose of decompression of the biliary tract.

General

Diagnostics

To establish a diagnosis of acute cholangitis, laboratory tests are performed primarily. Biochemical liver tests reveal an increase in bilirubin levels, alkaline phosphatase, triglycerides, ALT and AST. Reduced total Protein of blood due to albumin and increase γ-globulins. Often, with acute cholangitis, an increase in the level of amylase, lipases, as well as trypsin and its specific inhibitors, is observed, which indicates the involvement in the pancreas process. With the development of signs renal failure Creatinine and urea level increases. IN general Analysis Blood can be seen a significant increase in the number of leukocytes with a shift of the formula to the left, an increase in ESR. In blood often detect bacteremia.

With duodenal sensing in bile, a significant amount is found. epithelial cells, raising the level of lipids, sialic acids, different types of transaminases, fibrin. When crops, a huge number of bacteria is detected, often not one, but two or even three different pathogen. On the ultrasound of the liver and gallbladder, you can see extended intrahepatic and extrahepatic ducts, an increase in the gallbladder, liver, structural changes in its parenchyma. If the picture is not informative enough, the CT of biliary tract is additionally carried out, magnetic resonant tomography of the liver and biliary tract.

From instrumental methods for diagnostics use endoscopic retrograde pancreatocholangiography and percutaneous christsect cholangiography. The first technique also has the therapeutic importance, helps to eliminate blockage in the choleret if it is caused by a small and medium-sized stone. These studies make it possible to visualize bile ducts well, determine the obstruction site.

Treatment of acute cholangitis

Therapy of acute cholangitis is aimed at eliminating the blockage of the biliary tract and the fight against infection. From the very beginning, antibiotics prescribed the patient. The choice of the drug depends on the sensitivity of the flora. If a sensitivity test fails, antibiotics acting on the intestinal and anaerobic flora are used. These are synthetic penicillins, aminoglycosides, cephalosporins (mainly III and IV generations), fluoroquinolones. Antibiotics reserve - carbapenes. When choosing drugs, it is desirable to give preference to those derived through the liver together with bile, for example, ceftriaxone or cefoperazon. If the drug was chosen correctly, the improvement of the patient's condition occurs after 12-24 hours. The course of antibiotic therapy is 14-21 days.

In addition to antibiotics, the patient necessarily assign disintellation therapy. In manifestations of heavy liver failure, steroid hormones can be used. Also carry out the correction of the activities of the kidneys and heart. Under acute cholangitis caused by glitne invasion, anthehelminth drugs are prescribed. If acute cholangitis is accompanied by blockage of biliary tract, make their decompression by the endoscopic RPHG method. On open operational intervention It is rare and only after stabilizing the state of the patient.

Prediction and prevention

The prognosis in acute cholangitis largely depends on its stage and the degree of blockage of biliary tract. If blockage is insignificant and it was possible to eliminate it in time, the flow of cholangitis is favorable. With a protracted cholangitis, late diagnosis, after the development of infectious and toxic shock, the forecast deteriorates significantly. At the prospects for treatment also affects the type of pathogen. Poorly treatable sharp cholangitis caused by pneumococcal and multi-resistant flora. The forecast of cancer patients is worsening, over 50 years old.

Prevention of acute cholangitis is the treatment of the underlying disease (gallstone disease, dyskinesia of the biliary tract, etc.). Patients who are in the risk group, gastroenterologists advise correctly eat, follow the mass of the body, on time to pass by planned medical examinations.

Cholangitis is an inflammatory lesion of both intravenous and extra-erased bile ducts. In most cases, such a disease is diagnosed with female representatives, men suffer from ailment less often. The main risk group make up older people - from fifty to sixty years. Extremely rarely disease develops in children.

The disease does not have specific symptoms, which is why it is necessary to establish a proper diagnosis. wide spectrum Laboratory and instrumental examinations. The most characteristic clinical manifestations You can consider the development of jaundice, the appearance of strong pain sensations Under right ribs, as well as increasing body temperature.

In the treatment of the disease, conservative techniques prevail, but surgical intervention may be required during severe flow.

What it is?

Cholangitis is the inflammation of grained ducts due to the penetration of infections from the gully bubble, intestines, blood vessels (more often) or on lymphatic paths (less often). A frequent cause of cholangitis is toxoplasmosis, toxoplasm carriers - cats.

Causes of cholangitis

Severe, chronic and primary sclerosing cholangitis isolated.

The primary sclerosing cholangitis is isolated, the inflammation of which is not associated with infection. The disease develops as a result of autoimmune inflammation when disorders occur in immune system And its own antibodies are produced against healthy, normal tissues of the body, as a result of which there is a gradual narrowing of both extrahepatic and intrahepatic bile ducts. The reasons for the development of the disease are not fully known. Family and genetic predisposition, stress playing a major role.

Classification

Depending on the duration of the flow, the following pathology options are allocated:

1. Acute. The most common option at which they manifest typical symptoms, developing within 1-2 days.
2. Chronic. The most difficult option for diagnostics. It can occur independently or in the outcome of an acute form. Clinical picture In this case, it is often erased - often the only complaint of patients is a liquid chair or periodic abdominal pain.
3. Lightning or fulminant. The most severe I. dangerous formIn which all signs of the disease and blood infection appear suddenly and quickly progress (within a few hours). The fulminant ends with death in 90-100% of cases, even despite timely and qualified medical care.

The second principal moment in determining the form of pathology is the type of inflammatory process. In any diagnosis, this nuance is necessarily indicated, since further therapeutic tactics depends on it.

Currently, the doctors allocate the following options:

Form of the disease	Acute or chronic?	a brief description of
Serous		The most favorable pathology option, in which blood is extremely rarely developing. In the cavity of the ducts there is no pus - inflammation is manifested by the increase in the production of serous fluid.
Fibrino-serous	May be sharp and chronic, but more often the first option	Proceeds by analogy with the serous form. The main difference is due to the inflammatory process - in the organ, in addition to the liquid, there are protein (fibrinous) overlays.
Sclerosing	Only chronic	Hidden a slow-ending form of pathology at which there are practically absent characteristic signs. It is dangerous by the development of severe irreversible liver damage, up to.
Necrotic	Just sharp	It is the final stage of purulent cholangitis, in which the walls of the organ begin to die. The greatest danger is the possibility of penetrating the particles of dead tissues, bile and pus in the blood. The natural result of this is the development of infection of blood and shock.
Purulent	As a rule, sharp	A severe form in which a large number of bacteria is in the cavity of the organ and is aggressively proceeding. It often marks the development of sepsis and the occurrence of infectious-toxic shock is possible.

Symptoms of cholangitis

Despite the fact that different types of cholangitis there are several (including those already mentioned primary sclerosing cholangitis, cholecystocholangitis, etc.), their symptoms are quite similar.

These signs characteristic for cholangitis will be listed below.

1. , nausea, strong vomit urge.
2. Increase liver in size.
3. Weakness, lethargy.
4. Yellowing skin Pokrov and eye proteins. Arises because of the stagnation of yellow.
5. Strong fever, chills. Especially such symptoms are characteristic if sharp cholangitis occurs.

For acute form Diseases All these symptoms will be very bright, so not to notice them will be difficult. But in chronic form, all the symptoms are somewhat muted: instead of fever, there is a subfebilitation, instead of constant vomiting - a slight nausea, pain in the hypochondrium is not so strong. On the one hand, the chronic form of the disease is less painful for the patient, on the other - a person often decides to pull out not too strong pain, and in the case of cholangitis it can have deposited consequences.

What will happen if not treated?

In the absence of timely treatment inflammatory process With bile ducts applies to the peritoneum - peritonitis (inflammation of peritoneum) occurs on the surrounding tissues - subiaphragmal, intrahepatic abscesses, sepsis, bacterial-toxic shock are formed. The patient's condition becomes extremely difficult and requires resuscitation activities.

The long-term inflammatory process with chronic cholangitis leads to sclerotic changes in the liver tissues and the development of biliary liver cirrhosis.

Self-treatment and treatment of cholangitis by folk remedies is unacceptable, as time can be missed for treatment. In the later stages of the disease, the forecast is unfavorable.

Diagnostics

The diagnosis is made on the basis of characteristic symptoms Cholant, careful inspection and data of hardware and laboratory research:

1. Ultrasound of the gallbladder, liver and bile ducts;
2. Radioisotope examination of the biliary tract;
3. General I. biochemical analysis blood;
4. Laboratory explorer bile.
5. Cholangiomanometry (pressure measurement inside bile ducts);
6. Choledochoscopy (endoscopic study of bile ducts);
7. Retrograde pancreatocholangiography (X-ray rhythm of the biliary tract and pancreas with endoscopic administration of a contrast substance);
8. Intravenous cholangiography (X-ray radoscopy of the biliary tract with intravenous administration of a contrast agent that allows you to see intra- and extrahepatic ducts).

How to treat cholangitis?

Treatment of cholangitis is carried out only in the hospital. Folk remediesthat a person wants to spend at home does not contribute to recovery. Here is needed by medication, therapeutic and sometimes surgical treatment.

How to treat cholangitis? The doctor prescribes medicines if a normal bile outflow is observed:

• Antibiotics;
• Spasmolytics;
• Sulfonamides;
• Medications that reduce intoxication;
• Medicines that improve bile outflows;
• Anthegermic drugs.

In case of ineffectiveness conservative treatment Surgery surgical. Endoscopy is carried out with the drainage of bile ducts, eliminating the narrowing, the removal of stones. For purulent inflammation A long-distance operation is carried out to remove purulent or necrotic sites. Sometimes cholecystectomy is carried out - removal of the gallbladder or a complete liver transplant.

Medicia treatment

As mentioned above, preparations that reduce pain syndrome are widely used, eliminate the infection and contribute to the rapid restoration of the body.

A broad spectrum antibiotics are used to suppress infection. These include metronidazole, tetracycline and levomecitin. You can take them no more than 2 weeks in an individual dosage.

1. Tetracycline. This drug It has a bacteriostatic action. It is necessary to apply it to 200 -250 mg 2-3 times a day. For children, enough - 20-25 mg / kg. The duration of treatment is assigned individually. Contraindications: Hypersensitivity, pregnancy, lactation period, violation of the liver and kidney function. Side effects: Pigmentation of the skin, inflammation of mucous membranes, dysbacteriosis, allergic reactions. Typically, the drug is moved well.
2. Metronidazole. it antimicrobial preparation. Apply it on one tablet 2-3 times a day. In special cases, the dosage increases to 4-5 tablets. It is not necessary to make adjustments to yourself, the remedy has a number of side effects. So, it is possible nausea, vomiting, weakness, availability metal Tribus In the mouth, dizziness. When symptomatics appears, it is worth consulting a doctor. Contraindications: Pregnancy, childhood, hypersensitivity and breastfeeding period.
3. Levomecitin. The medication actively destroys bacteria. It is necessary to use it at 250-500 mg 3-4 times a day. Daily dose should not exceed 2 grams. The nature of the treatment and dosage is appointed by the attending physician. Contraindications: pregnancy, lactation period, psoriasis, eczema, hypersensitivity. Side effects: anemia, nausea, vomiting, fever, allergic reactions.

It is also worth noting that in the presence of such a disease, resort to help folk Medicine Do not. After all, while the person will pick up optimal treatment, pathology will begin to progress.

Food and diet

Diet with cholangitis implies compliance with such rules:

• frequent and fractional food intake;
• consumption of only warm meal;
• grinding I. careful foaming products;
• full refusal of greasy and sharp dishes, smoked and preservatives;
• the preparation of dishes should be carried out only by cooking, extinguishing, steaming or baking without adding fat;
• abundant drinking mode - drink no less than two liters of liquid. All drinks are allowed, except for strong coffee and soda;
• the enrichment of dietary dietary varieties of meat, fish and birds, porridge, especially buckwheat and oatmeal, degreased dairy products, fruits and vegetables after the thermal processing is passing.

Physiotherapeutic treatment

During the remission, physiotherapeutic treatment is prescribed:

1. UHF (high-frequency electromagnetic field);
2. Parafinotherapy (heat collecting with heated paraffin);
3. Diathermy (use alternating current);
4. Chloride sodium baths (mineral waters);
5. Electrophoresis (effects of electrical pulses);
6. Industothermia (application magnetic field high frequency);
7. Mud appliqués (used heated healing dirt);
8. Microwave therapy (exposure to the electromagnetic field, microwave vibrations);
9. Ozocertotherapy (heat collecting with medical heated ozokerite - oil substance, wax consistency).

Surgical intervention

With ineffective medical treatment, abnormal disorders of bile shown the operation:

1. Extensive operation - resection (removal) of affected (purulent, dead) sections.
2. Endoscopic technique. Drainage (the introduction of the catheter for the outflow of the contents of the biliary tract, eliminate the stenosis (narrowing), remove the concrections, without resorting to the weighting operation. This method avoids bleeding, reduce the risk of operational injury, speed up the period of rehabilitation (recovery) after the manipulation.

Forecast

The disease prognosis is completely dependent on the state of the person and the form of the flow, as well as the outflow of bile. If the treatment was carried out in a timely manner, then no complications should be. Fast intervention leads to positive results. But it is important to maintain the body so that there is no relapse. Permanent repeating pattern of pathology leads to chronic flow. In this case, the forecast can be extremely unfavorable.

If we talk about late stages of pathology, then everything depends on treatment. But all, the probability of an unfavorable forecast is several times higher. Save a person is not always possible, especially if he has cirrhosis of the liver. Here you need exclusively organ transplantation. Worsen the forecast is capable additional symptomsrelated to acute liver failure, cirrhosis and liver abscess. In the risk group there are women over the age of 50. Therefore, it is important to pass surveys and react to any symptoms in a timely manner.

Prevention

The prevention of the occurrence of cholangitis is timely treatment other pathologies digestive tract (gastroduodenitis, cholecystitis, etc.), glider invasions and observation of the gastroenterologist after surgical interventions on horse bubble and yellow paths.

- This is a non-specific inflammatory process of bile ducts, which arises as a result of a violation of the passage of biliary tract and contamination of bile.

Cholangitis is often combined with bile duct cysts, choledocholiticiasis and bile duct cancer.

The causes of the occurrence of cholangitis.

As a rule, cholangitis is formed as a result of causative agent bacterial infection From the lumen duodenal gut In bile ducts, lymphogenic, or hematogenic way.

The nature of the flow of cholangitis can be both acute and chronic. The acute form of cholangitis can be purulent, catarrhal, necrotic and diphtheritic, depending on the degree inflammatory changes.

The chronic forms of cholangitis include recurrent, latent, long-term septic, sclerosing and abscessive.

Symptoms and signs of cholangitis.

The symptoms of this disease largely depends on the absence, or the presence of an acute form of destructive cholecystitis, which is quite often complicated by cholangitis.

Cholant begins with manifestation owl syndromewhich reminds colic and replaced mechanical jaundice, skin itch and increasing body temperature.

The inspection is detected by the image of the skin, traces of combs on the skin and a wet language. With palpation of the abdomen area, muscle rigidity in the right hypochondrium and soreness are noted. With an in-depth palpation, an increase in the liver is marked, the edge of which is rounded. A chill may occur or a hectic temperature.

Due to direct Bilirin Hyperbirubinemia occurs, and a moderate increase in liver enzymes occurs due to damage to the toxins of hepatic parenchyma.

Complications of cholangitis.

In the absence of timely treatment, the inflammatory process can move from the walls of bile ducts to nearby fabrics, which can trigger the impregnation with the bile of hepatic and duodenal ligament and peritonitis, development sclerotic changes In the hepatic tissue, secondary biliary cirrhosis and the formation of intrahepatic abscesses.

Treatment of cholangitis.

The patient with cholangitis needs to be immediately hospitalized to prepare for surgical treatment. At the stage prefigure The patient is prescribed anti-inflammatory, as well as spasmodic drugs, antibiotics of a wide range of impacts that are not hepatotoxic.

It is advisable primarily to ensure the correct outflow of bile, which will make it possible to simultaneously reduce the manifestations of cholangitis and intoxication. Further action should be a radical intervention, which must be sent to eliminate the cause of the formation of this disease.

In the medical institution, the patient is carried out antibacterial and disintellation therapy, and also prepare the patient to surgical operation.

Under the acute form of cholangitis, endoscopic methods of drainage of bile ducts were obtained, which are able to provide the desired bile outflow.

Forecast for cholangitis.

With catarrial cholangitis, the forecast is favorable in case of timely treatment. In the diferitical, necrotic and purulent cholangitis, the forecast is more serious and largely depends on the degree of severity of morphological changes, the factor that caused this disease and general status Health patient. With long-term cholangitis chronic form An abscessive cholangitis can be formed, whose forecast is unfavorable.

Halgitis Prevention.

Preventive measures At cholangitis include timely detection and treatment of diseases of biliary tract and places of a large duodenal pacifier.

For decompression of the biliary tract, endoscopic papillosphincterotomy is carried out after retrograde cholangiography.

After holding papilosophyrtherotomy, in the presence of residual stones of Kolado, the extension of the concrections arises. When chosening the phenomena of cholangitis, the question of holding a re-operation disappears.

Cholangit- inflammatory process in bile ducts (cholangolit - damage to small bile ducts; cholangitis or angiiology - the defeat of larger intra-and extrahepatic bile ducts; choledochitis - the defeat of the total bile duct; papillitis is the defeat of the area of \u200b\u200bthe packer).

Classification of cholangita(Yu. I. Fishzon Riesh, I. A. Postelov, 1985)

1. By etiology:

• 1.1. Bacterial.
• 1.2. Helmintous.
• 1.3. Toxic and toxic-allergic.
• 1.4. Viral.
• 1.5. Autoimmune.

2. For the flow:

• 2.1. Acute.
• 2.2. Chronic.

3. By pathogenesis:

3.1. Primary (bacterial, helminthous, autoimmune).

3.2. Secondary and symptomatic:

3.2.1. On the soil of a litter cholestasis:

• 3.2.1.1. Stones hepato-choledoch.
• 3.2.1.2. Scooted and inflammatory strictures of the main bile ducts and a large duodenal nipple.
• 3.2.1.3.Slocal I. benign tumors With occlusion hepatocholed or a large duodenal nipple.
• 3.2.1.4. Pancreatitis with chopped choledoch.

3.2.2. On the basis of diseases without a tune cholestasis:

• 3.2.2.1. Billiodigenic anastomoses and fistulas.
• 3.2.2.2. The deficiency of the sphincter is apparently.
• 3.2.2.3. Postoperative cholangitis.
• 3.2.2.4. Callest hepatitis and biliary cirrhosis of the liver.

4. According to inflammation and morphological changes:

• 4.1. Catarial.
• 4.2. Purulent.
• 4.3. Obstructive.
• 4.4. Destructive unmann.

5. By the nature of complications:

• 5.1. Liver abscesses.
• 5.2. Necrosis and perforation of hepatucholes.
• 5.3. Sepsis with extrahepatic purulent foci.
• 5.4. Bacterial-toxic shock.
• 5.5. Acute renal failure.

Most often cholangitis have bacterial nature, the pathogens are most often intestinal wand, Enterococci, Friedland Bacillus, Pneumococci, Streptococci.

Cholangit sharp

Clinical symptoms. In the first stage, the main symptom - heat Body with stunning repeating chills. The beginning is sudden, stormy. Temperature of the body rises daily or 1 time in 2-3 days. Characteristic pain in the right hypochondrium, vomiting. Developing severe weakness is reduced arterial pressure. In the second stage the symptoms described above An increase in the liver joins, it is sharply painful, the hepatic functional samples are disturbed, subiterity occurs, and then a small jaundice. By the end of the first week, the spleen increases. Pneumococcal cholangitis are particularly difficult, most often complicated by the development of liver abscesses. In the third stage, if there is no improvement, the picture of hepatic insufficiency has been developing with a pronounced jaundice, and pronounced changes appear in the urine, urea and creatinine in the blood (hepatorenal syndrome) are increased, and cardiac activity (tachycardia, deaf tones, arrhythmia, is significantly disturbed. dystrophic changes Myocardia on ECG), collaps possible, pancreatitis often occurs. In the fourth, ultimate, the stage develops pronounced liver and renal failure, coma.

Acute catarrhal cholangitis is manifested by an increase in body temperature, chills, increasing and soreness of the liver, but the severity of intoxication does not achieve a very serious degree. Purulent cholangit It takes very hard, pronounced intoxication is characterized up to the development of bacterial-toxic shock. Often the defeat of the central nervous system in the form of prostration, the perisage of consciousness. Purulent cholangitis is often complicated by subadiaphragmal, intrahepatic abscess, reactive exudative pleuritis and the epipherable of pleura, abscess of the lungs, peritonitis, endocarditis, pancreatitis.

Laboratory data.

• 1. Oak: moderate or high (more than 1.5-109 / l) leukocytosis, blood formula shift to the left, toxic grit neutrophils, increase.
• 2. Tank: increasing the content of bilirubin with the predominance of the conjugate fraction, α2 and γ-globulins, transaminases, alkaline phosphatase, y-glutamyl trapeptidase, sialic acids, fibrin, serumcoid.
• 3. OA urine: the appearance of protein, cylinders, bilirubin.

Chromatic fractional duodenal sensing. Portion in: In large numbers, small cylindrical epithelium. Portion with: decreased by the concentration of lipid complex, increase the content of sialic acids, fibrin, transaminase, sowing an abundant bacterial flora, may be detected large number leukocytes. Ultrasound procedure - an increase in the size of the liver, the heterogeneity of the acoustic picture, the expansion of intrahepatic bile ducts.

Survey program

1. OA blood, urine, feces. Study of urine on bile pigments. 2. Tank: common protein and its fractions, sialic acids, fibrin, serumcoid, transaminase, aldolaza, alkaline phosphatase, bilirubin, γ-glutamyltranspendase, urea, creatinine. 3. Study of blood for sterility. 4. Duodenal fractional sensing with bacteriological research Portions in and C and determination of the sensitivity of the flora to antibiotics. 5. Ultrasonic examination of the liver and biliary tract.

Chronic cholangitis

Chronic cholangitis - chronic bacterial inflammation of bile ducts (extrahepatic and inside-hepatic).

Clinical symptoms. Latent shape: pain and pain in the right hypochondrium or absent, weakness, octvinations, subfebrile temperature Body, occasionally skin itching, skin characteristics and visible mucous membranes, gradual increase in the liver. Recurient form: pain and pain in the right hypochondrium during palpation, nausea, bitterness in the mouth, skin itching; In the period of exacerbation - jaundice, fever, a long subfebilitation is possible; With a long flow - the thickening of the end phalange in the form of drum sticks and nails in the form of watch glasses, the liver and spleen are increased, dense. Tightening septic shape: heavy flow With fever, chills, pains in the right hypochondrium, increasing liver, spleen, severe intoxication, kidney damage, jaundice. Reminds septic endocarditis. Sclerosing (stenosing) Form: general weakness, malaise, body temperature, octvine, skin, jaundice, liver, spleen; Frequent combination with nonspecific ulcerative colitis, Crohn's disease, vasculitis, thyroiditis.

In the later stages of chronic cholangitis, the biliary liver cirrhosis is possible.

Laboratory data The same as acute cholangitis, but for chronic more natural anemia.

Instrumental research The same as acute cholangitis. Intravenous cholangiography or endoscopic retrograde pancreato-langiography reveals extended bile ducts (outside and intrahepical), with sclerosing cholangitis - intrahepatic ducts in the form of a rosary, often sharply narrowed with reduced branches, narrowing in some departments or throughout the total bile duct.

Survey program The same as in acute cholangitis. In addition, laparoscopy with cholangiography and aiming biopsy of the liver is needed in difficult differential and diagnostic cases.

Diagnosis wording

The diagnosis is formulated based on the etiological and pathogenetic features of cholangitis and its role in a number of other manifestations of the pathological process.

Primary cholangitis develop as an independent disease. Among them should be the primary sclerosing cholangitis - a disease of the presumably autoimmune nature. Eastern cholangitis is also described as primary - insufficiently studied shape, endemic for industrial areas of Asia, and possibly associated with clonorhose. With a secondary symptomatic cholangitis, a disease that served as a prerequisite for its development is put forward or associated with it. True, with cholestatic hepatitis and primary biliary liver cirrhosis, it is not customary to look for the participation of cholangitis in the formation of the pathological process, but it is appropriate to mean. If cholangitis acts as independent diseaseHis primacy is appropriate to reflect in the diagnosis. Thus, it is emphasized by the separation of similar rare forms from the absolutely dominant cases of secondary cholangitis. Examples of diagnosis formulation

• 1. Acute primary bacterial cholangitis, sepsis, liver abscesses.
• 2. Gallgamed disease (choledocholiticiasis), exacerbation of secondary bacterial cholangitis.

Cholangitis primary sclerosing

Chillege Primary Sclerosing (CPS) - Chronic inflammatory disease Liver, accompanied by fibrous obliteration of the part of bile ducts.

Etiology and pathogenesis of CPSfinally not installed. There are hypotheses about the relationship of the disease with bacterial, viral, toxic factors, with thrombosis of branches of the bubble artery. IN last years Much attention is paid to the role of immune mechanisms and genetic factors for the development of CPS. In general, two concepts are discussed. According to the first, CPS refers to autoimmune diseasesAccording to the second, develops in persons with genetic predisposition when a starting factor is any infection or toxic process. In patients with HPS, HLA BE, DR3 haplotype is often detected and very rarely - B12.

Clinical symptoms

Pretty man is sick young age. Patients complain of weakness, fatigue, pain in the right hypochondrium, epigastrics, nausea, loss of body weight, increase body temperature to subfebrile, jaundice, itchy skin. In case of inspection, characterity is found, with pronounced portal hypertension - Expansion of the veins of the front abdominal wall, ascites, swelling. The hepatomegaly is determined. A sharp deterioration in the course of the disease in the form of bright signs of obstructive cholangitis (strengthening of the Halemi, fever with chills, strong pain In the right hypochondrium) indicates the development of the complications of the disease: choledocholitiasis, acute bacterial cholangitis, carcinomas of biliary ducts.

CPS is often combined with ulcerative colitis, pronounced fibrosis of the mediastinum, retroperitoneal space, thyroid gland (Treareitis Ridel), pancreas ( chronic pancreatitis, diabetes), less often with krone disease, autoimmune thyroid, thyrotoxicosis, hypothyroidism, SLE, rheumatoid arthritis, Bekhtereva's disease, Shegren's disease.

Diagnostic criteria

The presence of obstructive jaundice of the progressive type; The lack of stones in the biliary ways (previously not carried out operations in the hepatobiliary zone); Detection with the laparoto-mii common thickening and narrowings of extragrantic bile ducts, the passability of their intrahepatic departments is confirmed by the operating halligography; lack of malignant neoplasms; The elimination of the primary bi-liar cirrhosis of the liver, filed by the morphological study of the liver bioptate.

Laboratory data

• 1. OAK: an increase in ESP, signs of anemia, leukocytosis.
• 2. Urine analysis - positive reaction on bilirubin.
• 3. Tank: an increase in the blood content of alkaline phosphatase, bilirubin (predominantly conjugated), alanine transferase.

Instrumental research

Laparoscopy: The liver in the initial stages may look unchanged, consequently formed cirrhosis. Its color from a dark cherry to green, but less intensity than with a tune cholestasy. On the surface of the liver, the stars of star shapes are detected, combined with severe fibrosis, small nodes of purple-red or black color, resembling metastases. The "big green liver", due to chronic chronic cholestaste, is noted in the far stages of macroscopically, but there are no extended bile capillaries characteristic of obstructive jaundice on its surface. Retrograde endoscopic cholera-hyopancratography: the simplest and most convenient view of the study to confirm the diagnosis. On the cholagiograms, beadowless changes in large intrahepatic bile ducts, combined with small intrahepatic ducts with a decoration (a picture resembling a "dead" tree). Describes characteristic, chaotic scattered, short finger-shaped ties, connected by normal in size with bile ducts and combined with common strictures, diverticopod-like protruding and microctases, which causes the irregularity of the walls of the ducts. In addition to intrahephells are affected and exposed gallways. Lack of extensive expansion - an important feature HPS, distinguishing it from secondary cholangitis. Liver biopsy: fibrous inflammation of bile ducts.

Survey program

1. OA blood, urine, urine analysis on urobilin, bilirubin. 2. Tank: bilirubin, transaminase, alkaline phosphatase, general protein and protein fractions, cholesterol. 3. Blood II: T- and B-lymphocytes, immunoglobulins, CEC. 4. Laparoscopy with sight biopsy liver. 5. Retrograde endoscopic cholangiopancopyography (if it is impossible to perform laparoscopy with a sight biopsy of the liver).

Diagnostic director of the therapist. Chirkin A. A., Okorokov A.N., 1991

Cholant is inflammation of external or internal hepatic ducts. Pain in the right hypochondrium, giving in the shoulder? Pulling painful feelings Or a feeling of cutting? Most likely it is cholangitis. It is impossible to postpone the visit to the doctor with such symptoms, since dysfunction of liver ducts leads in the absence of therapy to severe diseases. How to determine the presence of pathology than to treat the inflammatory process and whether it is possible to prevent his answers to all questions in the article.

The overall cholanthite code on the ICD-10 - K83.0, which combines all varieties of the disease. This term denotes non-specific inflammation of biliary liver ducts, which occurs by different reasons. The risk group in the incidence is, above all, women in the postmenopausal period. Usually this pathology Accompanied by other disorders of the functions of the tract: gastroduodenitis, hepatitis, HCB, pancreatitis and inflammation of the most gallbladder.

Classification

The inflammatory process can be sharp or chronic, both stages have several varieties. Acute cholangit divided into:

• Catarial, accompanied by edema and hyperemia mucous membranes. The epithelium is listed, the walls of the vessels are infiltrated by leukocytes.
• Difteric, in which internal surface Duchs are formed fibrinous films.
• Purulent cholangitis leads to melting the walls of biliary vessels and the emergence of multiple abscesses.
• Non-necrotic is the formation of foci of dead fabric.

However, the disease is more often diagnosed in the chronic phase (or may initially take a protracted sluggish character). Allocate the following varieties of this process:

• latent;
• septic;
• recurrent;
• abscessive;
• sclerosing.

The last form of chronic inflammation - the sclerosing cholangitis of the liver leads to deformation of the ducts due to growth connective tissue, their narrowing or complete infection (obliteration).

Prerequisites for the development of the inflammatory process can be various factors. Stagnation of bile, dyskinesia of the ducts or their innate anomalies, the cyst of the general duct, malignant neoplasms, cholelithiasis Usually lead to inflammation. Provoke it can also surgical interventions And other medical manipulations: cholangitis after removing the gallbladder, sphincterotomy, pancreaticolangiography is also possible.

Most often, cholangitis is a consequence of infection pathogenic microorganismswhich fall into the liver ducts of the duodenum (upward way), with blood flow through a dutiful vein or together with lymph when the gallbladder is inflammation, fine intestine, pancreas. The most common pathogens are intestinal chopstick, entero and staphylococci, protea and anaerobes. Sometimes there is an infection caused by tuberculous mycobacteriums, pale spirochete or typhoid salmonella. In the hepatitis of viral nature, small ducts are affected.

Aseptic inflammatory process occurs for various reasons. For instance, aukoimmune defeat (Primary biliary cholangitis), leading to sclerosis and often accompanied by vasculitis, thyroiditis, non-specific ulcerative colitis, crown disease. Aseptically B. initial stage The inflammation of enzymes and enzymes occurs: with pancreatoatobiliary reflux, pancreatic juice falls into the bile ducts and annoys them. Later will join a bacterial infection.

Diagnostics

The primary diagnosis in the acute phase can be exhibited on the basis of a specific symptom complex - Charcot triads. For clarification, a number of instrumental and laboratory studies are carried out. The visualization method is an ultrasound examination - signs of cholangitis on ultrasound serve deformation of the ducts (expansion or narrowing, the presence of cyst, inflammatory foci). Computed tomography, ultrasonography of the liver are also held.

Basic instrumental studies - endoscopic pancreaticolangiography, MRPHG (computer scanning in a magnetic field), as well as percutaneous chrsechin cholangiography. The latter involves a radiographic examination of biliary ducts after their filling with a contrasting agent.

Symptoms and cholangitis treatment

For the flow and manifestation of acute and chronic cholangit differ significantly. For the first characteristic, the so-called Triad Charco:

• Fever that starts suddenly with a sharp increase in temperature to 38 ° C and higher, chills and intensive sweating.
• Severe pain under the ribs to the right, giving right side Body (neck, shoulder and shovel) and similar to the bile colic.
• Jaundice, which will join later. Shoe sclera and leather, itching occurs, because of what the multiple bumps are detected during inspection.

Due to the increase in temperature, symptoms of intoxication appear. The patient is nauseous, it worsens appetite, progresses weakness. Complaints are also characteristic of headaches, and in particularly severe cases, shock phenomena and violation of consciousness are joined.

The chronic stage of the disease is characterized by a weakly pronounced symptomatology, which progresses over time. For example, the symptoms of the sclerosing cholangitis appear fairly late in the form of pain in the stomach, skin itch, weight loss, jaundice, general weakness. Jaundice, as a rule, suggests that the pathological process came far enough.

The treatment of cholangitis can be both conservative and surgical. Its main tasks are to eliminate intoxication, the relief of inflammation and decompression of biliary ducts. The patient recommended bed and fasting, medicines, in some cases - operational intervention until the liver transplantation.

Cover treatment with drugs drugs

Purpose medicines It is carried out in accordance with the exact diagnosis. The list of drugs can be included:

Hepatoprotectors are also used to restore and protect liver cells.

Operational treatment

Conservative medical therapy It is shown only in the case when the permeability of bile ducts is not violated. However, it is often necessary to restore borties with the help of surgical manipulations. Operational treatment Cholant may be minimally invasive: endoscopic papilionfinotomy or sledging, percutaneous or outer drainage, etc. With the sclerosing variety of the pathological process optimal option is liver transplantation.

Physiotherapy

The list of physiotherapy methods includes the following:

• ultra- and microwave therapy;
• inductance and diathermy;
• electrophoresis;
• mud;
• parafinotherapy;
• salt baths.

Physiotherapy is prescribed only during the remission of the disease.

Treatment of cholangitis by folk remedies

In the acute phase, only qualified health care, and recipes alternative medicine can be used for chronic inflammation. Most effective are considered:

• Golden infusion made of a mixture of aid, calendula and yarrow. Two tablespoons of crushed collection need to be insteaded for about an hour in 0.5 liters of boiling water, then strain and take a three times a day before eating.
• In the same proportions, you can brew and collect from cornfights, immortals and chamomile. You can drink it instead of ordinary tea.
• Mint-honey mixture contributing to the secretion of bile is prepared from an equal number of flower honey and dried leaves peppermint. It is necessary to take it on a teaspoon twice a day.

Treatment folk methods Must be coordinated with the doctor, as individual contraindications can be available.

Diet with cholangitis

During the exacerbation, the patient is shown starvation (24-48 hours, with a gradual expansion of the diet).

With the normalization of the state, a special diet is prescribed, from which greasy products are excluded, duff, marinades, smoked spices, sharp spices, chocolate, legumes, garlic and onions. Cannot drink coffee, gas production and alcoholic beverages. Of particular importance is the method of preparation: food must be boiled, baked or stew, and frying products is prohibited.

Diet with cholangitis implies frequent nutrition in small portions. Food should not be cold or too hot, the maximum break between meals is 4 hours. The patient is allowed to eat low-fat fish and meat, cereals, pasta, bread, soups on the secondary broth, vegetables, dairy products, non-acid berries and fruits. You can drink tea with milk, diluted juices, compotes. Of the sweets are permissible in the limited number of marmalade, jam, grazing.

Forecasts and prevention

Complicated with cirrhosis, abscesses, sepsis cholangitis - the diagnosis is extremely unfavorable in terms of recovery. Difteric, purulent and necrotic is difficult to treat, often lead to disablement. When catarrhal form, the forecast is the most favorable. Prevent inflammation of biliary ducts will help the timely treatment of gastrointestinal diseases, cool invasions.