Inflammation of the bile duct cholangitis. Cholangitis: causes, symptoms, treatment tactics

Date of: 19.07.2019

Cholangitis - A syndrome that characterizes a non-specific inflammatory process with damage to the extra- and / or intrahepatic bile ducts.

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

What triggers / Causes of Cholangitis:

A condition for the occurrence of cholangitis is stagnation of bile and the presence of infection. There are many reasons that prevent the outflow of bile. Obstruction of the bile ducts, as a result of the primary pathological process, contributes to the occurrence of bile hypertension, a change in the physicochemical properties of bile, which serves as a prerequisite for its infection. The most common causes of bile duct obstruction are choledocholithiasis, benign strictures of the bile ducts, duodenal ulcer, pancreas, choledochal cysts, Caroli’s disease, sphincter of Oddi’s dyskinesia, cystic duct stump syndrome, invasion of Clonorchissinensis, Fascihehehorchatica and others. predispose the throwing of the contents of the small intestine into the biliary tract, complications after reconstructive operations on the bile ducts.There are several ways of introducing infection into the bile duct Most often pathogenic pathogens enter the biliary system via the enterogenous, hematogenous, and lymphogenous pathogens. The causative agents leading to the development of cholangitis are the microorganisms of the intestinal microflora that are found in associations. Most often, cholangitis is bacterial in nature, among the pathogens are representatives of the family of enterobacteria (E. coli, Klebsiellaspp., Serratiespp., Proteusspp., Enterobacterspp., Acinetobacterspp.), Gram-positive microorganisms (Streptococcus, Enterococcus), non-spore forming anaerobes (Bacteroidesspp., Clostridiumspp., Fusobacteria, Pseudomonasspp. other).

Bacterial cholangitis has a tendency to ascend and spread to the intrahepatic ducts. In severe cases of the disease, the development of empyema of the gallbladder, hepatitis, liver abscesses, septicemia, pylephlebitis, subdiaphragmatic abscess, peritonitis, cicatricial stenosis of the large bile ducts can be observed.

Classification of cholangitis.Topically distinguish cholangitis or angiocholitis - the defeat of large intra- and extrahepatic bile ducts; choledochitis - damage to the common bile duct; papillitis - damage to the area of \u200b\u200bthe Vater's nipple. Aseptic and cholangitis caused by infectious factors are distinguished. Aseptic cholangitis includes autoimmune forms in primary biliary cirrhosis, autoimmune cholangiopathies, and sclerosing (primary and secondary sclerosing) forms. According to the clinical picture, acute, chronic, stenosing and septic cholangitis are distinguished. Cholangitis caused by infectious agents is acute obstructive, recurrent, bacterial, secondary sclerosing.

Symptoms of Cholangitis:

Features of clinical manifestations.Acute cholangitis occurs as a complication of choledocholithiasis with total or subtotal obstruction of the bile duct, less often it develops as a complication of cholangiography or after endoprosthesis replacement of the bile duct, endoscopic papillosphincterotomy. The clinical symptoms of acute cholangitis include malaise, jaundice, pain in the right hypochondrium with radiation to the right shoulder, forearm, shoulder blade, intermittent fever with chills and profuse sweat, nausea, vomiting, confusion, arterial hypotension (infectious toxic shock) Reynolds pentad. Patients often develop thrombocytopenia as a manifestation of intravascular coagulopathy, signs of hepatic cell failure.

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

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

Diagnosis of Cholangitis:

Features of diagnosis.In a clinical blood test, neutrophilic leukocytosis with a shift to the left is determined, an increase in CO. A biochemical study shows an increase in the level of biliru bin, triglycerides, activity of alkaline phosphatase, AcAT, AlGHTP, a decrease in the content of total protein and albumin, a relative increase in the number of γ-globulins. It is advisable to study the activity of amylase, lipase, trypsin and its inhibitors, as well as blood for sterility. In the general analysis of urine, an increase in the level of urobilin and bile pigments is observed. Duodenal fractional sounding with bacteriological examination of portions B, C and determination of sensitivity to antibiotics of the duodenal contents, ultrasound of the abdominal cavity provide reliable information about the nature of the violations. Ultrasound reveals signs of biliary hypertension, expansion of the intra- and extrahepatic bile ducts, signs of damage to the pancreas, which caused the development of cholangitis. Echographically with cholangitis, the ducts are unevenly linearly expanded, the walls are homogeneously thickened, weakly echogenic (edematous). In the process of effective treatment, there is a narrowing of their lumen, thinning of the wall until it completely merges with the parenchyma of the liver.

In some cases, according to sonography, the diameter of the bile ducts may not change, which requires computed tomography. It is advisable to carry out intravenous cholangiography or endoscopic retrograde pancreatocholangiography, with which you can detect the expansion of the bile ducts. If it is impossible to conduct these studies, percutaneous transhepatic cholangiography (HCHG) is performed.

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

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

Cholangitis Treatment:

Features of treatment.Treatment of cholangitis in the first place should be aimed at eliminating stagnation of bile and fighting infection.

In acute obstructive cholangitis, it is advisable to use broad-spectrum antibiotics to affect the family of enterobacteria and anaerobes. Currently, there is no unified construction approach for the use of antibacterial drugs for ascending cholangitis.

The most commonly used penicillins

ampicillin has a bactericidal effect against E. coli
ampicillin with sulbactam affect the staphylococcus, Bacteroides and Klebsiellaspp strains producing gentinillinase
ureidopenicillin (meslocillin) is effective against enterococci

Aminoglycosides have a bactericidal effect on bacteria of the enterobacteria family.

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

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

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

An appropriate regimen comprising aminoglycoside (amikacin at 0.5 g after 12 hours iv in combination with ampicillin at 1.0 g after 6 hours intramuscularly and metronidazole at 0.5 g after 8 hours iv).

It is effective to use third-generation cephalosporins ceftriaxone 1-2 g once iv or cefoxitin 2 g after 4 hours iv in combination with metronidazole 0.5 g after 8 hours iv or clindamycin 0.15-0, 45 g after 6 hours iv. Clindamycin can be replaced with aminoglycoside amikacin at a dose of 0.5 g after 12 hours iv.

With a mild process, antibiotics can be used as monotherapy of piperacillin / tazobactam 4.5 g after 8 hours iv, ampicillin / sulbactam 1.5-5 g after 6 hours iv, cephalosporins of the third or fourth generation (ceftriaxone 1 -2 g per day or 0.5-1 g after 12 hours iv).

The reserve antibiotics are carbapenems (imipenem-cilastatin 0.5 g after 6 hours iv or meropenem 1 g after 8 hours iv). These drugs are used as empirical therapy in critically ill patients with E. coli, Acinetobacterspp, Paeruginosa.

Fluoroquinolones (ciprofloxacin, ofloxacin, mefloxacin) are also used when isolating strains resistant to most antibiotics or when they are intolerant, at a dose of 0.2-0.4 g after 12 hours iv.

Nitro-furan compounds, especially furazolin, furazolidone, furadonin (0.1 g 4 times a day with meals) have a high antibacterial sensitivity.

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

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

In the case of effective treatment, improvement occurs within 6-12 hours. The duration of antibiotic therapy is 14-21 days. The clinical effectiveness of the scheme used (even empirical) or a single drug indicates the appropriateness of its use throughout the treatment period. While maintaining the fever, it is necessary to audit the drainage on its patency, as well as the exclusion of the possibility of complications.

It is advisable for patients with cholangitis to carry out detoxification therapy according to the generally accepted rules for the treatment of septic conditions.

with ascariasis, gelmex is used at 10 mg / kg per day once, or vermox 100 mg 2 times a day for 3 days, or levamisole 150 mg once,
clonarchosis and opisthorchiasis respond to biltricide therapy at a dose of 25 mg / kg 3 times a day for 1-3 days,
with fascioliasis, a 2-week course of bitional is carried out in a dose of 1 g 3 times a day

It is advisable for patients with primary sclerosing cholangitis to carry out symptomatic therapy of digestive disorders with enzyme preparations (creon, pancreophlate, mesimforte, etc.).

Severe cholangitis is an indication for emergency ERCP, which has an advantage over emergency surgery.

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

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

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

Which doctors should be consulted if you have Cholangitis:

Gastroenterologist

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

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

Table of contents:

general information

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

note

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

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

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

Causes

Inflammatory changes in the biliary tract directly causes an infectious agent that has got into them in different ways. Most often it is:

different forms;
enterococci;
non-clostridial anaerobic infection.

Defeat by an infectious agent that causes specific infectious diseases is quite rare - but it should also be remembered (in particular, if typical cholangitis does not lend itself to classical treatment). These may be the following pathogens:

koch's wand (mycobacteria);
pale spirochete (pathogen).

note

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

An infectious agent most often penetrates the bile ducts:

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

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

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

enzymatic nature, when activated pancreatic juice irritates the bile duct wall from the inside (this is observed with the so-called pancreatobiliary reflux, when the pancreatic secret is “poured” into the bile duct, which should not be normal). At first, inflammation occurs without the participation of an infectious agent, but it can join later at different stages of the disease;
sclerosing cholangitis - occurs due to autoimmune inflammation of the bile ducts (when the body reacts to its own tissues as if it were someone else's).

Suspicion that cholangitis is an autoimmune nature should appear if the patient has signs of immune diseases such as:

(the formation of ulcerations of the mucous membrane of the colon along its entire length);
(formation of granulomas throughout the gastrointestinal tract);
(inflammation and subsequent destruction of the walls of blood vessels);
(connective tissue disease that goes away with joint deformity);
thyroiditis (inflammatory damage to the thyroid gland)
and some other diseases.

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

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

Damage to the walls of the bile duct during endoscopic manipulations - most often such as:

retrograde pancreatocholangiography (administration of a contrast agent using a probe through the duodenum 12 into the bile ducts);
stenting (installation of special frames supporting the normal shape of the bile ducts);
sphincterotomy (dissection of the sphincter of Oddi - muscles at the confluence of the common bile duct and pancreatic duct into the duodenum);
surgical treatment of diseases of the biliary system of the liver.

Flow

With the course of cholangitis can be:

sharp
chronic.

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

catarrhal;
purulent;
diphtheria;
necrotic.

At catarrhal cholangitis in the walls of the bile ducts there is a usual uncomplicated inflammation in its classical manifestation - this is redness and swelling of the mucous membrane, peeling of its surface layer.

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

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

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

The chronic course of cholangitis is observed more often. It can develop:

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

There are such forms of chronic cholangitis as:

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

Cholangitis can occur in the form of such varieties as:

choledochitis - inflammation of the common bile duct (common bile duct);
angiocholitis - damage to the smaller bile ducts;
papillitis - an inflammatory lesion of the Vater papilla (the site of the confluence of the common bile duct in the duodenum 12);
total defeat of the entire biliary tract system.

Symptoms of Cholangitis

Signs of cholangitis depend on its shape.

Acute cholangitis always begins suddenly. Its symptoms are:

fever and hyperthermia;
signs of intoxication;
dyspeptic phenomena;

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

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

Characteristics of pain:

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

Signs of intoxication are:

progressive weakness;
loss of appetite;
decreased performance.

Dyspeptic phenomena soon develop:

which does not bring relief;

The most common jaundice is yellowing of the skin, sclera and visible mucous membranes. Due to the accumulation of bile pigments and their irritation of the nerve endings, jaundice provokes skin itching.

Characteristic is an increase in itching at night, which is why the patient's sleep is disturbed.

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

significant hyperthermia (rise in body temperature);

If the course of acute cholangitis is particularly complex, then disturbances from the side of consciousness and manifestations of shock join in - these five most important symptoms of this disease are called the Reynolds pentad. We can say that this is the main guideline due to which clinicians diagnose acute cholangitis.

Signs of a chronic form of cholangitis are similar to signs of an acute form, but are erased - on the other hand, as the disease progresses, they gradually increase . In this case, abdominal pain:

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

Jaundice in chronic cholangitis is present, but it occurs rather late, when inflammation arose and worsened in the bile ducts a long time ago - in fact, these are far-reaching pathological changes.

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

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

Complications

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

Diagnostics

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

When examining such a patient, the following are revealed:

yellowness of the skin, sclera and visible mucous membranes;
tongue dry, coated with a yellow coating;
traces of combing are visible on the skin, sometimes quite pronounced, to the blood (with severe itching).

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

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

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

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

Auscultation is not informative.

Instrumental methods that are used to diagnose cholangitis are:

In the diagnosis of cholangitis use such laboratory methods as:

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

Differential diagnosis

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

Cholangitis Treatment

Cholangitis is treated with a conservative or surgical method. The choice of method depends on:

causes of the disease;
degrees of manifestation;
complications.

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

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

The basis of conservative treatment are the following:

If acute phenomena were overcome, then during the period of remission, physiotherapeutic methods of treatment are successfully practiced - such as:

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

All these methods can be carried out in the physiotherapeutic room of the clinic or during the spa treatment, which is recommended to the patient at the stage of remission.

If necessary, resort to surgical correction of disorders of the biliary tract - this:

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

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

Prevention

The measures that help prevent the inflammatory lesion of the biliary tract are based on the following:

Forecast

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

If inflammation of the biliary tract is complicated, the prognosis is poor. This is especially true for diseases such as:

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

Kovtonyuk Oksana Vladimirovna, medical observer, surgeon, medical consultant

- This is an acute purulent inflammation of the biliary tract, developing as a result of a violation or complete blockage of the outflow of bile. The disease has a characteristic clinical picture: rapidly growing jaundice on the background of hyperthermia with chills and pain in the right hypochondrium. In the absence of decompression, biliary sepsis rapidly develops with impaired hemodynamics, consciousness, kidney and other organs. Diagnosis is based on visualization of a mechanical obstruction with ultrasound or CT of the abdominal organs. Surgical treatment (decompression of the biliary tract with the elimination of obstruction) in combination with antibiotic therapy, correction of hemodynamics and other disorders.

General information

Despite the continuous improvement of diagnostic and therapeutic methods, purulent cholangitis remains an acute problem, as it often leads to biliary sepsis. The disease is especially severe in patients of older age groups, in the presence of severe concomitant pathology, which prevents the effective surgical removal of the cause of the disease.

Causes

Normally, this flora supports the tone of the immune system, causing a reaction of the lymphoid nodes of the intestine and Kupffer liver cells. Microorganisms are captured by the reticuloendothelial system, partly enter the biliary tract, but with a normal outflow of bile, infection does not develop. In conditions of impaired outflow, and even more so with complete obstruction, the number of bacteria in bile is equal to that in the contents of the intestine. Most often purulent cholangitis is caused by gram-negative flora, less often - staphylococci, streptococci, pseudomonas.

An important pathogenetic mechanism for the development of purulent cholangitis is bacteremia. The reason for the entry of microorganisms into the bloodstream is an increase in pressure inside the ductal apparatus of the liver, in which the resistance of the bile ducts is impaired and their contents enter the collecting veins. In the blood, monobacterial flora is much more common than polybacterial; in most cases, Escherichia coli or Klebsiella is determined.

The ingress of microorganisms into the systemic circulation leads to severe hemodynamic disturbances - biliary septic shock develops. The cause of the clinical picture of sepsis is also endotoxemia. Bacterial endotoxins have a pyrogenic effect, activate the blood coagulation system and intravascular thrombosis, a humoral immune response, and disrupt kidney function. A major role in the development of toxemia is given to the violation of the mechanisms of local intestinal and general immunity.

Symptoms of purulent cholangitis

Pathology has a characteristic clinical picture. The disease always begins acutely, the symptoms develop rapidly. The main signs of acute purulent cholangitis are combined in the Sharko triad: hyperthermia, pain in the right hypochondrium and jaundice. The patient is worried about severe weakness, chills. Biliary sepsis is always observed - in abdominal surgery and gastroenterology, this term is used to describe the extremely serious condition of the patient with this disease.

In acute obstruction of the biliary tract, sepsis develops rapidly, within a few hours; can occur with lightning speed with the formation of multiple liver abscesses and multiple organ failure. In fact, acute purulent cholangitis and biliary sepsis are morphological substrates of the same pathological process, but changes in the intrahepatic ducts are local manifestations, and sepsis is a generalized inflammation, the body's response to the infectious process. The main symptoms of biliary sepsis are arterial hypotension, impaired consciousness, oliguria.

Diagnostics

Diagnostic examination begins with a detailed assessment of patient complaints and medical history. In favor of the diagnosis of purulent cholangitis, data on the transferred diagnostic or therapeutic endoscopic interventions in the bilioduodenal region, operations on the biliary tract can testify. Consultation of an abdominal surgeon makes it possible to determine the preliminary diagnosis, since the symptoms are quite typical: a rapid increase in pain, jaundice, and fever.

With a combination of these symptoms with tachycardia, tachypnea, arterial hypotension, we are talking about the development of biliary sepsis. Its criteria are thick pus in the biliary tract, confirmed by bacteriological examination of bacteremia, the lack of response of the body to the introduction of 0.5 l of physiological sodium chloride intravenously. Laboratory methods can identify symptoms of acute inflammation. A general blood test shows neutrophilic leukocytosis, an acceleration of ESR, in liver samples - hyperbilirubinemia, an increase in cholesterol, hyperphosphatemia. In the case of acute developing obstruction of the common bile duct, an increase in the activity of transaminases is possible.

Ultrasound of the abdominal organs is highly informative, which allows to identify the cause of purulent cholangitis and visualize the mechanical obstruction, signs of intrahepatic hypertension (expansion of the bile ducts above the level of mechanical obstruction), and characteristic changes in the parenchyma during the formation of liver abscesses. To refine the data, CT of the liver is used. An obligatory examination method is esophagogastroduodenoscopy - against the background of changes in the duodenal mucosa, papillitis is detected, as well as the absence of bile in the lumen of the duodenum. Possible visualization of calculus in the large duodenal papilla, cicatricial changes.

In the case when the above methods do not provide complete information, an ERCP (endoscopic retrograde cholangiopancreatography) is performed, and if it is impossible to carry out it, percutaneous transhepatic cholangiography is performed. In the course of these studies, the contents of the bile ducts are necessarily obtained for bacteriological examination (the pathogen is detected and its sensitivity to antibiotics), bile is visually evaluated: the presence of pus in it confirms the diagnosis of purulent cholangitis.

Treatment of purulent cholangitis

The disease requires the immediate provision of adequate assistance, and in the case of developed biliary sepsis, only medical treatment is not enough, emergency biliary tract decompression is mandatory. Despite the continuous improvement of surgical methods, resuscitation care, classical abdominal operations are highly traumatic for patients, very often accompanied by complications, and have a high mortality rate, especially in the presence of severe concomitant diseases.

Therefore, at present, preference is given to minimally invasive interventions (endoscopic papillosphincterotomy, percutaneous transhepatic cholangiostomy, mechanical lithotripsy, and others). The choice of decompression method is determined individually for each patient and depends on the degree of violation of the outflow of bile, the level of location of the mechanical obstacle. If cicatricial changes are the cause of purulent cholangitis, adequate decompression is ensured by the installation of an endoprosthesis in the common bile duct.

Endoscopic papillosphincterotomy is the method of choice in calculous-inflammatory etiology of the disease and completely eliminates stasis of bile and obstructive jaundice. Percutaneous transhepatic cholangiostomy is considered as a method of preoperative preparation, provides the removal of bile to the surgical removal of the obstacle. In severe concomitant pathology, external drainage of the common bile duct may be the final method of treatment. After emergency decompression, radical treatment can be carried out: cholangioiododenostomy, cholecystectomy. If purulent cholangitis is caused by cicatricial narrowing of the biliodigestive anastomosis, it is recanalized.

After emergency decompression, adequate antibiotic therapy plays a decisive role in the treatment. The difficulties of antibiotic treatment of purulent cholangitis are that the definition of the pathogen is a long process, and after external drainage, the composition of the flora can change significantly. Empirically, antibiotics are prescribed from the first day of the disease to prevent bacteremia and sepsis even before the results of bacteriological studies are obtained: at the initial stages, the use of cephalosporins and ureidopenicillins in combination with metronidazole is preferable.

Since endotoxemia is one of the most severe manifestations of the disease, detoxification is considered an important pathogenetic method of treatment. A specific endotoxin-binding antibiotic is polymyxin B; lactulose, which reduces the plasma concentration of lipopolysaccharide, is highly effective.

For detoxification purposes, it is used to remove endotoxins, circulating immune complexes, and cytokines from plasma. Enterosorption is used - sorbents remove toxins from the lumen of the gastrointestinal tract, preventing them from entering the portal bloodstream. Correction of hemodynamic and respiratory disorders, immunocorrection, nutritional support.

Forecast and Prevention

Purulent cholangitis is a severe surgical pathology, the prognosis of which is determined by both the degree of blockage of the bile ducts and the timeliness of specialized care - decompression and antibiotic therapy. Mortality in this disease is very high, often developing biliary sepsis, endotoxic shock, DIC, and multiple organ failure. However, the improvement of surgical technique, timely endoscopic treatment of gallstone disease, as a method of prevention, can avoid serious complications.

Patients with a history of episodes of obstructive jaundice, as well as after surgical treatment of purulent cholangitis, must always be monitored by a gastroenterologist, regularly undergo a routine examination for the presence of calculi and cicatricial biliary tract strictures, and follow all the doctor’s recommendations for outpatient treatment and diet.

Cholangitis is a violation of the functioning of the liver, in which the bile ducts become inflamed.

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

What it is?

Cholangitis (cholangitis) is an infectious disease of the biliary tract. It occurs due to a bacterial infection. Allocate an acute and chronic form. Sometimes it develops as an independent disease, more often it is a consequence of other diseases of internal organs. It usually occurs in women in old age.

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

Classification

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

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

Chronic cholangitis is divided into the following forms:

sclerosing (with proliferation of connective tissue);
latent;
recurrent;
septic for a long time;
abscessed.

According to the location of the inflammatory process, there are:

choledochitis (inflamed common duct);
angiocholitis (intra- and extrahepatic bile ducts are affected);
papillitis (inflamed large duodenal papilla).

By origin, cholangitis happens:

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

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

Reasons for development

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

Infection into the biliary tract mainly enters from the intestine, since bile congestion disrupts the mechanism that prevents the intestinal contents from penetrating into the upper parts of the gastrointestinal tract. In addition to the ascending (intestinal) pathway of infection, there is a descending pathway when the infection enters the biliary tract with blood or lymph flow from another inflammatory focus in the abdominal cavity.

Symptoms

The disease in acute form occurs suddenly. But like any disease, cholangitis also has symptoms and signs:

Very high temperature up to 40 ° C.
Characteristic pain on the right in the area of \u200b\u200bthe ribs.
Yellowness of the skin and mucous membranes of the eyes.
Chills, heavy sweating.
General intoxication of the body, which is characterized by diarrhea, general weakness, vomiting and loss of appetite.
Due to jaundice, itchy skin appears.
If the form of the disease is severe, the patient may lose consciousness.

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

Sclerosing primary cholangitis (PSC)

A few statistical facts about this form:

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

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

Diagnostics

When examining such a patient, the following are revealed:

yellowness of the skin, sclera and visible mucous membranes;
tongue dry, coated with a yellow coating;
traces of combing are visible on the skin, sometimes quite pronounced, to the blood (with severe itching).

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

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

On palpation at the peak of a pain attack, severe pain is observed in the right hypochondrium. When percussion (tapping the palm of the palm on the right costal arch), the patient reacts very painfully.

Instrumental methods that are used to diagnose cholangitis are:

Ultrasound diagnosis of the liver (ultrasound) and ultrasonography (ultrasound) of the biliary tract - these methods allow you to evaluate the biliary tract, determine the pathological changes in them - in particular, their expansion, as well as changes in the liver that occur due to disturbance of the flow of bile in the biliary tract ;
Computed tomography of the bile ducts (CT) - an assessment of the very parameters that are evaluated using ultrasound, will help to conduct computer sections of the bile ducts;
Endoscopic retrograde pancreatocholangiography (ERCP) - with the help of an endoscope inserted into the gastrointestinal tract, a contrast agent is introduced into the biliary tract, an x-ray is taken and its evaluation is carried out;
Magnetic resonance pancreatocholangiography (MRPC) - bile ducts with contrast introduced are studied using magnetic resonance imaging;
Percutaneous transhepatic cholangiography - contrast into the bile ducts is introduced not through the digestive tract, but by puncturing (piercing) the skin and liver;
Duodenal sounding - with its help, bile is taken with subsequent bacteriological culture on nutrient media.

In the diagnosis of cholangitis use such laboratory methods as:

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

Effects

If timely treatment is not available, then the inflammatory process can become more serious. Gradually, it spreads to the peritoneum, because of this, the development of peritonitis is possible. Pathology is capable of "spreading" to the surrounding tissue. As a result, subphrenic and intrahepatic abscesses begin to form. Often there is sepsis, as well as toxic shock. The last complication develops against the background of the bacterial form of cholangitis.

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

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

Cholangitis Treatment

In the treatment regimen of cholangitis, there are several fundamental points that every patient should know:

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

Acute treatment

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

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

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

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

Chronic treatment

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

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

Adhere to a diet (table No. 5 according to Pevzner), which involves frequent fractional nutrition 5-6 times a day, in a small amount, with the exception of fatty foods;
If possible, exclude physical and psychological stress;
Stop smoking, drinking alcohol and caffeinated drinks;
Take multivitamin complexes with the presence of vitamins K, D, E and A. Absorption of precisely these substances is impaired with prolonged inflammation of the biliary system.

Prevention

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

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

In addition, a full medical examination is systematically recommended. This will detect chronic diseases in the early stages. In no case should you neglect the preventive examination. It is better to spend some free time on a doctor’s consultation than to treat a neglected form of pathology for a long and tedious way.

Forecast for life

The prognosis for cholangitis is different.

With the catarrhal form of cholangitis, it is satisfactory, with purulent, diphtheria and necrotic forms - it is more serious: in this case, the outcome can be favorable for the patient only in the case of verified appointments and scrupulously adhered to treatment. If inflammation of the biliary tract is complicated, the prognosis is poor. This is especially true for diseases such as:

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

Cholangitis is an inflammation of the bile ducts. This is a severe disease that can be independent, but more often combined with inflammation of the gallbladder or liver.

Causes of Cholangitis

Types of Cholangitis

By the nature of the course, acute and chronic cholangitis are distinguished.

Acute cholangitis, depending on the type of inflammation, can take the following forms:

Catarrhal cholangitis, in which there is swelling of the mucous membrane of the bile ducts. This form, if untreated, becomes chronic inflammation, and subsequently leads to cicatricial narrowing of the ducts;
Purulent cholangitis. The bile ducts are filled with purulent discharge, mixed with bile. This form often spreads to the gall bladder and liver, involving these organs also in purulent inflammation;
Diphtheria cholangitis. The mucous membrane of the bile duct is ulcerated, and then necrotic, which leads to the destruction of the walls of the bile ducts and purulent fusion of surrounding tissues, including the liver;
Necrotic cholangitis. It occurs when aggressive pancreatic enzymes enter the bile ducts, which leads to the development of areas of necrosis of the mucous membrane of the biliary tract.

Chronic cholangitis by the nature of the course can be latent (hidden), recurrent, septic and abscessed.

A special form of chronic cholangitis is sclerosing cholangitis. This is a primary chronic inflammation that occurs without an infectious agent of a presumably autoimmune nature. At the same time, inflammation occurs in the bile ducts, leading to sclerosis - hardening and overgrowth of the lumen of the ducts, which in turn leads to cirrhosis of the liver. Sclerosing cholangitis is not amenable to treatment, has a slowly progressive course and, on average, leads to severe impairment with a possible fatal outcome for 10 years.

Symptoms of Cholangitis

The acute symptoms of cholangitis are violent, there is a fever with chills and torrential sweat, biliary colic pain is quite intense, aching, localized in the right hypochondrium, sometimes extending to the shoulder blade and shoulder. It is accompanied by nausea, vomiting. The skin and sclera take a yellow color, itching appears.

The symptoms of acute cholangitis in elderly patients and children have some differences. In older people, pain may be absent, and with scanty symptoms of cholangitis, inflammation, however, takes a severe, usually purulent form.

In children, acute cholangitis is rare, mainly as a secondary infection (usually streptococcal) in another disease. Acute cholangitis in children proceeds very rapidly, the symptoms of cholangitis in this case are nonspecific and are characteristic of any acute inflammation of the gastrointestinal tract, and therefore acute cholangitis in children can be mistaken for another gastrointestinal disease.

Symptoms of cholangitis in a chronic form are less pronounced, intense pain is characteristic only in the presence of stones in the bile ducts. The main symptoms of cholangitis in this case are general weakness and fatigue, unexplained periodic rises in temperature, skin itching. Signs of cholangitis include thickening of the terminal phalanges of the fingers and redness of the palms of the hands.

Chronic cholangitis in children causes a decrease in body weight due to a lack of appetite and nausea, constant intoxication leads to anemia, pallor or yellowness of the skin, the child’s physical development slows down, there may be a lag in general development, and chronic headaches appear.

Diagnosis of cholangitis

The diagnosis is made on the basis of the characteristic symptoms of cholangitis, a thorough examination and data from hardware and laboratory studies:

Ultrasound of the gallbladder, liver and bile ducts;
Radioisotope study of the biliary tract;
Intravenous cholangiography (bile duct fluoroscopy with intravenous administration of a contrast agent, allowing you to see the intra- and extrahepatic ducts);
Retrograde pancreatocholangiography (fluoroscopy of the biliary tract and pancreas with endoscopic administration of a contrast medium);
Cholangiomanometry (pressure measurement inside the bile ducts);
Choledochoscopy (endoscopic examination of the bile ducts);
General and biochemical blood analysis;
Laboratory study of bile.

Cholangitis Treatment

Treatment of cholangitis can be conservative or surgical, depending on the form of the disease. Treatment of cholangitis is carried out only in a hospital, due to the danger of developing serious complications - purulent abscesses of the liver and gall bladder, peritonitis, and in case of chronic cholangitis, cirrhosis of the liver.

Conservative cholangitis treatment methods are used when there is no mechanical obstruction to the outflow of bile through the bile ducts. In this case, antibacterial drugs are prescribed (broad-spectrum antibiotics and sulfonamides), drugs that reduce intoxication (intravenous administration of hemodesis, etc.), improve the outflow of bile, antispasmodics (for example, Duspatalin).

In the case when conservative treatment does not give results, as well as in all cases when it is impossible to create a normal outflow of bile with medications, they resort to surgical treatment of cholangitis. Currently, in the absence of contraindications (purulent, necrotic processes, abscesses), the endoscopic technique is the method of choice.

This method allows drainage of the bile ducts, removal of stones, elimination of stenosis (narrowing) without resorting to extensive abdominal surgery, which reduces surgical trauma, avoids bleeding, improves recovery. In the presence of more severe forms of cholangitis, abdominal surgery is performed, removing areas that have undergone purulent fusion or necrotic decay. In the postoperative period, antibiotic therapy is prescribed.

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