Cholangitis phenomenon. Acute cholangitis

Date: 19.07.2019

- nonspecific inflammatory lesion bile ducts acute or chronic course. With cholangitis, there is pain in the right hypochondrium, fever with chills, dyspeptic disorders, jaundice. Diagnostics of cholangitis includes analysis of biochemical parameters of blood, conducting fractional duodenal intubation with bile examination, ultrasound, percutaneous transhepatic cholangiography, RCPH. In the treatment of cholangitis, antibiotic therapy, detoxification therapy, the appointment of enzymes, FTL (mud therapy, sodium chloride baths, paraffin and ozokeritotherapy, UHF, diathermy) are used, sometimes surgical decompression of the biliary tract.

ICD-10

K83.0

General information

With cholangitis, intra- or extrahepatic bile ducts can be affected. The disease occurs more often in women aged 50-60 years. In gastroenterology, cholangitis is usually diagnosed in conjunction with gastroduodenitis, cholecystitis, hepatitis, cholelithiasis, pancreatitis.

Cholangitis classification

Cholangitis can be acute or chronic. Depending on the pathomorphological changes, acute cholangitis can take a catarrhal, purulent, diphtheritic or necrotic form. Catarrhal cholangitis is characterized by hyperemia and edema of the mucous membrane of the bile ducts, leukocyte infiltration their walls, desquamation of the epithelium. With purulent cholangitis, the walls of the bile ducts melt and multiple abscesses are formed. A severe course is noted with the formation of fibrinous films on the walls of the bile ducts (diphtheritic cholangitis) and the appearance of foci of necrosis (necrotizing cholangitis).

The most common chronic cholangitis, which can develop as an outcome of acute inflammation or from the very beginning, acquire a protracted course. Allocate latent, recurrent, long-term septic, abscessing and sclerosing forms of chronic cholangitis. With sclerosing cholangitis, connective tissue grows in the walls of the bile ducts, which causes strictures of the bile ducts and their even greater deformation.

Cholangitis reasons

Aseptic enzymatic cholangitis can develop as a result of irritation of the walls of the bile ducts with activated pancreatic juice, which occurs during pancreatobiliary reflux. In this case, first there is aseptic inflammation, and the addition of the infection occurs a second time, in a later period.

Sclerosing cholangitis, caused by autoimmune inflammation of the bile ducts, also proceeds according to the aseptic type. At the same time, along with sclerosing cholangitis, ulcerative colitis, Crohn's disease, vasculitis, rheumatoid arthritis, thyroiditis, etc. are often noted.

The prerequisites for the development of cholangitis are cholestasis, which occurs with biliary dyskinesia, biliary tract anomalies, choledochus cyst, biliary tract cancer, choledocholithiasis, stenosis of the Vater papilla, etc. stents, sphincterotomy), surgical interventions on the biliary tract.

Cholangitis symptoms

The clinic of acute cholangitis develops suddenly and is characterized by the Charcot triad: high body temperature, pain in the right hypochondrium and jaundice.

Acute cholangitis manifests itself with fever: a sharp rise in body temperature to 38-40 ° C, chills, severe sweating. At the same time, intense pains appear in the right hypochondrium, resembling biliary colic, with irradiation in right shoulder and scapula, neck. In acute cholangitis, intoxication rapidly increases, weakness progresses, appetite worsens, worries headache, nausea with vomiting, diarrhea. Somewhat later, with acute cholangitis, jaundice appears - a visible yellowing of the skin and sclera. Against the background of jaundice, itchy skin usually worse at night and disrupting normal sleep. As a result of severe itching on the body of a patient with cholangitis, skin scratching is determined.

In severe cases, disturbances of consciousness and shock phenomena can join the Charcot triad - in this case, a symptom complex develops, called the Reynolds pentad.

The clinical manifestations of chronic cholangitis are erased, but progressive. The disease is characterized by dull pains in the right side of weak intensity, with a feeling of discomfort and bursting in the epigastrium. Jaundice in chronic cholangitis develops late and indicates far-reaching changes. General violations in chronic cholangitis include subfebrile condition, fatigue, weakness.

Complications of cholangitis can be cholecystopancreatitis, hepatitis, biliary cirrhosis, multiple liver abscesses, peritonitis, sepsis, infectious toxic shock, liver failure.

Diagnostics

Cholangitis is usually suspected on the basis of the characteristic Charcot triad; clarifying diagnostics is carried out on the basis of laboratory and instrumental studies.

Imaging tests for cholangitis include ultrasound abdominal cavity and liver, ultrasonography of the biliary tract, CT. With their help, it is possible to obtain an image of the bile ducts, to reveal their expansion, to determine the presence of structural and focal changes in the liver.

Among the instrumental methods for diagnosing cholangitis, the leading role is played by endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography (MRPCG), percutaneous transhepatic cholangiography. On the obtained roentgenograms and tomograms, the structure of the biliary tract is well visualized, which makes it possible to identify the cause of their obstruction.

Differential diagnosis of cholangitis is necessary with gallstones, non-calculous cholecystitis, viral hepatitis, primary biliary cirrhosis, pleural empyema, right-sided pneumonia.

Cholangitis treatment

With cholangitis complicated by abscess formation, cirrhosis, hepatic renal failure, generalized septic process, the prognosis is unsatisfactory. Timely therapy catarrhal cholangitis can be cured; with a purulent, diphtheritic and necrotic form, the prognosis is more serious. Long-term course of chronic cholangitis can lead to permanent disability.

Prevention of cholangitis dictates the need for timely treatment of gastroduodenitis, acalculous cholecystitis, gallstone disease, pancreatitis, helminthic and protozoal invasions; observation by a gastroenterologist after undergoing surgical interventions on the biliary tract.

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Cholangitis is a disease in which the intrahepatic and extrahepatic bile ducts form in inflammatory process... Pathology most often develops in women aged 50-60 years. Rarely occurs as an independent disease, most often in combination with hepatitis, cholelithiasis, cholecystitis, oncological diseases bile ducts and bladder.

The reasons

The main reasons for the formation of cholangitis:

Classification

By the nature of the course, the disease is divided into acute and chronic forms.

Acute cholangitis

Acute cholangitis, depending on the type of inflammatory process, is divided into the following types:

Diphtheritic... The mucous membrane of the biliary tract becomes covered with ulcers, necrosis (death, necrosis) of tissues is noted, due to this, the walls of the ducts are destroyed and the surrounding tissues and liver are suppurating;
Catarrhal... The easiest form of the course of the disease, with this form, the mucous membrane of the ducts swells and becomes hyperemic. In the absence of treatment, this type goes into chronic course, subsequently scarring of the ducts occurs;
Purulent... The ducts are filled with purulent contents mixed with bile. Can spread to the liver gall bladder;
Necrotic... It is formed against the background of the ingress of enzymes (protease, amylase) of the pancreas into the ducts, due to this, the mucous membranes die.

Chronic cholangitis

Chronic cholangitis has 4 types of course:

Latent (hidden), there are no symptoms of the disease;
Recurrent. Has relapse (exacerbation) and remission (no symptoms);
Septic. The severe form proceeds as sepsis (blood poisoning);
Absolute. Purulent process with the formation of abscesses (purulent cavity).

Chronic sclerosing cholangitis

Chronic sclerosing (autoimmune, associated with malfunctioning immune system, there is the production of killer antibodies against healthy tissues, cells of the body), a type of cholangitis, is not an infectious process, but an inflammatory process is formed in the ducts.

Chronic sclerosing cholangitis can cause cirrhosis of the liver!

The biliary tract hardens, narrowing of the lumen occurs, does not respond to treatment, there is a slow progression of the disease (within 10 years). As a result, it is formed, a lethal outcome is possible.

Symptoms

Cholangitis in acute form has a rapid current, characterized by the Charcot triad: hyperthermia ( heat), jaundice, pain syndrome in the right hypochondrium.

The disease manifests itself in the following symptoms:

In severe cases, the phenomenon of shock, impaired consciousness (Reynolds pentad) may join.

In children, cholangitis is rare disease, characterized by acute, nonspecific, intense symptoms, clinical picture course, as in other pathologies of the gastrointestinal tract (dyspepsia, intestinal disorders, epigastric pain and more). This makes it difficult to make a correct diagnosis.

Chronic cholangitis in adults is characterized by the following features:

Periodic rise in temperature;
Increased fatigue, weakness;
Itching skin;
Hyperemia (redness) of the palms;
Thickening of the terminal phalanges of the fingers;
Intense pain only with stones in the ducts.

In children chronic cholangitis manifests itself as follows:

Diagnosis of the disease

The diagnosis of cholangitis is made on the basis of the patient's complaints, taking anamnesis (when symptoms first appeared, diseases of relatives, past illnesses and other). The doctor conducts a thorough examination (palpation of the abdominal cavity, examination of the skin, sclera of the eyes), prescribes a complex of examinations for the patient.

TO diagnostic research include:

Treatment methods

Acute cholangitis should be treated in a hospital as the patient may require urgent surgery. Depending on the degree of impairment of bile flow, the type of disease, the doctor selects an individual tactic of therapeutic measures.

Drug therapy

Conservative (treatment drugs) therapy is carried out if the patient does not have mechanical obstacles to the outflow of bile from the gallbladder.

The main drugs for the treatment of cholangitis:

Physiotherapy treatment

During the period of remission, physiotherapy is prescribed. :

Surgical intervention

With ineffective drug treatment, for violations of the outflow of bile, surgery is indicated:

Endoscopic technique. Drainage (introduction of a catheter to drain the contents) of the biliary tract, eliminate stenosis (narrowing), remove calculi without resorting to abdominal surgery. This method allows you to avoid bleeding, reduce the risk of surgical injury, accelerate the period of rehabilitation (recovery) after the manipulation;
Abdominal surgery - resection (removal) of the affected (purulent, dead) areas.

ethnoscience

Recipes traditional medicine for the treatment of cholangitis:

Diet

IN acute stage diseases prescribe hunger, after the exacerbation subsides, food should be in small portions, at least 5-6 times a day, the interval between meals is not more than 4 hours. All dishes are steamed, baked, boiled.

Allowed Products:

Low-fat varieties of meat, poultry, fish;
Soups with vegetable broth, milk;
Bran bread, pasta;
Cereals, cereals;
Dairy products;
Vegetables, herbs;
Not sour berries, fruits;
Compotes, juices, weak tea.

Limit sugar intake to 70 grams. per day, eggs up to 1 per day.

Prohibited foods:

Fresh baked goods, bread;
Canned food;
Smoked, fatty, spicy foods;
Mushroom broth;
Semi-finished products;
Hot seasonings, spices;
Ice cream, chocolate, pastry with fat cream;
Coffee, carbonated drinks, alcohol, cocoa.

Complications

If treatment is started late, ineffective therapy, the patient may develop the following complications:

Cholangitis can be fatal, if symptoms appear, be sure to see a doctor!

Viral hepatitis ( infection liver)
Cholecystitis (inflammation of the gallbladder);
Primary biliary cirrhosis of the liver (chronic, inflammatory disease liver);
Empyema of the pleura (accumulation of pus in the lungs - pleural cavity);
Pneumonia (pneumonia)
Fatal outcome.

Filtration of toxins, storage of vitamins, production of glycogen - these are the main tasks performed by the liver in the body of every person. If for some reason these functions cannot be full extent execute, then. Yellowing of the skin or sclera of the eyes are clear signs that the liver is starting to malfunction.

What is cholangitis?

What is cholangitis? This is an inflammation of the bile ducts. Their obstruction with the addition of infection is a sure sign of the disease.

Types and forms

Cholangitis has its own types and forms of development. By forms it is divided into:

Acute. According to the inflammatory nature, acute cholangitis is divided into types:

Catarrhal - swelling of the bile ducts with their further scarring and narrowing.
Purulent - affects the liver and gallbladder, characterized by the accumulation of pus and bile in the bile ducts.
Necrotic - the formation of necrosis of sections of the bile duct after the ingestion of pancreatic enzymes.
Diphtheritic - manifestations and necrotization of the mucous membrane, destruction of the walls of the bile duct, purulent fusion of the surrounding tissue.

Chronic. According to the inflammatory nature, they are divided into types:
- Hidden (latent).
- Septic.
- Recurrent.
- Absolute.
Sclerosing (autoimmune) cholangitis - it is assumed that it develops as a result of the body's autoimmune response to itself. There is hardening, narrowing and overgrowth of the bile ducts, which leads to cirrhosis of the liver.
Bacterial.

The reasons

What can be the reasons for such an unpleasant disease as cholangitis? Let's consider the most common:

Cholelithiasis in the bile ducts (choledocholithiasis).
Scarring and narrowing of the bile duct due to removal of a cyst, tumor, or chronic cholecystitis.
Ascaris, helminthic invasion.
Hepatitis.
The penetration of infection from the intestines, through the flow of lymph or blood. A favorable environment for her is a violation of the outflow (stagnation) of bile.

The contributing factors for these anomalies are:

Genetic predisposition.
Psychogenic factor.
Congenital anomalies.
Giardiasis.
Dyskinesia.
Endocrine Disorders.
Immunological reactions.
Pancreatobiliary reflux.
Dyscholia, which develops for the following reasons:
- Eating disorder.
- Obesity.
- Overweight.
- Hormonal disruptions.
- Taking hormonal medications.
- Violation of the blood supply to the liver and gallbladder.
- Dyshormonal disorders.
- Alcoholism, smoking.

Symptoms and signs of bile duct cholangitis

Symptoms and signs of bile duct cholangitis should be considered according to the form of their course:

Acute:
- Attack of pain in the right side chest(shoulder, shoulder blade) and abdomen.
- Raising the temperature to 40 ° C.
- Nausea.
- Lowering blood pressure.
- Weakness.
- Vomiting.
- Itchy skin.
- Chills.
- Yellowness of the skin, mucous membranes, sclera.
- Impaired consciousness.
- Development of a hepatic coma is possible.
Chronic:
- The pain is mild, but intense in the presence of stones.
- Itchy skin.
- Distension or squeezing in the right hypochondrium.
- Weakness.
- Periodically high fever.
- Fatigue.
- Thickening of the fingers, redness of the palms.
Sclerosing:

Pain in the upper abdomen and right hypochondrium.
Stool disorder, as in ulcerative colitis or Crohn's disease.
Jaundice and itching of the skin.
Temperature up to 38 ° C.

Cholangitis in children

In children, cholangitis occurs mainly for reasons of genetic or congenital... In other cases, the disease is not seen in children.

Cholangitis in adults

In adults, cholangitis develops due to genetic, congenital and In women, it occurs when hormonal disruptions during pregnancy or childbirth. In men, it occurs due to the presence bad habits or untreated diseases. An unhealthy lifestyle and poor nutrition are major contributors to cholangitis in adults.

Diagnostics

Diagnosis of inflammation of the bile ducts begins with a general examination and collection of complaints. For some outward signs the doctor has reasons for the following procedures:

Ultrasound of the liver.
Blood test.
Magnetic resonance cholangiography.
Analysis of feces for eggs of worms.
Endoscopic retrograde cholangipancreatography.
Analysis of urine.
Duodenal intubation.
X-ray cholegraphy.
Cholangiomanometry.
Choledochoscopy.
Liver biopsy.
Radioisotope examination of the bile ducts.

Treatment

Cholangitis is treated only in a hospital. Folk remedies that a person wishes to carry out at home do not contribute to recovery. It requires medication, therapeutic and sometimes surgical treatment.

How to treat cholangitis? The doctor prescribes medications if there is a normal outflow of bile:

Antibiotics
Antispasmodics.
Sulfonamides.
Medicines that reduce intoxication.
Medicines that improve the outflow of bile.
Anthelmintic drugs.

In case of inefficiency conservative treatment resort to surgical. Endoscopy is performed with drainage of the bile ducts, elimination of constriction, and removal of stones. When purulent inflammation held abdominal surgery to remove purulent or necrotic areas. Sometimes cholecystectomy is performed - removal of the gallbladder or complete liver transplant.

In the treatment of cholangitis, a rigid diet is actively used:

Eating small portions at least 5 times.
A ban on eating before bedtime.
Exclusion from the menu of fresh bread, spicy, fried, spicy, onion, bacon, sour berries and fruits, garlic, strong tea, alcohol.
Included in the menu are lean fish, cottage cheese, buckwheat, oatmeal, warm milk, egg whites, boiled meat, vegetables, milk soups, kefir, stale bread, honey, jam.
Ban on hunger strike.
Tea drinking special fees herbs. Compotes, jelly, mineral waters.

Sclerosing cholangitis is treated as follows:

Vitamin therapy.
Antihistamines.
Ursodeoxyisolic acid.
Sedatives.

Physiotherapy procedures are used:

Amplipulse therapy.
Diathermy.
Microwave therapy.
Paraffin and mud applications.
Sanatorium treatment.
Physiotherapy.

Life span

How long do people live with cholangitis? The disease itself does not affect life expectancy, but it provokes complications that lead to death:

Peritonitis.
Abdominal abscess.
Liver failure.
Intrahepatic abscesses.
Sepsis.
Biliary cirrhosis.
Cholangiocarcinoma.

Here you should not delay treatment and do not self-medicate. Seek medical attention at the first symptoms.

Cholangitis is inflammation of the external or internal hepatic ducts. Pain in the right hypochondrium, radiating to the shoulder? Pulling painful sensations or a feeling of bloating? This is most likely cholangitis. It is impossible to postpone a visit to the doctor with such symptoms, since dysfunction of the liver ducts leads, in the absence of therapy, to serious illnesses... How to determine the presence of pathology, how to treat the inflammatory process and whether it can be prevented - the answers to all the questions in the article.

The general code for cholangitis according to ICD-10 is K83.0, which unites all types of the disease. This term designates nonspecific inflammation of the bile ducts of the liver, which occurs by different reasons... In the risk group for morbidity are, first of all, women in the postmenopausal period. Usually this pathology accompanied by other disorders of the gastrointestinal tract: gastroduodenitis, hepatitis, gallstone disease, pancreatitis and inflammation of the gallbladder itself.

Classification

The inflammatory process can be acute or chronic, both stages have several varieties. Acute cholangitis is subdivided into:

Catarrhal, accompanied by edema and hyperemia of the mucous membrane of the ducts. At the same time, the epithelium sloughs off, the walls of the vessels are infiltrated with leukocytes.
Diphtheric, in which fibrinous films form on the inner surface of the ducts.
Purulent cholangitis leads to melting of the walls of the biliary vessels and the occurrence of multiple abscesses.
Necrotic is the formation of foci of dead tissue.

However, more often the disease is diagnosed already in the chronic phase (or may initially take on a protracted, sluggish character). There are the following types of this process:

latent;
septic;
recurrent;
abscess;
sclerosing.

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

Various factors can be prerequisites for the development of the inflammatory process. Stagnation of bile, duct dyskinesia or their congenital anomalies, cyst common duct, malignant neoplasms, gallstone disease usually lead to inflammation. It can also be provoked surgical interventions and others medical manipulations: Cholangitis after removal of the gallbladder, sphincterotomy, cholangiopancreatography is also possible.

Most often, cholangitis is a consequence of infection pathogenic microorganisms that enter the liver ducts from duodenum(ascending path), with blood flow through the portal vein or together with lymph with inflammation of the gallbladder, small intestine, pancreas. The most common pathogens are colibacillus, entero- and staphylococci, proteus and anaerobes. Sometimes there is an infection caused by mycobacterium tuberculosis, pallidum spirochete, or typhoid salmonella. With hepatitis of a viral nature, small ducts are also affected.

The aseptic inflammatory process occurs for various reasons. For example, autoimmune damage(primary biliary cholangitis) leading to sclerosis and often accompanied by vasculitis, thyroiditis, nonspecific ulcerative colitis, Crohn's disease. Aseptically, in the initial stage, inflammation provoked by enzymes also proceeds: with pancreatobiliary reflux, pancreatic juice enters the bile ducts and irritates them. Later, a bacterial infection will join.

Diagnostics

The primary diagnosis in the acute phase can be made on the basis of a specific symptom complex - the Charcot triad. For clarification, a number of instrumental and laboratory research... The imaging method is ultrasound examination - signs of cholangitis by ultrasound are deformations of the ducts (expansion or narrowing, the presence of cysts, inflammatory foci). There are also CT scan, ultrasonography of the liver.

The main instrumental studies are endoscopic cholangiopancreatography, MRPHG (computerized scanning in a magnetic field), as well as percutaneous transhepatic cholangiography. The latter involves an X-ray examination of the bile ducts after they are filled with a contrast agent.

Cholangitis symptoms and treatment

The course and manifestation of acute and chronic cholangitis differ significantly. The first is characterized by the so-called Charcot triad:

Fever that begins suddenly with a sharp rise in temperature to 38 ° C and above, chills and intense sweating.
Severe pain under the ribs on the right, radiating into right side body (neck, shoulder and scapula) and similar to biliary colic.
Jaundice, which will join later. The sclera and skin turn yellow, itching occurs, which is why multiple scratches are revealed during examination.

Due to the increase in temperature, symptoms of intoxication appear. The patient experiences nausea, his appetite worsens, weakness progresses. Complaints of headaches are also characteristic, and in especially severe cases shock phenomena and impaired consciousness join.

The chronic stage of the disease is characterized by mild symptoms, which progress over time. For example, symptoms of sclerosing cholangitis appear quite late in the form of abdominal pain, itching, weight loss, jaundice, and general weakness. Jaundice, as a rule, indicates that the pathological process has gone far enough.

Cholangitis can be treated both conservatively and surgically. Its main tasks are elimination of intoxication, relief of inflammation and decompression of the bile ducts. The patient is recommended to bed rest and fasting, medicines, in some cases - surgery up to liver transplantation.

Treatment of cholangitis with drugs

Appointment medicines is carried out in accordance with the exact diagnosis. The list of drugs may include:

Hepatoprotectors are also used to restore and protect liver cells.

Operative treatment

Conservative drug therapy is indicated only when the patency of the bile ducts is not impaired. However, it is often necessary to restore bile excretion using surgical procedures. Operative treatment cholangitis can be minimally invasive: endoscopic papilosphincterotomy or stenting of the common bile duct, percutaneous or external drainage, etc. the best option is liver transplantation.

Physiotherapy

The list of physiotherapy methods includes the following:

ultra- and microwave therapy;
inductive and diathermy;
electrophoresis;
mud therapy;
paraffin therapy;
salt baths.

Physiotherapy is prescribed only during the period of remission of the disease.

Cholangitis treatment with folk remedies

In the acute phase, only qualified health care and recipes alternative medicine can be used with chronic inflammation... The most effective are:

Choleretic infusion from a mixture of knotweed, calendula and yarrow. Two tablespoons of the crushed collection should be infused for about an hour in 0.5 liters of boiling water, then strain and take half a glass three times a day before meals.
In the same proportions, you can also brew the collection from corn silk, immortelle and chamomile. You can drink it instead of regular tea.
Bile-Secreting Mint Honey Blend made with equal amounts of flower honey and dried leaves peppermint... You need to take it in a teaspoon twice a day.

Treatment folk methods should be agreed with the doctor, as there may be individual contraindications.

Diet for cholangitis

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

When the condition is normalized, a special diet is prescribed, from which fatty foods, baked goods, marinades, smoked meats, hot spices, chocolate, legumes, garlic and onions are excluded. You cannot drink coffee, soda and alcoholic drinks... The method of preparation is of particular importance: food should be boiled, baked or stewed, and frying food is prohibited.

Diet for cholangitis involves frequent meals 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 lean fish and meat, cereals, pasta, bread, soups in secondary broth, vegetables, dairy products, non-acidic berries and fruits. You can drink tea with milk, diluted juices, compotes. From sweet, marmalade, jam, marshmallow are acceptable in a limited amount.

Forecasts and prevention

Cholangitis complicated by cirrhosis, abscesses, sepsis is an extremely unfavorable diagnosis from the point of view of recovery. Diphtheria, purulent and necrotic are difficult to treat, often lead to disability. With a catarrhal form, the prognosis is most favorable. Prevent inflammation of the bile ducts will help timely treatment diseases of the gastrointestinal tract, helminthic invasions.

Cholangitis- inflammatory process in the bile ducts (cholangiolitis - lesion of small bile ducts; cholangitis or angiocholitis - lesion of larger intra- and extrahepatic bile ducts; choledochitis - lesion of the common bile duct; papillitis - lesion of the Vater's nipple region).

Cholangitis classification(Yu.I. Fishzon-Ryss, I.A.Postrelov, 1985)

1. By etiology:

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

2. Downstream:

2.1. Acute.
2.2. Chronic.

3. By pathogenesis:

3.1. Primary (bacterial, helminthic, autoimmune).

3.2. Secondary and symptomatic:

3.2.1. On the basis of subhepatic cholestasis:

3.2.1.1. Stones of hepato-choledochus.
3.2.1.2. Cicatricial and inflammatory strictures of the main bile ducts and the greater duodenal nipple.
3.2.1.3. Malignant and benign tumors with occlusion of hepatocholedochus or large duodenal papilla.
3.2.1.4. Pancreatitis with compression of the common bile duct.

3.2.2. Due to diseases without subhepatic cholestasis:

3.2.2.1. Biliodigestive anastomoses and fistulas.
3.2.2.2. Insufficiency of the sphincter of Oddi.
3.2.2.3. Postoperative cholangitis.
3.2.2.4. Cholestatic hepatitis and biliary cirrhosis of the liver.

4. By the type of inflammation and morphological changes:

4.1. Catarrhal.
4.2. Purulent.
4.3. Obstructive.
4.4. Destructive, non-purulent.

5. By the nature of complications:

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

Most often, cholangitis is of a bacterial nature, the causative agents are most often Escherichia coli, enterococci, Friedlander's bacillus, pneumococci, streptococci.

HOLANGITIS ACUTE

Clinical symptoms. In the first stage, the main symptom is high body temperature with tremendous repetitive chills. The beginning is sudden, violent. The body temperature rises daily or once every 2 to 3 days. Cramping pains in the right hypochondrium, vomiting are also characteristic. Severe weakness develops, decreases arterial pressure... In the second stage, an enlargement of the liver joins the above symptoms, it is sharply painful, hepatic functional tests are disturbed, subictericity occurs, and then a slight jaundice. By the end of the first week, the spleen is enlarged. Pneumococcal cholangitis is especially difficult, most often complicated by the development of liver abscesses. In the third stage, if there is no improvement, a picture of liver failure with severe jaundice develops, at the same time there are pronounced changes in the urine, urea and creatinine in the blood increase (hepatorenal syndrome), cardiac activity is significantly impaired (tachycardia, muffled heart sounds, arrhythmia, dystrophic changes myocardium on an ECG), collapses are possible, pancreatitis often occurs. In the fourth, final, stage, severe hepatic-renal failure, coma, develops.

Acute catarrhal cholangitis is manifested by an increase in body temperature, chills, an increase and soreness of the liver, but the severity of intoxication does not reach a very severe degree. Purulent cholangitis is very difficult, characterized by severe intoxication up to the development of bacterial-toxic shock. Often, the defeat of the central nervous system in the form of prostration, clouding of consciousness. Purulent cholangitis is often complicated by subphrenic, intrahepatic abscess, reactive exudative pleurisy and pleural empyema, lung abscess, peritonitis, endocarditis, pancreatitis.

Laboratory data.

1. OAK: moderate or high (more than 1.5-109 / l) leukocytosis, shift of the blood formula to the left, toxic granularity of neutrophils, increased ESR.
2. BAC: an increase in the content of bilirubin with a predominance of the conjugated fraction, α2- and γ-globulins, transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, sialic acids, fibrin, seromucoid.
3. OA of urine: the appearance of protein, casts, bilirubin.

Chromatic fractional duodenal intubation... Serving B: large number of small columnar epithelium. Portion C: a decrease in the concentration of the lipid complex, an increase in the content of sialic acids, fibrin, transaminases, sowing of abundant bacterial flora, detection is possible a large number leukocytes. Ultrasound procedure- an increase in the size of the liver, heterogeneity of the acoustic picture, expansion of the intrahepatic bile ducts.

Examination program

1. OA of blood, urine, feces. Examination of urine for bile pigments. 2. TANK: total protein and its fractions, sialic acids, fibrin, seromucoid, transaminases, aldolase, alkaline phosphatase, bilirubin, γ-glutamyl transpeptidase, urea, creatinine. 3. Blood test for sterility. 4. Duodenal fractional sounding with bacteriological examination portions B and C and determination of the sensitivity of flora to antibiotics. 5. Ultrasound examination of the liver and biliary tract.

CHRONIC HOLANGITIS

Chronic cholangitis- chronic bacterial inflammation of the bile ducts (extrahepatic and intrahepatic).

Clinical symptoms. Latent form: pain and soreness in the right hypochondrium, blurred or absent, weakness, chills, subfebrile temperature body, occasionally itching, icterus of the skin and visible mucous membranes, gradual enlargement of the liver. Recurrent form: pain and soreness in the right hypochondrium on palpation, nausea, bitterness in the mouth, itching; in the period of exacerbation - jaundice, fever, prolonged subfebrile condition is possible; with prolonged course - thickening of the terminal phalanges in the form drum sticks and nails in the form of watch glasses, the liver and spleen are enlarged, dense. Prolonged septic form: heavy course with fever, chills, pain in the right hypochondrium, enlarged liver, spleen, severe intoxication, kidney damage, jaundice. Resembles septic endocarditis. Sclerosing (stenosing) form: general weakness, malaise, fever, chills, pruritus, jaundice, enlarged liver, spleen; frequent combination with ulcerative colitis, Crohn's disease, vasculitis, thyroiditis.

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

Laboratory data the same as in acute cholangitis, but for chronic cholangitis, anemia is more natural.

Instrumental research the same as in acute cholangitis. Intravenous cholangiography or endoscopic retrograde pancreatocho-langiography reveals dilated bile ducts (extra- and intrahepatic), with sclerosing cholangitis - intrahepatic ducts in the form of beads, often sharply narrowed with reduced branching, narrowing in some parts or throughout the common bile duct.

Examination program the same as in acute cholangitis. In addition, in difficult differential diagnostic cases, laparoscopy with cholangiography and targeted liver biopsy is necessary.

Diagnosis formulation

The diagnosis is formulated on the basis of the etiological and pathogenetic 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, primary sclerosing cholangitis should be distinguished - a disease of a presumably autoimmune nature. Eastern cholangitis, an insufficiently studied form endemic to some regions of Asia and possibly associated with clonorchiasis, is also described as the primary one. With secondary symptomatic cholangitis, the disease that served as a prerequisite for its development or is associated with it comes to the fore. True, with cholestatic hepatitis and primary biliary cirrhosis, it is not customary to stipulate the participation of cholangitis in the formation of the pathological process, but it is appropriate to imply. If cholangitis acts as independent disease, it is advisable to reflect its primacy in the diagnosis. This emphasizes the isolation of such rare forms of the absolutely predominant cases of secondary cholangitis. Examples of wording a diagnosis

1. Acute primary bacterial cholangitis, sepsis, liver abscesses.
2. Cholelithiasis(choledocholithiasis), exacerbation of secondary bacterial cholangitis.

CHOLANGITIS PRIMARY SCLEROSING

Primary sclerosing cholangitis (CPS) is a chronic inflammatory disease of the liver, accompanied by fibrous obliteration of a part of the bile ducts.

Etiology and pathogenesis of chronic heart disease not definitively established. Hypotheses are put forward about the connection of the disease with bacterial, viral, toxic factors, with thrombosis of the branches of the cystic artery. In recent years great attention the role of immune mechanisms and genetic factors in the development of chronic heart disease is given. In general, two concepts are being discussed. According to the first, HPS refers to autoimmune diseases, according to the second, it develops in individuals with a genetic predisposition, when the triggering factor is any infectious disease or toxic process. In CHD patients, the HLA Be, DR3 haplotype is more often found and, very rarely, B12.

Clinical symptoms

Mostly men are ill young age... Patients complain of weakness, fatigue, pain in the right hypochondrium, epigastrium, nausea, weight loss, fever up to low-grade fever, jaundice, itching of the skin. On examination, icterus is found, with severe portal hypertension- varicose veins of the anterior abdominal wall, ascites, edema. Hepatomegaly is determined. A sharp deterioration in the course of the disease in the form of clear signs of obstructive cholangitis (increased cholemia, fever with chills, severe pain in the right hypochondrium) indicates the development of complications of the disease: choledocholithiasis, acute bacterial cholangitis, carcinoma of the bile ducts.

CHD is often combined with ulcerative colitis, severe fibrosis of the mediastinum, retroperitoneal space, thyroid gland(Riedel's thyroiditis), pancreas ( chronic pancreatitis, diabetes), less often with Crohn's disease, autoimmune thyroiditis, thyrotoxicosis, hypothyroidism, SLE, rheumatoid arthritis, ankylosing spondylitis, Sjogren's disease.

Diagnostic criteria

The presence of obstructive jaundice of the progressive type; absence of stones in the biliary tract (previously no operations were performed in the hepatobiliary zone); detection of widespread thickening and narrowing of the extrahepatic bile ducts during laparotomy, the patency of their intrahepatic sections is confirmed by operating cholangiography; absence malignant neoplasms; exclusion of primary biliary cirrhosis of the liver, filed by morphological examination of liver biopsy.

Laboratory data

1. OAK: increased ESR, signs of anemia, leukocytosis.
2. Urinalysis - positive reaction to bilirubin.
3. LHC: increased blood levels of alkaline phosphatase, bilirubin (mainly conjugated), alanine amine transferase.

Instrumental research

Laparoscopy: liver in initial stages may look unchanged, subsequently cirrhosis is formed. Its color is from dark cherry to green, but less intense than with subhepatic cholestasis. On the surface of the liver, stellate retractions are revealed, combined with pronounced fibrosis, small nodes of purple-red or black color, resembling metastases. In advanced stages, macroscopically marked "large green liver" due to chronic cholestasis, but on its surface there are no dilated bile capillaries characteristic of obstructive jaundice. Retrograde endoscopic cholangiopancreatography: the simplest and most convenient type of examination to confirm the diagnosis. Cholangiograms show bead-like changes in large intrahepatic bile ducts, combined with depletion of small intrahepatic ducts (a picture resembling a "dead" tree). Described are characteristic, chaotically scattered, short finger-like constrictions, replaced by bile ducts of normal size and combined with widespread strictures, diverticulum-like protrusions and microectases, which causes unevenness of the walls of the ducts. In addition to intrahepatic biliary tract... Lack of supra-stenotic expansion - important sign CHD, distinguishing it from secondary cholangitis. Liver biopsy: fibrotic inflammation of the bile ducts.

Examination program

1. OA of blood, urine, urinalysis for urobilin, bilirubin. 2. BAC: bilirubin, transaminases, alkaline phosphatase, total protein and protein fractions, cholesterol. 3. II blood: T- and B-lymphocytes, immunoglobulins, CEC. 4. Laparoscopy with targeted liver biopsy. 5. Retrograde endoscopic cholangiopancreatography (if it is impossible to perform laparoscopy with targeted liver biopsy).

Diagnostic reference book of the therapist. Chirkin A.A., Okorokov A.N., 1991