Chronic cholecystitis

Chronic cholecystitis

Chronic cholecystitis is a chronic inflammation of the gallbladder, characterized by recurrent subacute symptoms, most often due to the presence of stones in its lumen. Frequency – see Cholangitis. The predominant gender is female (2:1). Etiology

• • Gallstones – 90-95% of cases. If stones migrate along the bile outflow tract, they can cause obstruction of the cystic duct, leading to acute cholecystitis; obstruction of the common bile duct causes jaundice, and obstruction of the pancreatic duct causes pancreatitis
  • Gallbladder sludge is a viscous material in the lumen of the gallbladder, insoluble in bile, which is found in sheets on ultrasound, sometimes causing cholecystitis, obstruction of the common bile duct, or pancreatitis. Occurs in most pregnant women, often with total parenteral nutrition and in most patients who have lost a lot of weight in a short period of time
  • Acalculous cholecystitis – 5% of cases. Associated with a severe stressful situation, including heart surgery, multiple trauma. May be associated with ischemic damage to the gallbladder wall
  • Bacteria do not traditionally serve as a trigger, but play an important role in the development of complications (for example, empyema and ascending cholangitis). In emphysematous cholecystitis, clostridium is most likely responsible for the onset of the process and the development of complications.
  • Tumors and strictures of the common bile duct are traditionally associated with cholangitis and pancreatitis.
  • Ischemia may be a cause in diabetic patients but is not commonly seen.

Risk factors

• • Operations on the heart
  • Abdominal injury
  • Parasitic invasion of the bile ducts
  • gallstones
  • Fast weight loss
  • long-term parenteral nutrition
  • Pregnancy. Pathomorphology
  • Thickening and fibrosis of the gallbladder wall
  • Infiltration by inflammatory cells.

Clinical picture and classification

• • latent form. It should be considered rather as a period of the course of gallstone disease. May last indefinitely.
  • Dyspeptic chronic form
  • Feeling of heaviness in the epigastric region
  • Heartburn
  • Flatulence
  • Unstable chair
  • Symptoms are provoked by the use of fatty, fried, spicy foods, too large portions of food.
  • Painful chronic form
  • Pain in the epigastric region and the projection of the gallbladder of a aching nature, radiating to the region of the right scapula
  • Weakness, malaise, irritability.
  • Biliary colic and chronic relapsing form
  • Sudden attack of sharp pains in the right hypochondrium and in the epigastric region.
  • It is provoked by eating fats, spices, negative emotions, physical stress, pregnancy, menstruation.
  • Nausea, vomiting.
  • Positive symptoms of de Mussy-Georgievsky, Ortner, Boas, Murphy
  • Painful point of Boas – painful point, detected by deep palpation, located 8.5 cm to the right of the spinous process of the XII thoracic vertebra
  • Murphy’s sign – involuntary breath holding on inspiration with pressure on the area of ​​the right hypochondrium
  • Ortner’s symptom – pain when tapping along the edge of the right costal arch
  • Symptom de Mussy-Georgievsky (phrenicus-symptom) – soreness when pressed with a finger between the legs of the right sternocleidomastoid muscle.
  • The duration of the attack is from several minutes to a day or more.
  • After the attack stops, the symptoms of the disease quickly subside.
  • Other forms
  • Angina – in older people with coronary artery disease
  • Saint’s syndrome is a combination of cholelithiasis with diaphragmatic hernia and diverticulosis of the colon.

Laboratory research

• • General blood test – leukocytosis with neutrophilia, increased ESR
  • General urine test – positive reaction for bilirubin
  • Biochemical blood test – increase in the concentration of bilirubin, transaminases, alkaline phosphatase, utlutamyl transpeptidase, a- and y-globulins, seromucoid, sialic acids, fibrin
  • Cystic bile
  • Calculous cholecystitis – an increase in the relative density of bile, microliths, sand, a decrease in the cholate-cholesterol coefficient, a decrease in the concentration of cholic and an increase in lithocholic bile acids, a decrease in the lipid complex, a large number of cholesterol crystals, biliary

calcium rubynate, leukocytes, columnar and squamous epithelium

• • Non-calculous cholecystitis – an acid reaction, a decrease in the relative density of bile, flakes of mucus, a large number of leukocytes, cylindrical and squamous epithelium, fatty acid crystals, an increase in the content of sialic acids and aminotransferases, a decrease in the concentration of the lipid complex, bilirubin, cholic acid. Special Studies
  • X-ray examination
  • 20% of gallstones are X-ray negative
  • If there is a fistula between the intestine and the gallbladder, cholangiography is likely to detect gas in the bile ducts
  • Emphysematous cholecystitis – gas in the lumen of the gallbladder
  • Ultrasound – thickening of the gallbladder wall (more than 3 mm), an increase in volume, in the lumen of the bladder – a thick secret (sludge), within it – liquid
  • Oral cholecystography
  • Used to diagnose gallstones in patients without jaundice
  • Contraindicated in patients with acute cholecystitis
  • A prerequisite is the absence of pathology of the intestines and liver
  • CT
  • For the detection of gallstones and the diagnosis of acute cholecystitis has no advantages over ultrasound
  • Detection of an enlarged pancreas, a forming abscess, in cancer allows you to detect thickening and heterogeneity of the gallbladder wall
  • Iminodiacetic acid test during an acute attack
  • Endoscopic retrograde cholangiopancreatography to assess the condition of the bile and pancreatic ducts
  • Percutaneous transhepatic cholangiography – assessment of the state of the intrahepatic biliary system
  • Laparoscopy
  • Laparotomy – in case of doubt in the diagnosis after less invasive research methods.

Differential Diagnosis

• • Hepatitis
  • pancreatitis
  • Peptic ulcer of the stomach and duodenum
  • ischemic heart disease
  • gallbladder cancer
  • Pneumonia
  • Acute appendicitis
  • Urolithiasis disease.

Treatment:

Mode

• • Outpatient for asymptomatic patients
  • Stationary for patients with biliary colic lasting more than 6 hours, signs of severe intoxication, jaundice.

Diet – table number 5 according to Pevzner

• • Low-calorie food containing a large amount of vegetable fiber, vitamin C, a reduced amount of proteins and fats, mainly of plant origin
  • The multiplicity of food intake – 5-6 r / day in small portions. Drug therapy
  • Oral cholelitholytics (effective for X-ray negative [cholesterol] stones).
  • Ursodeoxycholic acid (ursofalk) – 8-10 mg / kg / day in 2-3 oral doses for a long time (up to 2 years).
  • Chenodeoxycholic acid (chenofalk) – 250 mg 2 r / day for 2 weeks, then increase the dose by 250 mg / day to 13-15 mg / kg / day (or until side effects appear), take up to 1 year or more.
  • Antibiotics
  • Ampicillin 4-6 g/day
  • Cefazolin 2-4 g/day
  • Gentamicin 3-5 mg/kg/day
  • Clindamycin nbsp; 1.8-2.7 g / day. Surgery
  • Retrograde endoscopic papillosphincterotomy
  • Laparoscopic operations
  • Cholecystostomy
  • Cholecystectomy
  • Open Operations
  • Cholecystostomy
  • Cholecystectomy: from the neck, from the bottom. Alternative Methods
  • Direct contact dissolution of stones is indicated only for a small part of patients, because. high relapse rate
  • Contact dissolution of stones with methyl-(tert)-butyl ether can only be carried out by a doctor who has experience in using this method.
  • Extracorporeal

shock wave lithotripsy—the role of this technique is unclear and is currently under study.

Complications

• • Destructive cholecystitis with the threat of perforation and peritonitis
  • Cholangitis
  • Blockage of the bile ducts by a stone with the development of subhepatic cholestasis
  • Secondary biliary cirrhosis
  • pancreatitis
  • Bowel obstruction induced by gallstones
  • liver abscess
  • Gastrointestinal fistula
  • Gallbladder cancer.

Course and forecast

• • The prognosis is favorable. Death during an exacerbation of chronic cholecystitis is most often due to coronary artery disease, peritonitis
  • Gallstones traditionally cause recurrence of symptoms within 3–6 months after the first episode.
  • After cholecystectomy, stones can form in the gallbladder

ducts.

Features of cholecystitis in the elderly

• • Diagnosis is difficult
  • Greater risk of developing complications
  • Higher mortality rate after cholecystectomy.

See also Gallstone disease, Jaundice, Tumors of the gallbladder and bile ducts, Cholangitis, Acute cholecystitis ICD

• K80.0 Gallbladder stones with acute cholecystitis
• K80.1 Gallbladder stones with other cholecystitis
• K81 Cholecystitis
• K81.8 Other forms of cholecystitis