Chapter 5. DISEASES OF BILIARY TRACTS

Diagnostics

Hyperkinetic form

Hypokinetic form

Complaints

Attacks of acute pain in the right hypochondrium, epigastrium, nausea, sometimes vomiting

Aching pain in the right hypochondrium and epigastrium, nausea, bitter taste in the mouth, liquid stools

Anamnesis

Dietary errors, diseases of the gastro-intestinal tract (GIT), emotional disorders

Physical examination

Moderate tenderness at palpation in the right hypochondrium and epigastrium

Laboratory findings

Moderate hyperbilirubinemia

Instrumental studies

Ultrasonic investigation (US): persistent spasm of the gallbladder

US: persistent atony of the gallbladder

Treatment

Hyperkinetic form

Hypokinetic form

Diet excluding fatty, fried, pungent foods. Fractional food intake.

Spasmolytics, analgetics

Cholagogues

Dyskinesia is often the trigger mechanism of stone formation, cholecystitis, cholangitis, pancreatitis (bombarding of duodenal contents, bile congestion).

Definition and statistical data

Cholelithiasis is a systemic pathology characterized by formation of stones in the biliary system, mainly in the gallbladder, caused by dyskinesia of the biliary tracts, infection and disturbance of cholesterol and calcium metabolism.

It affects 10-20% of the population of the developed countries. It occurs in women 50 times more frequently than in men. People suffering from obesity are affected more frequently. Recently there is observed the increase of the number of patients with cholelithiasis. Representatives of the black race are affected rarely.

Definition and statistical data

Acute cholecystitis is a disease which clinical course is conditioned by acute inflammation of the gallbladder.

In Russian Federation cholecystitis is found in 10-15% of the population. Acute cholecystitis occurs in people of various age groups, people above 50 years old being affected more frequently. Elderly and senile patients account for more than a half of the total number of patients with cholecystitis. The ratio of the disease developing in men and women is 1:5.

In the structure of urgent pathology of the abdominal cavity acute cholecystitis takes the second place after acute appendicitis.

Differential diagnostics

Acute cholecystitis should be differentiated from other acute diseases of the abdominal organs in atypical clinical picture (acute appendicitis, acute pancreatitis, perforating ulcer, mesenteric thrombosis, intestinal obstruction), as well as from the diseases of the thoracic organs (thoraco-abdominal syndrome in pneumonias, pleurites, lung cancer). Sometimes it is necessary to differentiate acute cholecystitis from the diseases of the heart (angina pectoris, infarction of the posterior wall).

In mechanical jaundice it is necessary to differentiate acute cholecystitis from other diseases causing jaundice (hepatitis, cirrhosis, cancer of the pancreas, etc.). Knowledge of clinical manifestations of the differentiated diseases, as well as modern reliable instrumental studies contribute to the accurate diagnostics of the disease.

Medicamentous treatment

Purposes

Means

Criteria of effectiveness

Liquidation of acute inflammation

Anti-microbial preparations: antibiotics of a wide spectrum of action in combination with metronidazol, fluoroquinolons.

Clinical improvement. Decrease of leukocytosis, temperature. Positive dynamics according to the USI data.

Liquidation of bile hypertension

Diet. Spasmolytics.

Detoxication

Intravenous infusions of blood substitutes of hemodynamic and detoxication action. Forced diuresis.

Liquidation of pain

Non-narcotic analgetics

Treatment of complications

In biliary pancreatitis - anti-enzymatic preparations, proton pump blockers. In mechanical jaundice - hepatoprotectors, correction of hemostatis.

Decrease of amylase, transaminases, normalization of hemostasis.

Correction of the comorbid pathology

In atherosclerosis and hypertensive disease - hypotensive, cardiac preparations. In diabetes mellitus - insulin therapy.

Normalization of arterial pressure (AP), cardiac output, blood glucose level.

Methods of surgical treatment of acute cholecystitis are analogous to those in chronic cholecystitis and will be described in the section "Surgical treatment of acute and chronic cholecystitis".

Other diseases of the biliary tracts

Nosologic units

Clinical picture

Diagnostics

Treatment

Cyst of the common bile duct (local widening of the common hepatic and common bile duct up to 15 cm)

Aching pain in the epigastrium and right hypochondrium, possibly - jaundice due to the accumulation of the thickened bile in the cystic cavity

US, CT, ERCP

Cystoduodeno- or cystojejunostomy with the anastomosis according to Roux on the long loop with dissection of the cystic walls

Polyps (singular and multiple)

These have no specific clinical picture

US, CT

These are indications to cholecystectomy due to a high probability of malignization

Cancer of the bile ducts

Jaundice without previous attack of pain, sometimes - an intermittent course due to the tumor lysis. Courvoisier's sign.

US, CT, ERCP

Dissection of the tumor, biliodigestive anastomosis. In disseminated cancer - pancreato-duodenal resection. Palliative operations - tumor recanalization on the drainage, bilio-digestive anastomoses

Cancer of Vater's papilla

Aching pain in the epigastrium and in the right hypocondrium. Jaundice, Courvoisier's sign.

Duodenography, fibro-gastroduodenoscopy (FGD) with biopsy

Papillectomy. In invasion of the tumor into the surrounding tissues - pancreatoduodenal resection (PDR). Palliative operations - biliodigestive anastomoses.