ACUTE CHOLECYSTITIS2

Acute cholecystitis is inflammation of gall-bladder. After frequency this disease takes second place after appendicitis and makes about 10 % in relation to all acute surgical diseases of organs of abdominal cavity.
Anatomy of the hepatoduodenal region: 1-А. gastrica sinistra; 2-А. spleni­ca (lienalis); З — Rami oesophageales (r. A. gastrica sinistra); 4 — A. phreni-ca inferior (dextra et sinistra); 5 — Aa. gastricae breves; 6-А. splenica (lienalis) (Endastre); 7-А. gast-roomentalis (epiploica); 8-А. pancre-atica dorsalis; 9-А. hepatica commu­nis; 10 — A. gastroomentalis (-epiploica) dextra; 11 — A. gastroduodenalis; 12 — A. pancreaticoduodenalis; 13-А, pan­creaticoduodenal superior posterior; 14 —A. supraduodenalis; 15—A. gastri­ca dextra; 16 — V. portae; 17 — Ductus choledochus; 18 — A. hepatica propria; 19 — Ductus cysticus; 20 — A. cystica; 21 — Ramus dexter; 22— Ramus sinis­ter; 23 — Truncus coeliacus; 24 — Aor­ta abdominalis; 25 — A. phrenica infe­rior (dextra et sinistra); 26 — Vesica fellea
In etiology of cholecystitis major factorsare considered the following: infection, discoordination passage of bile and metabolic disturbance. All of them predetermine formation of concrement.
At bacteriological examination of maintenance of gall-bladder intestinal stick is sown, staphylococcus and enterococcus. Rarer there is streptococcus and other microorganisms.
Considerably more frequently (70–80 %) women are ill in whom during pregnancy the passage of bile in duodenum is always violated. It is promoted by immobile way of life, “sedentary work” and other types of hypodynamia.
The catarrhal develops at acute cholecystitis fibrinogenous and festering inflammation. The wall of gall-bladder is thickened, swollen, hyperemic with stratifications of fibrin and pus. Progress of process can bring walls over of gall-bladder to necrosis (gangrene).

Classification

Acute cholecystitis is divided into:
I. Acute calculous cholecystitis
II. Acute non-calculous cholecystitis
1. Catarrhal.
2. Phlegmonous.
3. Gangrenous.
4. Perforated.
5. Complicated:
a) Hydropsy;
b) Empyema;
c) Pancreatitis;
d) Icterus;
e) Hepatitis;
f) Cholangitis;
g) Infiltrate;
h) Abscess;
i) Hepatic-kidney insufficiency;
j) Peritonitis (local, poured out, general).

Symptoms and clinical passing

The disease, as a rule, begins after violation of diet: reception of plenty of rich, meat food, especially in combination with strong drinks.
Pain syndrome. Characteristic for it is great arching pain in right hypochondrium and epigastric area with an irradiation in right supraclavicular area and right shoulder. If pain syndrome has the strongly expressed cramp-like character, it is named hepatic colic.
Dyspepsia syndrome. Frequent symptoms which disturb a patient, are nausea, frequent vomitting, at first by gastric maintenance, and later — with a touch of bile. Afterwards feelings of swelling of stomach, delay of emptying and gases often join to them.
Examination. During examination almost in all patients subicterus of sclera even at the normal passage of bile can be observed. Tongue, as a rule, assesses by stratifications of whiter-grey colour. Patients complain for dryness in mouth. In difficult cases the tongue is usually dry, assessed by white stratification with a yellow spot in the center, that depends on passing of attack of disease.
Increase of temperature of body is brief and insignificant (on the average to 37,2 0С) at catarrhal cholecystitis and more proof (within the limits of 38 0 С) at its destructive forms.
Tachycardia to a certain extent testifies the degree of intoxication. At first hours of disease the pulse, usually, is relevant to the temperature, and at progress of process, especially with development of peritonitis, it becomes frequent and of weak filling.
During palpation painfulness in the place of crossing of right costal arc with the external edge of direct muscle of stomach can be observed (the Kehr's point). By superficial and deep palpation of right hypochondrium, as a rule, painfulness, increased gall-bladder is exposed, that can be important as a symptom, and sometimes determining for the diagnosis.
The row of characteristic symptoms is determined in the clinic of acute cholecystitis
Murphy's symptoms is a delay of breathing during palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at pressure on the area of gall-bladder, especially on deep inhalation.
Ortner's symptom — painfulness at the easy pattering on right costal arc by the edge of palm.
Mussy's symptom — painfulness at palpation between the legs (above a collar-bone) of right nodding muscle.
Blumberg's signs are the increases of painfulness at the rapid taking away of fingers by which a front abdominal wall is pressed on. This symptom is not pathognomic for cholecystitis but matters very much in diagnostics of peritonitis.
It is also needed to mark the importance of gradation of expression of symptoms: acutely positive, poorly positive, doubtful, absent.
Symptoms of acute cholecystitis can grow during 2–3 hours, and then without some treatment, under act of hot-water bottle or only after the conservative treatment is begun, quickly go to the slump and disappear completely. It always means, that the reason which caused acute inflammation is liquidated (a spasm disappeared, concrement passes by a duct, the ball of mucus moves up and others).
Destructive cholecystitis by the demonstration is the most difficult clinical picture. Thus, gangrenous cholecystitis as a rule, runs across with the acutely expressed phenomena of intoxication and is accompanied by the clinic of bilious peritonitis. The perforation can complicate phlegmonous or gangrenous cholecystitis and then the sudden worsening of the patient’s condition comes on the background of the expressed clinic of destructive process. It shows up at the beginning the sudden strengthening of pain and rapid growth of the phenomena of peritonitis. But it is needed to mark that such clinical picture can develop only in case of perforated maintenance of gall-bladder in free abdominal cavity.
Laboratory information. Leukocytosis within the limits of 10x109/L and more, change of leukocytic formula to the left, lymphopenia and increased ESR.
Sonographic examination of gall-bladder can expose the increase of its sizes, bulge of walls, development of perivesical abscesses, presence or absence of concrement and their sizes.
Sciagraphy survey of organs of abdominal cavity allows to establish the presence X-ray photography-positive of concrement with maintenance of calcium in the projection of gall-bladder.

Variants of clinical passing and complications

Clinical passing of acute cholecystitis is various and depends on the row of reasons among which degree of violation of passage of bile by a cystic duct and choledochus, virulence of infection, presence or absence of pancreato-cystic reflux (pelting of pancreatic juice) have the most value. To this passing it is needed to add the preceding anatomic and functional changes of gall-bladder and adjoining organs, and also the state of protective and regulator mechanisms of patient.
Features of passing of acute cholecystitis in the declining and old-year patients. For them large frequency of development of destructive forms of cholecystitis and their complication by peritonitis are characteristic. Thus, it is needed to state that such changes in gall-bladder can develop already in the first hour of peritonitis as a result of perforation of bubble. Atipical passing in these patients shows up, mainly, by disparity of clinical picture of disease to the pathomorphologic changes present in gall-bladder. In clinical picture in patients with the first plan the symptoms of intoxication come often forward, while pain and signs of peritonitis can be not acutely expressed.
Hydropsy of gall-bladder is its aseptic inflammation, that arises up as a result of blockade of cystic duct by concrement or mucus. The bile from a bubble is sucked in, and on replacement transparent exudation accumulates in its formation. During palpation increased and unpainfully gall-bladder is marked in patients.
Empyema of gall-bladder is unliquidated timely hydropsy, that at repeated infection is transformed in a new form. Gall-bladder in such patients is palpated as a dense, moderately painful formation, however, the symptoms of irritation of peritoneum, as a rule, are absent. The high temperature of body, chill are periodically observed. In blood high leucocytosis with the change of formula of blood to the left is present.
Biliary pancreatitis. Worsening of the patient’s condition, appearance of pain, frequent vomitting, signs of cardio-vascular insufficiency, high amylasuria, presence of infiltrate in epigastric area and positive Voskresensky's and Mayo-Robson's symptoms are its basic signs.
An icterus arises up at violation of passage of bile in duodenum as a result of obturation of choledochus by concrement, by putty or through the edema of head of pancreas. Thus icterus sclera, bilirubinemia, dark urine and light unpainted excrement arise.
Cholangitis. The Sharko triad is characteristic for the patient with this pathology. Next to pain syndrome and icterus, the temperature of body rises to 38–39 0С, there is a fever, high leucocytosis and decline of sizes of functional tests of liver is observed.
Hepatitis shows up by icterus, growth of the phenomena of general weakness, increase in the blood of indexes of alanine aminotransferase and asparaginase and alkaline phosphatase. Liver at this pathology during palpation is painful with acute edges.
Infiltrate is a complication, that can arise on 3–4 days after the attack of acute cholecystitis. Dull pain presence of dense tumular formation with unclear contours in right hypochondrium, increase of temperature of body to 37,5–38 0С that negative symptoms of irritation of peritoneum are characteristic for it.
Abscess. Patients with this pathology complain about high temperature, pain in the right overhead quadrant of abdomen, where painful tumular formation is palpated, the fever, general weakness, absence of appetite, icterus, sometimes vomitting. Roentgenologicly in right hypochondrium the horizontal level of liquid and gas is observed above it. High leucocytosis with the change of leukocytic formula to the left is present in blood.
Hepatic-kidney insufficiency often can arise at the most difficult forms of cholecystitis. The general condition of patient is difficult, acutely expressed intoxication, excitation, hallucinations, delirium, oliguria and anuria are observed.
Peritonitis is the most frequent complication during the perforation of gall-bladder in free abdominal cavity and shows up by tormina and repeated vomitting. Patients are covered with a death-damp, the skin is pale, arterial pressure falls, pulse is frequent and of weak filling. During the objective inspection the tension of muscles of front abdominal wall is marked, positive guardian symptom in the right half of abdomen or along it is observed.
Differential diagnostics

Perforated ulcer. For this disease the Mondor's triad (knife-like pain, tension of muscles of front abdominal wall and ulcerous anamnesis) and positive Spizharskyy's symptom are characteristic (disappearance of hepatic dullness). During roentgenoscopy survey of organs of abdominal cavity in a patient pneumoperitoneum as sickle-shaped strip under the right or left dome of diaphragm is exposed.
Kidney colic. Pain at right-side kidney colic also can be localized in right hypochondrium. However, it is always accompanied by disorders of urination, and at cholecystitis, it as a rule, is not present. Next to it, kidney pain always irradiates downward after passing of ureter, in privy parts. Except, for this pathology micro- or macrohematuria, presence of concrement in a bud, exposed at sonography and on survey urogram, absence of function of bud during chromocystoscopy can be characteristic.
Acute appendicitis. It is needed always to remember, that the subhepatic location of the pathologically changed appendix is also able to show up pain in right hypochondrium. However, for patients with acute appendicitis beginning of pain in epigastric area, absence of hepatic anamnesis, expressed dyspeptic phenomena, inflammatory changes from the side of gall-bladder at sonography are inherent.
Heart attack of myocardium. The so called cholecysto-cardial syndrome which quite often imitates stenocardia pain and suspicion on possibility of origin of heart attack of myocardium can develop. Electrocardiography examination is decisive in establishment of diagnosis. However, laparoscopy is applied in doubtful cases.
Pancreatitis. Acute pancreatitis is accompanied by the expressed pain in the epigastric area of belting character. At palpation in left costal-vertebral corner patients feel painfulness (the Mayo-Robson's symptom), and it is not at cholecystitis.



Tactics and choice of treatment method

Conservative treatment to the patients in default of the expressed signs of destructive or complicated cholecystitis and convincing information which specify on a calculous process in them is expedient to application.
It must include:
1. Bed rest.
2. Hunger of 1–3 days, in the following table № 5 by Peuzner.
3. Cold on right hypochondrium.
4. Spasmolytics (sulfate of atropine, platyphyllin, papaverine, ni-shparum, baralgin).
5. Antibacterial therapy:
а) semisynthetic penicillin (ampicillin, oxacilline, ampiox);
б) cephalosporin (kefzol, klaforan);
в) nitrofurans (nitrofurantoin, furazolidon);
g) sulfanilamides (biseptol, ethazzole, norsulfazole).
6. Inhibitors of protease (contrical, trasilol, gordox, antagosan).
7. Desensitizing preparation (dimedrole, pipolphen, tavegile).
8. Disintoxication therapy (neohemodes, reopolyglucine).
9. Vitamins (С, В1, В6, В12 vitamins).
Intensive pain in patients is taken off by morphine (1 % – 1,0) together with introduction of atropine (0,1 % – 1,0). Less acute pain is halted by baralgin with platyphyllin and papaverine. If the patient’s condition from the conducted treatment does not get better, it is necessary to offer urgent surgical interference.
Indication to surgical treatment. All forms of acute calculous cholecystitis, destructive and complicated forms of noncalculous cholecystitis (except for infiltrateу), and also acute catarrhal cholecystitis conservative treatment of which was uneffective are subject to surgical treatment.
Overhead-middle laparotomy is considered the best choice. However, many surgeons give advantage to pararectal laparotomy, oblique (by Koher) and angular (by Fedorov) accesses.
Methods of operative treatment. Most rational of operations at this pathology counts cholecystectomy from the neck (retrograde). At its implementation the cystic duct and artery are bandaged, and then gall-bladder is already deleted, sewing up its bed. It is applicable at presence of shallow concrement in gall-bladder.
Cholecystectomy from the bottom (antegrade) is applied in case of technical difficulties during the selection of elements of neck of bubble. It consists in deleting of bubble from the bottom to the neck with the next bandaging of cystic duct, to the artery and suturing of bed of gall-bladder.
Atipical cholecystectomy. At this operative treatment gall-bladder is exposed after its longitudinal axis, released from maintenance and under the control of the finger led in its lumen, position of neck is determined, and then deleted. Operation is executed in case of widespread infiltrate and when accretions surround not only the bubble but also neck, cystic and bilious ducts. A surgeon must remember thus, that the searches of cystic duct and artery in such terms can be dangerous.
Laparoscopy cholecystectomy. For its implementation it is drawn on complex of special apparatus: operating laparoscop with a video camera and coloured video monitor. After creation of pneumoperitoneum and introduction to the abdominal cavity of laparoscope through the separate punctures of abdominal wall instruments-manipulators are entered. With their help under the visual control in accordance with the image on video monitor, gall-bladder is deleted. Thus on stump of cystic duct and on an artery metallic clips are imposed.
Ideal cholecystolytotomy is operation that includes opening of gall-bladder, deleting of concrement and its suturing. Applicable for patients with large single concrement in default of the expressed changes from the side of wall of gall-bladder.
Cholecystostomy is an operation, that is based on creation of external fistula of gall-bladder. During this operation the bottom of the last is taken in a wound so that it was isolated from abdominal cavity.
Laparoscopic cholecystostomy is imposition of external fistula on gall-bladder under the control of laparoscope. It is the only operation, executed under the control of laparoscope.
Cholecystectomy is applied, mainly, as the first stage of operation in the very loosened patients for taking out the infected maintenance from bubble and ducts. This operation is palliative and often in the future requires repeated operation for the removal of bilious fistula — cholecystectomy.
It is needed to remember that during cholecystectomy it is necessary to conduct the intraoperative revision of bilious ducts, which must include the examination, palpation and determination of diameter of hepatico-choledochus (norm is to 8 mm), and also instrumental methods of examination of bilious ducts.
Intraoperative cholangiography is contrasting of bilious ducts by introduction iodine preparations (bilignost, cardiotrust, verigraphine in the concentration 30–33 %) in them through stump of cystic duct of soluble. Cholangiography enables to define the width of ducts, presence or absence of concrement in them, and also cone-shaped narrowing of terminal part of choledochus characteristic of stenosis.
Cholangiomanometry is a method, that allows to expose the degree of bilious hypertension in ducts by the water manometer of the Valdmann device. Normal pressure is within the limits of 80–120 mm of waters. item (0,78–1,17 kPa), and the higher testifies to bilious hypertension.
Debitomanometry is a method of determination of amount of liquid at perfusion through the Fater's papilla under permanent pressure for time unit (1 min). In patients with normal passing of bilious ducts the size to the debit of liquid at pressure 150 mm water.col. (1,47 kPa) makes from 5 to 8 ml/min. In similar terms, at their obturation, this debit diminishes, and at insufficiency of sphincteric device — is increased. However, much cholangio- and debitomanometry at operations in patients with acute cholecystitis are applied rarely. These methods of examination are used for chronic cholecystitis mainly.
Choledochoscopy is a method of endoscopy examination of bilious ducts by choledochoscope during choledochustomy.
External draining of bilious ducts can be executed by such methods:
1) by Pickovskyy ­– polyethylene catheter which is entered through stump of cystic duct;
2) by Kehr — by Т-shaped latex drainage;
3) by Vyshnevsky — drainage to the gate of liver;
4) by Holsted.
Indication to external draining: 1) after diagnostic choledochustomy; 2) after choledocholytotomy; 3) at accompanying cholangitis, pancreatitis.
For internal draining of bilious ducts are applied by transduodenal sphincteroplasty or choledochoduodenostomy. At acute cholecystitis these operations are executed under absolute indications. Such is the structure and tired out concrement of large duodenal papilla, multiple choledocholithiasis, presence of putty in ducts or their expansion.
The best method of renewal of normal outflow of bile at stenosis and jammed concrement of large duodenal papilla is considered its transduodenal dissection. This method of internal draining allows to liquidate the reason of impassability of ducts and store the physiology passage of bile in intestine.
At forming choledochodiodenoanastomosis most distribution acquired methods by Jurash, Flerken, Finsterer and Kirschner's methods. The principle difference of them consists in correlations of direction of cut of choledochus and duodenum (longitudinal, slanting, transversal). The width of anastomosis must be not less than 2,5–3 cm. It is thus needed to remember, that imposition of choledochoduodenoanastomosis in the conditions of presence of inflammatory process in abdominal cavity always needs to be connected with external draining of choledochus by Pikovskyy (double draining).