- What a cholecystitis is and why it occurs
- What stimulates developing cholecystitis
- Types of cholecystitis
- How cholecystitis manifests?
- Whether cholecystitis is dangerous: possible complications
- Principles of treatment
Cholecystitis is one of the most common diseases of modern mankind. It is diagnosed on average in 7-10% of adults, and in developed countries this figure reaches 15-20%. Moreover, the signs of cholecystitis in recent decades are increasingly discovered in people of working age and even in adolescents, whereas in the first half of the 20th century this disease was considered typical for the representatives of elder generations.
What a cholecystitis is and why it occurs
The cholecystitis is a disease characterized by inflamed gallbladder walls. According to the current International Classification of Diseases ICD-10, it is classified as a disease of the digestive system, and is diagnosed as K81.
In the pathogenesis of cholecystitis, two key factors play a role:
- Bile stasis (cholestasis) in the lumen of the gallbladder, especially if it is accompanied by intravesical bile hypertension - increased bile pressure. This leads to appearing microdamages, deteriorating tissue blood supply, changing bile composition and concentration. The emerging aseptic (noninfectious) inflammation reduces the mucosa stability to infectious agents and predisposes to developing chronic and complicated form.
- Infected bile and gallbladder walls. Inflamed gallbladder is usually of a bacterial nature, although the causative agents may also be the protozoa, lamblia and even helminths (parasitic worms) that enter the intestines. But this does not mean that cholecystitis refers to infectious diseases. In most cases, a banal mixed conditionally pathogenic microflora forms in the gallbladder, which becomes excessively active under certain conditions and starts being aggressive to the tissues. But penetrating pathogen is also possible with the blood and lymph flow.
Simultaneous presence of these 2 mutually complementary conditions is the main cause of developing cholecystitis. And the inflammation arisen supports and strengthens cholestasis stimulating turning disease to a chronic stage. This is explained by the tendency to forming stones from the thickened bile, bad patency of the outflow duct due to clots of mucus, increasing intravesical pressure due to exudate releasing into the gallbladder lumen (fluids of inflammatory origin), creating favorable conditions for reproducing microorganisms.
What promotes developing cholecystitis
Predisposing factors include:
- Individual anatomical features of the gallbladder in the form of an inflection of its neck, anomalous shape, existing internal partitions.
- Functional disorders of the biliary system (biliary dyskinesia). They develop by stressful situations, neurotic reactions, overeating, low physical activity. In pregnant women and women with hormonal disorders, motor activity of the internal organs is often significantly reduced, that is explained by acting increased hormone called progesterone.
- Bad nutrition: having fried and excessively fatty meals, episodes of pronounced overeating. A large amount of bile is produced in response to the excess intake of fat, which stretches the gallbladder and stagnates.
- Existing pancreatitis (inflamed pancreas). The biliary and pancreatic ducts have a common outlet in most cases, and sometimes even merge with their terminal sites. With pancreatitis, there is often edema in this area, which disrupts the outflow of bile and creates conditions for entering activated pancreatic enzymes into the bile ducts. Therefore, a fairly large number of patients are diagnosed simultaneously with cholecystitis and pancreatitis.
- Lean diet, irrational unbalanced diets for the sake of weight loss, various conditions leading to impossibile having meal in natural way. When a lack of nutrients (especially fats) enters the digestive system, a very small amount of cholecystokinin is produced, which stimulates reducing walls of the bile excretory system. If this situation repeats regularly, hypotension of the gallbladder develops with congestion and thickening bile.
- Squeezing of the gallbladder from the outside, which negatively affects its contractility. This is possible with flatulence, regular overeating, pregnancy, tumors in the abdominal cavity and retroperitoneal space, increased intrathoracic pressure on the background of various lung diseases.
Of particular importance are also metabolic disorders, obesity, bile condensation on the background of dehydration of various origins.
Metabolic disorders, obesity, bile inspissation on the background of dehydration of various origins are of particular importance.
Types of cholecystitis
The cholecystitis can be acute and chronic by duration. If the patient features signs of the disease persist for more than 3 months, it means the disease gets chronic stage. At the same time, he/she can make no special complaints, but according to the research, signs of inflammation will be revealed in the wall of the gallbladder and next to the cystic fibrous tissue.
According to the nature of the pathological process, cholecystitis can be:
- Calculous (with present stones of various sizes and numbers in the lumen of the gallbladder) and uncalculous (without stones). When a stone is found, a cholelithiasis is diagnosed, using the code for ICD-10 K80.
- Catarrhal, purulent (phlegmonous, gangrenous), necrotic.
- Uncomplicated and complicated, with perforated gallbladder and unperforated one.
Acute cholecystitis is always a stroke with strongly pronounced symptoms. But chronic cholecystitis is divided into several forms according to the nature of the current:
- Latent is almost an asymptomatic variant of the disease, often observed early in forming chronic cholecystitis.
- Recurrent is characterized by alternating periods of exacerbating and relieving symptomatology.
- Continuously flowing (persistent, monotonous), when symptoms are more or less constant in varying degrees.
How the cholecystitis reveals.
An attack of acute cholecystitis or exacerbation of an existing chronic disease is most often provoked by having fatty, fried, spicy, pickled meal, overeating, drinking alcohol. The first symptoms usually get acute after 2-3 hours after such diet failures.
Treating typical attack of cholecystitis includes:
- Pain. With cholecystitis in adults, the pain is felt mainly in the right upper quadrant, but also in the right side, under the right scapula and in the right side of the lower back. The pain is so intense that it makes the sick person take a sparing position and sharply limit moving. In this case, they talk about developing biliary or hepatic colic. But the pain may not be so strong with the cholecystitis, it is often described as a heavy right side, cramping-pulling sensations, bursting.
- Dyspepsia (signs of digestive disorders in the upper gastrointestinal tract). Most often there is a nausea, poor repeating unrelieving vomiting, distention in the upper abdomen, dry mouth, empty (without meal) eructation with an acid-bitter taste. Appetite deteriorates, taste perception changes.
- Increased body temperature. Usually it is within 37-38 ° C, its increase may indicate appearing complications, turning catarrhal process to purulent. But fever is not a mandatory symptom of the acute cholecystitis, it is rather a universal response to pain and inflammation.
Severe attack of cholecystitis is often accompanied by rapid heartbeat, cool feet and hands, sticky sweat and other vegetative reactions to severe pain syndrome. Many patients soon get signs of pancreatitis, i.e. painful left hypochondrium and disordered distestion, reduced intestine motor activity.
When the patient suffers from chronic cholecystitis, he/she can feel no discomfort between the attacks, or sometimes experiences a feeling of heaviness in the right hypochondrium or side, in 1-3 hours after failed nutrition. And with stones existing in the gallbladder, pain can appear after intense work out, especially after jumping and running.
Whether cholecystitis is dangerous: possible complications
Possible complications of cholecystitis include:
- Blocking common bile duct lumen with a stone that has escaped from the gallbladder (with calculous cholecystitis) or a clot of mucus, which leads to absorption of an increased amount of bilirubin into the blood with developing obstructive jaundice.
- Suppurated accumulated bile leading to forming empyema (abscess) of the gallbladder.
- Necrosis or purulent fusion of the gallbladder wall. Its content releasing into the abdominal cavity is fraught with developing dangerous bile peritonitis.
- Involving in the inflamed close-to-gallbladder tissue, which is called pericholecystitis. Later it leads to forming adhesions between the gallbladder walls and surrounding organs, which further worsens its motor function and makes it challenging to evacuate the bile.
- Forming biliary fistula - abnormal gallbladder ways that can open into the stomach, various parts of the intestine, abdominal cavity, bile ducts and even the anterior abdominal wall.
In some cases, cholecystitis leads to a complete blocking gallbladder with its gradual wrinkling, reducing, overgrowing. In this case, a condition similar to postcholecystectomy syndrome after surgical removing gallbladder is formed.
Objective signs revealed by the doctor during examination:
- Moderate tension and soreness in palpation of the abdomen in the left hypochondrium.
- Sharp local soreness at the point of the gallbladder.
- Increased pain when tapping along the edge of the right costal arch (Ortner's symptom).
- Existing painful point on the neck between stems of the right sternoclecho-mastoid muscle (a frenicus symptom or a de Mussie-Georgievsky symptom).
- Changing gallbladder revealed during deep palpation (densification, enlargement, pronounced soreness and decreased mobility). However, with severe pain, the doctor does not always manage to test the liver area to the fullest.
Also, dry and furred tongue, a mild swelling in the upper half of the abdomen due to reflex oppressing intestine activity are usually present. When inflammation goes from the gallbladder to the surrounding tissues, the symptoms of irritation of the peritoneum occur in the right hypochondrium. And in the case of a purulent-necrotic process, growing signs of intoxication appear, the general condition worsens, the abdominal pains take on a diffuse character.
Laboratory-instrumental diagnostics with cholecystitis allows to clarify nature and severity of the inflammation, to reveal existing stones and complications. The survey includes:
- Ultrasound is the simplest, most accessible and popular method for visualizing changes in the gallbladder and detecting stones.
- CT (computed tomography) and MRI (magnetic resonance imaging) are more accurate and technically sophisticated visualization techniques with stratified images.
- Cholecystography is a X-ray research of the gallbladder with entering X-ray contrast drugs intravenously or orally (through the mouth).
- Fractional duodenal sounding with taking portion of cystic bile for a biochemical and bacteriological research.
- Hepatobiliary scintigraphy, which allows tracking the process of bile formation, accumulation and excretion. It is applied infrequently, since not all medical institutions can get this expensive equipment.
It is the data of the conducted research that allows the doctor to choose the optimal treating cholecystitis regimen.
Principles of treatment
The tactics of treating cholecystitis depends on the nature and severity of the inflammation, existing severe and surgery-requiring complications. Operations can be carried out in an emergency and planned manner using classical and minimally invasive techniques (for example, endoscopically).
With mildly expressed pain syndrome, a satisfactory general condition of the patient and no signs of suppuration, the therapy can be performed in outpatient settings. But the hepatic colic lasting for more than a few hours, spacious pain, growing intoxication are the basis for urgent hospitalization in a surgical hospital. In other cases, the decision on the appropriate inpatient treatment is taken individually.
Conservative therapy of the acute stage of cholecystitis includes:
- Therapeutic diet (table N5a and then N5), and in the first 1-3 days of severe hepatic colic the hunger is recommended.
- Spasmolytic drugs for reducing sphincter tonus in the neck of the gallbladder and facilitating bile outflow.
- Antibacterial agents for eliminating infectious inflammation factor.
- Nonsteroidal anti-inflammatory drugs for reducing inflammation, tissue edema, and pain. They also have antipyretic effect.
- Prokinetics, which regulate gastric and small intestine motor activity, have an antiemetic effect.
- Anesthetic non-narcotic drugs, as symptomatic therapy for a period of severe pain.
- Enzymatic medications for compensating concomitant enzyme deficiency, improving nutrient digestion and assimilation, reducing functional load on the pancreas. To this end, Micrasim® is prescribed to treat cholecystitis, which has a natural origin and a high safety profile. Its enzymes include lipases contributing into fat absorption in conditions of disordered bile secretion and, thereby, reduce severity of concomitant cholecystitis of intestinal disorders.
- Some types of physiotherapy, but with exacerbation of calculous chronic cholecystitis, are used with extreme caution.
After relieving acute cholecystitis symptoms, it is recommended to continue following diet, taking enzyme preparations, completing spasmolytic therapy course. According to the doctor's decision, choleretics can be prescribed during this period, which increase the bile secretion or stimulate producing (cholekinetics or holaga).
The basis for treating chronic cholecystitis after exacerbation is a diet, intaking enzyme medications with failed nutrition and appearing signs of digestive disorders, applying mineral waters and other types of balneal treatment. If there are gallstones, the entire gallbladder or only concrements from its lumen should be removed with hardware lithotripsy (contactless stone crushing). In some cases, litholytic therapy is effective for the gradual destruction of biliary calculus.
Prophylaxis of cholecystitis includes avoiding provoking factors, timely treating acute and chronic infected sites, competent treating pancreatitis. With an increased risk of bile stagnation and stone formation in the gallbladder, regular ultrasound control and individual selection of preventive measures are recommended.
In most cases, timely and competent treatment reduces attack of cholecystitis in a conservative way. In the future, it is necessary to follow the doctor's recommendations to prevent relapse and turning process to a chronic and complicated stage.
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