Chronic cholecystitis
The content of the article:
- Causes and risk factors
- Forms of the disease
- Chronic cholecystitis symptoms
- Diagnostics
- Chronic cholecystitis treatment
- Possible complications and consequences
- Forecast
- Prevention
Chronic cholecystitis is a polietiologic (caused by a combination of several reasons) wavy and long-term (6 months or more) inflammatory disease, which is characterized by:
- inflammatory damage to the gallbladder wall;
- dystonia and violation of the tone of the bile ducts;
- changes in the physical and chemical properties of bile;
- in the case of calculous chronic cholecystitis - the formation of calculi (stones).
Cholecystitis is one of the most common diseases of the digestive system.
The disease is most common among women over 40 years of age. The conditional pentad "F" characteristic of chronic cholecystitis is described: "Female, fat, fair, fertile, forty" - a woman with overweight, fair hair color, capable of reproducing healthy offspring (fertile), forty or more years.
The stoneless variant occurs in 10-15% of cases (on average 6-7 episodes per 1000 people), much more often chronic cholecystitis is accompanied by the formation of calculi.
Chronic calculous cholecystitis (with stones in the gallbladder cavity) is one of the most common diseases of the gastrointestinal tract, characteristic of the age group from 40 to 60 years old (more than 70% of the total mass of patients in gastroenterological departments). This form of the disease is the main clinical variant of gallstone disease.
Causes and risk factors
The main cause of chronic cholecystitis is infection:
- pathogenic flora (shigella, salmonella, hepatitis B, C viruses, actinomycetes, etc.);
- conditionally pathogenic flora, which is activated in conditions of a decrease in local immune protection (Escherichia, strepto-, staphylo- and enterococcus, Proteus, Escherichia coli);
- parasites (liver fluke, fasciola, ascaris, lamblia, etc.).
The causes of chronic cholecystitis can be pathogenic and opportunistic microflora
With regard to calculous cholecystitis, there are two developmental concepts that consider infection or the formation of stones as the root cause:
- Primary inflammation of the gallbladder wall, against the background of which changes in the physicochemical properties of bile, along with dystonia and dyskinesia of the biliary zone, create conditions for the formation of stones.
- Accession of a secondary infection against the background of an already existing cholelithiasis, which changes the normal functioning of the organ.
In addition to infectious agents, generalized allergic reactions and exposure to various toxins can cause chronic cholecystitis.
Pathogenic microflora enters the gallbladder cavity in several ways:
- ascending (enterogenic) - infection occurs as a result of the penetration of pathogens from the duodenum due to impaired motility of the intestines and bile ducts, insufficiency of the sphincter of Oddi in conditions of duodenal stasis and increased pressure inside the intestine, etc.;
- hematogenous from distant foci of inflammation through the hepatic artery into the artery supplying the gallbladder (for example, chronic diseases of the ENT organs, foci of infection in the dentoalveolar system, etc.);
- lymphogenous along the pathways of lymph flow from the urogenital area, hepatic and extrahepatic ducts, intestines.
Characteristic is the manifestation of signs of chronic cholecystitis in full after exposure to provocateurs.
Factors provoking an exacerbation of chronic cholecystitis:
- an increase in intra-abdominal pressure, leading to a violation of the passage of bile (prolonged sitting position, pregnancy, obesity, wearing corsets, etc.);
- improper diet (fatty, fried, spicy, overly salty food, strong alcoholic drinks, a small amount of coarse fiber in the diet);
- fasting (contributes to the stagnation of bile and an increase in its concentration);
- biliary dysfunction;
- neuroendocrine disorders;
- chronic psycho-emotional overstrain or acute stress;
- congenital anomalies in the structure of the biliary zone;
- metabolic diseases;
- drastic weight loss;
- elderly age;
- chronic pathology of the digestive tract;
- autoimmune pathology;
- genetic predisposition;
- long-term pharmacotherapy with certain drugs (estrogens, clofibrate, octreotide, ceftriaxone).
Despite the extensive list of risk factors, it is the non-observance of the diet in chronic cholecystitis that is the fundamental provocateur of the exacerbation of the disease.
Forms of the disease
The main symptom of chronic cholecystitis, according to which it is classified, is the presence of calculi, stones:
- chronic calculous cholecystitis;
- chronic acalculous cholecystitis (with a predominance of inflammation or motor-tonic disorders).
Depending on the causative factor of inflammation, the following forms of the disease are distinguished:
- bacterial;
- viral;
- parasitic;
- allergic;
- non-microbial (immunogenic);
- enzymatic;
- idiopathic (of unknown origin).
Depending on the course of the inflammatory process:
- rarely recurrent;
- often relapsing;
- monotone;
- atypical.
According to the phase of the disease:
- aggravation;
- fading exacerbation;
- remission (persistent, unstable).
Depending on the severity, the disease is classified into mild, moderate and severe.
Chronic cholecystitis symptoms
Symptoms of chronic cholecystitis form several syndromes that make up the picture of the disease and are expressed depending on individual characteristics:
- abdominal pain;
- digestive disorders (dyspeptic);
- autonomic dysfunction;
- jaundice syndrome;
- intoxicating;
- cholecystocardial; and etc.
The main subjective symptom of chronic cholecystitis is abdominal pain of varying intensity (from severe colic to a feeling of heaviness and distention), localized in the right hypochondrium, much less often in the projection of the stomach. Pain syndrome has a maximum severity during an exacerbation or after exposure to provoking factors (in remission, pain syndrome rarely bothers patients, although in some cases it has a constant aching character of weak or moderate intensity).
The main symptom of chronic cholecystitis is abdominal pain
Pain accompanying chronic cholecystitis is characterized by spread to the shoulder, arm, collarbone on the right, sometimes to the right half of the lower jaw, neck.
In patients with calculous cholecystitis, pain syndrome, as a rule, is provoked by an episode of biliary colic - a condition in which the excretory ducts (at various levels) are blocked by calculus, which leads to the cessation of excretion of bile, an increase in pressure inside the gallbladder and its overstretching.
The nature of the pain is unbearably intense, rapidly growing cramping, irradiating to the right arm, shoulder, often encircling. The attack usually lasts from 15-20 minutes to 5-6 hours, the maximum severity of pain (in the absence of positive dynamics) is noted 20-30 minutes after the onset of colic. Biliary colic develops more often against the background of complete well-being, suddenly, after exposure to provoking factors: physical or psychoemotional overstrain, diet disturbances, alcohol abuse.
In the case of complications of chronic cholecystitis by pericholecystitis, pain becomes diffuse, constantly bothering the patient, increasing when the body is tilted or twisted, and abrupt movements.
Dyspepsia syndrome manifestations:
- nausea, vomiting, often mixed with bile (observed in half of patients);
- bitterness, metallic taste, dry mouth;
- yellow coating on the root of the tongue;
- belching with air, bitter or rotten;
- bloating;
- decreased appetite;
- lability of stool with a tendency to diarrhea;
- intensification of painful manifestations after exposure to provocateurs.
Vegetative dysfunction is manifested by attacks of heartbeat and hyperventilation, lability of blood pressure, emotional instability, irritability, disturbed sleep and wakefulness, general unsatisfactory health, asthenization, decreased exercise tolerance, etc.
Intoxication syndrome is observed in 30-40% of patients in the acute phase of the disease. It is expressed in hyperthermia, sometimes up to 38-39 ºС, the appearance of chills, sweating, a feeling of general weakness.
Intoxication syndrome is observed in 30-40% of patients with chronic cholecystitis
Up to half of the patients who are carriers of the diagnosis note pain in the left half of the chest, interruptions in the work of the heart, objectively in this case, atrioventricular blockade, diffuse ischemic changes in the heart muscle are recorded. These manifestations are due to the development of cholecystocardial syndrome and are provoked to a greater extent by reflex influences and the presence of autonomic disorders leading to a change in myocardial metabolism.
Icteric staining of the skin, visible mucous membranes, icterus of the sclera, darkening of urine (along with discoloration of feces) are more often observed with calculous chronic cholecystitis, especially often with obstruction of the bile ducts.
In approximately 30% of patients, chronic non-calculous cholecystitis manifests itself with atypical symptoms in the absence of characteristic complaints:
- cardialgic form - pain in the region of the heart, not stopped by taking nitrates, heart rhythm disturbances, episodes of brady- and tachycardia, reaching maximum severity after an abundant intake of food, alcohol, stress, as a rule, decreasing against the background of taking choleretic drugs;
- esophagalgic form - manifested by persistent heartburn, soreness along the esophagus, less often - difficulty in swallowing;
- intestinal form - diffuse pains are characteristic throughout the entire abdomen, combined with severe flatulence, constipation.
Diagnostics
The diagnosis is confirmed by the results of the following studies:
- general blood test (accelerated ESR, leukocytosis, neutrophilic shift of the formula to the left, eosinophilia with parasitic invasions);
- biochemical blood test (increased atherogenic lipids, bound bilirubin, alkaline phosphatase, acute phase indicators during exacerbation of the disease);
- Ultrasound of the abdominal organs (a characteristic picture of changes in the organs of the biliary zone, the presence of calculi);
- X-ray contrast study of the gallbladder and ducts (cholecysto-, cholangiography);
- if necessary, fractional (multi-stage) duodenal intubation is performed (to determine the amount, type of secretion, physicochemical characteristics of bile, the degree of emptying of the gallbladder), followed by microscopic examination and seeding of bile on a nutrient medium;
- endoscopic retrograde cholangiopancreatography (ERPCG).
Chronic cholecystitis treatment
The tactics of treating chronic cholecystitis differs depending on the phase of the process. Outside of exacerbations, the main therapeutic and prophylactic measure is diet.
A diet for chronic cholecystitis involves frequent fractional meals, refusal of fatty, fried, overly spicy or salty foods, and strong alcohol. Long breaks between meals, overeating are unacceptable. Table 5 is recommended for patients, an easily digestible food with an optimal content of protein and carbohydrates, vitamins and microelements.
During the exacerbation period, the treatment of chronic cholecystitis is similar to the treatment of the acute process:
- antibacterial, antiparasitic agents;
- drugs that normalize the motor-tonic activity of the gallbladder and ducts, eliminate pain syndrome (selective or systemic myotropic antispasmodics, prokinetics, M-anticholinergics);
- choleretic drugs (choleretics).
As an auxiliary treatment for chronic cholecystitis, dietary food is indicated
In the presence of calculi, litholysis (pharmacological or instrumental destruction of stones) is recommended. Drug dissolution of gallstones is carried out using preparations of deoxycholic and ursodeoxycholic acids, instrumental - extracorporeal methods of shock wave, laser or electrohydraulic effects.
In the presence of multiple stones, persistent recurrent course with intense biliary colic, large calculi size, inflammatory degeneration of the gallbladder and ducts, operative cholecystectomy (cavity or endoscopic) is indicated.
Possible complications and consequences
Chronic cholecystitis can have the following complications:
- pericholecystitis;
- cholangitis;
- perforation of the gallbladder; the formation of calculi with a stoneless form;
- malignancy;
- pancreatitis;
- hepatitis;
- irritable bowel syndrome.
Forecast
With timely diagnosis, complex treatment and adherence to nutritional recommendations, the prognosis is favorable.
Prevention
- Compliance with a diet, a regular diet.
- Adequate physical activity.
- Timely rehabilitation of foci of chronic infections.
- Refusal from overeating, starvation, rapid weight loss.
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Olesya Smolnyakova Therapy, clinical pharmacology and pharmacotherapy About the author
Education: higher, 2004 (GOU VPO "Kursk State Medical University"), specialty "General Medicine", qualification "Doctor". 2008-2012 - Postgraduate student of the Department of Clinical Pharmacology, KSMU, Candidate of Medical Sciences (2013, specialty "Pharmacology, Clinical Pharmacology"). 2014-2015 - professional retraining, specialty "Management in education", FSBEI HPE "KSU".
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
