What a housing complex. Symptoms of gallstone disease. Signs of gallstone disease, treatment. Surgical treatment of cholelithiasis

A fairly common disease today is called cholelithiasis.

It is not surprising that the disease has been mentioned since ancient times, starting with the Renaissance. This is a disease in which stones appear in the gallbladder or liver and bile ducts.

Often, a stone appears in the gallbladder, but it occurs much less frequently in the ducts and in the gallbladder at the same time. The disease appears when there are general metabolic disorders, as well as when bile stagnates and infections occur.

Stones often contain cholesterol, so the main factor is a deterioration in cholesterol metabolism, which causes an increase in cholesterol in the bile and blood. This factor is obvious, since gallstones, atherosclerosis, overweight, as well as for other diseases with an increased amount of cholesterol in the body.

More than 80% of the cholesterol in our bodies appears in the liver. Created by the body cholesterol is distributed into bile only in the form of micelles generated by bile acid and phospholipids. When the amount of bile acids and phospholipids decreases, lithogenic bile appears, its own characteristics deteriorate, and cholesterol crystals appear.

IN in good condition With the help of phospholipids and bile acids, cholesterol remains in the form of a dissolved substance. When the amount of these substances in the body decreases significantly, cholesterol can settle.

Often with increased weight there is an increased secretion of cholesterol. Lithogenicity of bile, that is, its tendency to form stones, appears with poor nutrition, deterioration of metabolism, as well as with the body’s original predisposition. Blood cholesterol increases during pregnancy, hypothyroidism, diabetes, and other hormonal imbalances.

Infectious factors are also relevant, since inflammation of various nature the gallbladder disrupts the chemical, colloidal composition of bile, which causes precipitation of calcium, bilirubin and cholesterol.

IN European countries the disease is detected in a third of women and a quarter of men. More often cholelithiasis concerns obese women over 60 years of age.

Classification

There is the following classification of the disease.

1. 1) First stage, called prestone or initial. Characterized by heterogeneous thick mucus; the creation of biliary sludge, when microliths or putty bile are formed: their combination.
2. 2) At the second stage stones are formed directly. They are located: in the gallbladder, in the bile or hepatic ducts. By the number of stones: single or multiple. Composition: pigment, cholesterol and mixed. According to the course: latent course, with the presence of all clinical signs, dyspeptic form, with hidden symptoms of other diseases.
3. 3) Third stage– recurrent chronic form of the disease.
4. 4) Fourth- occurrence of complications.

Timely diagnosis of the disease allows for competent prevention of stone formation. Diagnosis at the second stage makes it possible to identify precise therapy or surgery. At the third stage in mandatory in the absence of contraindications, surgery is recommended.

Where do stones come from?

The main provoking factors of cholelithiasis are the following:

• malnutrition or not proper nutrition.
• Irregular eating.
• starvation.
• food that is too fatty and poorly digestible.
• sedentary and stationary work.
• problems with the pancreas.
• state of pregnancy.
• predisposition to the disease, especially on the maternal side.
• usage hormonal drugs(contraceptives).
• constant constipation (see).
• anatomical changes in the gallbladder - adhesions, scars.

Symptoms of gallstone disease

The first symptoms of cholelithiasis that you should pay close attention to are nausea, heavy sensation, etc. In addition, the patient may be bothered by belching.

If a stone passes into the bile ducts from the gallbladder, colic may occur. Biliary colic is provoked by errors in the diet when a person eats a large number of fat or fried food. The patient will feel rapid cutting pain in the right part of the hypochondrium, the pain can move to the back, right hand or collarbone. The patient experiences vomiting, which does not bring improvement, as well as nausea and bitterness in the mouth.

If the patient has a pebble relatively small sizes, it can immediately enter the duodenum, passing through the bile ducts. In this case, the attack of biliary colic passes, the stone passes with feces.

Diagnosis of cholelithiasis

Ultrasound examination also determines the activity of the bladder. How is the research going? Study of the gallbladder is necessary on an empty stomach, as well as after the choleretic first meal. If the course of gallstone disease is complicated, ultrasound will help analyze the stages of damage to the gallbladder wall and the space around it.

In addition, X-ray methods are used to diagnose cholelithiasis, computed tomography. The last type of diagnosis is informative as an additional study. Tomography is used to assess the condition of the surrounding tissue. gallbladder and ducts.

Choledocholithiasis is best diagnosed by ERCP when transabdominal ultrasound scans have not provided a clear picture of suspected choledocholithiasis. However, since ERCP or endoscopic retrograde cholangiopancreatography most often cannot detect small stones in the gall bladder, endoscopic ultrasonography is called the most optimal and appropriate study.

Treatment of cholelithiasis

Conservative methods treatment of cholelithiasis is suitable when the patient applies for initial stage, that is, prestone. At this first stage they use: regular physical activity, normal hygiene regime, proper nutrition in small portions, improving the flow of bile with the help of medications, preventing the appearance of excess weight, eliminating bad habits.

Based on the shape of the stones and the condition of the gallstones, bile acid preparations and hepabene are used. For small stones (up to 2 mm), drugs with chenodeoxycholic acid are used. However, they are not very effective, since in more than half of patients the stones appear again. To stimulate bile acids, zixorine and phenobarbital are used for a course of one month to 7 weeks.

At the end of the course, patients undergo tests. There is a normalization of the spectrum of bile acids and bilirubin. For prevention, Lyobil is prescribed in a course of 3 weeks. Henofalk and henochol are drugs used to dissolve cholesterol stones. With treatment, the lithogenicity of bile decreases, and the stones go away in about a year.

Shock wave cholelithotripsy is a therapy that involves crushing large stones into small fragments using shock waves. Acceptable with normal contractility of the gallbladder. When stones are crushed into small pieces, they pass out on their own in the feces. The therapy is carried out under anesthesia. The method is painless and well tolerated by patients.

In some cases, the optimal treatment for gallstone disease is surgery. Indications for carrying out the operation serve:

• the presence of small and large stones that occupy more than a third of the volume in the gallbladder;
• disabled gallbladder;
• biliary pancreatitis;
• constant attacks of biliary colic;
• deterioration of gallbladder contraction function;
• presence of Mirizzi syndrome;
• cholangitis or cholecystitis;
• fistulas, perforations;
• dropsy;
• deterioration of the patency of the gallbladder.

Gallstones are removed in 2 main ways: using laparoscopic cholecystectomy and classical cholecystectomy. The first method is carried out with the introduction of abdominal area through small holes of special tools.

This operation is minimally traumatic and scars are not visible after it. Restoring your normal lifestyle with laparoscopic cholecystectomy is much faster. In comparison with the classical form of cholecystectomy, the time required for hospitalization is reduced to 5 days.

While the classic operation involves a larger and deeper abdominal incision. After the surgeons intervene, a suture remains.

Or cholelithiasis– a disease of the gallbladder, accompanied by the formation of stones in its cavity or bile ducts. It is generally asymptomatic or accompanied by a variety of clinical manifestations.

Gallstone disease is widespread throughout the world and occupies a leading place among other pathologies of the human digestive system. There is a clear differentiation of the disease by gender - women are affected 2 times more than men. Moreover, mothers with many children more often suffer from stones in the gallbladder or its ducts, which arise due to insufficient emptying of bile in the last trimesters of pregnancy. In 1/3 of multiparous women, characteristic symptoms of the disease are detected.

Classification of cholelithiasis

1) Initial (physiochemical) – pre-stone stage, characterized by changes in the composition of bile.
2) Asymptomatic stone carriers - the presence of stones in the gallbladder that do not manifest any complications or symptoms.
3) Clinical manifestations of the disease indicating the development of chronic or acute form inflammation of the gallbladder.

In some cases, the fourth stage of gallstone disease is included, accompanied by the development of associated complications.

Causes of stone formation

1. A disorder in the process of bile secretion, leading to its oversaturation with cholesterol, thickening and the formation of crystals.
2. Lack of bile outflow resulting from obstruction of the bile ducts, valves of Oddi, pancreatic and bile ducts, small intestine, which is combined with impaired intestinal motility.
3. Changes in intestinal microflora associated with excessive reproduction and accumulation of bacteria in ileum, with a subsequent increase in pressure in the duodenum.
4. Disorder of the digestion and absorption process nutrients, creating the prerequisites for the development of biliary pancreatitis.

An important factor influencing the course of gallstone disease is hereditary predisposition, elderly age, diabetes, poor nutrition, taking medications, obesity, pregnancy, inflammatory diseases intestines, physical inactivity, quick loss weight, chronic constipation etc.

Types of gallstones

homogeneous– pigment (bilirubin), cholesterol and calcareous;
mixed– the core consists of organic compound, and the shells are made of layers of bile pigment, calcium salts and cholesterol (up to 80% of all stones);
complex– the core contains cholesterol, shells of calcium, bilirubin, cholesterol (10% of cases).

Complications of gallstone disease

Acute cholecystitis;
obstructive jaundice;
choledocholithiasis;
cholangitis;
chronic pancreatitis.

Cholecystectomy, an operation to remove the gallbladder, can also be complicated by postcholecystectomy syndrome, which worsens the patient’s quality of life. Clinical manifestations of the syndrome include abdominal pain, bitterness in the mouth, diarrhea, nausea, bloating, and increased body temperature. Sometimes patients experience yellowing of the skin and sclera of the eyes.

Symptoms of gallstone disease

Diagnosis of gallstone disease

1. Medical examination of the patient to identify characteristic symptoms diseases of the gallbladder, tension and soreness of the skin in the abdominal area, presence on the skin yellow spots, general yellowness of the skin and sclera of the eyes. At the same time, the medical history is studied
2. Biochemical blood test to determine high content cholesterol, bilirubin, alkaline phosphatase, alanine or aspartic aminotransferases in her serum.
3. Carrying out general analysis blood to determine the number of ESR and leukocytes indicating the presence nonspecific inflammation in organism.
4. The use of cholecystography to detect an enlarged gallbladder and the presence of calcareous deposits on its walls.
5. Ultrasound examination of the abdominal cavity to detect stones in the gall bladder, obtain additional information about the condition of the bile ducts, liver, and pancreas.
6. Execution plain radiograph organs abdominal cavity or cholangiography: endoscopic retrograde, magnetic resonance imaging, percutaneous transhepatic or intraoperative, if there is a suspicion of the presence of stones in the bile ducts.

If ultrasound results are negative, microscopic examination of bile collected during endoscopy is used. The detection of cholesterol crystals in it indicates the presence of stones in the gallbladder or its ducts. The presence of pigment granules is not such an important factor in the diagnosis of gallstone disease.

Treatment of gallstone disease

1. Diet, balanced in the amount of vegetable fats and proteins. At the same time, patients are not recommended to consume high-calorie spicy and spicy food, containing high amounts of cholesterol and refined carbohydrates. To prevent acidity, their menu includes dairy products, and flour products and cereal dishes are limited. Following a diet reduces the likelihood of gallbladder spasms, which can cause migration of sand and small stones. If the patient has an exacerbation chronic pancreatitis, complete fasting and drinking water are prescribed, subsequently fractional and frequent meals by the hour, excluding spicy, sour, smoked and fried foods.

2. Drug therapy . If the patient has contraindications for surgery or refuses surgery, medications containing bile salts are prescribed. The tablets must be taken orally as prescribed by your doctor. The effectiveness of treatment is 80-100% if the stones are round in shape, cholesterol in nature, size no more than 10 mm and have a smooth surface. However, such therapy is not recommended if the patient has large pigment stones with a diameter of more than 20 mm, as well as frequent and severe attacks of biliary pain.

By agreement with the patient, a single dose of ursodeoxycholic acid (Ursosan) is prescribed. daily dose up to 900 mg. Side effects are quite rare and account for only 5%. The medicine is taken until the stones are completely dissolved for up to 12 months and continues to be used for 3 months to prevent relapse.

When cholelithiasis is complicated by attacks of cholecystitis and violation intestinal microflora apply antibacterial therapy. Medicines such as ciprofloxacin, cefuroxime, cefotaxime, imipenem are used in combination with antibacterial drugs: tetracycline, rifampicin, isoniazid. The use of probiotics that stimulate the growth of intestinal microflora is mandatory. To normalize digestion and absorption of nutrients, buffer antacids and enzyme preparations are prescribed.

Every ten years, the number of people suffering from gallstone disease doubles.
- 25% of women and 10% of men living in the northwestern regions of Russia have gallstones.
- 25% of women aged 40 suffer from gallstone disease.
- 50% of people over the age of 70 are diagnosed with gallstone disease.
- Gallstone disease is most often observed in children who have reached school age.

In some countries, extracorporeal therapy is used to crush stones. shock wave lithotripsy. Small fragments of stones are dissolved using litholytic therapy, in which oral administration bile acids.

Prevention of gallstone disease

Systematic exercise stress;
limiting alcohol consumption and smoking;
correct and balanced diet, including proteins, vegetable fats, green tea, ripe and sweet fruits, herbs, dried bread, boiled chicken, raw pureed vegetables.

It is necessary to eat regularly, at least 4-5 times a day, since less frequent meals contribute to the stagnation of bile, its thickening and the formation of stones. Long breaks (over 4 hours) between traditional breakfast, lunch and dinner should be supplemented by drinking tea, juice, compote or kefir. Fried foods, legumes, garlic, onions and radishes are completely excluded from the diet. It is recommended to prepare all dishes from stewed, baked or boiled foods.

Traditional methods of treating cholelithiasis

To prevent further exacerbation of the disease, rosehip is used, which helps dissolve gallstones. A warm decoction of its roots is consumed 3-4 times a day for a month. Treatment course rosehip is repeated after 1-1.5 weeks.

Extremely varied folk recipes, helping with severe pain in the area of ​​the gallbladder, and combining honey and various herbs, such as lemon balm, buckthorn, immortelle, rose hips, celandine. Strained herbal decoction drink warm with 1 teaspoon of honey. Treatment of gallstone disease folk ways should be carried out with the permission of the attending physician and only as additional therapeutic assistance.

Gallstone disease is also called cholelithiasis. The gallbladder or its ducts enter the pathological condition with this disease due to the formation of stones in them. These are rocky deposits, popularly called stones. But, of course, it is wrong to compare them with natural stones. They did not come from outside, but formed independently and were deposited inside a person for several reasons. Cholelithiasis is dangerous and carries with it serious problems health, painful sensations, complications, generates secondary pathologies. The sooner you pay attention to the symptoms and go to a doctor who diagnoses and begins treatment of the disease, the better it will be possible to avoid surgical intervention to remove stones and the consequences of their formation.

Nature has designed the human body in the wisest way. Everything in it is a single coherent system, which, if it functions normally, does not cause problems or reasons to think about your health. But when a person feels pain, this is a signal of trouble, some kind of malfunction, which the body sends to the brain so that it takes actions that can get rid of the problem.

Important! Doctors call the main and first symptom of cholelithiasis pain, namely, sudden colic, which is localized in the right side under the ribs. But this is a sign of an emergency operational situation, when the stones have moved and created a pathogenic focus. It all begins, at the stage of small formations, with bitterness in the mouth, heaviness spreading throughout the abdomen, starting on the right, and a transient feeling of nausea.

Bitterness in the mouth is one of the first signs of cholelithiasis

For what reason do stones suddenly appear in a well-functioning, normally functioning body, and why do they accumulate in the gallbladder?

The main reason is a violation of metabolic processes. The metabolism of calcium, protein, bilirubin, cholesterol, and so on is disrupted. Participants in these metabolic processes that do not dissolve in bile accumulate in it. There they, fastened to each other, turn into a monolithic compound, which over time hardens under the pressure of more and more particles arriving and clinging to it.

Important! When microscopic particles form stones, they can reach truly huge size, compared to the size of their container - the gallbladder - five centimeters.

Statistically, the formation of gallstones occurs in every seventh person, and women are twice as susceptible to this pathology as men. Their bodies contain more estrogens, which inhibit the release of bile hormones.

Estrogens are hormones that stimulate stagnation of bile in the gallbladder.

In addition to slow bile outflow, low mobility and a predominantly static lifestyle, in which everything is inhibited, can provoke the growth of stones. metabolic processes. Also constant use fatty foods creates cholesterol accumulations, greatly increasing the likelihood of stone formation.

Concretions are divided into four types, depending on the components.

On a note! While the formations are small (and they range from 0.1 mm), they lie quietly at the bottom of the gallbladder, and the owner does not even know about their existence.

If he (or she) is lucky, he will be able to feel bitterness, heaviness and nausea after eating. early stage stone formation, before they are overgrown with sediments, reach large sizes and begin to move along narrow channels, causing unbearable pain.

Signs and diagnosis

So, when a stone or several from the gallbladder decides to go out (under the pressure of bile), it is sent along the only available path - the bile duct. The mouth of the duct is narrow, and the paradox is that small stone, which could pass through it without problems, will remain at the bottom of the bubble until it grows to a certain size. Only then will its volume and weight begin to interfere with the bile contents, and it will try to “put pressure” on the calculus, expelling it out.

What happens to the duct when it gets into solid object having a volume greater than the width of the passage? Of course, the duct will become clogged.

Among themselves, doctors call this situation a “rockfall.” If it has begun, the pain may still stop and return, but it will intensify and become more frequent until it becomes incessant.

Important! If the outflow of bile is completely blocked, without providing assistance to the patient, the pancreas will soon become inflamed (it will begin pancreatitis), the gallbladder itself (the name of the pathology is cholecystitis), and also forms obstructive jaundice with all the consequences.

Diagnostic methods

Until the patient suffers from pain in the form of colic, it is quite difficult to diagnose cholelithiasis by eye. After all, nausea and heaviness in the stomach are symptoms of many diseases, even those not related to the gastrointestinal tract. Bitterness in the mouth can also be caused by more than just a single pathology. Even colic on the right does not indicate one hundred percent of cholelithiasis. How can you find out about the presence of stones? Using ultrasound.

Attention! Primary stones, which are not visible on ultrasound, at the initial stage, can only be detected when bile is taken for biochemical analysis.

Ultrasound or fluoroscopy of the abdominal cavity (if early diagnosis the last procedure - with the introduction of contrast) will give excellent result and will help detect even small stones.

And if for some reason these two types of research are not available, today there is an alternative - special study, called choledochoscopy. On it, the doctor will see the stones with his own eyes, determine their size and location with an accuracy of a tenth of a millimeter, and also inform the patient how necessary it is to operate in order to remove the stones.

Choledochoscope - a device for conducting choledochoscopy

On a note! The opinion of surgeons regarding stones is clear - remove them in any case. Most doctors of therapeutic specialization believe that it is better not to touch stones in the bile, as long as they behave calmly.

No symptoms - no treatment? It's not quite like that. It is possible and necessary to treat stones. More precisely, stones cannot be treated, but they can be crushed, dissolved, or removed in a less invasive way than surgery.

How to rid a patient of stones

Surgeons believe that getting rid of the patient’s stones conservative methods doesn't make sense. This takes a long time, is not always effective, is fraught with side effects, most importantly, stones with high probability will grow again.

That is, in principle, two ways are proposed. If stones are found, but their size is small and they do not give symptoms, it is recommended to ignore their presence, while following a diet and monitoring their size in order to notice their increase in time, health threatening patient. This situation can last for years and even decades.

The second way, if a “rockfall” has begun, is to completely remove the entire gallbladder.

Is there life without a gallbladder? Today medicine answers: “yes,” but its representatives on this issue are divided into two camps. Many people believe that a modern person does not need a gallbladder. And although it moves away, together with the stones and channels there, emergency situations, for example, at the beginning acute cholecystitis, which is about to develop into peritonitis, inflammatory the entire peritoneum, or with complete blockage and rapidly developing pancreatitis, you can live without a gallbladder.

Moreover, the patient’s life and health will remain full, subject to regular nutrition. No, you won't need it special diets and strict regimes.

Regular nutrition is the key to permanent removal of the gallbladder

On a note! Our primitive ancestors did not have refrigerators or supermarkets. They received food only when they hunted successfully, and this did not happen every day. And if they are full, accordingly, irregularly. But on the day of a successful hunt, they ate “for future use.” This is why the gallbladder was needed - to store bile in a “reservoir” until the moment when it is needed to digest food (fats and proteins).

Since today a person can easily afford not to eat “for future use,” bile can be released directly from the liver in small doses gradually, carrying out a continuous digestive process.

The second “camp” is categorically against removing the bladder without endangering the patient’s life. They believe that the gallbladder plays a vital role in the digestive process. It’s true, the organ accumulates bile and throws it in portions into the intestines and stomach to ensure the digestion process. Without a bladder, bile will flow directly, its concentration will be more liquid, food will be digested less efficiently, which will eventually lead to gastrointestinal diseases.

Treatment options

Leaving aside surgical radical ways, there are still a few options left to deal with the stones.

Table. Non-surgical methods of treating cholelithiasis.

In all cases except the first, the stones will almost certainly grow back. And the patient, exhausted from the fight against stones, will sooner or later agree to an operation to excise the gallbladder.

On a note! In case of surgery to remove the gallbladder, it is best to choose laparoscopy. With it, the anterior one is pierced abdominal wall(that is, the tissue is not cut), and through these punctures the gallbladder with all its contents is removed. There are practically no marks, healing proceeds quickly.

Prevention and complications

The development of cholelithiasis is fraught with a number of complications.

What's the best thing to do? Do not have stones, or have them, but they are small, and try to prevent them from growing to a size where they will have to be removed along with the blister. To do this, it is necessary to engage in the prevention of cholelithiasis.

Important! If you have small stones, you should not take it in any form. choleretic drugs, not only medications, but also herbal medicines. They will certainly cause migration of stones and complications. You should also not drink mineral water.

Preventive measures include:

In general, there is nothing terrible or difficult in observing the above preventive measures No. This is the norm healthy person which he must adhere to if he does not want to have not only gallstones, but also many other diseases. After all, maintaining health is not the highest price to pay in order not to one day be faced with a dilemma: to live with a gallbladder filled with stones or without it.

Video - GSD: symptoms

Gallstone disease (GSD) is a multifactorial and multistage disease characterized by impaired metabolism of cholesterol and/or bilirubin with the formation of stones in the gall bladder and/or bile ducts.

GSD is one of the most common human diseases. She ranks third after cardiovascular diseases And diabetes mellitus.

IN developed countries Cholelithiasis is detected on average in 10-15% of the adult population. In Russia, among various populations examined, the prevalence of cholelithiasis ranges from 3-12%.

In women, cholelithiasis occurs 3-4 times more often than in men. The incidence among both men and women gradually increases with age, reaching a maximum at 60 years of age. Among children, the incidence of cholelithiasis is about 5%. Depending on the chemical composition allocate

There are 3 types of gallstones - cholesterol (cholesterol content 70% or higher), black pigmented and brown pigmented. Cholesterol and black pigment stones are formed mainly in the gallbladder, and brown ones - in the bile ducts. The prevalence of these types of stones varies greatly by country. In Europe and Russia, 80-90% of patients have cholesterol stones.

Etiology

GSD is a multifactorial disease. For gallstone formation and disease progression a necessary condition is the simultaneous existence and long action 3 factors: oversaturation of bile with cholesterol, imbalance between pronucleating and antinucleating factors, decreased evacuation function of the gallbladder.

Oversaturation of bile with cholesterol. This factor is caused by its excess production or deficiency of bile acids. Hereditary predisposition also matters. The risk of gallstone formation is 2-4 times higher in individuals whose relatives suffer from cholelithiasis. An important risk factor for the development of cholelithiasis is excess body weight. Obesity is accompanied increased synthesis and excretion of cholesterol into bile. Eating foods high in cholesterol increases its level in bile. Low fiber foods slow down intestinal transit, which in turn promotes increased absorption secondary bile acids, resulting in increased lithogenic properties of bile.

Usage oral contraceptives leads to increased lithogenic properties of bile. In women using contraception, gallstones occur 2 times more often. Taking estrogen-containing drugs during menopause increases the risk of gallstone formation by 2.5 times. The lithogenic properties of bile are also affected by the intake of other drugs. Thus, clofibrate increases the excretion of cholesterol and increases the lithogenic properties of bile. Treatment with octreotide (Sandostatin) in patients with acromegaly leads to oversaturation of bile with cholesterol, a decrease motor activity gallbladder and the formation of gallstones in 13-60% of patients.

The course of a number of diseases is accompanied by cholelithiasis. With cirrhosis of the liver, gallstones are detected in 30% of patients. In PBC, bile duct stones (usually pigmented) occur in 39% of patients. It has been suggested that persons with HbsAg have increased risk formation of gallstones. Diseases of the small intestine with localization pathological process in the terminal section lead to disruption of the enterohepatic circulation of bile acids and, as a consequence, to dyscholia. Thus, in Crohn's disease with predominant localization in the terminal part of the small intestine, the frequency of stone formation reaches 26.4%. At the same time, there is no difference in the frequency of formation of gallstones between men and women, as well as the age dependence characteristic of cholelithiasis. The degree of risk of stone formation is influenced by the location and extent of resection of the small intestine for various diseases. Subtotal and total hemicolectomy also increases the risk of gallstone formation. In severe malabsorption syndrome (celiac enteropathy, small intestinal resection, Crohn's disease, etc.), all main types of metabolism change, including the absorption of bile acids, which contributes to stone formation.

Factors contributing to the precipitation of cholesterol and the formation of a crystallization nucleus. The matrix for stone formation is bile proteins, cholesterol or bilirubin crystals. One of the most significant and identified pronucleators is mucin-glycoprotein gel. It should be noted that normally mucin is constantly secreted by the mucous membrane of the gallbladder, but its secretion increases in the presence of lithogenic bile. Proteins that accelerate the precipitation of cholesterol, in addition to mucin, include N-aminopeptidase, acidic α1-glycoprotein, immunoglobulins, phospholipase C; to antinucleators - aspirin and other NSAIDs. Apolipoproteins A1 and A2 slow down the deposition of cholesterol. In this case, weight loss is accompanied by an increase in the content of mucin and calcium in the gallbladder bile and thereby contributes to the formation of gallstones.

Factors leading to disruption of the basic functions of the gallbladder (contraction, absorption, secretion, etc.). In the gallbladder, bile is concentrated due to the absorption of Na+, Cl-, HCO- by the mucous membrane. At the same time, the wall of the gallbladder is virtually impermeable to bilirubin, cholesterol and bile acids, as a result of which bile thickens and the concentration of its main components increases by 5-10 times. When the contractile function of the gallbladder is preserved, its contents are constantly emptied, including from biliary sludge (BS), which can provoke the formation of gallstones. Stagnation of bile in the gallbladder, while its concentration function is preserved, significantly increases the risk of stone formation. Emptying the gallbladder is difficult due to flatulence, pregnancy, as well as a decrease in the sensitivity and number of receptors to cholecystokinin, motilin and other stimulants of motor activity, which is noted in chronic and xanthogranulomatous cholecystitis, cholesterosis of the gallbladder. With age, the sensitivity of the gallbladder receptor apparatus to various stimulants, including cholecystokinin, decreases.

Pathogenesis of the formation of cholesterol stones

Oversaturation of bile with cholesterol is the result of a violation of complex biochemical processes, the main of which is an increase in the activity of hydroxymethylglutaryl-coenzyme A reductase (HMG-CoA reductase), leading to an increase in cholesterol synthesis, or a decrease in the activity of cholesterol 7α-hydroxylase, leading to a decrease in the synthesis of bile acids These 2 enzymes are considered key in biliary lithogenesis. Cholesterol is insoluble in aquatic environment and is excreted from the liver in the form of mixed micelles (in combination with bile acids and phospholipids), which are water-soluble. Mixed micelles are able to keep cholesterol in a stable state. When bile is oversaturated with cholesterol, all cholesterol cannot be transported in the form of mixed micelles. Its excess is transported in phospholipid vesicles, which are unstable and easily aggregate, and such bile is called lithogenic. In this case, large multilayer bubbles are formed, from which cholesterol monohydrate crystals precipitate, creating the basis for the formation various options BS. In addition to cholesterol monohydrate crystals, BS may contain calcium salts - calcium bilirubinate, calcium carbonate and phosphate, mucin-glycoprotein gel and other components. If the conditions for cholelithiasis persist, gallstones form over time. The growth rate of stones is 3-5 mm per year, and in in some cases and more.

Classification of cholelithiasis

Wide use ultrasonic method research (ultrasound) contributed to the detection of cholelithiasis at an early, pre-stone stage. However practical application Unfortunately, these achievements of clinical gastroenterology were not found. One of the reasons is the lack clinical classification, which would highlight the initial stages of the disease.

The first, most significant attempt to identify the initial stages of the disease was made in the classification of cholelithiasis, proposed back in 1974 by D. M. Small, in which 3 of the 5 stages could be designated as prestone. However, the classification, due to its complexity, was not used in the clinic and had more theoretical than practical significance.

More convenient for clinical application the classification of cholelithiasis was proposed by Kh. Kh. Mansurov in 1982. IN clinical period GSD, in which the author identified 3 stages, its initial stage is designated by the author as physicochemical. However, to identify this stage it is necessary to carry out biochemical and microscopic examination bile.

Other noteworthy classifications of cholelithiasis reflected only the features of the clinical course of the disease.

In 2002, the Congress of the Scientific Society of Gastroenterologists of Russia adopted new classification GSD, in which 4 stages of the disease are distinguished.

Stage I - initial, or pre-stone:

• thick heterogeneous bile;
• formation of biliary sludge: with the presence of microlites; with the presence of putty-like bile (PG); with a combination of putty-like bile with microliths.

Stage II - formation of gallstones:

• by localization: in the gallbladder; All in all bile duct; hepatic ducts;
• by the number of stones: single; multiple;
• composition: cholesterol; pigmented; mixed;
• By clinical course: latent flow; with the presence of clinical symptoms - painful form with typical biliary colic; dyspeptic form; under the guise of other diseases.

Stage III is the stage of chronic recurrent calculous cholecystitis.

Stage IV - stage of complication.

Identification of cholelithiasis at its initial stage - the formation of BS - provides ample opportunities for primary prevention cholelithiasis. Stage II allows you to more clearly define the indications for various types conservative therapy or surgical treatment. At stage III in the form of chronic recurrent calculous cholecystitis, the main method of treatment is surgery (in the absence of contraindications).

According to the proposed classification, the following diagnosis options can be formulated: cholelithiasis, biliary sludge (putty-like bile in the gallbladder), dysfunction of the gallbladder and sphincter of Oddi; cholelithiasis, cholecystolithiasis (single stone in the gallbladder), latent course; cholelithiasis, chronic recurrent calculous cholecystitis(multiple gall bladder stones) with attacks of biliary colic; cholelithiasis, chronic recurrent calculous cholecystitis (multiple gallbladder stones), disabled gallbladder, biliary pancreatitis.

Clinic

About 80% of patients with cholelithiasis do not complain. In some cases, the disease is accompanied by various dyspeptic disorders. The classic symptom of cholelithiasis is biliary colic. Attacks of biliary colic are usually associated with errors in diet and develop after heavy intake of fatty, fried or spicy foods.

Currently, the following characteristics of biliary colic are accepted:

• severe pain lasting from 15 minutes to 5 hours;
• localization of pain in the epigastrium, right hypochondrium, sometimes radiating to the back, under the right shoulder blade;
• the patient needs bed rest and application medicines;
• pain occurs most often in the evening or at night;
• pain recurs at various intervals.

The disease can be slow or characterized by a rapidly progressive course with various complications.

Diagnostics

To diagnose cholelithiasis, laboratory and instrumental research methods are used.

Laboratory parameters in uncomplicated cholelithiasis, as a rule, are not changed. After an attack of biliary colic, in 40% of cases an increase in the activity of serum transaminases is detected, in 23-25% - ALP, GGTP, in 45-50% an increase in the level of bilirubin. A week after the attack, the indicators usually return to normal. If the course of the disease is complicated by the development of acute cholecystitis, then leukocytosis and acceleration of ESR are noted.

Instrumental research methods play a leading role in the diagnosis of cholelithiasis. The main one is ultrasound, which makes it possible to identify the disease at the stage of formation of BS. Transabdominal ultrasound scanning (TUS) detects gallstones in 90-98% of cases and choledocholithiasis in 40-70% of cases. Using ultrasound, the size of stones, their number, location, mobility, and, to a certain extent, structure are determined. Ultrasound also allows us to judge the motor activity of the gallbladder. To do this, study the volume of the bladder on an empty stomach and after a choleretic breakfast. Ultrasonography makes it possible to assess the condition of the gallbladder wall, for example, to determine the presence or absence inflammatory process, cholesterol, intramural abscesses. In case of complicated cholelithiasis, ultrasound is used to assess the degree of destruction of the gallbladder wall and the condition of the circumvesical space.

The ultrasound criterion for diagnosing gallstones is a triad of signs: the presence of dense echo structures, an ultrasound shadow behind the stone (with soft cholesterol stones the shadow may be weak or absent), stone mobility.

X-ray methods have faded into the background, but have not lost their importance. The diagnostic value of oral cholegraphy in identifying cholelithiasis does not exceed 80-85%, and intravenous - 50-60%.

Computed tomography (CT) is used as an additional method to assess the condition of the tissues surrounding the gallbladder and bile ducts, as well as to detect calcification in gallstones when deciding on litholytic therapy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the “gold” standard in the diagnosis of choledocholithiasis in many countries. However, this method plays a rather modest role in identifying cholecystolithiasis (CL). It is important to note that ERCP can be used not only for diagnostic purposes, but also for medicinal purposes(papillosphincterotomy, extraction and crushing of stones, nasobiliary drainage for biliary hypertension, etc.). ERCP is indicated, first of all, in situations where there is a suspicion of choledocholithiasis, and other diagnostic methods, including TUS, do not allow it to be excluded.

The diagnostic value of ERCP in detecting choledocholithiasis is 79-98%. False-negative results are due to small-sized stones, as well as X-ray negative stones.

With ERCP, in some cases, complications develop, such as acute pancreatitis, acute cholecystitis, purulent cholangitis, suppuration of a pancreatic cyst, bleeding, injuries of the common bile duct, and penetration of a contrast agent into the retroduodenal tissue. ERCP does not detect small (<3 мм) камни в общем желчном протоке, поэтому, по мнению отдельных авторов, в настоящее время не может считаться «золотым» стандартом диагностики холедохолитиаза . В связи с этим все большее значение в выявлении камней в желчных протоках приобретает эндоскопическая ультрасонография.

Endoscopic ultrasonography (EUS)

In obese patients with severe flatulence, TUS in most cases does not allow sufficiently good visualization of the gallbladder and especially the bile ducts and exclude cholecysto- or choledocholithiasis. At the same time, ERCP cannot always be performed due to technical difficulties in its implementation, organic changes in the sphincter of Oddi, surgical interventions in the gastroduodenal area, increased sensitivity to contrast agents, etc.

In these situations, EUS is indicated. Ultrasound scanning of the gallbladder and bile ducts is performed using an echoendoscope from the stomach or duodenum. Of the existing methods for detecting stones in the bile ducts, EUS is the most accurate.

Complications

Acute cholecystitis. Among the total number of patients with acute cholecystitis, the vast majority (up to 90%) are patients with cholelithiasis. The development of acute cholecystitis is promoted by mechanical damage to the mucous membrane from stones, as well as disruption of the outflow of bile (partial or complete obstruction of the cystic duct with mucus, small stones, putty-like bile).

Chronic cholecystitis may arise as an outcome of acute cholecystitis or develop gradually, in the form of a primary chronic form. Laboratory parameters are usually within normal limits. On ultrasound, the gallbladder is deformed, reduced in size, the walls are compacted and unevenly thickened. In the lumen of the bladder there are clots of heterogeneous bile with an admixture of bile.

Hydrocele of the gallbladder develops when the cystic duct is obstructed by a stone or a clot of gastric fluid and is accompanied by the accumulation of transparent contents mixed with mucus in the cavity of the bladder. Diagnosis is made using ultrasound, sometimes supplemented by CT. The addition of infection threatens the development of empyema of the gallbladder.

Empyema of the gallbladder develops against the background of a disabled gallbladder as a result of infection. Clinical symptoms correspond to the picture of an intra-abdominal abscess. On palpation of the abdomen, the gallbladder is enlarged, tense, sharply painful, positive symptoms of peritoneal irritation. Treatment is surgical, in combination with antibiotic therapy.

Cellulitis of the gallbladder wall and abscess in the area of ​​the gallbladder bed can be the outcome of acute cholecystitis, or form as a result of a bedsore from a large stone, followed by the addition of an inflammatory process. Diagnosis is based on clinical data, laboratory and instrumental studies (ultrasound, CT). Often accompanied by the formation of various fistulas. Treatment is surgical, in combination with antibiotic therapy.

Gallbladder perforation occurs with transmural necrosis of the gallbladder wall. It most often occurs as a result of a bedsore that develops from the pressure of a large stone on the wall of the gallbladder. Less commonly, as a result of rupture of the Rakitansky-Aschoff sinuses. A breakthrough of the contents of the gallbladder into the free abdominal cavity is observed relatively rarely, since the adhesive process around the bladder and the surrounding organs limit its spread. A breakthrough into the hollow organs adjacent to the bladder leads to the formation of internal fistulas. With CT and ultrasound, in addition to gallstones, it is possible to additionally identify abscesses and effusion in the abdominal cavity. The prognosis is poor, with a mortality rate of approximately 30%.

Biliary pancreatitis. Both mild forms of pancreatitis and severe ones, up to pancreatic necrosis, can develop. Treatment primarily consists of eliminating the cause of biliary pancreatitis.

Mirizzi syndrome. Wedging of a stone into the neck of the gallbladder with the subsequent development of the inflammatory process can lead to compression of the common bile duct (Mirizzi syndrome type I). Subsequently, a cholecystocholedochal fistula (Mirizzi syndrome type II) may form. Currently, there are 4 types of this syndrome. Treatment is surgical.

Biliary fistulas. With necrosis of the bladder wall, internal bile fistulas are formed. Diagnosing them is difficult, since the clinical picture is masked by the symptoms of the underlying disease. Most internal fistulas are discovered incidentally during cholangiography or surgery.

Intestinal obstruction, caused by a gallstone, is rare, usually occurs in patients over 70 years of age and is accompanied by high mortality. Occurs after perforation of the gallbladder and entry into the intestine of a gallstone of at least 2.5 cm in diameter. Intestinal obstruction occurs in the most narrowed areas of the intestine, usually 30-50 cm proximal to the ileocecal valve. Treatment is surgical.

Gallbladder cancer. Gallstones and a wrinkled gallbladder, as a rule, do not lead to the development of gallbladder cancer; the incidence of its occurrence in patients with cholelithiasis usually does not exceed 3-5%. However, 90% of cases of gallbladder cancer are accompanied by cholecystolithiasis.

Treatment

Conservative methods. Conservative therapy is indicated at the pre-stone stage of the disease; in some patients it can be used at the stage of formed gallstones.

Treatment at the pre-stone stage. The appearance of clinical symptoms in BS, the development of complications and the formation of gallstones in some patients are the basis for adequate therapy and dynamic monitoring of such patients.

Depending on the form of BS and the state of the contractile function of the gallbladder, bile acid preparations or hepabene are used.

Ursodeoxycholic acid (UDCA) drugs for BS are prescribed in a standard daily dose of 10 mg/kg body weight once, at night. The course of treatment depends on the form of BS. For BS in the form of a suspension of hyperechoic particles (HHP), a month's course of treatment is usually sufficient. With other forms, the course of treatment is longer, but, as a rule, does not exceed 3 months.

In patients with a low cholate-cholesterol ratio, it is advisable to add chenodeoxycholic acid (CDCA) preparations to UDCA treatment, replacing 1/3 of the daily dose with them. This is due to the different mechanisms of action of bile acids, so their combined use is more effective than monotherapy with each drug separately. According to our data, after a 3-month course of ursotherapy in patients with BS in the form of HHV, the effectiveness was 60%; clots of echoheterogeneous bile (HBC) - 85.7%; putty-like bile - 87.5%.

Gepabene is prescribed 1 capsule 3 times a day; for severe pain, add 1 capsule at night. The course of treatment is 1-3 months. The drug contains extract of fumaria officinalis, which has a choleretic and antispasmodic effect, and milk thistle fruit extract, which improves hepatocyte function.

According to our data, the effectiveness of hepabene for BS in the form of HHV was maximum and amounted to 100%; with BS in the form of SEF - 70%; in patients with BS in the form of gastrointestinal tract, therapy did not have a noticeable effect.

Treatment at the stage of formed gallstones. According to our information, about 30% of patients with cholecystolithiasis can be subjected to litholytic therapy (LT). For treatment, CDCA and/or UDCA drugs are used.

RT is prescribed in cases where patients are contraindicated for other types of treatment, as well as in the absence of the patient’s consent to surgery.

The effectiveness of RT depends on the correct selection of patients. Successful treatment is more often with early detection of cholelithiasis and much less often with a long history of the disease due to calcification of stones. Single stones dissolve worse than multiple ones (the latter have a more optimal ratio of the surface of the stones to the volume of the gallbladder). If the contractile function of the gallbladder is preserved, the prognosis for the success of therapy is much more optimistic.

The patient selection criteria are based on ultrasound and oral cholecystography data. One of the main conditions determining the effectiveness of RT is determining the composition of gallstones. Stones with a high cholesterol content dissolve best. According to ultrasound, these are stones with a homogeneous and low-echoic structure, a soft acoustic shadow behind (or without); according to cholecystography - “floating” stones. To clarify the composition of stones, it is advisable to conduct a CT scan. Stones with a weakening coefficient below 70-100 Hounsfield units are more likely to dissolve. A prerequisite for RT is the absence of obstruction of the bile ducts.

Numerous studies have shown that large stones require long-term (at least 2 years) therapy with a fairly low effectiveness. Currently, it is not recommended to carry out treatment for stone diameters greater than 10 mm.

Contraindications to RT are pigment stones, cholesterol stones with a high content of calcium salts, stones more than 10 mm in diameter, stones whose total volume is more than 1/4-1/3 of the volume of the gallbladder, as well as reduced contractile function of the gallbladder (ejection fraction< 30%). ЛТ не показана больным с частыми коликами. Однако в ряде случаев, согласно нашим данным, на фоне терапии частота их заметно снижалась или они исчезали вовсе.

Severe obesity is considered a relative contraindication. For successful therapy, such patients need to increase the daily dose of bile acids. Ursotherapy is not a contraindication for the treatment of cholelithiasis in pregnant women.

The results of RT depend on the careful selection of patients, the duration of therapy and vary widely: from 0 to 80-90% and even 100%.

Stone recurrence after successful oral radiotherapy is approximately 10% per year for 5 years, most often in the first 2 years, then its frequency decreases. To prevent recurrence of stones, it is necessary to continue therapy for another 3 months. It is advisable to reduce body weight, avoid taking drugs that increase cholesterol synthesis, and long periods of fasting.

Extracorporeal shock wave lithotripsy (ESWL)

The method is based on the generation of a shock wave. Within 30 ns, a pressure 1000 times higher than atmospheric pressure is reached at the focus. Due to the fact that soft tissues absorb little energy, most of it falls on the stone, resulting in its destruction. The method is currently used as a preparatory step for subsequent oral litholytic therapy.

Indications for ESWL:

• single cholesterol stones with a diameter of no more than 3 cm;
• multiple stones (no more than 3) with a diameter of 1-1.5 cm;
• functioning gallbladder;
• no obstruction of the bile ducts.

Contraindications to ESWL:

• presence of coagulopathy or anticoagulant therapy;
• the presence of cavity formation along the shock wave.

We found that approximately 20% of patients with cholelithiasis meet the criteria necessary to undergo ESWL.

With proper selection of patients for ESWL, stone fragmentation can be achieved in 90-95% of cases. Lithotripsy is considered successful if it is possible to achieve fragmentation of stones with a diameter of less than 5 mm. After ESWL, bile acid preparations are prescribed in the same doses as for oral RT. Side effects with ESWL are relatively rare. The most significant are biliary colic, in some cases mild signs of cholecystitis, hyperaminotransferasemia.

Stone recurrence is less after ESWL than after oral RT. This circumstance is due to the fact that patients with ESWL are selected mainly with single stones, in whom relapses are observed less frequently, compared to patients with multiple stones.

Contact dissolution of gallstones

In contact litholysis, a solvent is injected directly into the gallbladder or bile ducts. The method is an alternative for patients with high surgical risk and has become increasingly widespread abroad in recent years. In Russia, there are isolated reports of successful dissolution of gallstones using contact litholysis. Only cholesterol stones are dissolved, and the size and number of stones are not of fundamental importance. Methyl tert-butyl (ether) (MTBE) is used to dissolve stones in the gall bladder, and propionate (ether) in the bile ducts. Dissolution occurs in 4-16 hours.

A multicenter study conducted in 21 medical centers in Europe, which included 803 patients, showed the high effectiveness of contact litholysis. The puncture was successful in 761 patients (94.8%), and the stones were dissolved in 95.1% of cases. In 43.1% of patients, after lysis of stones, stones remained in the bladder. The method can be successfully used to dissolve fragments remaining after ESWL.

Surgery

Surgical treatment for cholecystolithiasis consists of removing the gallbladder along with stones or only stones from the bladder. In this regard, the following types of operations are distinguished:

• traditional (standard, open) cholecystectomy from the upper middle or right oblique laparotomy approach;
• laparoscopic (videolaparoscopic) cholecystectomy;
• cholecystolithotomy.

Options for surgical interventions for cholelithiasis are described in sufficient detail in the specialized literature. Based on our own experience, we offer a list of the following main indications for surgical treatment:

• HL with the presence of large and small gallbladder stones, occupying more than 1/3 of the gallbladder volume;
• HL, regardless of the size of the stones, occurs with frequent attacks of biliary colic;
• CL, disabled gallbladder;
• HL complicated by cholecystitis and/or cholangitis;
• HL in combination with choledocholithiasis;
• HL complicated by the development of Mirizzi syndrome;
• HL complicated by dropsy, empyema of the gallbladder;
• HL complicated by penetration, perforation, fistulas;
• HL, accompanied by a decrease in the contractile function of the gallbladder (ejection fraction after a choleretic breakfast less than 30%);
• HL complicated by biliary pancreatitis;
• HL in combination with obstruction of the common bile duct.

For questions regarding literature, please contact the editor.

A. A. Ilchenko, Doctor of Medical Sciences
Research Institute of Gastroenterology, Moscow

An attack of cholelithiasis is a condition caused by a violation of the outflow of bile due to blockage of the gallbladder and/or bile ducts by stones. found in every 5th woman and every 10th man. Up to 60% of people with gallstones do not experience any unpleasant symptoms, but their likelihood of having an attack of the disease increases by 2-3% each year. What is the danger of exacerbation of cholelithiasis and what are the principles of first aid? To answer this, you should first become familiar with the causes of the pathology.

Bile is a mixture of bile acids, pigments, phospholipids and cholesterol. The action of a negative factor provokes the precipitation of solid sediment, which gradually turns into calculi (stones). This can be observed against the background of metabolic disorders, inflammatory diseases of the biliary system. In the first case, the concentration of bile acids and cholesterol in bile increases. In the second, its physicochemical properties change. Depending on the predominant component, cholesterol and pigment stones are distinguished. In rare cases, calcifications (stones with large amounts of calcium) occur.

There are several factors that increase the risk of cholelithiasis. Namely:

• Errors in the diet. Predominance of animal fats, long-term total parenteral nutrition (bypassing the gastrointestinal tract). The likelihood of developing cholelithiasis increases by 30% with fasting and rapid weight loss.
• Diseases of the biliary system. Most often chronic cholecystitis. With liver cirrhosis, the risk of stone formation increases 10 times.
• Endocrine pathologies. Stone formation is common in individuals with uncorrected hypothyroidism. Patients with diabetes mellitus suffer from cholelithiasis 3 times more often than those who do not have this endocrine disease.
• Obesity, elevated triglycerides. 2 out of 10 people with metabolic syndrome (a complex of changes associated with metabolic disorders) develop symptoms of an attack of cholelithiasis over time.
• Taking a drug that affects the composition of bile and motility of the biliary tract. For example, ceftriaxone.
• Female gender, age. Women suffer from cholelithiasis 2 times more often than men. With age, the difference in incidence levels out. The main category of patients is people over 40 years old.
• Pregnancy. Stones form in 5–12% of pregnancy cases, but often they disappear spontaneously after childbirth. The risk is greater in 2 and subsequent pregnancies.
• Taking estrogen regardless of gender. With hormone replacement therapy in postmenopause, the risk of cholelithiasis increases by 3.7 times.
• Burdened heredity. People who have blood relatives with cholelithiasis are 4-5 times more susceptible to the disease.

Pathogenesis of cholelithiasis attack

A gallbladder attack is caused by blockage of its neck/or excretory ducts by migrating stones. But the pathogenesis is not limited to this. Symptoms may be based on several processes at once. Types of manifestations of cholelithiasis and mechanisms of their occurrence:

• (biliary pain). The most common variant of disease manifestation (75% of cases). It is based on the wedging of a stone into the neck of the gallbladder, the entry of the stone into the bile ducts (cystic and common), followed by their reflex spasm. Because of this, bile cannot enter the duodenum, leading to increased pressure in the biliary tract.
• . Occurs in 10% of episodes of clinically significant cholelithiasis. Usually occurs as a complication of blockage of the neck of the gallbladder or cystic duct. Provocateurs are bacterial infection (50-85% of cases) and lysolecithin, a bile derivative that is chemically aggressive to previously damaged areas of the biliary tract.
• Cholangitis. Inflammation of the bile ducts. The provoking factors are the same as above.
• Acute biliary pancreatitis. Inflammation of the pancreas. Associated with the reflux of bile into the pancreatic duct, lymphogenous spread of infection from the biliary system.

Causes causing an attack

Migration of stones can be caused by increased production of bile, spasm of the gallbladder and excretory ducts. Provoking factors:

Symptoms

Most often, an attack of calculous cholecystitis begins with biliary colic. If it is associated with food intake, it occurs 1-1.5 hours after eating. Colic often occurs at night, a few hours after falling asleep. Symptoms of an attack of gallstone disease:

• Pain syndrome. Sharp, pronounced. Localized in the right hypochondrium with distribution to the epigastrium (projection area of ​​the stomach). It can radiate under the right shoulder blade, between the shoulder blades, thoracic spine, neck, right shoulder. The pain increases in waves, then becomes constant, bursting. Lasts from several minutes to several hours. May lead to painful shock.
• Dyspeptic syndrome. Possible nausea and vomiting. Emptying the stomach does not bring relief. Due to a reflex slowdown of intestinal motility, the abdomen is slightly distended.
• Autonomic disorders. Sweating, increased or slow heart rate, changes in blood pressure (usually decreased).
• Hyperthermia. Body temperature usually does not exceed 38°C.

Typical biliary colic is so severe that the patient tosses and turns in bed. He is constantly looking for a comfortable position in which the discomfort will decrease. Breathing becomes shallow as every movement of the chest increases the pain. Colic usually disappears on its own (if a small stone was able to pass into the duodenum) or after taking antispasmodics.

If colic has not disappeared after 6 hours, the development of acute cholecystitis is first suspected. The pain is similar to biliary pain. Hyperthermia from 38°C may indirectly indicate inflammation of the gallbladder, cholangitis, or pancreatitis. The condition may worsen to high fever (from 39°C) with chills. At later stages, jaundice occurs.

Important! Progressive deterioration of the condition, a hard “board-shaped” abdomen may indicate a rupture of the gallbladder with the development of peritonitis - inflammation of the peritoneum. This condition is life-threatening and requires immediate surgical intervention.

Diagnostics

The primary determination of the cause of colic is based on the study of complaints and examination data. In emergency situations, this is enough for a medical specialist to urgently relieve an attack of gallstone disease and prevent pain shock. Laboratory and instrumental research methods help to definitively confirm the diagnosis. The main ones:

• Ultrasound of the abdominal organs. It is possible to visualize stones and change the contractility of the gallbladder.
• Clinical blood test. Signs of bacterial inflammation are often observed: acceleration of ESR, increase in the number of leukocytes.
• Blood chemistry. Signs of bile stagnation. The level of bilirubin increases due to the direct fraction, the activity of alkaline phosphatase, ALT, and AST increases.

If necessary, ERCP (endoscopic retrograde cholangiopancreatography) is performed. This is x-ray visualization of the bile and pancreatic ducts using endoscopic injection of contrast agents. More often, such a study is combined with therapeutic manipulations, for example, dissection of the mouth of the duodenal papilla. ERCP is performed outside of exacerbation of cholelithiasis, so an attack of the disease is a direct contraindication to the procedure.

The abdominal form of myocardial infarction can simulate an attack of biliary colic. To avoid diagnostic errors, it is better to immediately contact a medical specialist.

What should you do if you have an attack of gallstone disease?

Typical biliary colic (not to be confused with mild dyspepsia due to dietary errors) is an absolute indication for calling an ambulance. The condition may require emergency surgery. The main task is to prevent complications until the team of specialists arrives. First aid for an attack of gallbladder colic:

• Provide bed rest;
• Stop the supply of food;
• Give an antispasmodic, avoiding exceeding the dosage (mebeverine, drotaverine, papaverine);
• Cover with a blanket if you have a chill;
• Constantly monitor the patient, as he may lose consciousness from pain.

Attention! Despite recommendations in some sources, you cannot warm up the right hypochondrium on your own and take a hot bath. An attack of colic may mask other diseases in which such procedures are dangerous. In case of cholelithiasis, it is forbidden to give choleretic drugs.

How can you relieve an attack of gallstone disease yourself? If this is typical biliary pain, then it is better to follow the above measures and wait for the doctor.

Prevention

Measures to prevent biliary colic are based on correction of diet and lifestyle. Namely:

• Dieting. Frequent split meals 4-5 times a day in small portions. Exclusion of fatty, fried, spicy foods, marinades. The restrictions include foods that stimulate bile production: garlic, coffee, egg yolks, carbonated drinks. The diet should be observed especially strictly after an attack of gallstone disease. You should not eat for 12 hours after colic.
• Balanced physical activity. Avoid physical inactivity and heavy lifting.
• Eliminate sources of stress. This also includes compliance with the work and rest regime.

Conclusion

Colic due to cholelithiasis is a condition that requires specialist intervention. Even if it was managed to stop on its own, it can recur at any time and lead to life-threatening complications. If gallstones are an asymptomatic ultrasound finding, a scheduled visit to a gastroenterologist and surgeon is mandatory. Otherwise, sooner or later they will cause an attack of cholelithiasis.