Calculous cholecystitis is a disease of the gallbladder, which is characterized by serious inflammatory processes. Compared to other abdominal diseases, this disease is very common.

Today, about 20% of the population is affected by this disease, and these figures are rapidly increasing. This is due to the fact that many people eat foods high in fat - butter, lard, fatty meat, eggs, and also adhere to a sedentary lifestyle. In addition, many people have endocrine disruption due to diabetes or obesity. Most often, women suffer from cholecystitis - this is due to the use of oral contraception and pregnancy.

Main reasons

Calculous cholecystitis has a main cause - infectious diseases. The human intestine contains microorganisms that help improve the digestion process, but they can sometimes pose considerable danger.

There are certain factors that provoke an increase in microorganisms, which subsequently cause the organ to malfunction:

Calculous cholecystitis has a fairly extensive etiology. The development of the disease is also observed against the background of autoimmune diseases and allergic reactions.

Many people suffer from chronic cholecystitis due to prolapse of organs located in the abdominal cavity, or as a result of a congenital disorder of the gallbladder structure. Very often, this disease develops against the background of pancreatitis, as a result of a failure in secretion production.

Symptoms

According to the clinical course, calculous cholecystitis can be chronic and acute, and in the first case, remission is replaced by exacerbation. The period of exacerbation quite often resembles the clinical manifestation of acute inflammation of the organ.

The primary symptoms suggestive of cholecystitis are:

• Vomiting and nausea.
• Heartburn.
• There is a bitterness in the mouth.
• Feeling of pain in the right hypochondrium.
• Belching.

The most striking manifestation is hepatic colic, which has the following clinical signs of chronic calculous cholecystitis:

An objective examination may reveal certain symptoms indicating the presence of this disease. All of them consist in the fact that during palpation a sharp pain occurs.

At the remission stage, calculous cholecystitis in most cases is asymptomatic. Remission due to errors in diet is replaced by exacerbation.

Diagnostics

If this disease is suspected, the diagnostic search consists of additional research methods:

• Ultrasonic.
• X-ray.
• Biochemical blood test to determine the total level of protein, its fractions, as well as cholesterol and triglycerides.
• Fibrogastroduodenoscopy and others.

Complications

In case of delayed diagnosis or late treatment, calculous cholecystitis can result in the following complications:

• Dropsy.
• Purulent inflammation (empyema).
• Acute inflammatory process in the biliary tract, acute cholangitis.
• Perforation of the bile wall with further development of peritonitis.
• Malabsorption in the intestine with all the ensuing consequences.
• Malignant oncological processes.
• Repeated inflammation of the pancreas.
• Narrowing (stenosis) of the papilla of Vater (major duodenal papilla).
• Obstructive jaundice, which develops when the function of the outflow of bile is impaired (blockage of the gallbladder, its outflows or the large duodenal nipple).
• Stone formation (choledocholithiasis).

Differential diagnosis of chronic calculous cholecystitis

Cholecystitis is distinguished from renal colic, inflammation of the pancreas, appendicitis, perforated ulcer of the duodenum and stomach.

Compared to acute cholecystitis, renal colic causes acute pain in the lumbar region. The pain radiates to the thigh and genital area. Along with this, there is a violation of urination. With renal colic, leukocytosis is not recorded and the temperature does not rise. A urine test indicates the presence of salts and formed blood components.

If the appendix is ​​located high, acute appendicitis can provoke acute calculous cholecystitis (the diet is described below). The difference between acute appendicitis and cholecystitis is that in the latter case the pain radiates to the shoulder and right shoulder blade, and there is also vomiting with bile. With appendicitis, there are no Mussi-Georgievsky symptoms.

In addition, acute appendicitis is much more severe, and peritonitis develops actively. The differential diagnosis of chronic calculous cholecystitis in this case is simplified by the presence in the medical history of information that the patient has stones in the gall bladder.

In some cases, a perforated ulcer of the duodenum and stomach is disguised as acute cholecystitis. However, unlike ulcers in acute cholecystitis, the medical history, as a rule, contains indications of the presence of stones in the organ.

Acute cholecystitis is characterized by painful sensations radiating to other parts of the body, as well as vomiting containing bile. Initially, the feeling of pain is localized in the hypochondrium on the right, gradually increasing, and fever begins.

Hidden perforated ulcers manifest themselves acutely. In the first hours of the illness, the muscles of the anterior abdominal wall are very tense. Very often, patients complain of pain in the right ilium, due to the fact that the contents of the stomach leak into the cavity. With cholecystitis, liver dullness is observed.

In acute pancreatitis, intoxication increases, intestinal paresis and rapid heartbeat are observed - this is precisely its main difference from cholecystitis. In the case of inflammation of the pancreas, the pain is often accompanied by severe vomiting. It is quite difficult to distinguish acute gangrenous calculous cholecystitis from acute pancreatitis, so diagnosis is carried out in an inpatient setting.

Diet

Cholecystitis is a rather serious disease. Proper nutrition with such a diagnosis contributes to a quick recovery. In this case, therapeutic nutrition should be aimed at reducing acidity and secretion of bile.

Smoked and fried foods are excluded from the diet. It is necessary to include fresh vegetables and fruits, vegetable oil, and cereals in the menu.

What should you not eat if calculous cholecystitis is diagnosed? The menu must be compiled taking into account certain requirements:

• You should avoid fried and fatty foods.
• You need to eat often, and the portions should be small.
• Reduce consumption of sweet and flour products.
• Avoid hot and cold food.
• Give preference to baked, boiled and stewed foods.
• Minimize strong tea and coffee.
• Eat no more than three eggs per week, and it is advisable to exclude the yolk.
• Consume more plant and dairy foods, as fiber improves motor skills and normalizes stool, and milk normalizes the acid-base balance.
• Stick to your diet and eat at the same time every day.

With a disease such as calculous cholecystitis, the diet after surgery should be the same as for the chronic form of the disease.

Nutrition

Proper nutrition for this disease can provide a long period of remission. You should remove foods from your diet that contribute to the formation of stones and burden the liver.

It is necessary to include in the menu foods containing fiber, milk proteins, vegetable oil, and consume large amounts of liquid. Reduce the amount of foods high in fat and cholesterol.

List of approved products

To prevent a possible attack of calculous cholecystitis, it is advisable to familiarize yourself with the list of permitted products:

• Dairy products.
• Vegetable and cereal soups, greens (except for rhubarb, sorrel and spinach), vegetables, cereals, boiled meat and fish.
• Cheese, cod liver, soaked herring.
• Wheat and rye bread baked yesterday, unsweetened cookies.
• Sunflower, olive and butter (small amount).

Calculous cholecystitis: how to treat?

The classic treatment for this disease is pain relief and hospitalization. In the case of a chronic form, treatment can be carried out on an outpatient basis. Bed rest, sulfonamide drugs or antibiotics, as well as fractional dietary meals are prescribed. When the inflammation subsides, physiotherapeutic procedures are allowed.

Treatment (exacerbation of calculous cholecystitis) is carried out as follows:

1. Based on prescribed tests, the doctor determines the stage and form of the disease.
2. A diagnosis is made.
3. If an acute inflammatory process is detected, the patient is prescribed anti-inflammatory drugs (No-spa, Papaverine hydrochloride) and antibiotics that have a wide spectrum of action.
4. After the inflammation has been relieved and the source of infection has been suppressed, choleretic drugs are prescribed to speed up the emptying of the gallbladder and weaken the inflammatory process.

If stones are found in the ducts of the gallbladder or in the organ itself, and the inflammatory process is pronounced, then surgery is prescribed. Depending on the location of the stones and their size, either the deposits or the gallbladder as a whole are removed. Failure of conservative treatment or diagnosis of gangrenous calculous cholecystitis are absolute indicators for this purpose.

Traditional medicine

When the acute process subsides, it is allowed to use alternative treatment. To restore organ function, decoctions and infusions (from corn silk, immortelle, etc.) are used, which have an antimicrobial and astringent effect.

• It is useful for the patient to include mineral waters (Essentuki No. 4 and No. 17, Slavyanskaya, Naftusya, Mirgorodskaya) and choleretic teas in the diet. Of the plant-based medications, it is allowed to use “Allohol” and “Holagol”.
• For chronic cholecystitis, tubeless tubes should be used 2-3 times a week. Drink warm water or decoction (1 glass) on an empty stomach. After 30 minutes, you need to drink Allohol, and then again a decoction of herbs. Next, you need to lie on your left side, while placing a heating pad on your right. It is recommended to stay in this position for 1.5-2 hours.

Therapy for a disease such as calculous cholecystitis (treatment and diet should be carried out only under the supervision of specialists) involves the use of traditional medicine. In the chronic form, such treatment significantly alleviates the condition, and most importantly, leads to positive results.

In general, treatment with traditional medicine can be divided into two main areas:

1. Through choleretic herbs.
2. Homeopathic medicines that involve influencing stones that have a certain chemical composition with a similar composition. For example, if phosphate or oxolinic acid was detected in a urine test, then the same acids are prescribed during the treatment process. For cholecystitis without stones, drugs are used that activate the immune system.

Decoction recipes

1. Oregano herb (a teaspoon) should be brewed with boiling water (a glass), and then left for two hours. In case of disease of the biliary tract, you need to drink 1/4 cup 3 times throughout the day.
2. Medicinal sage leaves (2 tsp) are brewed with boiling water (2 cups), then infused and filtered for half an hour. For inflammatory processes in the liver or gall bladder, you need to drink 1 tbsp. spoon every two hours.
3. Veronica brook (a teaspoon) is brewed with boiling water (a glass), and then infused for half an hour. You need to drink 3 times a day, 1/4 cup.
4. Corn silks (a tablespoon) are brewed with boiling water (a glass), and then infused for 60 minutes and filtered. You should drink 1 tbsp every 3 hours. spoon.
5. Agrimony herb (10 g) is brewed with water (3 cups) and boiled for 10 minutes. You should drink a glass of the decoction before meals three times a day.
6. Wheatgrass rhizomes (20 g) are brewed with boiling water (1.5 cups) and infused for several hours, and then filtered. For cholecystitis, take one glass 3 times a day. The course is 1 month.
7. St. John's wort herb (a tablespoon) is brewed with boiling water (a glass), boiled for 15 minutes, and then filtered. You need to drink 3 times a day, 1/4 cup. This decoction is characterized by choleretic and anti-inflammatory effects.
8. A hop seed (2 tbsp) is brewed with boiling water (1.5 cups), wrapped and infused for 3 hours. For cholecystitis, drink the decoction half an hour before meals, 1/2 cup 3-4 times a day.
9. Thoroughly grind chamomile, immortelle, trefoil, dill seed and joster flowers taken in equal quantities. Mix everything and pour the resulting mixture (3 tsp) with boiling water (2 cups). Next, the contents of the glass are infused for 20 minutes and filtered. Take 1/2 or 1/4 cup daily after meals in the morning and evening before bed.
10. Finely chop 3 parts of sandy immortelle flowers, 2 parts each of fennel fruit, wormwood herb, yarrow herb or mint leaf and dill. Pour the resulting mixture (2 tsp) with boiling water (2 cups). Leave for 8-12 hours and strain. Drink 1/3 cup before meals 3-4 times a day.
11. Chamomile flowers (a tablespoon) are brewed with boiling water (a glass). For cholecystitis, use warm for enemas. Do enemas 2-3 times throughout the week.
12. Ivy budra (a teaspoon) is brewed with boiling water (a glass) and infused for about 60 minutes, then filtered. You need to drink 3 times a day, 1/3 cup (before meals).
13. Peppermint (a tablespoon) is brewed with boiling water (a glass) and left for half an hour. Drink in small sips throughout the day (at least three times).

In most cases, people suffer from chronic cholecystitis for many years. Its course and frequency of exacerbations are directly related to a person’s desire to overcome this disease by all possible methods and means. If you are sick, try to adhere to a healthy and correct lifestyle (physical activity, balanced nutrition, proper rest and work schedule). Also, do not forget about drug treatment, while during periods of remission it is advisable to additionally use traditional medicine.

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Moscow State Medical and Dental University

Department of Faculty Surgery No. 2

Head Department: Doctor of Medical Sciences, Prof. Khatkov I. E.

Teacher: ass. Zhdanov Alexander Vladimirovich

Medical history

Head Department

Doctor of Medicine, Prof. Khatkov I. E.

Teacher

Ass. Zhdanov Alexander Vladimirovich

Moscow 2010

PASSPORT DETAILS

Last name, first name, patronymic of the patient

Age: 62 years

Marital status: married

Education: secondary specialized

Profession, position, place of work: pensioner

Place of residence

Time of admission to the clinic: November 21, 2010

COMPLAINTS UPON ADMISSION

Complaints of sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, vomiting twice - not bringing relief, dry mouth, weakness, low-grade fever.

History of present illness ANAMNESIS MORBI

He considers himself sick since 1990, when he first experienced an attack of acute pain in the right hypochondrium. A diagnosis of acute cholecystitis was made. To date, the patient has been hospitalized 4 times due to exacerbation of the disease. In 2005, based on ultrasound results, a diagnosis of cholelithiasis was made. Treated conservatively. A few days after the onset of the attack, under the influence of treatment, the pain subsided.

The onset of this attack is acute. On November 20, 2010, the patient felt a sharp, intense pain in the right hypochondrium, radiating to the lumbar region, which appeared several hours after eating a fatty meal. Vomiting did not bring relief. I independently tried to relieve the pain by taking no-shpa - without effect. 16 hours after the onset of the attack, the patient was hospitalized by emergency medical care at City Clinical Hospital No. 68.

Life history (Anamnesis vitae)

Brief biographical information: born in 1947, in Moscow, in a family of employees, the first child. He grew and developed, keeping up with his peers.

Education: secondary specialized.

Family and sexual history: Married since 1969, two children.

Work history: Started working at the age of 20 as an adjuster at a factory.

Working conditions: daily work, 8 hours a day, with a lunch break, indoors.

Occupational hazards: not noted.

Household history: Lives in a panel house in a two-room apartment with an area of ​​47 m2, with his wife. Has a separate bathroom, centralized water supply; I have not been in environmental disaster zones.

Meals: regular, 3 times a day, varied, medium calorie. There are addictions to salty, fatty foods.

Bad habits: does not smoke, does not abuse alcohol, does not take drugs, is not a substance abuser.

Past diseases: arterial hypertension since 2002.

As a child, he suffered from acute respiratory viral infections, acute respiratory infections, and chickenpox.

Surgeries undergone: tonsillectomy 1971, appendectomy 1976.

Denies sexually transmitted diseases and jaundice. No blood or blood substitutes were transfused.

Allergic history: not burdened. Denies drug intolerance and food allergies.

Insurance history: I have not taken sick leave for this disease in the last calendar year.

Heredity: mother died at 82 years old (suffered from cholelithiasis). My father died at 47 from cancer.

The patient's current condition (Status praesens)

General condition of the patient: satisfactory

State of consciousness: clear

Patient position: active

Body type: regular

Constitution: hypersthenic

Posture: correct

Gait: fast

Height - 167 cm

Weight - 95 kg

Body temperature: 36.7 C

Facial examination:

The facial expression is calm, there is no pathological mask; the shape of the nose is correct; nasolabial folds are symmetrical.

Examination of eyes and eyelids:

No swelling, dark coloration, or ptosis were noted; exophthalmos and enophthalmos were not detected.

Conjunctivae pale pink; sclera white; the shape of the pupils is correct, symmetrical, the reaction to light is preserved; There were no pulsations of the pupils or rings around the pupil.

Head and neck examination:

Musset's sign was not detected; the size and shape of the head are correct; curvature and deformation of the neck in the anterior section associated with an enlarged thyroid gland, no lymph nodes were detected; pulsation of the carotid arteries is moderate; pulsations and swelling of the jugular veins and Stokes collar were not detected.

Skin:

The skin is flesh-colored, skin moisture is moderate, skin turgor and elasticity are preserved, no pathological elements have been identified.

Skin appendages:

Male-type hair growth corresponds to gender and age; The hair is brown, not brittle, not dry, thinning and premature loss have not been detected. The shape of the nails is correct, pink in color, longitudinal striations are detected, but there is no transverse striation; Quincke's pulse was not detected; the symptom of drumsticks and watch glasses is absent.

Visible mucous membranes:

The conjunctiva is pale pink in color, moderate humidity, the vascular pattern is not pronounced, no pathological elements have been identified.

The nasal mucosa is pale pink in color and has moderate moisture.

The oral mucosa is pale pink, moist, the vascular pattern is moderate, no pathological elements have been identified.

Subcutaneous fat:

Overdeveloped, the places of greatest fat deposition are on the abdomen. The thickness of the skin fold on the abdomen near the navel is 4.5 cm, on the back at the angle of the scapula 3.5 cm. No edema was detected.

Lymph nodes:

The occipital, parotid, submandibular, anterior cervical, posterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal areas are not palpable.

Muscular system:

The muscles are developed satisfactorily; muscle tone is preserved. Muscle strength is preserved and symmetrical throughout the entire limb. No pain or hardness was noted on palpation.

Skeletal system:

Upon examination, the bones were of regular shape, and no pain was noted upon palpation or tapping of the skeletal bones. The symptom of “drumsticks” was not identified.

The joints are of regular shape and painless on palpation. The color of the skin and the local temperature of the skin over the joints corresponds to the color of the skin and the temperature of the surrounding tissues; active and passive movements in the joints are performed in full, painlessly.

Examination of hands and feet:

The hands are of regular shape, pale pink, no edema was detected, muscle atrophy was not detected, “clubs” syndrome, Bouchard’s nodes, Heberden’s nodes, tophi, and “liver palms” symptom were not detected.

The feet are of regular shape, pale pink in color, no edema was detected, and no tophi were detected.

RESPIRATORY ORGAN STUDY INSPECTION

Chest shape:

The shape of the chest is hypersthenic: the supra- and subclavian fossae are weakly expressed, the intercostal spaces are smoothed, the epigastric angle is obtuse, the shoulder blades and clavicles are moderately protruding; Respiratory excursions are symmetrical on both sides.

Spinal curvature: none

Chest circumference at the level of the IV rib: 101 cm, on inspiration - 104 cm, on exhalation - 100 cm.

Chest excursion: 4 cm.

Breathing: Breathe freely through the nose.

Breathing type - abdominal. Respiratory movements are symmetrical; the abdominal muscles are involved in the act of breathing. The number of respiratory movements per minute is 19. Breathing is shallow, rhythmic.

PALPATION

Determination of painful areas:

No painful areas were found on palpation of the chest.

Definition of resistance:

The chest is resistant.

PERCUSSION

Comparative percussion: A clear pulmonary sound is detected over the entire surface of the lungs during percussion.

Topographic percussion.

Standing height of the apex of the lung:
	4 cm above the collarbone	4 cm above the collarbone
		At the level of the spinous process of the VII vertebra
Width of Kroenig margins
Lower border of the lungs:
along the parasternal line
along the midclavicular line
along the anterior axillary line
along the midaxillary line
along the posterior axillary line
along the scapular line
along the paravertebral line
Respiratory excursion of the lower edge of the lungs 5 ​​cm 5 cm
along the midaxillary line

AUSCULTATION OF THE LUNG

Basic breath sounds:

Vesicular breathing is heard over the entire surface of the lungs, except for the interscapular space from the VII cervical to IV thoracic vertebrae - in this area, bronchial breathing is heard.

Adverse breath sounds:

No adverse breath sounds were detected.

Bronchophony:

Bronchophony over symmetrical areas of the chest is not changed over the entire surface of the lungs.

RESEARCH OF THE CARDIOVASCULAR SYSTEM

Examination of the heart area:

Protrusions of the heart region, apical impulse, cardiac impulse, pulsation in the second intercostal space near the sternum, pulsation of the arteries and veins of the neck, pathological pericardial pulsation, epigastric pulsation, dilatation of veins in the epigastric region were not detected.

PALPATION OF THE HEART

The apical impulse is localized 1.5 cm outward from the left midclavicular line along the 5th intercostal space, area 1.5 cm, strength, height and resistance are moderate. The heartbeat and tremors in the heart area are not detected by palpation.

PERCUSSION OF THE HEART

Limits of relative dullness of the heart:

Right: IV intercostal space, 1 cm outward from the right edge of the sternum

Left: V intercostal space 1.5 cm medially from the left midclavicular line

Upper: along the upper border of the third rib along the left edge of the sternum.

The diameter of the relative dullness of the heart is 11 cm.

Width of the vascular bundle 5 cm

The heart configuration is normal.

Limits of absolute dullness of the heart:

Right - along the left edge of the sternum

Left - 2 cm medially from the left border of the relative dullness of the heart

Upper - at the level of the IV rib.

AUSCULTATION OF THE HEART

Heart sounds are rhythmic, muffled. Heart rate 80 per minute.

Auscultation of the heart at the 1st point:

Auscultation of the heart at the 2nd point:

A melody of two tones is heard: tone 1 and tone 2. 1 tone follows after a long pause. The tonal ratio is correct: tone 2 is louder than tone 1, but not more than 2 times. No splitting or bifurcation of the 2nd tone was detected. The accent of the 2nd tone over the aorta was not detected.

Auscultation of the heart at the 3rd point:

A melody of two tones is heard: tone 1 and tone 2. 1 tone follows after a long pause. The tonal ratio is correct: tone 2 is louder than tone 1, but not more than 2 times. No splitting or bifurcation of the 2nd tone was detected. No accent of the 2nd tone over the pulmonary artery was detected.

Auscultation of the heart at the 4th point:

A melody of two tones is heard: tone 1 and tone 2. 1 tone follows after a long pause and coincides with the pulsation of the carotid artery. The ratio of tones is correct: 1 tone is louder than 2, but no more than 2 times. No bifurcation or splitting of 1 tone was detected.

Auscultation of the heart at the 5th point (Botkin-Erb point): A melody of 2 tones is heard: 1 and 2 tones. Tone 1 and 2 are approximately equal in volume to each other.

No additional tones or noises were detected.

No pericardial friction rub was detected.

VASCULAR STUDY

Examination of the arteries: pulsations of the carotid arteries and capillary Quincke's pulse were not detected during examination. Palpation of the carotid, temporal, radial, brachial, ulnar, femoral, popliteal arteries and arteries of the dorsum of the foot revealed no local dilations, narrowings, tortuosity, or compactions; pulsation is moderate; the arterial wall is elastic and smooth.

When listening to the carotid and femoral arteries, the double Traube sound and the double Vinogradov-Durozier murmur were not detected.

Arterial pulse on the radial arteries: synchronous on both radial arteries, rhythmic, tense (hard), moderate filling, large size, regular shape, uniform, frequency 68 beats per minute. No pulse deficiency was detected.

Blood pressure (BP): systolic 135 mmHg, diastolic 80 mmHg.

Vein research. Upon examination, swelling and pulsation of the neck veins were not detected, a visible pattern of the veins of the chest and abdominal wall was not detected, and varicose veins of the lower extremities were not detected.

On palpation, swelling and pulsation of the jugular veins were not detected. No “spinning top noise” was detected on the jugular veins. No thickening or tenderness of the veins was detected.

STUDY OF DIGESTIVE ORGANS

Gastrointestinal tract

INSPECTION

At the time of examination, complaints of heaviness in the right hypochondrium.

Oral cavity:

The tongue is pink, moderately moist, covered with a gray coating, the papillary layer is normal. There are no cracks or ulcers. The gums, soft and hard palate are pink; no hemorrhages or ulcerations were found.

Belly:

The abdomen is symmetrical, regular in shape, and participates in the act of breathing. There is no visible peristalsis of the stomach and intestines. Venous collaterals and striae are absent. The navel is retracted. There are no hernial protrusions.

Abdominal circumference at the navel level is 113 cm.

PERCUSSION

A tympanic percussion sound is heard over the entire surface of the abdomen. Free or encysted fluid in the abdominal cavity is not detected. The fluctuation symptom is negative.

PALPATION

Superficial palpation: The abdomen is soft, slight tenderness in the right hypochondrium. The abdominal wall muscles are not tense. There is no discrepancy of the rectus abdominis muscles. Superficially located tumor formations, inflammatory infiltrate, umbilical hernia and hernia of the white line were not detected. The Shchetkin-Blumberg symptom was not detected.

Methodical deep sliding palpation (according to Obraztsov-Strazhesko):

The sigmoid colon is palpated as a painless cylinder, 2 cm in diameter, moderately mobile, and does not rumble.

The cecum is palpated as a painless cylinder, 2 cm in diameter, moderately mobile, and rumbling.

The ascending colon is palpated as a painless cylinder, 3 cm in diameter, moderately mobile, and does not rumble.

The descending colon is palpated as a painless cylinder, 3 cm in diameter, moderately mobile, does not rumble.

The greater curvature of the stomach is palpated as a soft, painless ridge.

The pyloric part of the stomach is not palpable.

AUSCULTATION

Bowel sounds are heard. In the projection of the abdominal aorta and renal arteries, sounds and noises are not heard. There is no peritoneal friction noise.

surgical calculous cholecystitis

STUDY OF THE LIVER AND GALL BLADDER

Inspection:

There is no protrusion in the area of ​​the right hypochondrium and epigastric region, there is no breathing restriction in this area.

Liver percussion:

Upper limit of absolute stupidity:

along the right midclavicular line - 6th rib.

along the anterior midline - 6th rib.

Lower limit of absolute dullness:

along the right midclavicular line - 1 cm below the edge of the costal arch.

along the anterior midline - on the border between the upper and middle third of a line drawn from the xiphoid process to the navel.

along the left costal arch - at the level of the 8th rib.

Liver dimensions according to Kurlov:

along the right midclavicular line - 9 cm.

along the anterior midline - 7 cm.

along the left costal arch - 6 cm.

Palpation:

The edge of the liver is smooth, painful. The gallbladder is not palpable. Ortner's and Murphy's symptoms are positive, Mussy's symptom (phrenicus symptom) is negative.

Auscultation:

Friction noise There is no peritoneum in the area of ​​the right hypochondrium.

STUDY OF THE SPLEN

Inspection:

There is no protrusion in the left hypochondrium. There are no breathing restrictions in this area.

Percussion:

Length - 7 cm

Diameter - 5 cm

Palpation:

The spleen is not palpable.

Auscultation:

No friction noise was detected in the left hypochondrium.

Pancreas examination

Palpation:

The pancreas is not palpable.

URINARY SYSTEM

Dysuric disorders:

There is no difficulty urinating, involuntary urination, false urge to urinate, cutting, burning, pain during urination, frequent urination, or night urination.

Lumbar region:

There is no protrusion in the lumbar region. The halves of the lumbar region are symmetrical.

Percussion:

The effleurage symptom is negative on both sides.

Palpation:

The kidneys are not palpable.

Bladder:

The bladder is not palpable.

NEUROPSYCHIC SPHERE

Consciousness is clear, it makes contact easily, the mood is calm, speech is unchanged. Sensitivity is preserved, vision, hearing, and smell are normal. The motor sphere is unchanged.

RECTAL EXAMINATION

The sphincter tone is preserved, the ampoule is empty, the walls are painless, no organic pathologies were detected at the height of the finger, brown feces are found on the glove.

PRELIMINARY DIAGNOSIS

Based on complaints, examination, and medical history, the patient was diagnosed with acute calculous cholecystitis.

SURVEY PLAN

1) General blood test

2) General urine test

3) Blood test: determine blood group, Rh factor. serological tests: RW, HIV, HbsAg

4) Biochemical blood test for:

- total protein and its fractions

- bilirubin and its fractions

- cholesterol

- urea

- creatinine

- AST, ALT

- blood glucose

5) Ultrasound of the abdominal organs

6) X-ray of the chest and abdominal organs

7) ECG

8) EGDS

9) Intravenous cholangiography

10) Fibrocholedochoscopy

11) Endoscopic retrograde cholangiopancreatography

12) Hepatocholescintigraphy

DATA OF LABORATORY AND INSTRUMENTAL RESEARCH METHODS

General blood test:

Hemoglobin - 138 g/l

Red blood cells - 5.28*1012/l

Leukocytes - 7.8 *109/l

Platelets - 248*109/l

General urine test:

Color - straw yellow

Transparency - transparency

Relative density - 1010

Reaction: sour

Leukocytes - 1-0-2 in the field of view

Red blood cells - 1-0-2 in the field of view

Biochemical blood test:

Ultrasound of the abdominal organs:

Gallbladder size 10*4 cm, wall 0.5 cm, contents: calculus 1.5 cm.

Common bile duct 0.5 cm

The pancreas has clear, uneven contours, medium size, homogeneous structure, increased echogenicity.

The liver is not enlarged and has a homogeneous structure.

The spleen measures 4*4 cm and has a homogeneous structure.

The kidneys are located symmetrically, with clear, even contours, of medium size, the renal sinuses are not dilated, normal echogenicity, parenchyma thickness is 1.8 cm, the structure is homogeneous

Conclusion: acute calculous cholecystitis

The electrical axis of the heart is in a semi-horizontal position. The rhythm is sinus, regular. No pathological changes were detected.

X-ray of the abdominal organs:

There were no signs of intestinal obstruction or disruption of the integrity of a hollow abdominal organ.

RATIONALE FOR THE DIAGNOSIS

The diagnosis of acute calculous cholecystitis was made on the basis of:

The patient complains of sharp intense pain in the right hypochondrium with irradiation to the lumbar region, nausea, vomiting twice - which does not bring relief, weakness, low-grade fever.

Anamnesis data. Addiction to fatty and salty foods. The pain appeared after eating fatty foods. It was not controlled by taking No-shpa.

In 1990, a diagnosis of acute cholecystitis was made, and in 2005, a diagnosis of acute calculous cholecystitis was made.

The patient's mother suffered from cholelithiasis.

Objective examination data: presence of pain in the right hypochondrium; wet, gray-coated tongue; positive symptoms of Ortner, Murphy.

Data from additional instrumental studies. Ultrasound: gallbladder size 10*4 cm, wall 0.5 cm, contents: stone 1.5 cm.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis of acute calculous cholecystitis must be carried out with acute pancreatitis, peptic ulcer, acute appendicitis and an attack of renal colic.

1) With acute appendicitis:

Appendicitis most often affects young people. Cholecystitis affects older people and more often women. An attack of cholecystitis is caused by errors in diet, consumption of fatty, rich foods. Appendicitis begins for no apparent reason. However, the irradiation of pain in cholecystitis and appendicitis is of a different nature. With cholecystitis, irradiation to the lumbar region. Pain at the point of the gallbladder can exclude appendicitis.

Acute appendicitis is characterized by: it begins with acute pain in the epigastric region - for a short time, after 2-4 hours the pain moves to the right iliac region (Kocher-Wolkovich symptom), combined with tension in the abdominal wall. The symptoms of Rovzing, Sitkovsky, Voskresensky, Bartomier-Mikhelson are positive. These signs were not detected in this patient.

2) With acute pancreatitis:

Between acute pancreatitis and cholecystitis there are a number of common symptoms: sudden onset of the disease, acute pain, repeated vomiting that does not bring relief. But unlike acute pancreatitis, where pain radiates under the left scapula, epigastric region, into the left hypochondrium, in acute cholecystitis the pain is localized in the right hypochondrium and does not have a girdling character. Body temperature is subfebrile. In this patient, ultrasound did not reveal any changes in the pancreas; Ortner-Grekov, Murphy symptoms are positive; the Kerte, Voskresensky, and Mayo-Robson symptoms specific to acute pancreatitis are negative. Thus, the diagnosis of acute pancreatitis can be excluded.

3) with peptic ulcer:

Pain in the epigastric region, of varying intensity, associated with eating, relieved by taking antacids. Pain with cholecystitis does not have the same pattern as with a peptic ulcer, and vomiting and bleeding are common symptoms of an ulcer. Pain and vomiting occur at the height of a painful attack and are characteristic of an ulcer. Diseases of the gallbladder lead to an increase in temperature, and peptic ulcer disease occurs with a normal temperature. When an ulcer occurs, dyspeptic disorders appear - constipation, diarrhea, as well as the presence of an ulcer history and chronic course.

4) with renal colic

Stones in the right kidney cause attacks of pain - renal colic. Low back pain, paroxysmal, extremely intense, is relieved by the use of antispasmodics. The pain radiates down to the thigh, pubis, and testicle. With cholecystitis, pain radiates upward: to the shoulder, shoulder blade, neck. The behavior of patients with cholecystitis and renal colic is different. Patients with renal colic are usually restless and try to change their position, which is not typical for cholecystitis. Urine testing is of great importance. With renal colic, we often find blood in the urine. Possible dysuria. History of urolithiasis.

Treatment

Urgent hospitalization of a patient with suspected acute cholecystitis in a surgical hospital is mandatory.

In acute calculous cholecystitis, conservative treatment makes sense. If complications occur, surgical treatment is indicated.

Bed rest, an ice pack is placed locally on the area of ​​the right hypochondrium.

Nutrition - food restriction (hunger), only alkaline drinks are allowed. When the process subsides, table No. 5.

Pain relief:

1) Non-narcotic analgesics:

Rp: Sol. Analgini 50% - 2 ml

Sol. Dimedroli 1% - 1ml

S. i.m.

2) If the pain does not subside, narcotic analgesics are used:

Rp: Sol. Morphini hydrochloridi 1% - 1 ml

Sol. Natrii chloridi 0.9% - 20 ml

M.D.S. Every 10-15 minutes until a positive effect is obtained, 4-10 ml of the resulting solution is administered.

3) Antispasmodics:

Rp: Sol. Papaverini Hydrochloridi 2% - 2 ml

S. IM, 3 times a day

Relief of the inflammatory process (antibacterial therapy):

Rp: Sol. Ampicillini 0.5

S. IM, 4 times a day

Rp: Sol. Imipenemi

S. intramuscularly, 500 mg every 12 hours. Use together with cilastatin.

Detoxification therapy:

Rp: Sol. Glukozi 5%-200 ml

Sol. KCl-3%-30 ml

S. i.v.

Rp: Sol. Natrii Chloridi 0.9% - 400 ml

Sol. Euphyllini 2.4% - 10 ml

S. IV, drip

After the acute attack subsides, the patient must be operated on as planned in 2-3 weeks. If, against the background of treatment of acute cholecystitis, the patient’s condition does not improve within 48-72 hours, abdominal pain persists or intensifies, protective tension of the muscles of the anterior abdominal wall persists or increases, the pulse quickens, remains at a high level or body temperature rises, leukocytosis increases , urgent surgical intervention is indicated.

Surgical treatment of calculous cholecystitis

Early laparoscopic cholecystectomy is the mainstay of treatment.

Surgery is usually performed immediately after the symptoms of the disease have subsided. With this operation, mortality and complication rates are lower than with planned surgery performed after 6-8 weeks of conservative treatment.

Patients with acute cholecystitis complicated by peritonitis, gangrenous cholecystitis, and perforation of the gallbladder wall are subject to emergency cholecystectomy.

Percutaneous cholecystostomy in combination with antibacterial therapy is the method of choice in the treatment of seriously ill and elderly patients with complications of acute cholecystitis.

Contraindications to laparoscopic cholecystectomy are:

* High risk of poor tolerance to general anesthesia.

* Obesity, which interferes with the normal functioning of the body.

* Signs of gallbladder perforation (abscess, peritonitis, fistula formation).

* Giant gallstones or suspected malignancy.

* Severe liver damage with portal hypertension and severe coagulopathy.

In these cases, abdominal surgery is recommended - cholecystectomy.

It involves removing the gallbladder to prevent recurrence of gallstone disease.

The standard operation is performed through four very small punctures, located on the anterior abdominal wall.

Positive aspects of cholecystectomy:

Due to a more uniform flow of bile into the intestine after surgery and an increase in the rate of enterohepatic circulation of bile acids, the lithogenicity of bile decreases;

Removal of the gallbladder - a place where bile can crystallize;

A functionally defective organ is removed, which can become a source of serious complications;

The source of infection is removed.

The advantage of laparoscopic surgery is the immeasurably lower surgical trauma compared to a standard wide incision. This not only made it possible to activate patients earlier and reduce their length of stay in the hospital. It is much more important to reduce the number of general complications caused by major surgery (pneumonia, thromboembolism, heart failure), which in turn improves the results of treatment of elderly and debilitated patients.

An important role is also played by the fact that postoperative hernias are immeasurably less common after laparoscopic surgery.

It is advisable to perform cholecystectomy using the laparoscopic method; the advantages of this method are:

Low trauma;

The diameter of the stones is more than 2 cm;

Reducing the length of stay of the patient in the hospital;

Significant reduction in the need for narcotic analgesics in the postoperative period;

Reduced mortality in a group of elderly patients with severe concomitant diseases.

Performing cholecystectomy from a minilaparotomy access, 4-5 cm long. This technology arose in parallel with laparoscopy and consists in performing the operation with modified instruments using a specially designed wound retractor system. In terms of the amount of surgical trauma caused, cholecystectomy from a minilaparotomy approach is slightly inferior to laparoscopy, but is cheaper and allows for more extensive surgery while maintaining the cosmetic effect.

Diary: (from 11/24/2010 Time: 11.30)

Complaints of aching, low intensity pain in the right hypochondrium, without irradiation, weakness. Nausea, no vomiting. The condition is satisfactory, consciousness is clear, the patient is adequate. The skin and visible mucous membranes are of normal color and moisture. The sclera is of normal color. In the lungs, breathing is vesicular, carried out in all parts, there is no wheezing. NPV 19 per minute. Heart sounds are muffled, the pulse on the radial arteries is the same, frequency 80 per 1, rhythmic, satisfactory filling and tension. Blood pressure 130/80 mmHg. The tongue is moderately moist, with a gray coating. The abdomen is of normal shape, not swollen, and participates in the act of breathing. On palpation it is soft, moderately painful in the right hypochondrium. Shchetkin-Blumberg's symptoms are negative, Ortner's, Murphy's are positive. On percussion there are no dullnesses in the sloping areas of the abdomen. During auscultation, active bowel sounds are heard. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination is spontaneous and painless. Diuresis is adequate. Urine is straw-yellow, transparent. Physiological functions are normal.

Diary: (from 11/25/2010 Time: 12.00)

Complaints of minor pain in the right hypochondrium, without irradiation. Nausea, no vomiting. The condition is satisfactory, consciousness is clear, the patient is adequate. The skin and visible mucous membranes are of normal color and moisture. The sclera is of normal color. In the lungs, breathing is vesicular, carried out in all parts, there is no wheezing. NPV 18 per minute. Heart sounds are muffled, the pulse on the radial arteries is the same, frequency 78 in 1, rhythmic, satisfactory filling and tension. Blood pressure 140/70 mmHg. The tongue is moderately moist and clean. The abdomen is of normal shape, not swollen, and participates in the act of breathing. On palpation it is soft, moderately painful in the right hypochondrium. Shchetkin-Blumberg, Ortner, Murphy symptoms are negative. On percussion there are no dullnesses in the sloping areas of the abdomen. During auscultation, active bowel sounds are heard. The liver is not enlarged. The gallbladder is not palpable. The spleen is not enlarged. Urination is spontaneous and painless. Diuresis is adequate. Urine is straw-yellow, transparent. Physiological functions are normal.

Epicrisis

Patient Viktor Georgievich Latyshev, 62 years old, was admitted to the surgical department on November 21, 2010 with complaints of sharp intense pain in the right hypochondrium radiating to the lumbar region, nausea, double vomiting - which did not bring relief, dry mouth, weakness, low-grade fever. The real deterioration occurred within 17 hours. From the anamnesis it was established that these symptoms appeared after eating fatty foods. He independently tried to stop the pain attack with No-shpoy, but to no avail.

Upon examination at the time of admission, the general condition was of moderate severity, consciousness was clear, position was active, temperature was 37.8 °C; rhythmic breathing, frequency 20 per minute, on auscultation - vesicular breathing, no adverse respiratory sounds; heart sounds are muffled, rhythmic, blood pressure is 130/85 mmHg, rhythmic pulse is 80 beats/min; the tongue is moist, covered with a gray coating, the abdomen is not swollen, soft, painful in the right hypochondrium, Ortner-Grekov and Murphy symptoms are positive.

Ultrasound of the abdominal organs and kidneys - chronic calculous cholecystitis.

Based on the data obtained, a diagnosis was made - acute calculous cholecystitis. Conservative therapy was started, with pronounced positive dynamics (pain decreased, temperature subsided, according to ultrasound data - a decrease in the thickness of the gallbladder wall).

When the pain completely stops, a planned radical operation is indicated - cholecystectomy.

Forecast:

For life - favorable, with preservation of working capacity. Relapses of the disease are possible if the gallbladder is preserved.

Prevention of acute cholecystitis consists of following a balanced diet, exercising, preventing lipid metabolism disorders, and eliminating foci of infection.

References

1) M.I. Kuzin, O.S. Shkrob, M.A. Chistova “Surgical diseases” M., 1986

2) A.A. Rodionov “Educational and methodological manual on surgical diseases for 4th year students” M., 1990.

3) O.E. Bobrov, S.I. Khmelnitsky, N.A. Mendel “Essays on the surgery of acute cholecystitis” Kirovograd, POLIUM, 2008

4) N.I. Gromnatsky “Diseases of the digestive organs” LLC “Medical Information Agency” 2010

Posted on Allbest.ru

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Differential diagnosis of cholelithiasis must be carried out with acute appendicitis, peptic ulcer of the stomach and duodenum, biliary dyskinesia, pancreatitis.

1. Acute appendicitis.

In acute appendicitis, the pain is sudden, constant, dull, more often occurs in the evening and night hours, of moderate intensity, localized at the onset of the disease in the epigastric region (Kocher's symptom), less often in the umbilical region (Kümmel's symptom) or throughout the abdomen. Subsequently, within 2 to 12 hours, it moves to the right iliac region (Volkovich's symptom). Characterized by the absence of irradiation of pain (except for the pelvic, retrocecal and subhepatic location of the appendix), wave-like nausea and, at least twice, vomiting after the onset of pain, stool retention, and increased heart rate. Positive symptoms of Rovzing, Razdolsky, Sitkovsky, Voskresensky, Obraztsov, Krymov. The patient has intermittent, cutting pain, localized in the right hypochondrium and radiating to the lower back. Symptoms of acute appendicitis are negative, which allows us to exclude this pathology.

2. Peptic ulcer of the duodenum.

Pain in duodenal ulcers is diurnal and rhythmic (hunger pain, night pain); during an exacerbation, long-term pain lasting 3-4 weeks is typical. This patient is characterized by pain associated with eating fatty, “heavy” foods and is of short duration. The pain is localized in the right hypochondrium. The secretory function of the stomach, as a rule, remains normal, and with duodenal ulcer a hyperacid state is usually observed. Bleeding due to duodenal ulcer usually has characteristic manifestations: vomiting in the form of “coffee grounds”, melena, blanching of the skin, but in this patient these manifestations are not observed. There is no vomiting or bleeding. Based on the above phenomena and instrumental studies, the diagnosis of duodenal ulcer is excluded.

3. Peptic ulcer.

With a gastric ulcer, pain occurs immediately after eating or 15-45 minutes after eating. Evacuation of gastric contents can bring relief in this condition. This patient is characterized by pain associated with eating fatty, “heavy” foods, physical activity, and psycho-emotional stress. The localization of pain in peptic ulcers is usually between the xiphoid process and the navel, most often to the left of the midline, irradiating to the left half of the chest, to the interscapular region. In this patient, pain is localized in the right hypochondrium. The pain is located at a characteristic point - the point of projection of the gallbladder; Ortner's symptom is also positive. Consequently, this patient does not have characteristic signs of gastric ulcer, which is confirmed by esophagogastroduodenoscopy data.

4. Biliary dyskinesia.

Biliary dyskinesias combine a variety of functional disorders of the biliary system, in which signs of organic lesions (inflammation or stone formation) are not clinically established. The development of dyskinesia is based on disturbances in the complex innervation of the biliary sphincters. Clinically, biliary dyskinesias are characterized by periodically occurring biliary colic, which can be significant and simulate cholelithiasis. Painful attacks often occur in connection with strong emotions and other neuropsychic issues; less often they appear under the influence of significant physical exertion. With biliary dyskinesias, the connection between the occurrence of pain syndrome and negative emotions, the absence of tension in the abdominal wall during biliary colic, the negative results of duodenal intubation and, mainly, the data of contrast cholecystography, which does not reveal stones, stands out more clearly.

5. Pancreatitis.

Pancreatitis is inflammation of the pancreas. Pancreatitis is characterized by attacks of pain, which may be preceded by dyspeptic symptoms. Pain can have different localization depending on which part of the organ is involved in the pathological process. When the head of the gland is affected, they are localized in the epigastric region or in the right hypochondrium, when the body of the gland is affected in the epigastric region, and when there is diffuse damage - throughout the entire upper half of the abdomen. The pain usually radiates posteriorly to the lumbar region and scapula. An external examination may reveal jaundice. Differential diagnosis is facilitated by the peculiar localization of pain in the left part of the epigastric region, to the left of the navel, with irradiation to the back, to the left side of the spine, which is characteristic of diseases of the pancreas and is usually not observed in gallstone disease. The high content of diastase in the urine in acute pancreatitis is also important.

Etiology and pathogenesis.

Gallstone disease is considered as a polyetiological disease. The question of the cause of stone formation is currently not fully understood.

Most authors list the following as the main causes of stone formation:

Violation of the physico-chemical composition of bile.

With cholelithiasis, a change in the normal composition of bile occurs - cholesterol, lecithin, bile salts. Micellar structures consisting of bile acids and lecithin promote the dissolution of cholesterol in bile, which is part of the micelles. In micellar structures there is always a certain limit to the solubility of cholesterol. When the amount of cholesterol in bile exceeds the limits of its solubility, the bile becomes supersaturated with cholesterol, and cholesterol precipitates. The lithogenicity of bile is characterized by a lithogenicity index, which is determined by the ratio of the amount of cholesterol (IL) found in the bile under study to the amount of cholesterol that can be dissolved at a given ratio of bile acids, lecithin, cholesterol. A value equal to one indicates the normal saturation of bile, above one - its oversaturation, below one - its unsaturation. Bile becomes lithogenic with the following changes in ratio:

• - increased cholesterol concentration (hypercholesterolemia);
• - decrease in the concentration of phospholipids;
• - decrease in the concentration of bile acids.

It has been established that the body of patients with significant obesity produces bile that is oversaturated with cholesterol. The secretion of bile acids and phospholipids in obese patients is greater than in healthy individuals with normal body weight, but their concentration is insufficient to keep cholesterol in a dissolved state. The amount of secreted cholesterol is directly proportional to body weight and its excess, while the amount of bile acids largely depends on the state of the enterohepatic circulation and does not depend on body weight. The consequence of this imbalance is a glut of bile in obese people.

J. Deaver (1930) described the principle of five Fs, by which one can suspect patients with gallstones: female (woman), fat (full), forty (40 years and older), fertile (pregnant), fair (blonde). As can be seen from the above, this principle is not without pathogenetic foundations.

The reasons leading to a decrease in the flow of bile acids into bile can be divided into the following groups:

• - primary disruption (reduction) of bile acid synthesis and disruption of feedback mechanisms regulating the synthesis of bile acids: liver dysfunction, poisoning with hepatotropic poisons, taking hormonal contraceptives, chronic hepatitis, various forms of liver cirrhosis, pregnancy, increased levels of estrogen hormones;
• - disruption of the enterohepatic circulation of bile acids (significant losses of bile acids occur during resection of the distal small intestine, diseases of the small intestine); another mechanism for switching off bile acids from circulation - their deposition in the gallbladder - is observed with atony of the gallbladder and prolonged fasting.

Stagnation of bile.

The mere presence of a gallbladder (“bile sump”) in the biliary system is a predisposing factor to bile stagnation. In addition to this, in case of cholelithiasis, it is often possible (65 - 80%) to detect dysfunction of the gallbladder. Violation of the coordinated work of the sphincters causes dyskinesia of various types. There are hypertonic and hypotonic (atonic) dyskinesias of the bile ducts and gallbladder. With hypertensive forms of dyskinesia, an increase in sphincter tone occurs. Thus, spasm of the common part of the sphincter of Oddi (Westphal fibers) causes hypertension in the ducts and gallbladder. The increase in pressure is associated with the entry of bile and pancreatic juice into the ducts and gallbladder, while the latter can cause the picture of enzymatic cholecystitis. A spasm of the cystic duct sphincter is possible, which also causes congestion in the bladder. In hypotonic (atonic) forms of dyskinesia, the sphincter of Oddi relaxes, followed by reflux of duodenal contents into the bile ducts (infection of the ducts occurs). At the same time, against the background of atony and poor emptying of the gallbladder, congestion and an inflammatory process develop in it. In both hypertensive and hypotonic forms of dyskinesia, there is a disruption in the evacuation of bile from the gallbladder and ducts, which is a favorable factor for stone formation in the biliary system.

Biliary tract infections.

The initiating factor in the formation of gallstones, in addition to increasing the lithogenicity of bile, is the inflammatory process in the mucous membrane of the gallbladder. As a result of inflammation, microparticles enter the lumen of the bladder, which act as a matrix for the deposition of crystals of a substance that is in a supersaturated state. Inflammation of the gallbladder can be the result of bacteriocholia against the background of various forms of dyskinesia of the biliary tract and gallbladder, which cause stagnation of bile. Bile does not have bactericidal properties, which is explained by its alkaline reaction. Inflammation can be aseptic in nature - with various allergic, autoimmune reactions, as well as with the reflux of pancreatic juice into the bile ducts and gallbladder.

Differential diagnosis of acute calculous cholecystitis must be carried out with acute pancreatitis, peptic ulcer, acute appendicitis and an attack of renal colic.

1) With acute appendicitis:

Appendicitis most often affects young people. Cholecystitis affects older people and more often women. An attack of cholecystitis is caused by errors in diet, consumption of fatty, rich foods. Appendicitis begins for no apparent reason. However, the irradiation of pain in cholecystitis and appendicitis is of a different nature. With cholecystitis, irradiation to the lumbar region. Pain at the point of the gallbladder can exclude appendicitis.

Acute appendicitis is characterized by: it begins with acute pain in the epigastric region - for a short time, after 2-4 hours the pain moves to the right iliac region (Kocher-Wolkovich symptom), combined with tension in the abdominal wall. The symptoms of Rovzing, Sitkovsky, Voskresensky, Bartomier-Mikhelson are positive. These signs were not detected in this patient.

2) With acute pancreatitis:

Between acute pancreatitis and cholecystitis there are a number of common symptoms: sudden onset of the disease, acute pain, repeated vomiting that does not bring relief. But unlike acute pancreatitis, where pain radiates under the left scapula, epigastric region, into the left hypochondrium, in acute cholecystitis the pain is localized in the right hypochondrium and does not have a girdling character. Body temperature is subfebrile. In this patient, ultrasound did not reveal any changes in the pancreas; Ortner-Grekov, Murphy symptoms are positive; the Kerte, Voskresensky, and Mayo-Robson symptoms specific to acute pancreatitis are negative. Thus, the diagnosis of acute pancreatitis can be excluded.

3) with peptic ulcer:

Pain in the epigastric region, of varying intensity, associated with eating, relieved by taking antacids. Pain with cholecystitis does not have the same pattern as with a peptic ulcer, and vomiting and bleeding are common symptoms of an ulcer. Pain and vomiting occur at the height of a painful attack and are characteristic of an ulcer. Diseases of the gallbladder lead to an increase in temperature, and peptic ulcer disease occurs with a normal temperature. When an ulcer occurs, dyspeptic disorders appear - constipation, diarrhea, as well as the presence of an ulcer history and chronic course.

4) with renal colic

Stones in the right kidney cause attacks of pain - renal colic. Low back pain, paroxysmal, extremely intense, is relieved by the use of antispasmodics. The pain radiates down to the thigh, pubis, and testicle. With cholecystitis, pain radiates upward: to the shoulder, shoulder blade, neck. The behavior of patients with cholecystitis and renal colic is different. Patients with renal colic are usually restless and try to change their position, which is not typical for cholecystitis. Urine testing is of great importance. With renal colic, we often find blood in the urine. Possible dysuria. History of urolithiasis.

Surgical diseases Tatyana Dmitrievna Selezneva

38. Differential diagnosis and treatment of acute cholecystitis

Differential diagnosis. Acute cholecystitis must be differentiated from a perforated gastric and duodenal ulcer, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, kidney stones with localization of the stone in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia. Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Biliary dyskinesia is a violation of their physiological functions, leading to stagnation of bile in them, and subsequently to disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the closing apparatus of the lower end of the common bile duct.

Dyskinesia includes:

1) atonic and hypotonic gallbladders;

2) hypertensive gall bladders;

3) hypertension and spasm of the sphincter of Oddi;

4) atony and insufficiency of the sphincter of Oddi. The use of cholangiography before surgery makes it possible to recognize the main types of these disorders in patients.

Duodenal intubation makes it possible to establish a diagnosis of atonic gallbladder if there is an abnormally abundant flow of intensely colored bile, occurring immediately or only after the second or third administration of magnesium sulfate.

When cholecystography is performed with the patient lying on his stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile collects.

Treatment. When a diagnosis of “acute cholecystitis” is made, the patient must be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out for health reasons in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, emergency operations - if vigorous conservative treatment is unsuccessful during the first 24-48 hours from the onset of the disease.

Operations are performed within 5 to 14 days and later when an attack of acute cholecystitis subsides and an improvement in the patient’s condition is observed, i.e. in the phase of decreasing the severity of the inflammatory process.

The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.

Indications for choledochotomy are obstructive jaundice, cholangitis, obstruction of patency in the distal parts of the common bile duct, stones in the ducts.

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