Acute cholecystitis is one of the most common reasons for surgical intervention and a common complication of cholelithiasis. What is it? Acute cholecystitis is an inflammation of the gallbladder wall that occurs as a result of the development of infection in the bladder cavity.

The disease is classified into 2 types (taking into account the existing background of development): calculous and non-calculous. Women most often suffer from acute cholecystitis.

Causes and development of the disease

Typically, bile is not sterile and microorganisms from the duodenum constantly enter it, but only when stagnation occurs inside the gallbladder are favorable conditions formed for the proliferation of infectious agents and the development of inflammation.

The causes of bile stagnation in 90% of cases are stones in the gallbladder, which block the bile duct and create a mechanical obstacle to the outflow of bile. With the development of inflammation in this case, acute calculous cholecystitis is formed.

“Calculous” literally means “stone”. are detected in 10-20% of people, and their age is over 40 years. In Western countries, where there is a predominance of fats in food (national characteristics of cuisine), the most common chemical composition is cholesterol stones.

In African countries and Asia, pigment stones are detected, which is associated with infectious diseases of the biliary tract common in these regions (especially relevant in this context).

Acute cholecystitis, caused by stagnation of bile due to other reasons, occurs much less frequently. In these cases, acute cholecystitis will be acalculous, that is, acalculous:

• thickening of bile and the formation of a bile plug blocking the bile duct;
• biliary dyskinesia - a decrease in the ability of the walls of the bladder and ducts to contract, creating conditions for stagnation;
• anatomical feature of the structure of the gallbladder and duct, which impedes the outflow of bile (developmental anomalies);
• compression of the duct by a tumor, trauma;
• deformation and displacement of the duct due to inflammatory changes in neighboring organs;
• mechanical pressure from the outside, for example, when wearing uncomfortable, restrictive clothing (for example, corsets).

Types of cholecystitis

Depending on the depth of inflammation, the walls of the gallbladder are divided into:

• Catarrhal – non-purulent superficial inflammation;
• Phlegmonous - purulent inflammation with damage to all layers of the gallbladder;
• Gangrenous uncomplicated - the wall of the bladder partially or completely undergoes death (necrosis);
• Gangrenous complicated - a breakthrough of the gallbladder wall, thinned by inflammation and necrosis, with bile entering the abdominal cavity, which leads to the development of complications.

According to severity, acute cholecystitis is divided into 3 types:

1. A mild degree is characterized by a disease duration of less than 72 hours and the absence of symptoms observed in a more severe course; there are no disturbances in the functioning of other organs.

2. Moderate severity is characterized by the presence of at least one of the following symptoms:

• the duration of the disease is more than 72 hours;
• high level of leukocytes in the blood - above 18*109/l;
• the gallbladder can be palpated (normally it is inaccessible due to its small size);
• the presence of signs of local (non-extended), necrosis and swelling of the gallbladder, paravesical abscess, as well as liver abscess.

3. Severe degree is characterized by the presence of at least one sign of organ dysfunction:

• low blood pressure (less than 80/50 mmHg);
• disturbance of consciousness;
• respiratory depression;
• kidney dysfunction, which is expressed by oliguria - a sharp decrease in the amount of urine, and an increase in creatinine level more than 176.8 µmol/l, which indicates renal failure;
• changes in laboratory parameters of the liver (increase in prothrombin time, decrease in protein and other substances metabolized in this organ);
• decrease in platelet level less than 100*109/l

The appearance of symptoms is often associated with errors in diet, in the form of consumption of fatty foods, alcohol, and is also observed after emotional shock. The severity of symptoms depends on the stage of the disease and the activity of the inflammatory process.

The symptoms of catarrhal cholecystitis are as follows:

• acute pain. With cholecystitis, it may first be paroxysmal, then it becomes constant. Often radiates to the shoulder blade, shoulder and neck on the right;
• nausea, vomiting that does not bring relief;
• body temperature is moderately elevated – 37.5-38° C;
• moderate increase in heart rate up to 80-90 beats per minute, slightly increased blood pressure;
• slight tension in the abdominal muscles, but it may be absent.

Symptoms of phlegmonous cholecystitis:

• intense pain in the right hypochondrium, which intensifies when changing body position, coughing, breathing;
• nausea in this form of cholecystitis is more pronounced and more frequent than in the catarrhal form, vomiting is repeated;
• body temperature above 38° C;
• increases to 100 beats per minute;
• the tongue is wet, the stomach is swollen;
• when breathing, the patient tries to consciously not involve the right half of the abdomen in movement, so as not to increase pain;
• when palpating the abdomen on the right, under the ribs, a sharp pain occurs, and protective muscle tension is also expressed there;
• sometimes an enlarged gallbladder can be felt in the right hypochondrium.

The development of the gangrenous form of cholecystitis occurs if the body’s weakened defenses cannot contain the further development of the infection.

Initially, a period of “imaginary well-being” may occur, which is manifested by a decrease in the intensity of pain. This is due to the death of the sensitive nerve cells of the gallbladder. But then all the symptoms intensify, and when the wall of the gallbladder breaks through (perforation), clinical signs of inflammation of the peritoneum appear - peritonitis:

• severe pain emanating from the right hypochondrium spreads to most of the abdomen;
• high temperature 39-40° C;
• pulse 120 beats per minute or higher;
• breathing becomes rapid and shallow;
• the patient appears lethargic and lethargic;
• the tongue is dry, the abdomen is swollen, the abdominal muscles are tense;
• the stomach does not participate in breathing.

Gangrenous cholecystitis often occurs in older people. This is due to the liquefaction of the ability of tissues to recover, impaired circulation due to atherosclerosis and a general slowdown in metabolism.

Therefore, in older people, a mild course and mild symptoms are often observed: there is no severe pain and tension in the abdominal muscles, there is no increase in leukocytes in the blood, which significantly complicates timely diagnosis.

Diagnosis of acute cholecystitis is based on clinical and additional data:

1. The presence of complaints of the following nature - more than 30 minutes, nausea, vomiting, change in body temperature. Previously, 50% of patients could experience hepatic colic.

2. A medical examination reveals a characteristic Murphy symptom - involuntary holding of breath as a result of sharp pain when pressing in the area of ​​the right hypochondrium; Tension of the abdominal muscles is also detected, an enlarged gallbladder can be felt in 30-40% of patients; 10% of patients have jaundice;

3. Laboratory and instrumental diagnostics:

• a blood test shows an increase in the number of leukocytes - leukocytosis, the magnitude of which will depend on the severity of inflammation;
  blood biochemistry will reveal an increase in C-reactive protein, bilirubin with the development of jaundice, alkaline phosphatase, AST, ALT (specific liver enzymes);
• urine analysis changes only when the process worsens - with the development of jaundice, bilirubin appears in the urine, with the development of necrosis and severe intoxication, casts are also detected;
• Ultrasound of the gallbladder is the most accessible and informative method that allows you to identify stones and inflammatory thickening of the bladder wall. During the study, Murphy's symptom is observed in 90% of cases, which is a diagnostic sign of acute cholecystitis;
• scintigraphy cannot always be carried out practically, but is the most reliable method of proving occlusion of the cystic duct;
• carried out to identify acute cholecystitis in pregnant women when abdominal pain occurs;
• X-ray is informative in 10-15% of cases when the stones contain calcium and are visible through X-ray. X-rays also reveal the presence of gas in the wall of the bladder, which occurs with acute emphysematous cholecystitis in the elderly and patients with diabetes.

Treatment of acute cholecystitis, first aid

Pre-medical first aid for acute cholecystitis must be provided competently so as not to worsen the inflammation and not “blur” the clinical picture - otherwise it will be difficult for the doctor to quickly make the correct diagnosis.

If acute pain occurs, you need to lay the patient down and call an ambulance. To reduce pain, apply cold to the liver area. The use of thermal procedures is extremely dangerous due to the aggravation of inflammation, as the blood supply to the gallbladder increases and the risk of purulent complications increases.

It is not recommended to take any medications before being examined by a doctor. This is especially true for painkillers - they can mask the moment of perforation of the gallbladder wall, and this condition requires urgent surgical treatment.

For the same reason, you need to refrain from eating and drinking, since surgical treatment will require anesthesia. Performing it with a full stomach means exposing the patient to the risk of aspiration of vomit, which leads to severe aspiration pneumonia (the mortality rate for this pulmonary complication is very high).

All further measures for acute cholecystitis, identification of symptoms and treatment should be carried out by emergency doctors, and then by surgeons in a hospital.

The photo shows the gallbladder in acute cholecystitis

Emergency surgery for acute cholecystitis is always performed when peritonitis develops, which is caused by a spill of bile when the gallbladder ruptures. That is, surgical treatment is the main treatment for complicated gangrenous acute cholecystitis. In other cases, the method of treatment depends on the severity of acute cholecystitis.

After the diagnosis is established, infusion, antibacterial and analgesic therapy is immediately started, oxygen is supplied through a nasal catheter if breathing is impaired. Blood pressure, pulse, and urination adequacy are monitored.

What is calculous cholecystitis or inflammation of the walls of an organ with subsequent malfunction of the entire digestive system and how to live with it:

Treatment tactics depending on the severity are as follows.

1. Mild degree.

Antibiotic tablets, nonsteroidal anti-inflammatory drugs, and antispasmodics are prescribed. Usually, the use of drug therapy is sufficient to improve the condition, after which the issue of cholecystectomy - removal of the gallbladder - is decided.

Most patients can undergo laparoscopic surgery - laparoscopic cholecystectomy.

If there is no effect of treatment, and the operation is associated with risks, then percutaneous cholecystostomy is recommended. During this operation, the gallbladder is punctured through the skin and inflammatory fluid and pus are evacuated, which reduces the risk of bladder rupture and bile entering the abdominal cavity.

The operation is completed by installing a catheter, through which excess inflammatory fluid is then removed and antibiotics are administered. After improvement of the condition, cholecystectomy is performed.

A high operational risk is observed in patients over the age of 70 years, with diabetes mellitus, leukocyte levels above 15*109/l, the presence of an overstretched gallbladder on ultrasound, with a high risk of complications, and a period of inflammation lasting more than 7 days.

2. Moderate severity.

Patients in this group do not respond well to drug treatment, so within a week from the onset of the disease they decide on surgical intervention.

The method of choice is laparoscopic cholecystectomy; if technical difficulties arise, open cholecystectomy is performed. If there is a high surgical risk, percutaneous drainage of the gallbladder is performed as a temporary intervention to improve the situation.

3. Severe degree.

Due to the severity of the general condition, intensive therapy is prescribed to restore the functioning of the suffering organs and systems. Percutaneous puncture cholecystostomy is urgently performed. Stabilization and improvement of the condition makes it possible to remove the gallbladder. However, if there are signs of biliary peritonitis, an emergency cholecystectomy with drainage of the abdominal cavity is performed.

The general principles of treatment of acute cholecystitis are the following:

1. Bed rest, fasting for the first 3 days, the so-called water-tea break, then a gentle diet with the gradual introduction of solid foods, excluding fats, sugar, and alcohol.

2. Placement of a tube for vomiting or to empty the stomach before surgery.

3. Drug therapy:

• Antibiotics intramuscularly and orally. The following drugs are used: Cefazolin, Cefuroxime, Ertapenem, Ampicillin, Sulbactam sodium salt in combination with gentamicin; in case of allergies to them, fluoroquinolones are prescribed in combination with Metronidazole;
• Antispasmodics: atropine, no-spa, baralgin, platifillin;
• Non-steroidal anti-inflammatory drugs;
• Glucose solution, saline solutions for intravenous infusions.

After several cases of the acute form of the disease, the development of chronic cholecystitis is sometimes possible. Symptoms of the disease, treatment of exacerbations and diet:

Complications

Complications of acute cholecystitis are often observed and aggravate the course of the disease in older people with a weakened body response, making acute cholecystitis deadly. The following complications may develop:

1. Empyema of the gallbladder (accumulation of pus in its cavity);
2. Perforation of the gallbladder, which leads to the development of an abscess of the bladder itself, inflammation of the peritoneum (peritonitis), inflammation of adjacent organs (duodenum, stomach, pancreas);
3. The addition of an anaerobic infection leads to the development of an emphysematous form of acute cholecystitis: the wall of the bladder swells with gases. Often occurs in patients with diabetes;
4. Obstructive jaundice caused by complete blockage of the outflow of bile from the bladder;
5. Cholangitis is inflammation of the bile duct;
6. Biliary fistulas.

Prevention of acute cholecystitis

Primary prevention involves preventing the formation of gallstones in the first place by eating a low-fat diet and increasing the amount of vegetables and fiber that promotes normal bile flow.

It is important to lead an active lifestyle, do gymnastics, and physical education.

In case of existing gallstone disease, a preventive measure is to avoid rapid weight loss and prolonged fasting, which can provoke the movement of stones and disruption of the motor function of the gallbladder.

Among medications, it is possible to use ursodeoxycholic acid, which reduces the risk of biliary colic and acute cholecystitis. Carrying out planned surgical treatment of cholelithiasis is the main and reliable measure that will prevent the development of acute cholecystitis. But the operation is carried out only if there is evidence.

– forms of inflammatory damage to the gallbladder that differ in etiology, course and clinical manifestations. Accompanied by pain in the right hypochondrium, radiating to the right arm and collarbone, nausea, vomiting, diarrhea, flatulence. Symptoms occur against the background of emotional stress, dietary errors, and alcohol abuse. Diagnosis is based on physical examination, ultrasound examination of the gallbladder, cholecystocholangiography, duodenal intubation, biochemical and general blood tests. Treatment includes diet therapy, physiotherapy, analgesics, antispasmodics, and choleretic drugs. According to indications, cholecystectomy is performed.

General information

Cholecystitis is an inflammatory disease of the gallbladder, which is combined with motor-tonic dysfunction of the biliary system. In 60-95% of patients, the disease is associated with the presence of gallstones. Cholecystitis is the most common pathology of the abdominal organs, accounting for 10-12% of the total number of diseases in this group. Inflammation of the organ is detected in people of all ages; middle-aged patients (40-60 years old) suffer most often. The disease affects females 3-5 times more often. Children and adolescents are characterized by the acalculous form of the pathology, while calculous cholecystitis predominates among the adult population. The disease is diagnosed especially often in civilized countries, which is due to the characteristics of eating behavior and lifestyle.

Causes of cholecystitis

• Gallstone disease. Cholecystitis due to cholelithiasis occurs in 85-90% of cases. Stones in the gallbladder cause bile stasis. They clog the lumen of the outlet, injure the mucous membrane, cause ulceration and adhesions, supporting the process of inflammation.
• Biliary dyskinesia. The development of pathology is facilitated by a functional disorder of motility and tone of the biliary system. Motor-tonic dysfunction leads to insufficient emptying of the organ, stone formation, inflammation in the gallbladder and ducts, and provokes cholestasis.
• Congenital anomalies. The risk of cholecystitis increases with congenital curvatures, scars and constrictions of the organ, doubling or narrowing of the bladder and ducts. The above conditions provoke a violation of the drainage function of the gallbladder, stagnation of bile.
• Other diseases of the biliary system. The occurrence of cholecystitis is influenced by tumors, cysts of the gallbladder and bile ducts, dysfunction of the valve system of the biliary tract (sphincters of Oddi, Lutkens), Mirizzi syndrome. These conditions can cause deformation of the bladder, compression of the ducts and the formation of bile stasis.

In addition to the main etiological factors, there are a number of conditions, the presence of which increases the likelihood of the appearance of symptoms of cholecystitis, affecting both the utilization of bile and changes in its qualitative composition. Such conditions include dyscholia (violation of the normal composition and consistency of gallbladder bile), hormonal changes during pregnancy, and menopause. The development of enzymatic cholecystitis is facilitated by the regular reflux of pancreatic enzymes into the cavity of the bladder (pancreatobiliary reflux). Cholecystitis often occurs against the background of poor nutrition, alcohol abuse, smoking, adynamia, sedentary work, and hereditary dyslipidemia.

Pathogenesis

The main pathogenetic link of cholecystitis is considered to be stasis of gallbladder bile. Due to dyskinesia of the biliary tract, obstruction of the bile duct, the barrier function of the epithelium of the bladder mucosa and the resistance of its wall to the effects of pathogenic flora are reduced. Stagnant bile becomes a favorable environment for the proliferation of microbes, which form toxins and promote the migration of histamine-like substances to the site of inflammation. With catarrhal cholecystitis, swelling and thickening of the organ wall occurs in the mucous layer due to its infiltration by macrophages and leukocytes.

The progression of the pathological process leads to the spread of inflammation to the submucosal and muscular layers. The contractility of the organ decreases to the point of paresis, and its drainage function worsens even more. An admixture of pus, fibrin, and mucus appears in infected bile. The transition of the inflammatory process to adjacent tissues contributes to the formation of a perivesical abscess, and the formation of purulent exudate leads to the development of phlegmonous cholecystitis. Due to circulatory disorders, foci of hemorrhage occur in the wall of the organ, areas of ischemia and then necrosis appear. These changes are characteristic of gangrenous cholecystitis.

Classification

Diagnostics

The main difficulty in verifying a diagnosis is considered to be determining the type and nature of the disease. The first stage of diagnosis is a consultation with a gastroenterologist. Based on complaints, studying the medical history, and conducting a physical examination, a specialist can establish a preliminary diagnosis. Upon examination, positive symptoms of Murphy, Kera, Mussi, and Ortner-Grekov are revealed. To determine the type and severity of the disease, the following examinations are carried out:

• Ultrasound of the gallbladder. It is the main diagnostic method, it allows you to determine the size and shape of the organ, the thickness of its wall, contractile function, and the presence of stones. In patients with chronic cholecystitis, thickened sclerotic walls of the deformed gallbladder are visualized.
• Fractional duodenal intubation. During the procedure, three portions of bile (A, B, C) are collected for microscopic examination. Using this method, you can evaluate the motility, color and consistency of bile. In order to detect the pathogen that caused bacterial inflammation, the sensitivity of the flora to antibiotics is determined.
• Cholecystocholangiography. Allows you to obtain information about the functioning of the gallbladder and biliary tract in dynamics. Using the X-ray contrast method, impaired motor function of the biliary system, stones and deformation of the organ are detected.
• Laboratory blood test. In the acute period, neutrophilic leukocytosis and accelerated ESR are detected in the CBC. A biochemical blood test shows increased levels of ALT, AST, cholesterolemia, bilirubinemia, etc.

In doubtful cases, hepatobiliscintigraphy is additionally performed to study the functioning of the biliary tract.

1. Diet therapy. The diet is indicated at all stages of the disease. It is recommended to eat small meals 5-6 times a day in boiled, stewed and baked form. Long breaks between meals (more than 4-6 hours) should be avoided. Patients are advised to avoid alcohol, legumes, mushrooms, fatty meats, mayonnaise, and cakes.
2. Drug therapy. In acute cholecystitis, painkillers and antispasmodics are prescribed. When pathogenic bacteria are detected in bile, antibacterial agents are used, based on the type of pathogen. During remission, choleretic drugs are used to stimulate bile formation (choleretics) and improve the outflow of bile from the organ (cholekinetics).
3. Physiotherapy. Recommended at all stages of the disease for the purpose of pain relief, reducing signs of inflammation, and restoring the tone of the gallbladder. For cholecystitis, inductothermy, UHF, and electrophoresis are prescribed.

Removal of the gallbladder is carried out in case of advanced cholecystitis, ineffectiveness of conservative treatment methods, or calculous form of the disease. Two techniques for organ removal have found widespread use: open and laparoscopic cholecystectomy. Open surgery is performed for complicated forms, the presence of obstructive jaundice and obesity. Videolaparoscopic cholecystectomy is a modern, low-traumatic technique, the use of which can reduce the risk of postoperative complications and shorten the rehabilitation period. If stones are present, non-surgical stone crushing is possible using extracorporeal shock wave lithotripsy.

Prognosis and prevention

The prognosis of the disease depends on the severity of cholecystitis, timely diagnosis and proper treatment. With regular use of medications, adherence to diet and control of exacerbations, the prognosis is favorable. The development of complications (phlegmon, cholangitis) significantly worsens the prognosis of the disease and can cause serious consequences (peritonitis, sepsis). To prevent exacerbations, you should adhere to the basics of a balanced diet, exclude alcoholic beverages, lead an active lifestyle, and sanitize foci of inflammation (sinusitis, tonsillitis). Patients with chronic cholecystitis are recommended to undergo an annual ultrasound of the hepatobiliary system.

State budgetary educational institution of higher professional education

"Tyumen State Medical AcademyMinistry of Health of the Russian Federation"

DEPARTMENT OF FACULTY SURGERY WITH A COURSE OF UROLOGY

ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS

Module 2. Diseases of the bile ducts and pancreas

Methodological guide for preparing for the exam in faculty surgery and the Final State Certification of students of the Faculty of Medicine and Pediatrics

Compiled by: DMN, prof. N. A. Borodin

Tyumen - 2013

ACUTE CHOLECYSTITIS

Questions that a student should know about the topic:

Acute cholecystitis. Etiology, classification, diagnosis, clinical picture. Choice of treatment method. Methods of surgical and conservative treatment.

Acute obstructive cholecystitis, definition of the concept. Clinic, diagnosis, treatment.

Hepatic colic and acute cholecystitis, differential diagnosis, clinical picture, methods of laboratory and instrumental studies. Treatment.

Acute cholecystopancreatitis. Causes of occurrence, clinical picture, methods of laboratory and instrumental studies. Treatment.

Choledocholithiasis and its complications. Purulent cholangitis. Clinical picture, diagnosis and treatment.

Surgical complications of opisthorchiasis of the liver and gall bladder. Pathogenesis, clinical picture, treatment.

Acute cholecystitis This is an inflammation of the gallbladder from catarrhal to phlegmonous and gangrenous-perforated.

In emergency surgery, the concept of “chronic cholecystitis” or “exacerbation of chronic cholecystitis” is usually not used, even if this was not the patient’s first attack. This is due to the fact that in surgery any acute attack of cholecystitis is considered as a phase of a destructive process that can result in purulent peritonitis. The term “chronic calculous cholecystitis” is used almost only in one case, when the patient is admitted for planned surgical treatment in the “cold” period of the disease.

Acute cholecystitis is most often a complication of cholelithiasis (acute calculous cholecystitis). Often the trigger for the development of cholecystitis is a violation of the outflow of bile from the bladder under the influence of stones, then an infection occurs. A stone can completely block the neck of the gallbladder and completely “turn off” the gallbladder; this cholecystitis is called “obstructive”.

Much less often, acute cholecystitis can develop without gallstones - in this case it is called acute acalculous cholecystitis. Most often, such cholecystitis develops against the background of impaired blood supply to the gallbladder (atherosclerosis or thrombosis a.cistici) in elderly people; the cause may also be reflux of pancreatic juice into the gallbladder - enzymatic cholecystitis.

Classification of acute cholecystitis.

Uncomplicated cholecystitis

1. Acute catarrhal cholecystitis

2. Acute phlegmonous cholecystitis

3. Acute gangrenous cholecystitis

Complicated cholecystitis

1. Peritonitis with perforation of the gallbladder.

2. Peritonitis without gallbladder perforation (sweaty biliary peritonitis).

3. Acute obstructive cholecystitis (cholecystitis against the background of obstruction of the neck of the gallbladder in the area of ​​its neck, i.e. against the background of a “switched off” gallbladder. The usual cause is a stone wedged into the area of ​​the neck of the bladder. With catarrhal inflammation this takes on the character hydrocele of the gallbladder, with a purulent process occurs gallbladder empyema, i.e. accumulation of pus in the disabled gallbladder.

4. Acute cholecysto-pancreatitis

5. Acute cholecystitis with obstructive jaundice (choledocholithiasis, strictures of the major duodenal papilla).

6. Purulent cholangitis (spread of purulent process from the gallbladder to the extrahepatic and intrahepatic bile ducts)

7. Acute cholecystitis against the background of internal fistulas (fistulas between the gallbladder and intestines).

Clinical picture.

The disease begins acutely as an attack of hepatic colic (hepatic colic is described in the manual on cholelithiasis); when an infection occurs, a clinical picture of the inflammatory process and intoxication develops; the progressive disease leads to local and diffuse peritonitis.

The pain occurs suddenly, patients become restless and do not find rest. The pain itself is constant and increases as the disease progresses. Localization of pain is the right hypochondrium and epigastric region, the most severe pain is in the projection of the gallbladder (Ker's point). Irradiation of pain is typical: in the lower back, under the angle of the right shoulder blade, in the supraclavicular region on the right, in the right shoulder. Often a painful attack is accompanied by nausea and repeated vomiting, which does not bring relief. A subfibrile temperature appears, sometimes accompanied by chills. The last sign may indicate the addition of cholestasis and the spread of the inflammatory process to the bile ducts.

On examination: the tongue is coated and dry, the abdomen is painful in the right hypochondrium. The appearance of tension in the muscles of the anterior abdominal wall in the right hypochondrium (village Kerte) and symptoms of peritoneal irritation (Shchetkina-Blumberga village) speaks of the destructive nature of inflammation.

In some cases (with obstructive cholecystitis), you can feel an enlarged, tense and painful gallbladder.

Symptoms of acute cholecystitis

Ortner-Grekov symptom– pain when tapping the edge of the palm on the right costal arch.

Zakharyin's symptom– pain when tapping the edge of the palm in the right hypochondrium.

Murphy's sign– when pressing on the area of ​​the gallbladder with the fingers, the patient is asked to take a deep breath. In this case, the diaphragm moves down and the stomach rises, the bottom of the gallbladder collides with the fingers of the examiner, severe pain occurs and breathing is interrupted.

In modern conditions, Murphy's symptom can be checked during an ultrasound examination of the bladder; an ultrasound sensor is used instead of a hand. You need to press the sensor on the anterior abdominal wall and force the patient to take a breath; the device screen shows how the bubble approaches the sensor. When the device approaches the bladder, severe pain occurs and the patient interrupts his breath.

Mussi-Georgievsky's sign(phrenicus symptom) - the occurrence of painful sensations when pressing in the area of ​​the sternocleidomastoid muscle, between its legs.

Ker's symptom- pain when pressing with a finger into the angle formed by the edge of the right rectus abdominis muscle and the costal arch.

Pain on palpation of the right hypochondrium is called Obraztsov's symptom, but since it resembles other symptoms, sometimes this sign is called the Kera-Obraztsev-Murphy symptom.

Pain when pressing on the xiphoid process is called the xiphoid process phenomenon or Likhovitsky's symptom.

Laboratory research. Acute cholecystitis is characterized by an inflammatory reaction of the blood, primarily leukocytosis. With the development of peritonitis, leukocytosis becomes pronounced - 15-20 10 9 /l, the band shift of the formula increases to 10-15%. Severe and advanced forms of peritonitis, as well as purulent cholangitis, are accompanied by a shift of the formula “to the left” with the appearance of young forms and myelocytes.

Other blood counts change when complications occur (see below).

Instrumental research methods.

There are several methods for instrumental diagnosis of bile duct diseases, mainly ultrasound and radiological methods (ERCP, intraoperative cholangiography and postoperative fistulocholangiography). Computed tomography is rarely used to examine the bile ducts. This is written in detail in the Guidelines on cholelithiasis and methods for studying the bile ducts. It should be noted that for the diagnosis of cholelithiasis and diseases associated with impaired bile outflow, both ultrasound and x-rays are usually used. methods, but to diagnose inflammatory changes in the gallbladder and surrounding tissues - only ultrasound.

At acute cholecystitis, the ultrasound picture is as follows. Most often, acute cholecystitis occurs against the background of cholelithiasis, therefore, in most cases, an indirect sign of cholecystitis is the presence of stones in the gall bladder, or bile sludge or pus, which are determined in the form of suspended small particles without an acoustic shadow.

Often acute cholecystitis occurs against the background of obstruction of the neck of the gallbladder; this cholecystitis is called Obstructive; on ultrasound it is visible as an increase in the longitudinal (more than 90-100 mm) and transverse direction (up to 30 mm or more). Finally straight Ultrasound signs of destructive cholecystitis is: thickening of the bladder wall (normally 3 mm) to 5 mm or more, stratification (doubling) of the wall, the presence of a strip of liquid (effusion) next to the gallbladder under the liver, signs of inflammatory infiltration of surrounding tissues.

If not diagnosed or treated in a timely manner, acute cholecystitis leads to the development of a number of severe complications, which in some cases can lead to life-threatening consequences. Experts classify them based on the form of the disease.

In this article we will introduce you to the possible complications of acute cholecystitis. You will be able to understand what this disease sometimes leads to and make the right decision about the need to promptly consult a doctor if this disease develops.

Why complications develop

Failure to see a doctor in a timely manner is one of the most common causes of complications of acute cholecystitis.

The following factors can lead to the development of complications arising from acute cholecystitis:

• failure to consult a doctor in a timely manner;
• lack of professionalism of a specialist;
• the primary cause of the development of acute cholecystitis is an infectious agent;
• development of peritonitis;
• formation of intestinal fistula;
• the presence of an inflammatory process in the pancreas.

If cholecystitis is diagnosed incorrectly or untimely, the disease can become chronic. As a result, the patient may experience the following consequences of the disease:

• reactive hepatitis;
• reactive pancreatitis;
• pericholecystitis, etc.

Complications

Empyema of the gallbladder

With this consequence of the disease, purulent exudate accumulates in the cavity of the gallbladder due to blockage of the cystic duct and infection of bacterial origin. Due to such processes the patient:

• the temperature rises to high levels;
• intense pain occurs;
• symptoms of intoxication develop.

Empyema of the gallbladder can be detected using the following studies:

• bacterial blood culture;
• Ultrasound of the liver and bile ducts.

To treat this complication of acute cholecystitis, the patient is prescribed:

• antibacterial drugs before and after surgery for cholecystectomy, administered intravenously, and after stabilization of the condition - orally;
• detoxification therapy before surgery.

In some clinical cases, when the patient's condition is severe, surgery is postponed until the patient is stabilized, and gallbladder decompression is performed as a temporary measure. This requires the installation of transhepatic drainage, which is performed under X-ray control.

Without timely surgical treatment, empyema of the gallbladder can lead to death. This prognosis largely depends on the presence of complications and the stage of the pathological process. In cases where this complication is detected in time and the patient does not show signs of perforation or blood poisoning, the outcome can be favorable.

To prevent the development of pleural empyema, timely treatment or treatment should be carried out. Patients with immunodeficiency conditions or hemoglobinopathies should undergo regular preventive examinations, including studies such as ultrasound of the liver or abdominal organs.

Paravesical abscess

This complication of acute cholecystitis can develop 3-4 days after the onset of inflammation of the gallbladder. In the patient, an inflammatory infiltrate forms around this organ, which at first looks like a conglomerate loosely adjacent to the tissues. At this stage of the pathological process, the abscess can be easily removed surgically. At more advanced stages, the formed infiltrate increases in size, grows into the surrounding tissues and its treatment becomes more difficult.

When a paravesical abscess occurs, the patient experiences the following symptoms:

• stomach ache;
• vomiting and nausea;
• dry mouth;
• fever with chills;
• pain when moving.

If, against the background of an emerging complication, the patient takes antibacterial agents, then the abscess may not manifest itself with tangible symptoms. In such cases, to identify the pathological process, a physical examination is not enough and a dynamic ultrasound examination is necessary.

Gallbladder perforation

With this complication, the wall of the organ ruptures. The fluid contained in the gallbladder can enter the abdominal cavity. Subsequently, the patient may develop adhesions, subhepatic abscess and local peritonitis. In addition, intrahepatic abscesses and...

The greatest likelihood of the occurrence of such a complication of acute cholecystitis is observed in elderly patients with gallstones with attacks of colic and patients with sickle cell and severe systemic diseases, diabetes mellitus.

When perforation develops, the patient experiences the following symptoms:

• long-term persistent pain in the right side, radiating to the scapula and right shoulder;
• the appearance of symptoms of acute abdomen;
• high fever;
• vomiting bile;
• nausea;
• signs of liver failure and hepatorenal syndrome;
• depression of respiratory and cardiovascular activity;
• intestinal paresis and obstruction.

If treatment is not timely, this complication can cause death.

To identify perforation of the gallbladder, the doctor prescribes ultrasound examinations to detect stones and effusion around the organ or the development of peritonitis, intrahepatic or interloop abscess. If it is necessary to obtain a more detailed clinical picture, CT or MSCT of the areas under study is performed.

To treat a perforation of the gallbladder, the patient is immediately transferred to the intensive care unit or operating room. At the stage of preparation for the upcoming surgical intervention, the patient is given antibacterial, infusion and analgesic therapy. Such measures are necessary to partially eliminate multiple organ failure, and after stabilizing the patient’s condition, the surgeon performs the operation.

Purulent diffuse peritonitis

With the initial development of this form of peritonitis, which occurs against the background of acute cholecystitis, a serous-purulent exudate forms in the abdominal cavity. Initially, almost all patients experience pain in the abdomen and experience vomiting and nausea. However, with lightning-fast or uncharacteristic course of the disease, such patient complaints may be absent.

Due to severe pain, the patient has to take a forced position in bed, and some patients develop signs of fever. Upon examination, the doctor may notice moderate tension in the abdomen and its non-participation in the breathing process. When palpating the abdomen, more active intestinal motility is initially detected, but over time it weakens.

After 1-3 days, the patient’s condition worsens due to increased inflammation. He begins to vomit uncontrollably, leading to the appearance of fecal matter in the discharge from the oral cavity. The patient's breathing becomes shallow, the activity of blood vessels and the heart is disrupted, the abdomen swells and becomes moderately tense, and the separation of gases and feces from the intestines stops.

At the irreversible stage of purulent peritonitis, the patient's skin acquires an earthy tint and becomes cold to the touch. Consciousness is impaired to the point of manifestations of “getting ready for the trip” (the patient collects imaginary objects, does not react to his surroundings, catches midges in front of his eyes, etc.), and blood pressure and pulse indicators are almost not determined.

The transition to the stage of diffuse peritonitis can be lightning fast, and then it is impossible to separate one stage of the development of the pathological process from another.

To identify signs and symptoms of purulent peritonitis, the doctor prescribes blood tests, ultrasound, ECG and plain radiography. If difficulties arise in diagnosis, the patient undergoes diagnostic laparoscopy. With such a study, the doctor can collect inflammatory exudate to conduct a culture test for the sensitivity of the pathogen to antibacterial drugs. If diagnostic laparoscopy is not performed, the degree of inflammation intensity is determined by the level of leukocytes in the blood.

To eliminate purulent peritonitis, only surgical treatment should be performed. Before the intervention, the patient is prepared with medications aimed at eliminating anemia, electrolyte imbalance, detoxification and suppression of pathogenic flora.

To relieve pain from operations, general anesthesia is performed, and the intervention itself can be performed using classical methods or using video laparoscopic surgery.

Gangrene of the gallbladder

With this complication, purulent contents accumulate in large quantities in the cavity of the gallbladder. This consequence of acute cholecystitis is caused by obstruction of the cystic lumen, which is provoked by an infectious process of a bacterial nature.

When such a complication occurs, pain occurs in the right hypochondrium, the temperature rises and intoxication develops. In addition, the patient may experience yellowness of the sclera.

When palpating the abdomen, an enlarged gallbladder is detected, the size of which does not change over time. At any moment it can rupture and lead to peritonitis. Subsequently, if the infection enters the blood, the patient develops sepsis, which can lead to severe outcomes.

To identify gangrene of the gallbladder, the doctor prescribes a series of examinations to the patient to assess the degree of the inflammatory process, intoxication of the body and obstruction of the organ. For this purpose, the following studies are carried out: ultrasound, clinical tests, etc. In the future, to select treatment tactics after surgery, an analysis is prescribed to determine sensitivity to pathogenic microflora.

To treat gangrene of the gallbladder, surgical treatment should be carried out aimed at removing the organ affected by the purulent process. In addition, the patient is prescribed antibiotics that suppress bacterial inflammation. If surgical intervention cannot be performed in the next few hours, then, against the background of drug preparation, the patient undergoes decompression of the gallbladder with a drainage installed in the liver.

Pancreatitis

Acute cholecystitis can lead to the development of inflammation in the pancreas tissue.

Occurring against the background of acute cholecystitis, it can be provoked by the activation of pancreatic enzymes. This process leads to inflammation of the gland tissue. With a mild process, the affected organ can be cured, but with a severe process, pronounced destructive processes or local complications occur in the gland, consisting of necrosis, infection or encapsulation. In severe cases of the disease, the tissues surrounding the gland become necrotic and encapsulated by an abscess.

With the development of acute pancreatitis, the patient experiences intense pain, it is constant and becomes stronger when trying to lie on his back. In addition, pain is more intense after eating food (especially fatty, fried or spicy) and alcohol.

The patient experiences nausea and may experience uncontrollable vomiting. Body temperature rises, and the sclera and skin become icteric. Also, with acute pancreatitis, the patient may show signs of digestive disorders:

• bloating;
• heartburn;
• hemorrhages on the skin in the navel area;
• bluish spots on the body.

To identify an acute inflammatory process in the pancreas, the patient undergoes a study of blood and urine parameters. To identify structural changes, instrumental studies are performed: ultrasound, MRI and MSCT.

Treatment of acute pancreatitis consists of pain relief and bed rest. To eliminate inflammatory processes, the following are prescribed:

• bed rest and rest;
• hunger;
• enzyme deactivators;
• antibacterial therapy.

Pain can be eliminated by performing novocaine blockades and antispasmodics. In addition, detoxification therapy is carried out. If necessary - the appearance of stones, fluid accumulation, necrotization and abscess formation - the patient undergoes surgery.

The success of treatment of pancreatitis depends on the severity of pathological changes in the tissues of the pancreas. The duration of therapy also depends on these indicators.

In some cases, acute pancreatitis can cause the following complications:

• shock reaction;
• gland necrosis;
• the appearance of abscesses;
• pseudocysts and subsequent ascites.

Biliary fistulas

A fistula of the gallbladder in acute cholecystitis can form in rare cases with a long course of cholelithiasis. This pathology occurs when surgery is not performed in a timely manner and is detected in approximately 1.5% of patients with calculous cholecystitis and stones in the gallbladder.

Preoperative identification of fistulas is often difficult due to the lack of obvious clinical manifestations. Sometimes the first sign of such a pathological process is the appearance of large stones in the stool or vomit. More often, the entry of a calculus into the digestive organs leads to intestinal obstruction.

The development of cholangitis can be caused by the movement of infection through the fistula. Clinically, this pathology is accompanied by weakness, chills, diarrhea and increased pain. In the long term, symptoms manifest as jaundice and toxic cholangitis.

With an external fistula of the gallbladder, an open fistulous tract appears on the anterior abdominal wall, from which bile, mucous secretions and small stones flow. In the discharge, pus, dyspepsia and steatorrhea may be observed, leading to weight loss.

In some cases, biliary fistulas cause severe pain, shock, respiratory problems, bleeding, and a persistent cough. If surgery is not possible, such changes can lead to serious consequences and death.

Detection of a fistula is possible using plain radiography and fistulography. In some cases, choledochoscopy is performed. Sometimes obstructive obstruction that occurs can be determined using contrast radiography (EGD). To obtain a more detailed clinical picture, tests are performed to detect hypoproteinemia, hyperbilirubinemia and hypocoagulation.

Getting rid of a biliary fistula can only be achieved through surgery. To do this, the anastomosis between the gallbladder and adjacent tissues is eliminated, thereby ensuring the normal outflow of bile into the lumen of the duodenum. In addition, the doctor performs a cholecystectomy.

Cholangitis

With nonspecific inflammation of the bile ducts against the background of acute cholecystitis,

What is the most common cause of obstructive jaundice?

Answers:

1. cicatricial strictures of the extrahepatic bile ducts

2. choledocholithiasis *

3. cancer of the head of the pancreas

4. liver echinococcus

5. liver metastases of tumors

A 76-year-old patient was admitted to the clinic on the seventh day from the onset of the disease with complaints of

pain in the right hypochondrium, weakness, repeated vomiting, increased body temperature up to 38°C.

On examination, the general condition is moderate. Pale, enlarged palpable

painful gallbladder, tension in the abdominal muscles is noted in the right hypochondrium

walls. Suffers from hypertension and diabetes. What treatment method

preferred?

Answers:

1. emergency surgery - cholecystectomy *

2. emergency laparoscopic cholecystectomy

3. complex conservative therapy

4. microcholecystostomy under ultrasound control

A 56-year-old patient, suffering from cholelithiasis for a long time, was admitted to the 3rd

days from the onset of exacerbation of the disease. Carrying out complex conservative therapy

did not lead to an improvement in the patient's condition. During observation, significant

bloating, cramping pain, repeated vomiting mixed with bile. At

X-ray of the abdominal cavity pneumatosis of the small intestine, aerocholia. Diagnosis:

Answers:

1. acute perforated cholecystitis, complicated by peritonitis

2. acute destructive cholecystopancreatitis

3. dynamic intestinal obstruction

4. gallstone intestinal obstruction *

5. acute purulent cholangitis

What combination of clinical symptoms corresponds to Courvoisier syndrome?

Answers:

1. enlarged painless gallbladder in combination with jaundice *

2. liver enlargement, ascites, dilation of the veins of the anterior abdominal wall

3. jaundice, palpable tender gallbladder, local peritoneal phenomena

4. lack of stool, cramping pain, appearance of a palpable abdominal mass

5. severe jaundice, enlarged nodular liver, cachexia

What are the surgical tactics for an established diagnosis of gallstone obstruction?

intestines?

Answers:

1. complex conservative therapy in the intensive care unit

2. therapy in combination with endoscopic decompression of the small intestine

3. urgent surgical intervention: cholecystectomy by dividing the biliodigestive

fistula, enterotomy, stone removal *

4. urgent surgical intervention: cholecystectomy, removal of gallstones

5. perinephric blockade in combination with siphon enema

A 70-year-old patient underwent routine surgery for calculous cholecystitis. At

intraoperative cholangiography revealed no pathology. On the 3rd day after surgery

the appearance of jaundice, pain in the right hypochondrium with irradiation to the back was noted,

repeated vomiting. Diagnosis:

Answers:

1. suppuration of a postoperative wound

2. acute postoperative pancreatitis *

3. residual choledocholithiasis

4. cicatricial stricture of the common bile duct

5. intra-abdominal bleeding

A 70-year-old patient suffers from frequent attacks of calculous cholecystitis with severe

pain syndrome. He has a history of two myocardial infarctions and stage IIIb hypertension.

Two months ago I suffered a cerebrovascular accident. What treatment method

should be preferred?

Answers:

1. refuse surgical treatment and carry out conservative therapy

2. cholecystectomy under IV anesthesia with mechanical ventilation covered with coronary lytics,

ganglion blockers and intraoperative cardiomonitoring *

3. cholecystectomy under epidural anesthesia

4. cholecystostomy under ultrasound control with sanitation and obliteration of the bile cavity

5. External wave lithotripsy

Which method of preoperative examination is the most informative for

assessment of biliary tract pathology?

Answers:

1. intravenous infusion cholangiography

2. endoscopic retrograde cholangiopancreatography

3. percutaneous transhepatic cholangiography

5. oral cholecystocholangiography

A 62-year-old patient underwent surgery for chronic calculous cholecystitis. Produced

cholecystectomy, drainage of the abdominal cavity. During the first days after surgery

There was a decrease in blood pressure, hemoglobin levels, pale skin

covers, tachycardia. What postoperative complication should be suspected?

Answers:

1. myocardial infarction

2. pulmonary embolism

3. acute postoperative pancreatitis

4. dynamic intestinal obstruction

5. intra-abdominal bleeding *

10. Question

A 55-year-old patient who underwent cholecystectomy 2 years ago was admitted with the clinical picture

obstructive jaundice. Retrograde cholangiopancreatography revealed choledocholithiasis.

Which treatment method is preferable?

Answers:

1. endoscopic papillosphincterotomy

2. complex conservative therapy

3. transduodenal papillosphincteroplasty *

4. choledochotomy with external drainage of the common bile duct

5. extracorporeal lithotripsy

11. Question

Patients with uncomplicated calculous cholecystitis most often undergo:

Answers:

1. cholecystostomy

2. cholecystectomy from the cervix

3. cholecystectomy from the fundus

4. laparoscopic cholecystostomy *

5. cholecystectomy with drainage of the common bile duct according to Halstead-Pikovsky

12. Question

After cholecystectomy, drainage is most often used:

Answers:

1. according to Robson-Vishnevsky

2. according to Halstead-Pikovsky

3. according to Spasokukotsky

4. according to Keru

5. combined drainage according to Pikovsky and Spasokukotsky

6. according to Holted-Pikovsky *

13. Question

Intraoperative cholangiography is absolutely indicated for everything except:

Answers:

1. the presence of small stones in the common bile duct

2. suspicion of cancer of the large duodenal nipple

3. expansion of the common bile duct

4. history of obstructive jaundice

5. disabled gallbladder *

14. Question

It is not typical for jaundice due to choledocholithiasis:

Answers:

1. urobilinuria

2. increased alkaline phosphatase

3. normal or low protein in the blood *

4. increased blood bilirubin

5. normal or moderately elevated transaminases

15. Question

With the movement of a stone from the gallbladder into the common bile duct the following does not develop:

Answers:

1. hepatic colic

2. jaundice

3. purulent cholangitis

4. stenosing papillitis

5. Budd-Chiari syndrome *

16. Question

True postcholecystectomy syndrome can only be caused by:

Answers:

1. cicatricial stenosis of the common bile duct

2. common bile duct stone not found during surgery

3. stenosis of the large duodenal nipple

4. duodenostasis

5. decreased tone of the Eddy sphincter and expansion of the common bile duct after cholecystectomy *

17. Question

Intraoperative methods for studying extrahepatic bile ducts include everything

Answers:

1. palpation of the common bile duct

2. choledochoscopy

3. intraoperative cholangiography

4. Probing of the common bile duct

5. intravenous cholangiography *

18. Question

A patient with jaundice due to choledocholithiasis needs:

Answers:

1. emergency surgery

2. conservative treatment

3. urgent surgery after preoperative preparation *

4. catheterization of the celiac artery

5. plasmapheresis

19. Question

The following is not used to detect choledocholithiasis:

Answers:

4. transhepatic cholegraphy

5. hypotonic doudenography *

20. Question

Complications of acute calculous cholecystitis do not include:

Answers:

1. varicose veins of the esophagus *

2. obstructive jaundice

3. cholangitis

4. subhepatic abscess

5. peritonitis

21. Question

It is not typical for the clinic of acute cholangitis:

Answers:

1. high temperature

2. pain in the right hypochondrium

3. jaundice

4. leukocytosis

5. unstable loose stools *

22. Question

Intermittent jaundice is caused by:

Answers:

1. Wedged stone of the terminal part of the common bile duct

2. common bile duct tumor

3. cystic duct stone

5. structure of the common bile duct

23. Question

Gallstone disease is dangerous for all of the following, except:

Answers:

1. development of liver cirrhosis *

2. cancerous degeneration of the gallbladder

3. secondary pancreatitis

4. development of destructive cholecystitis

5. obstructive jaundice

24. Question

Courvoisier's sign is not observed in cancer:

Answers:

1. head of the pancreas and major duodenal papilla*

2. supraduodenal part of the common bile duct

3. retroduodenal section of the common bile duct

4. gallbladder

25. Question

In case of cholelithiasis, emergency surgery is indicated:

Answers:

1. with occlusion of the cystic duct

2. for cholecystopancreatitis

3. for perforated cholecystitis *

4. with obstructive jaundice

5. for hepatic colic

26. Question

Complications of choledocholithiasis are:

Answers:

1. hydrocele of the gallbladder

2. empyema of the gallbladder

3. jaundice, cholangitis *

4. chronic active hepatitis B

5. perforated cholecystitis, peritonitis

27. Question

For uncomplicated cholelithiasis, elective cholecystectomy is indicated:

Answers:

1. in all cases *

2. with a latent form of the disease

3. in the presence of clinical signs of the disease and decreased ability to work

4. in patients over 55 years of age

5. in persons under 20 years of age

28. Question

Method of choice in the treatment of chronic calculous cholecystitis?

Answers:

1. dissolution of stones with litholytic drugs

2. microcholecystostomy

3. extracorporeal wave lithotripsy

4. cholecystectomy *

5. complex conservative therapy

29. Question

A 57-year-old patient was admitted with moderate pain in the right hypochondrium,

radiating into the scapula. History of chronic calculous olecystitis. In terms of

There are no changes in the general blood test. There is no jaundice. Upon palpation it is determined

enlarged, moderately painful gallbladder. The temperature is normal. What is your diagnosis?

Answers:

1. empyema of the gallbladder

2. cancer of the head of the pancreas

3. hydrocele of the gallbladder *

4. acute perforated cholecystitis

5. Echinococcus liver

30. Question

What circumstances are decisive when deciding on the need for planned

surgical treatment for cholecystitis?

Answers:

1. severe dyspeptic syndrome

2. long history

3. accompanying liver changes

4. presence of episodes of recurrent pancreatitis

5. presence of stones in the gallbladder *

31. Question

During surgery for cholelithiasis, a patient experienced profuse bleeding from elements

hepatoduodenal ligament. What are the surgeon's actions?

Answers:

1. pack the bleeding area with a hemostatic sponge

2. pinch the hepatoduodenal ligament with your fingers, dry the wound, differentiate

source of bleeding, stitch or bandage *

3. pack the bleeding area for 5-10 minutes

4. use the drug zhelplastin to stop bleeding

5. apply laser coagulation

32. Question

In a 55-year-old patient suffering from chronic calculous cholecystitis, against the background of exacerbation

there were sharp pains in the right hypochondrium, nausea, vomiting, after a few hours

yellowness of the sclera, blood amylase level was 59 units. What complication follows

Answers:

1. perforation of the gallbladder

2. stone obstruction of the cystic duct

3. the picture is due to the development of acute papillitis

4. the picture is due to the presence of a peripapillary diverticulum

5. the picture is caused by a stone pinching the papilla *

33. Question

A patient admitted with sharp pain in the right hypochondrium, nausea, vomiting,

yellowness of the skin; emergency duodenoscopy revealed a strangulated stone

major duodenal papilla. What should be done in this situation?

Answers:

1. endoscopic papillosphincterotomy with basket-type stone removal

2. surgery, duodenotomy, stone removal

3. application of microcholecystostomy under ultrasound control

4. surgery, install Kera drainage in the common bile duct

34. Question

Specify one of the symptoms that is not typical for hydrocele of the gallbladder:

Answers:

1. enlarged gallbladder

2. pain in the right hypochondrium

3. jaundice *

4. X-ray-disabled gallbladder

5. absence of peritoneal symptoms

35. Question

A 78-year-old patient was admitted to the clinic with a diagnosis of acute recurrent calculous

cholecystitis. He also suffers from coronary artery disease and stage 4 obesity. Previously examined. On ultrasound - in

gall bladder 4 stones up to 3 cm. The attack is easily stopped with antispasmodics. Yours

Answers:

2. delayed cholecystectomy

3. cholecystectomy as planned

4. application of microcholecystostomy under ultrasound control

5. application of macrocholecystostomy

36. Question

Ultrasound-guided microcholecystostomy for destructive cholecystitis

indicated in the following situations: 1) acalculous cholecystitis 2) the first attack of acute

cholecystitis 3) presence of local peritonitis 4) advanced age of the patient 5) presence

severe concomitant diseases

Answers:

37. Question

During the operation, the cause of obstructive jaundice was determined - gastric cancer metastases into the hilum

liver. Tactics:

Answers:

1. hepaticoenterostomy

2. limit yourself to laparotomy

3. bougienage of the narrowed area and drainage of the ducts

4. transhepatic drainage of the hepatic tract

5. external hepaticostomy *

38. Question

Patient, 30 years old, emotionally labile, cholecystectomy 2 years ago. After the operation in

6 months, pain appeared in the right hypochondrium, heaviness in the epigastrium after eating, periodically

vomiting mixed with bile, especially after stress. With fluoroscopy of the stomach and duodenum

intestines - pendulum-like movements of barium in the lower horizontal branch of the duodenum.

Your diagnosis:

Answers:

1. choledocholithiasis

2. BDS stenosis

3. common bile duct stricture

4. duodenal ulcer

5. chronic duodenal obstruction *

39. Question

An 82-year-old patient developed a feeling of heaviness in the epigastrium after an error in diet.

nausea, pain in the right hypochondrium, belching, after 2 days icterus of the skin appeared and

dark urine. She was admitted to the hospital with symptoms of obstructive jaundice. During examination

A duodenal diverticulum was identified. What is the likely location of the diverticulum?

duodenum, leading to obstructive jaundice?

Answers:

1. duodenal bulb

2. descending duodenum

3. lower horizontal branch of the duodenum

4. in the area of ​​the large duodenal nipple *

5. intrapancreatic diverticula of the duodenum

40. Question

The patient underwent cholecystectomy 2 months ago. In the postoperative period

Bile was leaking from the abdominal cavity drainage; the drainage was removed on the 8th day. Leakage of bile

stopped, there was an increase in temperature daily to 37.5-37.8°C, sometimes chills.

Over the past week, dark urine, icteric skin, deterioration in health.

She was admitted with obstructive jaundice. With ERCP there is a block of hepaticocholedochus at the level

bifurcation, common bile duct 1 cm, no contrast is received above the obstacle. Diagnostic method for

clarification of the reason for the block:

Answers:

1. emergency surgery

2. percutaneous transhepatic cholangiography *

4. Liver scintigraphy

5. Rheohepatography

41. Question

A 76-year-old patient was admitted to the clinic with a picture of obstructive jaundice and was ill for a month.

The examination revealed cancer of the head of the pancreas. Suffering from diabetes mellitus and

hypertension. What type of treatment is preferable?

Answers:

1. cholecystostomy

2. cholecysto-gastroanastomosis *

3. pancreatoduodenal resection

4. endoscopic papillosphincterotomy

5. refuse surgery and carry out conservative therapy

42. Question

A patient who underwent endoscopic papillosphincterotomy has severe pain

syndrome in the epigastric region with radiation to the lower back, repeated vomiting, tension

muscles of the anterior abdominal wall. Pronounced leukocytosis and increased amylase levels

serum. What complication should you think about?

Answers:

1. perforation of the duodenum

2. acute cholangitis

3. gastrointestinal bleeding

4. acute postoperative pancreatitis *

5. intestinal obstruction

43. Question

Which study is most informative for diagnosing calculous

cholecystitis?

Answers:

1. oral cholecystocholangiography

2. laparoscopy

3. Plain X-ray of the abdominal cavity

5. endoscopic retrograde cholangiopancreatography

44. Question

A 64-year-old patient was admitted with a clinical picture of acute calculous cholecystitis. On

On the second day after admission, acute pain arose in the

right hypochondrium, spreading throughout the abdomen. On examination the condition is serious,

pale, tachycardic. Abdominal muscle tension and peritoneal phenomena are noted in all

its departments. What complication should you think about?

Answers:

1. acute destructive pancreatitis

2. subhepatic abscess

3. gallbladder perforation, peritonitis *

4. gallstone obstruction

5. thrombosis of mesenteric vessels

45. Question

A 58-year-old patient underwent endoscopic papillosphincterotomy and stones were removed.

from the common bile duct. On the second day after the intervention, repeated melena and pallor were noted

skin, decreased blood pressure. What complication should you think about?

Answers:

1. acute pancreatitis

2. perforation of the duodenum

3. cholangitis

4. bleeding from the intervention area *

5. acute intestinal obstruction

46. ​​Question

Retrograde cholangiopancreatography in a patient with obstructive jaundice revealed

extended stenosis of the orifice of the common bile duct. Which intervention should be preferred?

Answers:

1. transduodenal papillosphincteroplasty

2. supraduodenal choledochoduodenostomy *

3. endoscopic papillosphincterostomy

4. hepaticojejunostomy

5. Mikulicz operation

47. Question

During surgery for calculous cholecystitis with intraoperative

Cholangiography revealed dilatation of the biliary tract, it was suggested that

presence of stones. Which method of intraoperative examination is the most

informative to confirm the diagnosis?

Answers:

1. palpation of the bile duct

2. transillumination

3. probing of ducts

4. fibrocholangioscopy *

5. inspection with Dormia basket

48. Question

A 28-year-old patient was admitted to the clinic with a picture of jaundice, the onset of which was noted 4 days ago.

back. The pain syndrome is not expressed. There were two episodes of jaundice in the anamnesis. At

laboratory study notes bilirubinemia due to the indirect fraction. At

Ultrasound examination does not reveal any pathology. Transaminase and alkaline activity

phosphatases are not expressed. What diagnosis should be assumed?

Answers:

1. obstructive jaundice due to choledocholithiasis

2. liver cirrhosis

3. infectious hepatitis

4. Gilbert's syndrome *

5. hemochromatosis

49. Question

12 days after cholecystectomy and choledochotomy, Kera continues to flow through the drainage

up to 1 liter of bile per day. Fistulography revealed a calculus at the orifice of the common bile duct. What follows

to undertake?

Answers:

1. repeat laparotomy to remove the stone

2. carrying out litholytic therapy through drainage

3. external wave lithotripsy

4. endoscopic papillosphincterotomy, stone removal *

5. percutaneous transhepatic endobiliary intervention

50. Question

Acute destructive cholecystitis can lead to the following complications

Answers:

1. diffuse bile peritonitis

2. limited ulcers of the abdominal cavity (subphrenic, subhepatic, etc.),

liver abscess

3. cholangitis

4. hydrocele of the gallbladder

5. all of the above *

51. Question

A 50-year-old patient suffers from calculous cholecystitis, diabetes mellitus and angina pectoris.

voltage. Most appropriate for her

Answers:

1. diet therapy, use of antispasmodics

2. spa treatment

3. planned surgical treatment in the absence of contraindications due to concomitant

pathology *

4. treatment of diabetes and angina pectoris

5. surgical treatment only for vital indications

52. Question

Obstructive jaundice in acute cholecystitis develops as a result of all of the above,

Answers:

1. choledocholithiasis

2. obstruction with a stone or mucous plug of the cystic duct *

3. swelling of the head of the pancreas

4. cholangitis

5. helminthic invasion of the common bile duct

53. Question

Percutaneous transhepatic cholangiography is a method for diagnosing

Answers:

1. liver abscess

2. intrahepatic vascular block

3. biliary cirrhosis of the liver

4. obstruction of the bile ducts with obstructive jaundice *

5. chronic hepatitis

54. Question

Recognizing the cause of obstructive jaundice is most facilitated by

Answers:

1. oral cholecystography

2. intravenous cholecystocholangiography

3. retrograde (ascending) cholangiography *

4. Liver scintigraphy

55. Question

The occurrence of purulent cholangitis is most often associated

Answers:

1. with cholelithiasis *

2. with stenosing papillitis

3. with reflux of intestinal contents through a previously applied biliodigestive anastomosis

4. with pseudotumorous pancreatitis

5. with a tumor of the head of the pancreas

56. Question

The gallstone that caused obstructive intestinal obstruction enters the lumen

intestines most often through a fistula between the gallbladder and:

Answers:

1. cecum

2. lesser curvature of the stomach

3. duodenum *

4. jejunum

5. colon

57. Question

The common bile duct should be examined in all patients:

Answers:

1. obstructive jaundice

2. pancreatitis

3. with expansion of the common bile duct

4. with a choledocholithiasis clinic

5. in all of the above situations *

58. Question

Complications caused by cholelithiasis include:

Answers:

1. gangrene and empyema of the gallbladder

2. acute pancreatitis

3. jaundice and cholangitis *

4. all of the above

59. Question

For the first time in medical practice, he performed cholecystectomy

Answers:

1. Courvoisier L.

2. Langenbeck K. *

3. Monastyrsky N.D.

4. Fedorov S.P.

60. Question

Cicatricial stricture of the extrahepatic bile ducts is accompanied by all of the above,

Answers:

1. development of biliary hypertension

2. stagnation of bile

3. formation of stones and putty

4. development of obstructive jaundice

5. duodenostasis *

61. Question

Characteristics of cholangitis are

Answers:

1. fever, often manifested by high temperature of the hectic type

2. amazing chills

3. increased sweating, thirst, dry mouth

4. enlarged spleen

5. all of the above *

62. Question

Symptoms characteristic of obstructive jaundice arising from calculous

cholecystitis includes all of the following except

Answers:

1. paroxysmal pain such as hepatic colic

2. rapid development of jaundice after a painful attack

3. The gallbladder is often not palpable, its area is sharply painful

4. weight loss, severe weakness *

5. mild itching of the skin

63. Question

Patients with choledocholithiasis may experience all of the following complications except

Answers:

1. cholangitis

2. obstructive jaundice

3. cicatricial changes in the duct

4. bedsores of the duct wall

5. gallbladder cancer *

64. Question

If there is a strangulated stone in the area of ​​the major duodenal papilla, you should

Answers:

1. perform transduodenal papillotomy with removal of the stone, papilloplasty

drainage of the common bile duct. *

2. apply choledochoduodenoanastomosis

3. after duodenotomy and stone removal, drain the common bile duct through the cystic stump

4. open the common cold and try to remove the stone; if unsuccessful, perform duodenotomy,

remove the stone, suture the duodenal wound and drain

common bile duct

5. apply choledochojejunostomy

65. Question

Rational treatment of cholelithiasis is

Answers:

1. dietary

2. medicinal

3. surgical *

4. sanatorium-resort

5. treatment with mineral waters

66. Question

Intermittent jaundice can be explained

Answers:

1. cystic duct stone

2. gallstones with occlusion of the cystic duct

3. impacted stone of the large duodenal nipple

4. common bile duct valve stone *

5. tumor of the extrahepatic bile ducts

67. Question

During surgery for acute cholecystitis complicated by pancreatitis (edematous form)

the most appropriate surgical tactics should be considered

Answers:

1. typical cholecystectomy

2. after removing the gallbladder, drain the common bile duct through the stump of the cystic duct

3. after cholecystectomy, drain the common bile duct with a T-shaped drainage

4. after cholecystectomy, drain the bile duct and omental bursa *

5. apply cholecystostomy

68. Question

The most common causes of acute biliary hypertension include

Answers:

1. tumors of the hepatopancreatiduodenal region

2. stenosis of the major duodenal papilla

3. choledocholithiasis, as a complication of cholelithiasis and cholecystitis *

4. duodenal hypertension

5. helminthic infestation

69. Question

During surgery for cholelithiasis, a wrinkled gallstone was discovered.

a bladder filled with stones and the common bile duct dilated to 2.5 cm. The patient should

Answers:

1. perform cholecystectomy, choledocholithotomy, CDA *

2. perform cholecystectomy, then cholaniography

3. immediately perform cholecystectomy and revision of the duct

4. impose a cholecystostomy

5. perform a duodenotomy with revision of the large duodenal papilla

70. Question

Acute cholecystitis must be differentiated

Answers:

1. with a perforated stomach ulcer

2. with penetrating duodenal ulcer

3. with right-sided basal pneumonia

4. with acute appendicitis with a subhepatic location of the appendix

5. with all of the above *