Bilious fistulas

Description:

Outside bilious fistulas are usually formed after such interventions on the bilious ways as a cystifellotomy, transhepatic drainage of bilious ways and drainage of the general bilious channel by means of the T-shaped tube. Very seldom fistulas can be formed as a complication of cholelithiasis, cancer of a gall bladder or an injury of bilious ways.

Owing to losses of sodium and bicarbonate with bile at patients with outside bilious fistulas heavy giponatriyemichesky acidosis and a giperammoniyemiya can develop. Obstruction of bilious ways distalny fistulas interferes with its healing. In such cases endoscopic or transdermal installation of a stent allows to achieve closing of fistula without difficult repeated operation

Internal bilious fistulas.

In 80% of cases long existence of calculous cholecystitis is the reason of internal bilious fistulas. After soldering of the inflamed gall bladder with the site of a gut (usually duodenal, is more rare than colonic) and formations of a fistula stones get to a gleam of intestines and can block completely it (cholelithic intestinal impassability). Usually it happens in terminal department of an ileal gut.

Postoperative strictures of bilious ways, especially after repeated attempts of their elimination, can be complicated by formation of fistulas, is more often hepatoduodenal or hepatogastric. Such fistulas narrow, short are also easily blocked.

Bilious fistula can develop owing to a penetration in a gall bladder or the general bilious channel of a chronic ulcer of a duodenum, an ulcer of a large intestine at nonspecific ulcer colitis or a disease Krone, especially if the patient received corticosteroids.

In rare instances the stone can lead to formation of a fistula between a hepatic channel and a portal vein with a massive hemobilia, shock and the death of the patient.

Symptoms of bilious fistulas:

The disease is preceded by the long anamnesis of a cholelithiasis. Fistulas can proceed asymptomatically, independently be closed after a stone otkhozhdeniye in intestines. In such cases they are diagnosed during a cholecystectomia.

Approximately at a third of patients in the anamnesis or at receipt in a hospital jaundice is noted. Pain can be absent, but is sometimes expressed and on intensity reminds bilious colic. Cholangitis symptoms can take place. At holetsistoobodochny fistulas the general bilious channel is filled with stones, putrefactive and fecal masses that leads to a heavy cholangitis. Receipt in intestines of bilious salts is the reason of profuse diarrhea and the expressed body degrowth.

Diagnosis:

Availability of gas in bilious ways and unusual arrangement of concrements belong to radiological signs. Bilious ways can be contrasted after oral administration of barium (at holetsistoduodenalny fistulas) or after a barium enema (at holetsistoobodochny fistulas). In certain cases the inflated small bowel comes to light.

Usually fistula is visualized at ERHPG.

Treatment of bilious fistulas:

At the fistulas which developed as a result of diseases of a gall bladder surgical treatment is necessary. After division of the involved bodies and closing of defects in their wall carry out a cholecystectomia and drainage of the general bilious channel. The operational lethality high also makes about 13%.

Closing of holetsistoobodochny and bronkhobiliarny fistulas can happen after an endoscopic removing calculus of a holedokh. The intestinal impassability caused by a gallstone.

The gallstone with a diameter more than 2,5 cm getting into intestines causes obstruction, usually at the level of an ileal gut, is more rare - at the level of duodeno-eyunalny transition, a bulb of a duodenum, peloric department or even a colon. As a result of infringement of a stone inflammatory reaction of a wall of a gut or invagination develops.

The intestinal impassability caused by a gallstone meets very seldom, but at patients 65 years are more senior gallstones are the reason of obturatsionny impassability of intestines in 25% of cases.

The complication is usually observed at elderly women with chronic cholecystitis in the anamnesis. Intestinal impassability develops gradually. is followed by nausea, sometimes vomiting, colicy pains in a stomach. At a palpation the stomach which is blown up, soft. Body temperature is normal. Full obturation of a gut a stone leads to a bystry aggravation of symptoms.

On the survey roentgenogram of an abdominal cavity it is possible to see the inflated intestines loops with liquid levels, sometimes the stone which caused impassability. Availability of gas in bilious ways and a gall bladder indicates bilious fistula.

The survey X-ray analysis at receipt allows to establish the diagnosis at 50% of patients, at 25% of patients the diagnosis is established by means of ultrasonography, KT or X-ray inspection after reception of a baric suspension. In the absence of a cholangitis and fever the leukocytosis, as a rule, is not noted.

To a laparotomy cholelithic intestinal impassability manages to be diagnosed in 70% of cases.

The forecast of a disease bad and worsens with age.

After correction of water and electrolytic disturbances intestinal impassability is eliminated surgically. The stone is pushed in underlying departments of intestines or taken by an enterotomy. If the condition of the patient and the nature of defeat of bilious ways allow, carry out a cholecystectomia and closing of fistula. The lethality makes about 20%.