Acute cholecystitis

Description:

Acute cholecystitis is an acute disease of a gall bladder with dominance of inflammatory process which can develop against the background of a zhelchekamenny disease and without it. Recently the lethality from a disease much more decreased to 2,5%.
Kliniko-morfologichesky classification of acute cholecystitis includes division on complicated and uncomplicated.
As complicated, and uncomplicated cholecystitis can be calculous or acalculous.
Uncomplicated acute cholecystitis can proceed in one of 3 forms: simple (catarral), phlegmonous and gangrenous. These forms are at the same time and stages of development of inflammatory process.
Complications of cholecystitis develop at distribution of infectious process out of limits of a gall bladder. Carry to complications: paravesical infiltrate or abscess, perforation, peritonitis, mechanical jaundice, bilious fistula (internal and outside), cholangitis.

Reasons of Acute cholecystitis:

The major role in developing of acute cholecystitis is played by the infectious agent against the background of stagnation of bile. At bilious hypertensia conditions for development of inflammatory process are created. Infection can happen one of 3 known ways – ascending enterogenous, lymphogenous or hematogenous. Colibacillus, streptococci, staphylococcus are most spread. Often gram-negative flora, including a pseudo-monad comes to light. In a third of cases the mixed flora comes to light. Most often acute cholecystitis is caused in the hematogenous way at which the infection gets into a gall bladder through a portal vein or on system of the general hepatic artery. Infection is possible at disturbance in work to reticuloendothelial system, as a result microorganisms get into bilious ways. However in vesical bile it is difficult to reveal causative organisms, they are localized in Lyushk's courses and in a vesical wall.
Increase in intravesical pressure happens in case of obstruction by a concrement, slime of area of a neck of a gall bladder or a channel, at a spasm of a sphincter of Oddi, in case of anomalies of development of a gall bladder.  The so-called "obturatsionny" cholecystitis caused by existence of stones in a gall bladder comes to light at 70% of patients with acute cholecystitis.
The enterogenous way of development of acute cholecystitis wins first place in structure of incidence of children of the first years of life. It becomes possible against the background of imperfection of system of digestion.
Important value belongs to a lizolitsetin which increase in level happens at bile outflow disturbance, being followed by release of a phospholipase of A2. The phospholipase promotes transformation of a litsetin in лизолицетин, and it, in turn, injures a mucous membrane of a gall bladder. The colloid composition of bile and permeability of cellular membranes is as a result broken, there is an aseptic inflammatory process. Then there is стаз blood in capillaries and small vessels, a disturbance of microcirculation in a vesical wall. Vascular disorders develop owing to the accompanying pathology – atherosclerosis, an idiopathic hypertensia, an embolism and thromboses. Than is longer bilious hypertensia remains, especially fabric damages are expressed. Against the background of already available morphological disturbances there is an accession of an endogenous infection.

Symptoms of Acute cholecystitis:

Clinical displays of acute cholecystitis in many respects depend on the nature of morphological disturbances in a gall bladder, duration of a disease, reactivity of an organism and the developed complications. The disease lets know about itself sharply, there is a pain attack in the field of the right hypochondrium. According to a nervous innervation irradiation of pain - in a right shoulder-blade, the right shoulder, the right supraclavicular pole is shown. At the patient nausea begins, and then – vomiting. In emetic masses bile impurity is found. Emergence of bitterness in a mouth is characteristic. In process of progressing of a disease the pain syndrome becomes more intensively.
The general condition of the patient suffers, intoxication, the general weakness accrues. Body temperature increases to 38 °C and above, there is a fever. According to a temperature curve also pulse becomes frequent. Tachycardia is especially characteristic of complications of acute cholecystitis – perforation of a gall bladder, bilious peritonitis.

Survey of the patient and the signs revealed at the same time allow to suspect the diagnosis of acute cholecystitis. Due to the penetration of bilious pigments into blood of a sclera and integuments can have an ikterichny (icteric) shade. Sharply expressed ikterichnost is observed at mechanical impassability of a bilious channel.

At survey of an oral cavity the dry coated tongue is attracted attention. Carrying out a palpation of a stomach allows to find muscular La Défense (tension) which testifies to interest of a peritoneum, i.e. development of local peritonitis.
To specific symptoms of acute cholecystitis identification of painful points is. Grekov-Ortnera's symptom is found at easy effleurage by a palm edge  on right a costal arch. Emergence of morbidity at a deep palpation in right hypochondrium is designated as Kerr's symptom.  Strengthening of pain at a palpation at the breath height (Obraztsov's symptom), emergence of morbidity at a palpation between legs right грудино - a clavicular and mastoidal muscle (a symptom of Myussi - Of St. George), impossibility to inhale at a deep palpation in right hypochondrium (Murphy's symptom) also testifies in favor of the diagnosis acute cholecystitis.

The analysis of peripheral blood find  existence of a leukocytosis, a lymphopenia, a neutrocytosis.

Clinical displays of destructive cholecystitis (including phlegmonous and gangrenous) at all patients is followed by constant pain in the field of the right hypochondrium. 70% note vomiting, another 65% complain of temperature increase. Jaundice arises at 1/3 patients. Objective survey allows to reveal a muscle tension, sharp morbidity in right hypochondrium, increase in a gall bladder and liver. Positive symptoms of Myussi, Ortner, Kerr, Obraztsov, Shchetkin - Blyumberg, etc. are defined. It is worth to remember about a phenomenon of reduction of pain at gangrene of a gall bladder which can be observed at death of nervous cells in the thickness of its wall. Reduction of pain in that case is followed by an aggravation of symptoms of the patient with increase of intoxication.

Perforative cholecystitis is shown by pain. Pain at first has the localized character and is felt in the field of the right hypochondrium, and then - extends on all stomach. The similar complication develops in 2-3 days from development of acute cholecystitis, practically in all cases at elderly patients.
Bilious peritonitis develops as a result of fusion of a wall of a bubble proteolytic enzymes of a pancreas therefore through defects in a vesical wall bile comes out in a free abdominal cavity.
At accession to acute cholecystitis of a cholangitis or hepatitis  the disease protkat with intermittent fever, is followed by oznoba, jaundice, pouring sweats.
The expressed intoksikatsionny syndrome is followed by psychomotor block, is frequent – a condition of euphoria, consciousness oppression.

Treatment of Acute cholecystitis:

Treatment of acute cholecystitis is carried out only in the conditions of a hospital.
Patients have to keep to a bed rest and a rigid diet. For the first 1-2 days starvation, then gradual introduction to a diet of vegetable and fruit purees, fast porridges, low-fat meat, the fat-free lactic products is shown. It is necessary to drink more liquid.
The pain syndrome at acute cholecystitis is eliminated with purpose of analgetics – as narcotic (morphine, Omnoponum), and non-narcotic (analginum, кеторолак, катадолон). With the same purpose spasmolysants – atropine, Platyphyllinum are used.
Important point is timely purpose of an antibioticotherapia for the purpose of which it is used intramuscular and intravenous injections of combinations of antibacterial drugs (for example, a combination of a tseftriakson to metronidazole).  
However performing surgery – removal of a gall bladder remains by the most effective method of treatment of acute cholecystitis still. The cholecystectomia is carried out as soon as possible, for the purpose of prevention of development of complications.
Indications to an early cholecystectomia:
1. At precisely established diagnosis and lack of absolute contraindications to operation;
2. In the presence of the accompanying pathology in the form of a diabetes mellitus (higher risk of accession of consecutive infection);
3. The diagnosed empyema of a gall bladder or a gangrenous form of acute cholecystitis.
More thorough preoperative training should be carried out at a chronic serious illness of cardiovascular, urinary, digestive systems that will allow to reduce risk intra-and postoperative complications. In such cases perhaps an operation delay before stabilization of associated diseases or to permission of cholecystitis. If cholecystitis passes, the cholecystectomia can be made in a planned order, in 1,5 months and later. The delay of operation bears in itself risk of bilious complications.
The modern medicine allows to make a cholecystectomia by an endoscopic method which in this case is called a transdermal cystifellotomy.