Zhelchekamenny disease

Description:

The Zhelchekamenny disease is the pathology of gepato-billiarny system connected with disturbance of lipid metabolism and bilious pigments, which is followed by formation of concrements in a gleam of a gall bladder or bilious channels at any level.  

Intra hepatic cholelithiasis – formation of stones in hepatic bilious channels
Choledocholithiasis – formation of stones in the general bilious channel.
Cholecystolithiasis – formation of stones in a gleam of a gall bladder.

Reasons of the Zhelchekamenny disease:

Gallstones – the crystal structures of various sizes formed by a smeshaniye normal and pathological components of bile.
About 20%, other 80% - cholesteric and mixed fall to the share of pigmental stones.
The mixed and cholesteric stones contain not less than 70% of cholesterol, impurity of calcium ions, bilious pigments. Pigmental gallstones consist of bilirubin, calcium, at the same time the content of cholesterol does not exceed 10%.
Risk factors to formation of cholesteric stones:
- obesity;
- hypodynamia;
- high-calorific, rich with cholesterol and food poor in food fibers;
- advanced age;
- female;
- heredity;
- the accompanying diabetes mellitus;
- pregnancy;
- reception of female sex hormones, oral contraceptives, treatment by Clofibratum;
- long parenteral food;
- starvation;
- trunk vagisection;
- spinal injuries;
- diseases of a small bowel;
- anomalies of development of a gall bladder.

Risk factors of development of pigmental stones:
- chronic hemolysis;
- alcoholic cirrhosis;
- persistent infections of bilious ways;
- helminthoses;
- advanced age;
- demographic aspects (residents of the Far East, rural areas).

The pentade including the most widespread risk factors for a zhelchekamenny disease: the female, a blond hair which were giving birth age is more senior than 40 years full.

Pathogeny:

Formation of lipogenous bile is possible at increase in level of cholesterol in bile (at obesity, reception of Clofibratum, increase in activity of oxymethylreductase. As a result of such changes secretion by bile of bilious salts and lipids decreases. It can come owing to long parenteral food.
In the second stage of a lithogenesis there is a cholesterol crystallization bile. It is promoted by a mutsinovy glycoprotein, its synthesis is controlled by prostaglandins. Dyskinesia and anomalies of development of bilious ways has an important role.
Pathogenetic stages of development of process at a zhelchekamenny disease:
1 stage. Symptoms and concrements are absent. The diagnosis is made on the basis of a bile research where cholesteric flakes and precipitated calcium superphosphates come to light.
2 stage. Existence of stones and stagnation of bile, accession of signs of an inflammation.
3 stage. Development of calculous cholecystitis.

Symptoms of the Zhelchekamenny disease:

Staging of a disease:
1. Preclinical – disturbance of metabolism of cholesterol, bile acids, lipids.
2. Clinical:
      a) change of physical properties – disturbance of colloid stability;
b) a mode of formation of microlites – agglomeration of particles, dismotorny disturbances;
c) formation of macrolitas – agglomeration of microlites;
      3. Stage of complications.

About 30% of cases proceed asymptomatically, so-called "mute" stones.
The main symptom of a zhelchekamenny disease is the attack of bilious colic connected with advance of a concrement and a spasm of bilious ways.
Pain in right hypochondrium, with typical irradiation in the right hand, a clavicle, area of heart (imitation of stenocardia) disturbs. The pain syndrome intensive, usually develops after errors in a diet. Colic duration till several o'clock. The nausea and a cholemesis which is not giving relief joins.
At late diagnosis the empyema of a wall of a gall bladder, bilious peritonitis, vesical and duodenal fistulas quite often comes to light.
If stones get to the general bilious canal, its obstruction (choledocholithiasis) of which the megalgia and mechanical jaundice are characteristic is observed. The ascending cholangitis joins. Fever with fever attacks is observed, the level of bilirubin, SOE, alkaline phosphatase increases.

Diagnosis:

Survey of the patient allows to determine morbidity at effleurage by edge of the right costal arch (Kortner's symptom), in Kerr's point at breath height.
Kerr's point is defined in a corner between a direct muscle of a stomach and a costal arch on the right. A positive symptom of Myussi (frenikus-symptom) – morbidity when pressing between legs right грудино - a clavicular and mastoidal muscle.
Except morbidity, the palpation of a gall bladder allows to define increase in its sizes.
Informational content of ultrasonography diagnosis makes 95-98%. Difficulties at this research can be observed at the small sizes of a stone. Normal length of a gall bladder makes 7-10 cm, diameter about 3 cm, volume fluctuates from 30 to 70 ml, thickness of a front wall of a gall bladder of 2-3 mm. The concrement decides as roundish, echoic education, on a typical acoustic path at the sizes more than 0,5 cm. Cholesteric stones it is easier than bile therefore they "float" in a gall bladder.
Performing diagnostic ultrasonography after a cholagogue breakfast is widespread.
Big informative loading is born radiographic also by the KT-research.
At intravenous administration of contrast the holangiografiya which can be transhepatic, intraoperative or endoscopic is carried out.

Treatment of the Zhelchekamenny disease:

The regular dosed exercise stress and balanced diet is shown to patients with a cholelithiasis. The diet No. 5 with an exception of an alimentary excess of greasy food is appointed. Meal on hours is offered.
At the beginning of a disease medicamentous dissolution of stones is recommended. Chenodesoxycholic acid and ursodezoksikholevy acids is used. Only cholesteric stones give in to dissolution.
Conditions and indications to carrying out medicamentous dissolution of stones:
- cholesteric stones, rentgenotritsatelny, the sizes to 2 mm
- the functioning gall bladder
- employment stones to ½ volumes
- prescription of diagnosis of a disease no more than 2-3 years
- there are no stones in channels
- consent of the patient to prolonged treatment.
It is used хенофальк in capsules on 0,25 active ingredients, applied before going to bed, in the following dosages:
- to 60 kg – 3 capsules
- to 75 kg – 4 capsules
- 75 – 90 kg – 5 capsules
- more than 90 kg – 6 capsules
Treatment duration henofalky from several months to 2-3 years. Purpose of an ursofalk – about 10 mg of drug is also extended to each 10 kg of weight.

Cholecystectomia – an operative measure on removal of a gall bladder. The cholecystectomia is carried out by a laparotomichesky or laparoscopic way. Options of operation are cholecystolithotomy, a papillosfinkterotomiya, a cholecystostomy.
Indications to performing surgery at a zhelchekamenny disease:
• The existence of stones in a gall bladder which is followed by a clinical picture zhelchekamenny болезн;
• The accompanying chronic cholecystitis (repeated bilious gripes, a nonfunctioning gall bladder);
• Stones in the general bilious channel;
• Complications in the form of an empyema, edemas or gangrenes of a gall bladder;
• Perforation and a penetration of a bubble with formation of fistulas;
• Development of a syndrome of Mirizi;
• Suspicion of cancer of a gall bladder;
• Existence of the intestinal impassability caused by a gallstone.