Acholia is a clinical syndrome that occurs when the flow of bile into the small intestine stops. Pathology develops as a complication of cholelithiasis, neoplasms of the pancreato-hepatobiliary zone, viral and toxic hepatitis. The main feature is light gray feces, which contains drops of fat and undigested protein fibers. Ultrasound and CT of the hepatobiliary system, retrograde cholangiopancreatography, blood test are prescribed for the diagnosis of acholia. Treatment of acholia is carried out by pharmacotherapy methods, surgical interventions are performed according to indications.
K83 Other diseases of the biliary tract
Acholia as an extreme manifestation of hypocholia is a frequent syndrome in modern hepatology. It accompanies a large group of hepatobiliary pathologies, so it is not possible to estimate the true prevalence. About 30% of the adult population have liver and gallbladder diseases, each of these patients has a risk of developing acholia. The clinical syndrome is associated with severe manifestations of nutritional insufficiency, which is why it does not lose relevance in the practice of clinicians.
Causes of aholia
Pathology occurs when there is a violation of the flow of bile into the intestine. It develops a second time against the background of existing diseases of the hepatobiliary tract. Common etiological factors of aholia:
- Cholelithiasis. The most common cause is cholelithiasis (CI), which develops in 10% of adults. Untreated CI is manifested by blockage of the bile ducts with concretions and the development of mechanical jaundice.
- Tumors. Neoplasms of the head of the pancreas squeeze the extrahepatic bile ducts, so acholia and mechanical jaundice are the key signs of pancreatic cancer. Less often, a violation of the outflow of bile is associated with primary or metastatic tumors of the liver, gallbladder.
- Parasitosis. Most often, the problem is observed with ascariasis, since adult helminths are able to clog the biliary passages. Acholia refers to rare complications of opisthorchiasis, echinococcosis and alveococcosis.
- Cholangitis. In acute bacterial cholangitis, massive inflammatory edema of the walls of the bile ducts is observed, which disrupts their transport function. Acholia can occur as a complication of chronic inflammation, which results in sclerosis of the bile ducts.
- Viral hepatitis. Chronic viral hepatitis B and C are complicated by fibrosis and cirrhosis. Against this background, the mechanism of formation and transport of bile at the level of hepatocytes is disrupted. The intrahepatic ducts are sclerosed, as a result of which bile acids do not enter the extrahepatic passages.
- Toxic-allergic hepatitis. The mechanism of acholia development is similar to that of viral hepatitis. Non-infectious liver damage develops when FOS, aromatic hydrocarbons, phenols and heavy metal salts are poisoned. The cause of toxic damage to hepatocytes are drugs: antibiotics, anti-tuberculosis, psychotropic drugs.
- Congenital anomalies. Acholia is observed in Alazhil syndrome, a genetic disease that causes narrowing and deformation of the intrahepatic bile ducts.
Alcohol abuse is called the main risk factor, since fatty degeneration and more serious liver damage are diagnosed in 50-90% of people with alcoholism. Women are at risk because high estrogen levels are associated with an increase in the lithogenic properties of bile and the formation of concretions. The probability of developing acholia increases with biliary dyskinesia, chronic cholecystopancreatitis.
Normally, bile is produced by hepatocytes and enters the duodenum 12 through the biliary duct system. Its main function is the emulsification of fats to facilitate their digestion and absorption through the intestinal wall. Bile is involved in the assimilation of fat-soluble vitamins, cholesterol and calcium salts. In addition to the digestive function, the components of bile neutralize hydrochloric acid of the stomach, have a bactericidal effect.
With acholia, the digestive processes are disrupted due to the lack of bile. Bile acids do not enter the intestine, which activate lipase and emulsify lipids, so fats in unchanged form come out with feces. Fat molecules envelop protein fibers and interfere with their cleavage, resulting in creatorrhea. The absence of the bactericidal effect of bile increases the risk of intestinal dysbiosis.
Symptoms of aholia
The main sign of a violation of the biliary function is called acholic feces, which discolors due to the absence of the brown pigment sterkobilin in it. Fecal masses have a light gray color with a silvery tinge due to the high fat content (steatorrhea). In color and consistency, feces resembles construction putty. The stool may contain pieces of undigested food, muscle fibers.
In the absence of bile in the gastrointestinal tract, the processes of putrefaction and fermentation are intensified. Patients are concerned about constant rumbling in the stomach, flatulence, diarrhea. Admixtures of greenery and mucus are found in the feces – a typical manifestation of intestinal dysbiosis. There are cramping pains in the abdomen, which worsen after a heavy meal. Patients lose their appetite, deliberately limit themselves in food to avoid exacerbation of symptoms.
The clinical picture of acholia is complemented by signs of the underlying disease. Blockage of the biliary passages is manifested by mechanical jaundice, which is characterized by yellow staining of the whites of the eyes, mucous membranes and skin. Bile pigments begin to be released through the kidneys, so the urine acquires the color of “dark beer”. An increase in the level of bilirubin in the blood causes severe skin itching.
Patients complain of constant or periodic pain in the right hypochondrium. The pain syndrome worsens after eating fatty foods and is accompanied by nausea, vomiting, and bitter belching. Discomfort increases with deep breaths, in a position on the left side, with physical exertion. To reduce pain, patients take a forced position on the right side with bent knees.
Long-term acholia is accompanied by malabsorption and maldigestion syndromes. Protein-energy deficiency occurs, weight loss occurs due to fat and muscle tissue. With a lack of bile, the absorption of fat-soluble vitamins A, D, and E. Vitamin deficiency are manifested by deterioration of twilight vision, osteoporosis, and muscle weakness. Vitamin deficiency is accompanied by xerosis, hair loss, brittle nails.
One of the most dangerous consequences of blockage of the bile ducts is biliary colic. It is manifested by intense pain in the projection of the gallbladder, which have a cutting, stabbing, tearing character. The pain syndrome is so intense that patients are tossing in bed, moaning, screaming. Painful sensations can radiate under the shoulder blade, into the collarbone and supraclavicular zone.
Examination of patients with acholic feces is carried out by a gastroenterologist or a highly specialized hepatologist. To identify the root cause of aholia, a detailed collection of complaints and anamnesis, palpation of the abdomen, checking of bladder symptoms (Murphy, Mussi-Georgievsky, Ker, Ortner) is required. Then an extended program of laboratory and instrumental diagnostics is assigned:
- Ultrasound of the hepatobiliary zone. Transabdominal sonography determines the cause of acholia in 75% of cases. Ultrasound criteria for obturation of the bile ducts are: an increase in the diameter of the choledochus over 8 mm, deformation of the gallbladder and concretions in its lumen, stones in the ducts. With the help of ultrasound, pathologies of the pancreas are visualized.
- ERCP. The endoscopic method is used to visualize the bile ducts and determine the level of their blockage. As an alternative to ERCP, intravenous cholegraphy or oral cholecystography is prescribed.
- CT of abdominal organs. High-precision examination is used in complex diagnostic cases to determine parasitic and non-infectious liver cysts, to identify pathologies of the pancreatic zone. To assess the functional state of the organs, hepatobilioscintigraphy is performed.
- Laboratory diagnostics. In the biochemical analysis of blood, an increase in the level of direct bilirubin, alkaline phosphatase and gamma-glutamyltransferase is determined. Urine analysis shows the presence of bile pigments. Neutrophilic leukocytosis and acceleration of ESR are possible in the hemogram, which indicates an acute inflammatory reaction.
Discolored feces is a pathognomonic sign of aholia, therefore, making a syndromic diagnosis does not cause difficulties. Differential diagnosis is required when the disease manifests with an attack of biliary colic, which must be distinguished from right-sided renal colic, acute pancreatitis and appendicitis. With acholia and mechanical jaundice, pancreatic cancer should be excluded.
Treatment of acholia
To relieve acute pain, antispasmodic, analgesic and anti-inflammatory drugs are prescribed. Medications show a clinical effect in combination with a sparing diet, the principles of which correspond to the previously used table No. 5 according to Pevsner. Intensive conservative therapy relieves pain syndrome, normalizes the work of the biliary system. Complex treatment includes other groups of drugs:
- Antibiotics. Antimicrobial therapy is used for inflammatory processes in the gallbladder and ducts. Beta-lactam antibiotics are recognized as the drugs of choice, the second line of therapy includes aminoglycosides and fluoroquinolones.
- Enzymes. With concomitant chronic pancreatitis, digestive enzymes are used that improve the digestion of food, normalize the consistency and frequency of stool.
- Hepatoprotectors. The drugs are prescribed to restore the cell membranes of hepatocytes, neutralize oxidative stress and toxic effects on the liver. Drugs based on amino acids, ursodeoxycholic acid are recognized as the most effective.
With acholia on the background of calculous cholecystitis, radical treatment is recommended – removal of the gallbladder. The operation is performed in an emergency with the threat of perforation of the bladder wall, the risk of developing biliary peritonitis. The remaining patients are prescribed elective surgery after extended drug preparation. Cholecystectomy and choledochotomy are performed by laparoscopic, mini-laparotomy or open access.
The help of an abdominal surgeon is required for patients with parasitic cysts, after removal of which, together with the fibrous capsule, the symptoms of acholia and jaundice disappear. Surgical treatment is prescribed for malignant neoplasms of the pancreatic and hepatobiliary zones. In such a situation, radical surgical intervention with excision of the affected tissues, nearby lymph nodes and fiber is indicated.
Prognosis and prevention
The effectiveness of the treatment of acholia depends on the root cause of its occurrence. With calculous cholecystitis, it is possible to completely eliminate the symptoms after surgery. In the case of toxic and viral hepatitis, the prognosis is determined by the severity of fibrosis. Prevention of aholia consists in following a healthy diet, limiting alcohol intake, rational selection of pharmacotherapy. Vaccination against hepatitis B virus is recommended for all people.