Calculous cholecystitis is an inflammation of the gallbladder wall that has arisen against the background of cholelithiasis. It is manifested by biliary colic or dull pains in the right hypochondrium, dyspepsia, intoxication, jaundice. It is diagnosed by ultrasound, dynamic scintigraphy of the hepatobiliary system, survey radiography and MSCT of the abdominal cavity, retrograde cholangiopancreatography. Myotropic antispasmodics, NSAIDs, narcotic analgesics, antibiotics, infusion therapy, antiemetic and enzyme preparations are used for treatment. Cholecystectomy is performed outside of exacerbation.
Calculous cholecystitis is one of the forms of cholelithiasis, therefore its prevalence correlates with the frequency of GI in the population. Cholelithiasis affects up to 10-20% of the population of different countries, an acute variant of cholecystitis develops in a third of patients, chronic — in 60-96%. Pathology is usually diagnosed after 40 years, women get sick 3-5 times more often than men. The risk group includes patients with burdened heredity, overweight, physical inactivity, nutritional errors, suffering from diabetes mellitus, cirrhosis of the liver, Crohn’s disease, long-term use of estrogen-progestogenic drugs, somatostatin analogues, some antibiotics.
Causes of calculous cholecystitis
The development of calculous cholecystitis is closely related to the progression of cholelithiasis, provoked by the same etiological factors as the processes of stone formation. According to experts in the field of modern gastroenterology and hepatology, the main causes of inflammatory lesions of the membranes of the gallbladder in cholelithiasis are:
- Irritation of the mucosa with concretions. Initially, microliths and small concretions are suspended in the bile and are evacuated from the bladder during bile secretion. Against the background of increased lithogenicity of bile, stones increase in size, begin to exert mechanical pressure on the walls of the organ, provoking local inflammatory, atrophic, necrotic processes. The greatest danger is represented by large dense formations of a polyhedral or awl-shaped shape.
- Stagnation of bile. With cholestasis, crystallization and growth of concretions accelerates, the risk of blockage of the bile ducts and mechanical damage to the mucosa increases, conditions for rapid reproduction of microflora are created. Inflammation against the background of calculous process occurs more often with dyskinesia of the gallbladder and biliary tract, obstruction of the Fater papilla by pancreatic tumors, compression of the bile ducts by volumetric formations (neoplasia, echinococcal cysts).
- Infection of the gallbladder. In 50-75% of patients with calculous inflammation, pathogenic and opportunistic microorganisms are seeded from the bile. Pathogens usually enter the organ hematogenically, lymphogenically, less often ascending from the lumen of the duodenum. Inflammation is often caused by E. coli, bacteroids, develops in the presence of foci of infection in other organs or a decrease in immunity during pregnancy, against the background of diabetes mellitus, taking immunosuppressants.
The mechanism of development of pathological processes differs in acute and chronic forms of calculous cholecystitis. During obturation of the cystic duct by concretion, the outflow of bile is disrupted, which leads to stretching of the walls of the organ, damage to the mucous membrane, increased exudation, release of prostaglandins, phospholipase A, and other mediators. Compression of vessels, violation of their tone under the action of biologically active substances is accompanied by a disorder of microcirculation, the spread of inflammation to all layers of the bile bubble wall, in severe cases — acute ischemia, necrosis. Due to bacterial invasion, the situation is aggravated by the infectious process.
Sometimes chronic inflammation occurs after acute calculous, although it usually develops gradually as a result of constant pressure of stagnant bile and mechanical irritation of epithelial cells with concretions. More often the mucosa atrophies, less often there is hyperplasia with papillomatosis and polyposis. Diverticular insertion of the mucosa between smooth muscle fibers along the vessels (Rokitansky-Aschoff sinuses) is possible. All organ membranes are infiltrated by lymphoid cells and macrophages, mucus-forming glandular formations (adenomyosis) are formed in the muscular and subserous layers, and point necrosis occurs. The outcome of chronic inflammation is fibrosis, scarring, petrification of the organ.
When systematizing the clinical forms of calculous cholecystitis, the dynamics of the occurrence and course of pathology are taken into account. Taking into account the root cause, there is an acute process provoked by obturation of the gallbladder with concretion, and gradually progressive chronic inflammation. There are three forms of chronic cholecystitis that complicate cholelithiasis:
- Primary-chronic inflammation. It is characterized by gradually increasing dyspeptic disorders and mild pain syndrome. It requires a thorough diagnosis, since it is often disguised as other gastroenterological diseases.
- Chronic recurrent process. The main variant of the disease with a characteristic alternation of exacerbations and remissions, intense pain syndrome. Due to the similarity with acute cholecystitis, dynamic monitoring and inpatient treatment is required.
- Chronic residual cholecystitis. Is the outcome of an acute process. It is associated with unjustified conservative management of the patient, accompanied by chronic inflammation, the development of complications with the preservation of pain after normalization of temperature.
Taking into account the intensity of symptoms, there is a painful paroxysmal form of the disease and torpid inflammation with a predominance of dull pains, the occurrence of colic every few years. Depending on the frequency of attacks and concomitant symptoms, the course of the disease is mild (no more than 1-3 biliary colic per year), moderate (1-2 attacks per month), severe (from 3 or more relapses per month).
Symptoms of calculous cholecystitis
The clinical picture is dominated by pain syndrome. In an acute process, exacerbation of chronic inflammation after food errors or emotional experiences, biliary colic occurs — an attack of unbearable pain in the epigastrium and projection of the bladder, which can radiate into the shoulder blade, back, precardial region. A distinctive feature of colic in cholecystitis is a high intensity of pain, lasting up to several hours, a combination with febrile fever, sweating, chills, pallor of the skin, severe nausea, vomiting with an admixture of bile.
Pain in chronic cholecystitis is dull or aching, appears periodically, localized on the right in the hypochondrium. Sometimes patients complain not of pain, but of heaviness in the right hypochondrium. Dyspeptic disorders are also observed: bitterness in the mouth, nausea and vomiting, stool disorders with alternating constipation and diarrhea, bloating. Symptoms usually worsen after taking large portions of fatty foods, in women – before menstruation. With a prolonged course of the disease, patients become irritable, emotionally labile, complain of fatigue, insomnia.
As a result of the penetration of bacterial flora against the background of chronic stagnation of bile with calculous cholecystitis, empyema of the gallbladder, pericholecystitis may form. In 15% of patients, perforation of the organ wall occurs with the development of biliary peritonitis. Severe bacterial inflammation is complicated by sepsis. With a long-term current disease, vesico-intestinal fistulas are often formed, which is due to ischemia and necrosis of the wall in the area of pressure on it of a large concretion. In 1% of cases, the active reproduction of gas-forming bacteria leads to the development of emphysematous cholecystitis.
Obturation of the biliary tract provokes the occurrence of mechanical jaundice with intoxication of the body and damage to brain cells. The most dangerous complication of calculous inflammation is calcification of the walls with a decrease in the cavity of the organ (the so—called “porcelain” gallbladder). This condition requires immediate treatment, since in 5-7% of cases it causes the formation of a malignant tumor. When neighboring organs are involved in the process, papillitis, biliary pancreatitis, hepatitis, other inflammatory diseases and dystrophic processes are observed.
The diagnosis is made by a hepatologist or gastroenterologist. The possible development of calculous cholecystitis is indicated by a typical clinical picture, the presence of positive vesicular symptoms (Murphy, Ortner, Kera). To confirm the diagnosis, a comprehensive examination is carried out using methods that allow visualizing the concretions of the biliary system. The most informative are:
- Gallbladder ultrasound. Sonography is the main method of diagnosing calculous inflammation, which allows you to detect concretions more than 2 mm in diameter. Also, ultrasound examination reveals a thickening of the gallbladder wall, the presence of fluid in the amniotic space.
- Abdominal x-ray. An overview radiograph is used to diagnose complications: free gas in the lumen of the organ indicates emphysematous cholecystitis, diffuse calcification of the wall indicates the development of a “porcelain” gallbladder.
- CT of abdominal organs. Computed tomography is recommended in complex diagnostic cases and with insufficient information content of other methods. During the study, the thickness of the walls of the organ is determined, edema, inflammatory infiltration, rejection of the mucous membrane are detected.
- Dynamic scintigraphy of the hepatobiliary system. According to a series of X-rays after the introduction of the radiopharmaceutical, it is possible to assess the motor-evacuation function of the biliary system. The informative value of the method in confirming the diagnosis of calculous variant of cholecystitis reaches 95-100%.
- Retrograde cholangiopancreatography. Radiography, supplemented by endoscopy, is used to assess the condition of the bile ducts, to identify small stones that were not visualized during sonography. The method is used for medicinal purposes to extract concretions from the common bile duct.
Laboratory techniques play an auxiliary role in the diagnosis of calculous form of the disease. In the general blood test during the period of exacerbation, leukocytosis with a shift to the left, an increase in ESR is observed. In a biochemical blood test, an increase in total cholesterol and alkaline phosphatase is determined. To exclude diseases of the stomach and duodenum 12, gastroduodenoscopy can be performed. Differential diagnosis is carried out with pathologies of the gallbladder (acute and chronic stone-free cholecystitis, cholesterol), diseases of other organs of the digestive system (pancreatitis, hepatitis, gastroduodenitis), right-sided renal colic, lesions of the cardiovascular system (myocardial infarction, unstable angina).
Treatment of calculous cholecystitis
The choice of tactics depends on the form of cholelithiasis, surgical removal of the gallbladder is recommended for most patients. Patients with acute inflammation are hospitalized in a surgical hospital, where, after further examination and short preparation, laparoscopic cholecystectomy is performed. Performing the operation within three days after the onset of symptoms can reduce mortality and reduce the frequency of complications compared to planned interventions performed after 6-8 weeks of conservative therapy. In severe, complicated course of acute cholecystitis, elderly patients, percutaneous cholecystectomy supplemented with antibiotic therapy is the operation of choice.
In the chronic variant of calculous inflammation, conservative treatment is recommended until the signs of exacerbation are relieved. On the first day of relapse, nutrition is limited to the use of liquids, subsequently, the amount of refractory fats, extractives, products with cholesterol is reduced in the diet. The scheme of drug therapy includes:
- Painkillers. Myotropic antispasmodics are used, which eliminate cholestasis by affecting the muscular membrane of the bladder and bile ducts. With severe pain syndrome (biliary colic), nonsteroidal anti–inflammatory drugs are indicated, less often narcotic analgesics.
- Antibacterial agents. Usually drugs are used to which conditionally pathogenic intestinal microflora is sensitive (E. coli, klebsiella, pseudomonas). The most effective are aminoglycosides in combination with lincosamides, imidazoles in combination with 3rd generation cephalosporins, carbapenems.
With severe intoxication, detoxification therapy is required. Antiemetic and enzyme preparations are symptomatically prescribed. After stabilization of the condition, open, laparoscopic, SILS-cholecystectomy or mini-access cholecystectomy is performed as planned. Crushing of concretions in the organ cavity is rarely carried out if there are contraindications to other interventions.
Prognosis and prevention
In most patients, it is possible to achieve a steady improvement in the condition. The prognosis of uncomplicated calculous cholecystitis is relatively favorable. In the case of severe purulent complications, the mortality rate can reach 50-60%. Prevention is aimed at preventing stone formation, includes normalization of the diet (compliance with a balanced diet, restriction of high-calorie fatty meals, eating 4-5 times a day), feasible physical activity, refusal to prescribe drugs that stimulate the formation of concretions.