Chronic Cholecystitis Flashcards
What is Chronic cholecystitis
C.C is the inflammation of the gallbladder , mainly of bacterial origin sometimes appearing secondary in bile tracts dyskinesia and gallstones or parasitic invasion.
After how long can we diagnose C.C? Epidemiology
-if duration of the disease is more than 6 months
-morbidity among women is 3-4 times more than in men
C.C can occur without stones in 6-7 cases out of a 1000
What is the etiology of Chronic cholecystitis?
1.Infection
-due to conditionally pathogenic micro flora mainly-E.Coli, Streptococcus,staphylococcus,enterococcus)
In 10% of cases viral hepatitis B and C
- Duodenal-bile reflux- develops in chronic duodenal stase, sphincter of Oddi insufficiency and chronic pancreatitis
- Allergy
- Chronic inflammatory diseases of digestive organs- hepatitis,cirrhosis,intestinal diseases, pancreatitis
Predisposing factors;
1.Bile stagnation
E.g bile tracts diskinesia
Obesity and pregnancy
Stress
Disturbances of meal regimes
Insufficiency of rough vegetable cellular tissue of meal
Hypokinesia
Congenital abnormalities of gallbladder
2.Reflex influences of inflamed abdominal organs
3. Bowel disbacteriosis
4.Metabolic processes lesions, leading to physio-clinical properties and bile structure lesions(obesity,diabetes mellitus,podagra
5.Hereditary particularities
Ways of spread of infection in C.C
- Haematogenic- from the large circulation of blood through hepatic artery
- Uprising from intestine . Stomach hypo secretion e.g sphincter Oddi insufficiency
- Lymphogenic-along lymphatic tracts from intestine,sex sphere, liver or intrahepatic tracts
Pathogenesis of C.C
- favourable conditions for infection development are created in the gallbladder due to bile stagnation
- bile stagnation changes cholatocholesterol index promoting cholesterol stone formation
- This leads to gall bladder mucosa lesion, blood circulation insufficiency and inflammation
- chronic infection focuses decrease the patients immunity.
- specific and non specific sensibilization to different factors occurs and allergy
- if inflammation seizes all gallbladder layers thicken, sclerosis occurs, wall becomes wrinkled, pericholecystitis occurs
- inflammation can spread at bile tracts and cause cholangitis
Complications of chronic stoneless cholecystitis are
- pericholecystitis
- cholangitis
- gallbladder perforation
- empyema
- stone formation
Classification of C.C
According to heaviness
- light
- moderate
- severe forms
According to stages
- sharpness
- decreasing sharpness
- remission
According to complication-complicated
-uncomplicated
According to flow character
Recurrent
Monotonous
Intermittent
What is the clinical picture of C.C
Represented by syndromes Pain Dyspeptic Inflammatory Bowel function disturbance Lipid metabolism disturbance Cholestatic Involving in the process other organs and systems
Pain
-strict pain
-localised in point of gallbladder or under the rib
-pain occurs after eating fatty food, sharp fried meals, cold gas water, beer pain
-character is different
-irradiation is in scapula ,right shoulder, right neck,
-pain disappears because of local warm application, spasmolytics
Pain can be in spine as well
In no stone cholecystitis, pain is dull, bearable
In calculose cholecystitis pain is sharp, unbearable, can be provoked by jolly driving, heaviness, rarely by psycho emotional stress
Dyspeptic syndrome
Appears as a result of bile presence in stomach
Bitter taste, heaviness in epigastriun,nausea ,vomiting, change in appetite,bad digestion of fatty food are characteristic,
High temperature
Bowel dyspepsia
Meteriorism,bad digestion of milk,frequent diarrhea,rarely constipation,
Reflux from stomach,liquid fetid stools in pancreatitis
Markers of cholecystitis Subfebrile temperature Cholecystocardial syndrome- pain in heart due to viscera-visceral vagal reflex Artralgia Allergic syndrome Blood changes Neurasthenic syndrome
General physical exam of C.C
Cholecystitis can cause jaundice
Tongue is covered by white or brown thin coating
Palpation reveals skin hyperestesia zones in the right under rib, under right scapula
Gallbladder is wrinkled, decreased in volume ,commisured with neighbouring organs
“Peri processes can be seen- involving inflammatory processes of neighbouring organs(peritoneum, liver etc)
Palpatory symptoms are positive
1.Kehr’s symptom( most characteristic palpatory symptom)- its painful ness in the zone of gall bladder on inspiration
2.Lepenet’s symptom - painful ness revealed by a light tapping on the right hypochondriac with flexed fingers on inspiration
3.Murphy’s symptom-painfulness in the gallbladder often defined in a sitting position.
A physician stands to the right of a patient and gradually presses with his right hand deep into the right hypochondrium
On a deep inspiration a palpating hand feels the gallbladder as it comes down to meet the fingertips causing a sharp painful ness
- Mussis’ symptom-painless is detected by pressing a point of the phrenic nerve between peduncules of the right sternocleidomastoid muscle.
- Grekov-Orthners’s symptom- detected by thrashing at right rib.
Lab- instrumental diagnosis of C.C
- Biochemical-increase in cholesterol levels,conjugated bilirubin,alkaline phosphatase
- CBC- neutrophilic leukocytes is, increased ESR ,appearing CRP, increasing alpha 2 globulin, increasing salicylic acid
-Duodenal investigation of
Time of appearance of portions and quantity of bile
Flacks, mucus can be seen at portion B in inflammation
Microscopy reveals disquamated epithelium
Lambliae can be discovered
Changes in portion B indicate that the process is in gallbladder, in C in bile tracts
Big quantity of cholesterol crystals,calcium bilirubinate can show indirect decreasing stableness of bile colloid solution, predisposition to cholelithiasis.
-Xray
Per oral cholecystography- altered gallbladder is contrasted during a prolonged period
Intravenous cholecystography and cholangiography can be admitted according to special depositions
- FGS
- US
- ECG
- routine urine analysis
Treatment of C.C
Depends on disease stage-sharpening or remission
During sharpness
- diet excluding fat , fried , smoked, salt meal. Frequent fracrioned nutrition to improve bile flow
-treatment of pain syndrome- noshpa, galidor,papaverin
,baralgia parenterally then per oral
Antibacterial therapy by antibiotics -erythromycin(0,25gx6 a day) -doxycycline (0,05-0,1g x2 a day) -Methacyclin(0.2x 2-3 a day) -Furazolidon(0.05gx4 a day) Duration of treatment is 8-10days
- Physiotherapy at the phase of decrease sharpening of the disease-paraphyne, ozokerit, torph applications, diathermia,inductothermia
- Bile expelling medicines are contraindicated in this period
Two groups of bile expelling medicines are used
1.stimulating bile Genesis by liver(choleretics ) and
2.medicines stimulating bile expelling ( cholekinetics)
Examples
1st group-containing bile acids allochol, vestal
Synthetic medicines e.g nicotine, oksaphenamide
Of vegetable origin e.g flamin,sweet brier are cholinetics too
Hydrocholeretics increase bile quantity coz they increase its water component
2nd group-includes medicines relaxing Oddi sphincter e.g sorbit, MgSO4, sunflower and olive oil
Bile tract to us is relaxed by cholinolytics e,g euphyllin, nitroglycerin
6.Blind duodenal intubation in absence of stones is recommended 2-3times a week
7.Normalisation of vegetative nervous system function-using little
tranquilizers,sedativemedicines,psychotherapy
8.General organism reactiveness accellerating (T-activists, timeline,eleuteroccoc and other adaptogens
At the remission phase treatment includes special diet, using bile expelling medicine, therapeutic physical activity , mineral waters, sanatorium treatment at balneologic health resorts.
Prophylaxis
- rational nutrition
- active lifestyle
- treating digestive diseases on time
- treatment of infection focuses ,
- treatment of neurotic and metabolic lesions
What are the dyskinesias of biliary tracts?
Dyskinesias are formed by discoordination between contraction and relaxation of the gallbladder and sphincters of Oddi located in the bile papillae and Lutkens spincter located in the gallbladder cervix.
Types of gallbladder dysfunctions
- Hypokinetic(absence of proper peristalsis and of proper contractions)
- Hperkinetic(accelerated peristalsis, a tendency to strong contractions)
- hypotonic(large distended weakly contracting gallbladder)
- hypertonic(small and contracted gallbladder)
- dysfunction of Oddi spincter
Sometimes dyskinesias are caused by long intake of drugs e.g nitrates,cholinolytics
Combined forms of dyskinesias are referred to i.e hypotonic-hypokinetic is known as hypo motor dyskinesia
Hypertonic-hyperkinetic is hyper motor dyskinesia
What is hypomotor dyskinesia?
When tone and contractility of gall bladder is sharply decreased while tone of sphincters is high.
What is hyper motor dyskinesia?
High excitability and contractility of gallbladder with low tone of sphincters
Presentation of hyper motor dyskinesia
- stabbing brief pain
- pain enhances after intake of choleretic drugs and duodenal intubation
- in duodenal intubation, gallbladder reflexes occur quickly, bile is often secreted without stimulation just in response to introduction of the tube
- in duodenal intubation, a light colour liquid bile is rapidly excreted in small amounts
- pain is relieved by spasmolytic drugs
- hot water bag enhances pain, warm water bag reduces pain
- X-ray and US reveal a small pear shaped gallbladder
Presentation of hypo motor dyskinesia
- dull arching pain
- pain enhances after intake of spasmolytic drugs
- in duodenal intubation the gallbladder reflex is prolonged, repeated introduction of stimulus is required
- in duodenal intubation, dark almost black thick bile is slowly excreted for a prolonged period of time
- pain is relieved by intake of cholinekinetics
- hot water bag relieves pain,warm water bag enhances pain
- X-ray and US reveal a large round gallbladder
