Cholecystitis
Types and symptoms of acute and chronic cholecystitis
Description of the disease
Content:
- Cholecystitis symptoms
- Causes of cholecystitis
- Acute cholecystitis
- Chronic cholecystitis
- Types of cholecystitis
- Cholecystitis attack
- Consequences of cholecystitis
- Treatment and diet
Cholecystitis is an inflammatory process in the gallbladder, most often provoked by infection of the organ with intestinal microflora against the background of a violation of the outflow of bile through a blocked cystic duct. Usually cholecystitis is a complication of gallstone disease. The gallbladder is located next to the liver and is actively involved in the digestion process. In this case, the release of bile occurs through the small intestine, but sometimes problems arise with evacuation, and bile collects in the gallbladder, resulting in severe pain and an increased risk of infection.
As a rule, the disease occurs in combination with cholangitis - inflammation of the bile ducts. Cholecystitis is a common surgical pathology, especially among middle-aged and older women - they get sick three to eight times more often than men of their age.
The main reasons for a gender predisposition to cholecystitis:
- Chronic compression of the gallbladder during pregnancy provokes long-term consequences - an imbalance in cholesterol and bile acids, and, as a result, stagnation of bile;
- Features of hormonal metabolism in women - it has been proven that progesterone, produced in large quantities during pregnancy and menopause, and other female sex hormones negatively affect the functioning of the gallbladder;
- Women tend to be addicted to diets, and severe food restrictions impair the motility (contractility) of the gallbladder.
The risk group, regardless of gender and age, includes people who have previously been ill:
- Intestinal and / or liver infections;
- Parasitic diseases (helminthic and protozoal invasions, localized stationary or at one of the stages of development in the intestine and / or liver);
- Gallstone disease (GSD) with obstruction (blockage) of the neck and / or damage to the mucous membranes of the gallbladder;
- Diseases that disrupt the blood supply to the walls of the gallbladder.
A reflex connection between pathologies of the gallbladder and abdominal organs that are not anatomically related to it has been proven - these are the so-called viscero-visceral reflexes. All of the above causes of cholecystitis are caused either by impaired patency (obstruction) of the gallbladder, or by impaired motility (dyskinesia).
On the etiological basis, two large nosological groups of cholecystitis are distinguished:
- Calculus (lat. Calculus - stone);
- Non-calculous (stoneless).
Along the course, cholecystitis is divided into:
- Sharp;
- Chronic.
By the nature of the inflammation, they are:
- Catarrhal;
- Purulent;
- Gangrenous;
- Phlegmonous;
- Mixed.
Gangrenous and phlegmonous forms of the disease belong to the group of destructive cholecystitis.
The gallbladder is anatomically and physiologically similar to the liver. The functions of the liver are varied, one of them is the continuous production of bile and its release into the duodenum. Excess bile accumulates in the gallbladder and is consumed in portions.
The role of bile in the physiology of digestion:
- Dilutes food processed with gastric juice, changes gastric digestion to intestinal;
- Stimulates the peristalsis of the small intestine;
- Activates the production of physiological mucus, which performs a protective function in the intestine;
- Neutralizes bilirubin, cholesterol and a number of other substances;
- Launches digestive enzymes.
Cholecystitis symptoms
The initial symptoms of cholecystitis, as a rule, are sharp pains in the right side below the ribs, which occur unexpectedly. The reason for this is a stone that blocks the cystic duct. As a result, irritation and inflammation of the gallbladder develops.
The pain goes away after some time on its own or after taking the pain reliever, but in the future its gradual increase is observed, and then it becomes regular. The disease develops, which is accompanied by high fever, vomiting and nausea. The patient's condition continues to deteriorate.
The normal flow of bile into the intestines ceases, a sign of which is the icteric color of the skin and eye sclera. Prerequisites for jaundice are precisely the presence of stones that block the bile ducts. The severity of pathogenesis is characterized by the patient's pulse: usually the heart rate is from eighty to one hundred and twenty to one hundred and thirty beats per minute (or even higher), which is a serious sign that means that dangerous changes have occurred in the body.
As for the chronic form of cholecystitis, the symptoms may not be particularly evident; in the future, the disease may make itself felt in a more advanced form or take on an acute form. In this case, only treatment in a special medical institution will avoid the deterioration of the condition.
Symptoms of cholecystitis are detected during anamnesis, physical examinations (examination and palpation), laboratory and instrumental studies:
- Symptoms when taking anamnesis. On the basis of complaints of the patient, previous diseases of the gastrointestinal tract, liver and other organs, the nature of pain in the abdomen and digestive disorders (nausea and vomiting, diarrhea, constipation, bloating) are established;
- Symptoms determined by physical methods. A coated tongue is a sign of congestion in the gallbladder. The leading symptom of cholecystitis is soreness, determined by palpation, manifested in different projections of the trunk;
- Differential diagnosis based on laboratory and instrumental research methods. The instrumental diagnosis of cholecystitis is based on probing the duodenum and various modifications of X-ray and ultrasound studies. With their help, the peristalsis of the bladder, the permeability of bile into the lumen of the duodenum and other important functional and morphological parameters are determined.
Cholecystitis nausea is a common symptom. Nausea is a condition that usually precedes the gag reflex. In some cases, nausea and vomiting is a protective reaction of the body to intoxication. With cholecystitis, nausea and vomiting are always part of the pathogenesis of the disease.
Nausea with cholecystitis should be differentiated from similar symptoms in other diseases and pathologies:
- Appendicitis;
- Poisoning;
- Renal colic;
- Ulcer of the duodenum and stomach;
- Mesenteric artery obstruction;
- Pancreatitis;
- Ectopic pregnancy.
To differentiate nausea and vomiting with cholecystitis, it matters:
- The time of day for which nausea is most common;
- How long after a meal does it appear;
- The duration and outcome of nausea (whether it ends in vomiting);
- Whether or not there is relief from vomiting;
- The composition of the vomit (digested or undigested food);
- The presence of blood clots or other foreign matter in the vomit.
Diarrhea (diarrhea) with cholecystitis is very common. Diarrhea, constipation, bloating are invariable signs of diseases of the gastrointestinal tract, including cholecystitis. The sudden appearance of a stool disorder during the treatment of cholecystitis indicates a complicated course of the disease.
The appearance of diarrhea is typical when:
- Dysbacteriosis - a consequence of antibiotic therapy for cholecystitis;
- Layering toxicoinfection;
- Various disorders of intestinal motility when other digestive organs are involved in the pathogenesis.
Constipation and bloating are common with:
- Intestinal paresis (peritonitis) and a complicated form of cholecystitis (other symptoms should be taken into account when analyzing);
- Hypokinetic states (inactivity) of patients who are on bed rest for a long time;
- Reflex effect on the intestines of long-term inflammation of the gallbladder.
Causes of cholecystitis
The causes of the disease can be very different, but most often cholecystitis occurs due to the accumulation of stones in the cystic duct, body and neck of the gallbladder, which makes it difficult for bile to exit. The reason may also be some kind of injury or infection, as well as the presence of such serious diseases as diabetes mellitus, but here cholecystitis will manifest itself as a complication of an existing pathology, and not as an independent disease.
The result of all of the above can be an acute form of cholecystitis with an inflamed gallbladder. The chronic form of the disease is usually observed in those cases when the irritation does not subside for a long time and is of a protracted nature, as a result of which the walls of the organ become denser.
Acute cholecystitis
Harbingers of acute cholecystitis are attacks of nausea and pain some time after eating fatty foods, removed only with potent pain relievers.
Acute cholecystitis manifests itself clinically after the formation of calculi and their blockage of the bile duct or with an acute expansion of the organ cavity. The most important symptom is severe pain.
In addition to pain, the following symptoms of acute cholecystitis are determined:
- Nausea and vomiting combined with bitterness in the mouth;
- Febrile fever (temperature rise from 38 to 39 0 С);
- Enlarged liver;
- Neutrophilia in blood tests with a shift to the left (an increase in the proportion of stab forms of neutrophils).
Complications of acute cholecystitis:
- Purulent diffuse or limited peritonitis;
- Perforation (rupture) of the gallbladder;
- Acute pancreatitis (inflammation of the pancreas)
- Obstructive (mechanical) jaundice.
Pain in acute cholecystitis is a pathognomonic (main) symptom.
Pain manifests itself in the following body projections:
- Right hypochondrium, the area is located in front, on the right side of the body, the upper horizontal border (line) is directly under the last rib, the lower horizontal line is from the protrusion of the ilium to the navel, the central vertical line is from the solar plexus to the navel;
- Epigastric region. Triangular section located directly below the xiphoid process;
- The navel area. It is limited by four lines, the upper one connects the lower edges of the last ribs, the lower one connects the right and left protrusions of the ilium, the vertical ones run along the center of the pupar ligaments.
Pain with cholecystitis is a subjective sensation, patients describe it as strong, sharp, stabbing, dull, burning, aching, pressing, pulsating and bursting.
To diagnose cholecystitis, pain provocation techniques are used, moreover, acute cholecystitis is manifested by sharp pain in response to:
- Touching and light blows on the right lower rib is Ortner's symptom;
- Palpation of the neck area under the ear, palpation of the sternocleidomastoid muscle - a symptom of Mussey-Georgievsky;
- Termination of deep palpation (pressure) in the right hypochondrium is a symptom of Shchetkin-Mussey.
Chronic cholecystitis
The periods of remission of cholecystitis are always replaced by exacerbations.
The causes of chronic cholecystitis:
- Attenuation of the acute form of this disease;
- Slow development of pathogenesis.
Symptoms of the chronic form of cholecystitis are smoothed, it is characterized by:
- Feeling of heaviness in the epigastric region;
- Bloating;
- Attacks of nausea;
- Feeling of bitterness in the mouth;
- Subfebrile body temperature (from 37 to 38 0 С);
- Enlargement of the liver (in some cases, the organ is palpable through the abdominal wall);
- Thickening of the walls of the gallbladder (detected during instrumental examination).
Sharp pain in chronic cholecystitis is not observed. In some cases, pain syndrome may be absent altogether. More often, patients notice dull or aching pain in themselves. Chronic acalculous cholecystitis may well proceed without severe pain. Pain provocation techniques show negative or slightly positive responses. The pain increases with exacerbation of the disease.
Types of cholecystitis
- Calculous cholecystitis
- Cholecystitis of the gallbladder
- Calculous cholecystitis
- Destructive cholecystitis
- Catarrhal cholecystitis
- Purulent cholecystitis
There are two main types of cholecystitis:
- Calculous cholecystitis in acute and chronic forms;
- Non-calculous cholecystitis in acute and chronic forms.
In fact, these are two different diseases in terms of etiopathogenesis. In the first case, the reason is irritation and stretching of the membranes of the gallbladder, and in the second, a violation of the functioning of the walls of the bladder due to insufficient blood supply and innervation.
Calculous cholecystitis
Calculous cholecystitis (stone cholecystitis) is a combination and mutual action of three pathological processes in the body, including metabolic disorders, stone formation and inflammation.
The pathogenesis of calculous cholecystitis develops in several stages:
- Metabolic disorders - the formation of calculi (cholelithiasis) in the cavity of the gallbladder, or cholelithiasis (GSD);
- Injury of the mucous membranes of the gallbladder with acute calculi;
- Infection with intestinal microflora and subsequent inflammation of the walls of the gallbladder.
The formation of stones is the result of pathological processes caused by metabolic disorders. The stones are composed of cholesterol, pigments (bilirubin) and lime, they are almost always mixed, with a predominance of cholesterol. Normally, excess cholesterol, bilirubin and calcium are removed in the feces.
Gallstones can have the following structure:
- Crystalline;
- Fibrous;
- Amorphous;
- Layered.
The size of the stones varies. Stones with a diameter of less than 3 mm, having an even shape, are easily removed from the body through the intestines.
Stones with calculous cholecystitis are divided into:
- Primary (formed only in the gallbladder);
- Secondary (formed in the bile and intrahepatic ducts).
A detailed article about this type of cholecystitis is here
Chronic calculous cholecystitis is an inflammation of the walls of the gallbladder, which is characterized by periods of remission and exacerbation. The period of exacerbation of chronic calculous cholecystitis should be considered as an acute inflammation.
Periods of chronic calculous cholecystitis:
- The period of remission (sedation) is due to the elimination of the cause of concern (temporary restoration of the outflow of bile into the duodenum);
- The period of exacerbation occurs due to secondary obstruction (blockage) of the duct and / or stratification of infection.
Symptoms of exacerbation appear some time after eating fatty foods:
- A feeling of heaviness in the epigastric region, right hypochondrium or navel;
- Dyspeptic disorders (diarrhea and constipation, bitterness in the mouth, heartburn).
Since calculous cholecystitis is based on cholelithiasis (BC), diagnosis, treatment and prevention of chronic calculous cholecystitis are considered taking into account the course of cholelithiasis.
Cholecystitis of the gallbladder
Gallstone disease (cholelithiasis) is a pathological formation in the bile ducts of the liver and gall bladder of stones (gallstones). Initially, the disease proceeds as a metabolic disorder, without the participation of inflammatory reactions. The disease is characterized by staged pathogenesis. Gallstones can be latent (hidden) or subclinical (with minor symptoms) for a long time. In the later stages, cholelithiasis has a varied clinical picture, including atypical, disguised as similar diseases of the gastrointestinal tract and heart.
There are the following forms of ZhKB:
- Latent. It can proceed without clinical manifestations throughout the entire period of the disease. It is diagnosed by ultrasound examination of the liver and gallbladder. The absence of a clinic is explained by the presence of stones of small diameter (less than three millimeters). When making a diagnosis in this phase, you should consult a dietitian in order to correct the diet and include in the diet foods that reduce the risk of stone formation and have a moderate choleretic effect;
- Dyspeptic. The reasons for the development of dyspeptic gallstone disease are not well understood. Usually the clinical manifestation is provoked by prolonged hard work, general and local cooling. The disease is characterized by pain in the epigastrium and right hypochondrium. The pain is dull, aching, paroxysmal. In some cases, dyspepsia is noted (diarrhea, constipation, heartburn, bitterness in the mouth). The cause of the disorder in the activity of the gastrointestinal tract in this case is a change in the composition (absence) of bile in the small intestine;
- Torpid. A form of the disease characterized by dullness of sensitivity. It occurs after a series of acute attacks of cholecystitis. The exhausted nervous system reacts to pathogenesis only with aching pains in the solar plexus region;
- Shock. It occurs with hepatic colic and acute obstruction (obstruction) of the gallbladder and duct. The pain is accompanied by autonomic reactions - pallor of the skin and cold sweat against the background of chills and rapid heartbeat.
Chronic gallbladder cholecystitis in remission is diagnosed on the basis of laboratory and instrumental methods.
Laboratory methods include research:
- Blood (general indicators (ESR, leukocyte formula), as well as indicators of cholesterol, triglycerides, bilirubin, ALT, GGtP, alpha-amylase);
- Urine (for bilirubin);
- Contents of the duodenum (for bilirubin and cholesterol).
The following instrumental methods are used:
- Ultrasound diagnostics. It is carried out in order to detect signs of pathologically altered tissues of the gallbladder, in some cases, stones;
- Cholegraphy. X-ray examination method complementary to ultrasound. It is used to detect hidden pathologies of the gallbladder;
- Probing of the duodenum. Used to sample the contents of the small intestine.
Calculous cholecystitis
Inflammation of the gallbladder against the background of a difficult outflow of bile without cholelithiasis is called calculous cholecystitis. This disease is always combined with hepatitis, inflammation of the bile ducts and pancreas.
Calculous cholecystitis can develop under the influence of:
- Microbial infection of the gallbladder;
- Corrosion of the mucous membranes of the organ by pancreatic enzymes;
- Circulatory disorders in the walls of the gallbladder.
Calculous cholecystitis manifests itself with typical and atypical symptoms:
- Typical shape. The disease is characterized by dull, monotonous pain in the right hypochondrium forty to ninety minutes after eating, driving off-road or carrying weights. There was an increase in pain in the sitting position and calming down in the supine position. The pain is combined with heartburn, nausea and belching;
- Cardiac syndrome. Dull pain in the atrial region, arrhythmias and extrasystoles that occur after eating. On the electrocardiogram, there is a negative T wave, smoothed QRS waves;
- Esophagic syndrome. Persistent heartburn, dull pain and sensation of a foreign body behind the breastbone. Temporary dysphagia (difficulty swallowing food);
- Intestinal syndrome. Abdominal distension with non-localized pain and obstinate constipation.
Chronic non-calculous cholecystitis is an inflammation of the gallbladder that occurs as a result of microbial infection, accompanied by the proliferation of connective tissue and stagnation of bile without the formation of stones.
The penetration of microflora into the focus of pathogenesis occurs along an ascending or descending path, or lymphogenically:
- The ascending path is from the intestine to the neck of the bladder and above. Promotes dysfunction of the sphincter, which prevents the reverse flow of bile from the intestines;
- Descending path - with the circulation of the pathogen in the bloodstream. In some sources, it is called "hematogenous" by spreading the infection;
- Lymphogenous. Lymph is a biological fluid in the body that is involved in many functions, including neutralizing inflammatory reactions. With massive purulent infections (genitourinary, respiratory, digestive), lymph does not cope with its role and becomes a transmission factor for infection.
The development of the pathogenesis of chronic calculous cholecystitis is accompanied by the loss of the contractile and suction functions of the gallbladder, which leads to stagnation (occlusion) of bile, thickening of the walls and wrinkling of the organ.
Destructive cholecystitis
Two forms of cholecystitis - phlegmonous and gangrenous - are included in a single nosological group. The general name for severe inflammatory processes is destructive (destructive) cholecystitis. The prognosis of phlegmonous cholecystitis is cautious, gangrenous - unfavorable. Phlegmonous cholecystitis almost always acts as a continuation of catarrhal and purulent cholecystitis, but in some cases it has an independent pathogenesis.
The main symptom complex (severe pain, nausea, bitterness in the mouth) is joined by:
- Bloating is a sign of paresis or intestinal atony;
- Tachycardia up to 112 beats per minute - excitement of pain centers;
- When breathing, the right side of the body is not symmetrical to the left - a reflex sparing reaction.
Gangrenous cholecystitis is a continuation of phlegmonous cholecystitis. The disease is characterized by:
- Shallow breathing is a reflex sparing reaction;
- Depression of consciousness;
- Severe pain and tension in the peritoneal wall is a sign of peritonitis.
Catarrhal cholecystitis
Qatar is a type of exudative inflammation. The main component of catarrhal exudate is mucus. Differential diagnosis of catarrhal inflammation of the gallbladder is carried out according to the results of histological and pathological examination of the tissues of the bladder, as well as instrumental methods of laparoscopy.
Symptoms of catarrhal cholecystitis:
- Intense, paroxysmal pain in the right hypochondrium;
- Persistent vomiting of gastric and intestinal contents;
- All parts of the abdominal wall are involved in the act of breathing.
Purulent cholecystitis
Empyema of the gallbladder (purulent cholecystitis) is an inflammation of its walls, accompanied by the accumulation of pus in the organ cavity. The reason is infection with pyogenic microflora and subsequent inflammation of the mucous membrane of the gallbladder.
Complications of purulent cholecystitis:
- Melting of the walls of the gallbladder up to organ perforation and the transition of the process to peritonitis;
- Transformation of empyema into a state of destructive inflammation (phlegmonous and gangrenous process);
- General infection of the body - pyemia (pus in the blood) and sepsis.
The symptomatology of purulent cholecystitis in the initial stage resembles the clinical picture of catarrhal inflammation in the complicated course of the phlegmonous form of the disease.
There are three exudative forms of cholecystitis:
- Phlegmon - diffuse purulent inflammation in the walls of the gallbladder;
- Abscess - focal purulent inflammation (abscess on the inner wall of the organ);
- Empyema is a purulent inflammation covering the anatomical cavities of the gallbladder.
Diagnosis of purulent cholecystitis: detection of severe leukocytosis in laboratory blood tests, an increase in ESR against a background of high temperature. The result of purulent intoxication of the body is indomitable vomiting and severe headache.
Cholecystitis attack
Attacks are typical for both primary cholecystitis and exacerbations of the chronic form of the disease. The harbingers of seizures are discomfort in the abdomen after ingestion of fatty, spicy food or alcohol.
Symptoms of an acute attack of cholecystitis:
- Sharp cramping pain in the right hypochondrium, epigastrium or navel;
- Nausea and vomiting, belching with gas, bitter taste in the mouth;
- Subfebrile or febrile body temperature (37-38 0 C or 38-39 0 C).
How to remove an attack of cholecystitis?
To stop an attack of cholecystitis, you must:
- Call an ambulance;
- Go to bed and apply cold to the stomach;
- Take an antispasmodic (papaverine, no-shpa) and an analgesic (analgin, baralgin);
- To reduce nausea, drink mint tea or still mineral water at room temperature;
- If vomiting is present, ensure collection of vomit for analysis.
Consequences of cholecystitis
The acute form of cholecystitis without adequate therapy becomes chronic with periods of exacerbation and remission. And chronic diseases are difficult to treat, since other organs are involved in the pathogenesis. The advanced form of cholecystitis is diagnosed in 15% of patients. It can result in gangrene, biliary fistulas that communicate with the intestines, kidneys and stomach with the gallbladder, obstructive jaundice, abscess, acute pancreatitis, and sometimes sepsis.
Consequences (prognosis) of calculous and non-calculous cholecystitis:
- The prognosis of uncomplicated calculous cholecystitis is favorable. After intensive treatment, the clinical picture may not appear for a long time. Cases of complete cure are known. With complicated forms of calculous cholecystitis, the prognosis is more cautious;
- The prognosis of non-calculous cholecystitis is doubtful. With such a disease, one should be wary of purulent and destructive forms of inflammation.
Treatment and diet for cholecystitis
Treatment of acute cholecystitis and chronic disease in the acute stage is carried out in a surgical hospital. Treatment methods are selected individually according to indications.
Conservative treatment of cholecystitis:
- Antibiotics, the choice depends on the effectiveness of the drug;
- Antispasmodics to stabilize the function of the passage of bile into the small intestine;
- Choleretic with hypotension of the gallbladder and normal patency of the bile duct;
- Hepatoprotectors to support liver function.
Surgical treatment of cholecystitis:
Cholecystectomy - complete removal of the gallbladder, is performed immediately with symptoms of diffuse peritonitis and acute bile obstruction, in other cases - in a planned manner.
You can find out the list of the most useful products for cholecystitis from this article.
Diet for cholecystitis
During the period of an acute attack, the patient is given only warm drink in small portions. The volume of liquid is up to one and a half liters per day.
After the relief of acute pains, cereals, jelly, steamed cutlets from lean meat or fish, an egg in the form of an omelet, white bread are included in the diet.
Diet for cholecystitis:
- You need to take food in small portions (5-6 times a day) to maintain the rhythm of bile production;
- It is recommended to have dinner no later than 4-6 hours before bedtime.
The diet of patients with cholecystitis should include:
- Products of animal origin with a minimum amount of fat, finely chopped and steamed;
- Plant foods that do not contain coarse fiber, rich in vitamins and minerals.
With cholecystitis, the following foods are prohibited:
- Canned, pickled, smoked, salted, fermented, fatty, astringent;
- Indigestion and gas (milk, legumes, carbonated drinks);
- Changing the pH of the stomach environment (alcohol, sorrel, spinach, citrus fruits).
You can find an approximate menu for a week for patients with cholecystitis with recipes for soups, dishes and salads in this article.
The author of the article: Gorshenina Elena Ivanovna | Gastroenterologist
Education: Diploma in the specialty "General Medicine" received at the Russian State Medical University named after N. I. Pirogova (2005). Postgraduate studies in the specialty "Gastroenterology" - educational and scientific medical center.
