Acute And Chronic Calculous Cholecystitis

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Acute and chronic calculous cholecystitis

Description of the disease

Content:

• Description of the disease
• Signs and symptoms
• Chronic calculous cholecystitis
• Acute calculous cholecystitis
• Phlegmonous calculous cholecystitis
• Gangrenous calculous cholecystitis
• Treatment of calculous cholecystitis

Calculous cholecystitis is a special form of cholecystitis, which is characterized by the presence of stones (calculi) in the gallbladder. The disease is one of the manifestations of gallstone disease.

Calculous cholecystitis is characterized by inflammation of the gallbladder and the presence of stones in it. Concrements mainly have a mixed composition (calcareous-pigment-cholesterol), homogeneous bilirubin (pigment) or cholesterol are less common. The size of stones can reach the size of a hen's egg, and the number varies from units to hundreds, the shape is different.

They can be located in the cavity of the gallbladder, which is observed in 75% of cases, and maintain by their presence a mild inflammatory process leading to fibrosis, as well as the deposition of calcium salts (calcification). But if calculi are in the bile duct, they can obstruct or block the outflow of bile, cause acute inflammation, characterized by the appearance of attacks of biliary colic.

The prevalence of the disease is quite high, reaching 10% of the entire adult population, people who have crossed the 40-year mark most often suffer, but there are cases when calculous cholecystitis was diagnosed in children. Women are several times more likely to suffer from this disease, which is explained by the specifics of their hormonal levels.

The following population groups are at risk of developing the disease:

• women and especially pregnant women;
• people who are obese or those who have dramatically reduced weight;
• representatives of the Scandinavian and Indian peoples, their level of this disease is much higher than that of the rest;
• older people;
• those who take medications and contraceptives that affect hormonal levels.

Factors leading to the formation of gallstones and the development of calculous cholecystitis:

• dyscholia (change in the composition of bile);
• cholestasis (bile stasis);
• the inflammatory component, in this case, primary cholecystitis.

In a healthy body, such components of bile as pigments, minerals, bile acids, lipids have a colloidal state. But when the ratio between the concentration of cholesterol and bile acids changes, the former precipitates and subsequently crystallizes. Malnutrition, diabetes mellitus, hepatitis, obesity, and infectious diseases can provoke such a situation.

Dyscholia promotes thickening of bile and its stagnation, which leads to various types of infection of the gallbladder with pathogens such as bacteroids, E. coli and others. The infection causes inflammatory changes in the walls of the gallbladder.

Fasting or overeating, a high content of animal fats in the diet, physical inactivity, heredity and long-term use of hormonal contraception can increase the lithogenicity (ability to stone formation) of bile.

Often calculous cholecystitis is preceded by the usual, stoneless, which leads to a violation of the dynamics of emptying the gallbladder.

The risk of developing the disease is higher in patients with pancreatitis, biliary dyskinesia, duodenitis, chronic gastritis, liver cirrhosis, helminthiasis, and Crohn's disease.

Features of the clinical picture make it possible to distinguish chronic and acute forms of calculous cholecystitis. The course of each of them can be complicated or uncomplicated. Distinguish between catarrhal, purulent, gangrenous and phlegmonous forms. Based on the symptomatology, typical, atypical, cardialgic, intestinal, esophagalgic variants of the development of the disease can be distinguished.

Calculous cholecystitis has 4 stages:

1. pre-stone, initial, in most cases reversible stage - thick bile forms stasis, there are microlites in the gallbladder;
2. the period of calculus formation;
3. the development of the chronic stage of the disease;
4. complication of the disease.

Signs and symptoms of calculous cholecystitis

The presence of stones in the gallbladder may not affect a person's condition in any way, therefore, at the initial stage, the disease is often asymptomatic, latent.

Symptoms directly depend on the stage of development of the disease, therefore, acute calculous cholecystitis is characterized by the following signs of the presence of biliary colic:

• acute pain syndrome, localized in the right side and radiating to the area of the shoulder or right shoulder blade, caused by dietary disturbances, alcohol, exercise or stress;
• nausea, vomiting of gastric and bile contents;
• fever, which is especially characteristic of purulent inflammation;
• a sharp decrease in blood pressure;
• the appearance of weakness and cold sweats;
• separate manifestations of jaundice with a change in the color of the stool: feces contain a lot of fat and has a discolored appearance, and the urine is darker than usual.

The manifestations of chronic calculous cholecystitis are more smoothed:

• often aching pain in the area of the right hypochondrium;
• the appearance of acute pain syndrome caused by improper nutrition, which gradually subsides by itself;
• paroxysmal pain that occurs 3 hours after eating fatty, salty or fried foods;
• bitter nausea and belching;
• violation of nutritional rules can cause single bouts of vomiting with bile.

Chronic calculous cholecystitis

The chronic stage of development of calculous cholecystitis is characterized by the presence of stones in the gallbladder, a mild inflammatory process and periodic manifestations of the disease.

The chronic period can be almost asymptomatic or manifest itself with bouts of hepatic colic. With a latent form of the disease, a person experiences a feeling of heaviness on the right side of the hypochondrium. Suffers from flatulence, diarrhea, heartburn, belching, feels bitterness in the mouth. After overeating or fatty foods, the unpleasant symptoms worsen.

Hepatic colic can occur suddenly, in most cases it is preceded by a violation of the diet, hard physical labor, transferred psycho-emotional stress. An attack of colic causes spastic contractions of the gallbladder and its pathways, caused by irritation of mucous stones. There is an acute stabbing pain of varying intensity, localized in the right hypochondrium and radiating to the right side of the shoulder, scapula and neck. The duration of an attack can vary from a few minutes to a couple of days.

Colic may be accompanied by fever, vomiting, which does not relieve the patient's condition. Patients are agitated, and pulse dynamics may be slow, rapid, or arrhythmic. Blood pressure changes insignificantly. Reflex angina pectoris may develop in older patients.

At the time of the attack, the tongue becomes wet, plaque may be present, the abdomen is tense, swollen, painful in the region of the right hypochondrium, epigastrium. A blood test does not reveal any abnormalities, the gallbladder and liver are not enlarged, and there are no symptoms of peritoneal irritation.

An attack of colic stops suddenly, the patient experiences relief, weakness and weakness.

Acute calculous cholecystitis

Acute calculous cholecystitis is understood as a pronounced inflammation of the gallbladder, which contains calculi.

This form of the disease ranks second in terms of frequency of occurrence in the list of acute diseases of the abdominal organs. In most cases, it is complicated by concomitant ailments.

The development of an acute form of calculous cholecystitis is caused by an infection that has penetrated into the gallbladder, as well as an impaired outflow of bile. Staphylococci, Pseudomonas aeruginosa and Escherichia coli, enterococci and other microbial flora can enter the ascending and descending routes (from the duodenum and liver, respectively), as well as lymphogenous and hematogenous. Obstruction of the outflow of bile leads to clogging of stones in the cystic duct or the neck of the gallbladder, pathological processes in the periampullary zone. In addition, the development of an acute form of the disease is facilitated by changes in the vessels of the organ caused by atherosclerosis, damage to its mucous membrane by pancreatic enzymes, provoked by pancreatobilinar reflux.

Acute calculous cholecystitis is divided into three types:

1. catarrhal;
2. phlegmonous;
3. gangrenous.

All these forms of the disease are accompanied by pericholecystitis, which is characterized by a local or widespread adhesion process that limits the area of infection to the exclusively right hypochondrium.

The acute form of the disease is manifested by sharp pain that increases with any physical activity, nausea, repeated vomiting of a reflex nature.

On examination, dryness of the tongue, slight bloating of the abdomen, its limited participation in the breathing process, muscle tension and soreness in the projection area of the gallbladder, which has an enlarged, tense structure, are revealed. The body temperature is elevated, the blood test shows neutrophilic leukocytosis and increased ESR.

The duration of the course of the acute form of the disease can reach several weeks. Gradually, it turns into a chronic stage or complications appear.

Phlegmonous calculous cholecystitis

In the case when calculous cholecystitis is complicated by purulent inflammation, accompanied by infiltration of the gallbladder and the appearance of ulcers on its mucous membrane, it means that the disease has entered the phlegmonous stage. In this case, the organ wall is greatly thickened due to the abundant absorption of the inflammatory exudate. The gallbladder is greatly enlarged, filled with pus. The mucous membrane is hyperemic, coated with fibrin.

The patient experiences severe pain, which increases from changes in position, breathing, coughing. The general condition of a person worsens, the temperature rises, nausea and repeated vomiting appear, the pulse reaches 120 beats per minute. The abdomen is slightly swollen due to intestinal paresis, palpation of the right hypochondrium is painful, reveals an enlarged gallbladder. If phlegmonous calculous cholecystitis is not treated in time, it can turn into a gangrenous form, which is dangerous with the likelihood of death.

Gangrenous calculous cholecystitis

This most dangerous stage of the disease is also called gallbladder gangrene. This form of cholecystitis is characterized by partial or total necrosis of the bile organ wall, which develops against the background of cystic artery thrombosis. The onset of gangrene is noted on the 3-4th day of illness. Perforation (through violation of the integrity) of the bladder wall may occur, followed by the outflow of bile into the peritoneal cavity and the appearance of biliary peritonitis. The openings are usually localized on the neck of the gallbladder or in Hartmann's pocket, in places where stones accumulate.

Gangrenous calculous cholecystitis is more characteristic of the elderly, whose regenerative abilities are reduced and the blood supply to the gallbladder is weakened.

This form of the disease can be caused by infections coming from adjacent communicating organs, blood and lymph.

The gangrenous form of calculous cholecystitis is evidenced by a sharp increase in temperature against the background of the absence of complaints of well-being, usually appearing at night. The pain syndrome is pronounced, has a spasmodic character and can occupy not only the right region, but also spread to the entire abdomen. The pains are long and intense. The condition is complicated by nausea and vomiting, constipation or diarrhea, headaches, weakness, pallor and dampness of the skin, rapid breathing, drowsiness, fainting, bloating and abdominal distension. Signs of jaundice may be observed.

Treatment of calculous cholecystitis

Therapy for this disease is aimed at solving the following problems:

• stop an acute condition;
• prevent complications;
• eradicate the factors contributing to the formation of new calculi.

Treatment of calculous cholecystitis can be carried out by conservative and surgical methods. The first includes diet therapy, taking painkillers and antispasmodic drugs, antibacterial, detoxification therapy, and antiemetics. The second is focused on the removal of the gallbladder and calculi.

In most cases, surgery is the best way to get rid of the disease, as it removes the very source of the stones. Then conservative measures are used to stabilize the patient's condition and prepare him for surgery.

There are several types of surgical intervention for the treatment of calculous cholecystitis:

• Laparoscopy. Several incisions are made on the abdomen, through which special instruments and an optical device - a laparoscope, are inserted, which transmits an image to the monitor. Extensive opening of the peritoneum is not required, therefore, the period of postoperative recovery is shortened and the appearance of the operated person does not suffer.
• Open surgery. The gallbladder is removed through an abdominal incision. The method is used in severe cases, with a detected infection of the gallbladder or the presence of cicatricial adhesions in the abdomen after previous operations. The postoperative period is longer and requires hospital stay.
• Percutaneous cholecystostomy. A drainage tube is inserted into the gallbladder through a small incision in your abdomen. It is used for the course of elderly and severe patients who have complications of acute cholecystitis.

When the removal of the gallbladder is impossible for certain indicators, nonsurgical crushing of stones with medications or with the help of extracorporeal shock wave lithotripsy (ESWL) is prescribed. But with treatment with such methods, there is a risk of re-formation of calculi.

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.