Before performing surgery, it is important to make sure that the bile ducts are passable - this is necessary for the free flow of bile into the intestines. Aspects such as the presence or absence of stones in the gallbladder and the presence are not of fundamental importance.

The primary role is played by the severity of inflammation, its localization and prevalence to nearby organs, as well as signs of impaired supply to the duodenum.

In what cases can you do without surgery

So, in the first 24 hours after cholecystectomy, complete fasting is recommended. From the second day, the patient will be offered mashed vegetable food, fruit drink or compote. On the third day, light fermented milk products are allowed - yogurt or kefir, milk soup, jelly. From the fourth day, the diet begins to expand, adding raw fruits and vegetables, meat dishes to it.

If the rehabilitation period proceeds without complications, after 7 days the patient completely switches to. The main task of this nutrition system is a gentle load on the liver and the normal functioning of the organs of the digestive tract.

At the heart of the diet table number 5, the following principles can be distinguished:

1. Daily calorie content 2400-2800 kcal. The exact figure depends on the sex, weight, age and health of the patient.
2. Nutrient intake in a certain ratio: proteins of plant and animal origin in proportions 50/50, up to 80 gr, fats of vegetable and animal origin in proportions 30/70, up to 90 gr, carbohydrates, mostly complex, up to 350 gr.

1. Compliance with the drinking regime - at least 1.5 liters of clean water per day.
2. Limit salt intake to 10 grams per day.
3. Dishes at dietary table number 5 should be prepared in gentle ways. You can only eat raw vegetables and fruits that are not banned by the diet. In other cases, heat treatment of products in the form of stewing, boiling, baking should be carried out.
4. Food is important to eat warm.

Possible Complications

After cholecystectomy, early, late and postoperative complications are possible.

Early complications include bleeding caused by slipping of the ligature or metal clips applied to the blood vessels, as well as due to difficulties in removing the gallbladder from the abdominal cavity, for example, as a result of adhesive growth of nearby organs or if there are too large calculi in organ.

In case of bleeding, a second operation is performed to eliminate it and remove blood from the abdominal cavity. Perhaps transfusion of blood or plasma, infusion therapy with colloidal and saline solutions.

Also, an early complication may be biliary peritonitis resulting from bile entering the abdominal cavity, subdiaphragmatic and subhepatic abscesses with corresponding symptoms. In these cases, a second operation is also necessary, during which abscesses are opened, the consequences are removed, and bile drainage is restored. Antibiotic therapy is mandatory.

A late complication of cholecystectomy can be. This condition develops as a result of scarring of the bile ducts, the appearance of tumors of unknown origin, or stones in the bile ducts.

To normalize the outflow of bile, a second operation is necessary. Less commonly, a patient is diagnosed with external bile fistulas that appear after an injury to the bile duct, which also requires surgical intervention.

Postoperative complications after resection of the gallbladder are improper ligation of the cystic duct, damage to the portal and hepatic veins. Damage to the portal vein is often the cause of death of the patient on the operating table.

To reduce the likelihood of this, it is important to contact a specialized medical institution for cholecystectomy by qualified surgeons who know the rules and techniques of surgical intervention.

Reducing the risk of complications from cholecystectomy is easy. The main thing is to undergo a complete diagnostic examination before the operation and find out if there are any contraindications to its implementation. The procedure itself should be entrusted only to an experienced surgeon. Late complications can be avoided by following a special diet and a healthy lifestyle.

Useful video about gallbladder removal

Cholecystitis is a pathological condition in which inflammatory and degenerative changes develop in the gallbladder. Various reasons can lead to the development of this disease. As a rule, it develops as a result of obstruction of the bile duct (choledochus) in cholelithiasis.

Obstruction of the duct by gallstones is accompanied by an increase in bile pressure and its accumulation in the gallbladder. The attachment of a bacterial infection leads to inflammation, swelling and damage to its wall.

These changes are accompanied by a violation of the normal blood flow to the tissues and the development of degenerative changes. Treatment of cholecystitis should include not only the removal of symptoms, but also the elimination of the primary pathology (GSD).

Anatomy of the biliary tract (Fig. 2)

Classification of cholecystitis

According to the variant of the clinical course, there are:

1. Acute cholecystitis.

- Chronic calculous cholecystitis
- Chronic acalculous cholecystitis

For chronic cholecystitis, there is also a classification according to severity:

1. Mild (cholecystitis worsens 2 times a year or less);
2. Medium (cholecystitis worsens more than 3 times a year);
3. Severe (cholecystitis worsens once a month or more).

Depending on the changes occurring in the gallbladder, the following forms of cholecystitis are distinguished:

catarrhal cholecystitis. With this form, the bile duct increases in size, its mucous membrane is edematous, the walls are thickened and infiltrated. Mucus and exudate containing epithelial and lymphoid cells accumulate in the lumen of the bile duct.

Phlegmonous cholecystitis. With this form, the bile duct increases significantly, strains, becomes covered with a fibrous film, its walls thicken, become saturated with pus. Purulent-bloody exudate accumulates in the lumen of the bile duct. In small arteries, blood clots form, focal phenomena of necrosis occur. In this case, inflammatory changes can spread to neighboring organs and the peritoneum. At the same time, diffuse or diffuse bile-purulent peritonitis develops.

Gangrenous cholecystitis. It develops in case of accession of an infection that is caused by Escherichia coli (less often anaerobic microorganisms). Gangrenous cholecystitis is a common complication of phlegmonous inflammation. This occurs when the body's immune response is insufficient to suppress the growth of pathogenic microorganisms. In some cases, primary gangrenous cholecystitis may develop when the cystic arteries undergo thrombosis, and an acute circulatory disorder occurs.

Reasons for the development of cholecystitis:

1. Mechanical. The outflow of bile is disturbed due to the presence of a mechanical obstruction (stone) in the bile ducts, which can be located in various parts of the bile ducts (cervical part of the gallbladder, cystic bile duct or common bile duct). Scarring of the bile duct wall or its local narrowing can also prevent the outflow of bile.

2. Functional. This includes all functional disorders that lead to difficulty in the normal outflow of bile:

• Dyskinesia of the duct wall with impaired motility;
• Atony (decrease in tone) of the walls of the gallbladder;
• Atrophy of the smooth muscles of the gallbladder wall.

3. Endocrine. This group of causes includes hormonal deficiency conditions that lead to atony of the gallbladder wall. An example of such disorders may be a decrease in the level of cholecystokinin. This hormone is secreted by the duodenum in response to food intake. Normally, it stimulates the smooth muscles of the gallbladder, causing the secretion of bile. With its insufficiency, biliary hypertension occurs.

4. Chemical. This includes enzymatic cholecystitis. It develops due to reflux (reverse reflux) of pancreatic juice into the gallbladder. At the same time, its wall is damaged due to the aggressive action of proteolytic enzymes, which is accompanied by the development of foci of necrosis. Such cholecystitis is a frequent complication of pancreatitis.

5. Infectious. Violation of the passage of bile is very often accompanied by the addition of a bacterial infection that spreads with the blood or lymph flow. Most often, infection occurs with staphylococci, Klebsiella, Proteus, Escherichia coli and some anaerobic microorganisms. The presence of an infectious agent in patients with cholecystitis is detected in 50-60% of cases.

6. Vascular. This group of reasons is especially relevant for older and older people. Local circulatory disturbance, which occurs as a result of embolism or thrombosis of the cystic artery, leads to the development of dystrophic disorders in the gallbladder. Chronic bile stasis can also cause characteristic vascular changes, causing the development of acute cholecystitis.

Clinical symptoms of chronic cholecystitis

Chronic cholecystitis is characterized by an undulating course with recurrent exacerbations and remissions. The predominant symptom of this pathology is pain, and it occurs only during periods of exacerbation. The pain is usually felt in the region of the right costal arch, sometimes under the xiphoid process, and lasts for several days.

The onset of pain, as well as their further intensification, is usually associated with a violation of the usual diet, infection, excessive physical stress or exposure to physical factors (cold). The pain may increase against the background of a violation of the diet: the use of fatty and spicy foods, fried foods, alcoholic beverages, as well as after mental stress. Attacks of pain may be accompanied by fever, transient nausea, vomiting and diarrhea.

In chronic acalculous cholecystitis, the pain syndrome can develop as colic. The pain is localized in the region of the right hypochondrium and subsides after taking antispasmodics and analgesics. Vomiting for chronic acalculous cholecystitis is not typical and occurs relatively rarely.

Chronic calculous cholecystitis is accompanied by a more pronounced pain syndrome (hepatic colic). It appears when the bile duct is infringed and obstructed during the passage of a stone through it.

Pain is usually intense, characterized by a sudden onset, paroxysmal in nature. With exacerbation of calculous cholecystitis, jaundice is often noted, associated with a sharp violation of the outflow of bile.

Clinical symptoms of acute cholecystitis

Acute cholecystitis, as well as an exacerbation of its chronic form, begins with a feeling of severe pain under the costal arch on the right (it can radiate to the lumbar and right subscapular region). Pain begins suddenly, usually at night, 2-3 hours after eating (fatty or spicy), or prolonged physical work.

From the first minutes, the pain syndrome reaches its greatest intensity. Such an attack is often accompanied by severe nausea and repeated vomiting, which does not bring proper relief. There is an increase in temperature, the nature of which depends on the severity of the condition. Patients have moderate icterus (jaundice) of the skin and mucous membranes. Severe jaundice indicates the occurrence of an obstacle (a stone in the lumen of the duct) on the way out of bile into the intestinal lumen.

All patients with symptoms of exacerbation of cholecystitis should be treated inpatient and subject to hospitalization on an emergency basis. If there is no adequate response to ongoing drug treatment within two days, and the patient's health does not improve, then emergency surgery is indicated.

Treatment of chronic and acute cholecystitis

Chronic calculous cholecystitis cannot be cured conservatively. According to modern concepts, surgical treatment of cholecystitis in the acute stage should be active-expectant.

A number of authors consider it unreasonable to adhere only to expectant tactics, since the desire to eliminate the inflammatory process by conservative means can cause serious complications.

The principles of active-waiting tactics are:

• Urgently operate patients with gangrenous and perforated cholecystitis, as well as with cholecystitis complicated by diffuse peritonitis
• Operate urgently (24-48 hours after admission) in patients with ineffective treatment and increasing intoxication

Conservative treatment of chronic cholecystitis can only be used as an adjunct to surgical methods. In the period of remission, drug treatment is aimed at reducing the risk of stone formation (reducing hypercholesterolemia) and correcting the drainage function of the biliary tract.

This is achieved by following a special diet, which limits the use of eggs, animal fats, canned food and alcohol. With increased motility of the biliary tract, antispasmodics and choleretic agents are prescribed.

In the early period of development of acute cholecystitis, in the absence of intoxication, peritonitis and other complications, conservative treatment is also carried out. It includes antibacterial therapy, electrolyte balance correction, the use of antispasmodics and analgesics (including novocaine blockade).

The goal of such therapy is to suppress the development of inflammation and edema in the ducts and gallbladder and improve the passage of bile. The appointment of antispasmodics allows not only to relieve pain, but also to eliminate the spasm of the sphincter of Oddi.

Lipoic acid preparations, sirepar, methionine and glutamic acid are prescribed to eliminate metabolic disorders in the liver. With enzymatic cholecystitis or exacerbation of pancreatitis, a strict diet must be observed (up to complete hunger).

In addition, anti-enzymatic drugs are prescribed (kontrykal, trasilol).
To correct metabolic disorders, infusion therapy is prescribed: Ringer-Locke solution, glucose solution, potassium chloride solution, protein preparations, blood plasma, alvesin, albumin. Against the background of aggravated intoxication, there is a danger of developing liver failure.

For the purpose of detoxification, gemodez, polydez, neodez are prescribed. With the introduction of these funds, the phenomena of cholecystitis in some cases subside in the next 2-3 days.

In acute cholecystitis, the correct choice of antibacterial drugs is important. It is recommended to prescribe the following antibiotics:

• Ampicillin (4 times a day, 50-100 mg / kg);
• Cephalosporins (ceporin, kefzol, 40-100 mg/kg 4 times a day);
• Gentamicin (40 mg/kg, 2-3 times a day).

With the failure of conservative treatment, especially with the development of cholangitis, after confirming the diagnosis and short-term preoperative preparation, surgical intervention is performed.

In severe cholecystitis, there are almost no absolute contraindications to surgery. To save the life of patients, sometimes it is necessary to resort to surgery, even in patients who are in serious condition. Urgent surgical intervention is indicated for phlegmonous and gangrenous cholecystitis, obstructive jaundice and the development of purulent-inflammatory complications.

A conservative method of treatment is used only for catarrhal and bacterial cholecystitis and in those cases of phlegmonous cholecystitis, when serious complications have not yet developed, and the disease proceeds without symptoms of diffuse or mild local peritonitis.

In all other cases of acute cholecystitis, patients should undergo surgery for urgent and prompt indications.

The main task of the treatment is to remove the gallbladder (the site of formation of stones), remove stones from the biliary tract, restore the free passage of bile and create all conditions to prevent possible relapses.

To achieve these results, rational tactics and a differentiated approach to surgical intervention are required.

The volume of intervention depends on the severity of the disease and the presence of characteristic lesions of the biliary tract. The method of treatment is determined after a thorough revision of the bile ducts.

It is performed using both destructive research methods (probing) and intraoperative cholangiography. The data obtained allow us to reliably judge the patency of the bile ducts.

With cholecystitis, in addition to removing the gallbladder itself and stones, it is necessary to restore the outflow of bile in order to prevent the process of choledocholithiasis (stone formation). For this purpose, a cholecystectomy is performed. When the common bile duct is closed, its patency is restored. For this, choledochotomy is performed, stones are removed, after which the patency is again checked with a probe.

Further tactics of the operation depends on the nature of the identified changes, the age of the patient and his general condition. In the presence of complications (diffuse peritonitis, concomitant diseases), it is considered appropriate to perform the operation according to the changes in the biliary tract.

It is necessary not only to remove the inflamed gallbladder, but also to eliminate the hypertension detected in the biliary tract by draining the bile duct, especially in the presence of cholangitis and pancreatitis. The bile duct is dissected and drained not only to remove stones from its lumen, but also in the presence of sand, purulent bile and severe inflammation in it.

In excessively weakened patients and elderly people, it is indicated to perform an easier operation - cholecystostomy (removal of stones and purulent contents from the gallbladder). This operation, although it is a palliative intervention, makes it possible not only to eliminate inflammation in the gallbladder, but also to save the life of such patients.

After some time, with the re-development of acute cholecystitis, patients can be re-operated by performing a radical operation.

Conclusion

With timely treatment, the prognosis of the disease is favorable. Most patients recover within 1-3 weeks. Removal of the gallbladder completely prevents the possibility of recurrence.

About 70% of all patients with cholecystitis are elderly people. Therefore, it often proceeds with the development of complications that cause a high lethality of this disease (6-10%). With the development of complications of cholecystitis, such as perforation of the gallbladder, cholangitis, pancreatitis, the prognosis remains doubtful.

Inflammation of the gallbladder is called acute cholecystitis. The disease develops rapidly and is a complication of gallstone disease (). At the same time, the outflow of bile stops, microbes multiply in it. The pressure inside the gallbladder increases and it becomes like an inflated ball. The walls of the organ become inflamed.

Sometimes the disease occurs without stones in the bile ducts and develops with impaired blood supply (acalculous cholecystitis). This type of disease is more common in older people, and more often in females.

Causes

• Gallstone disease (blockage of the duct by a stone).
• Hypertension in the bile ducts.
• Diet violations.
• Change (due to atherosclerosis) of vessels in the biliary tract.
• Gastric diseases that are accompanied by dyscholia.

In case of violation of the closing function of the sphincters located in the common bile duct, a spasm occurs. This causes hypertension and leads to a delay in bile secretion.

Acute cholecystitis (in 80 - 90% of cases) is a complication of cholelithiasis. At the same time, calculi (stones) that are in the lumen of the gallbladder for a long time violate its contractile function and the integrity of the mucous membrane.

Also, the cause may be anacid gastritis (with a decrease in the production of gastric juice). In this case, from the upper parts of the digestive canal, the pathogenic microflora enters the gallbladder from the lumen of the duodenum.

The development of the disease also occurs with local ischemia of the mucous membrane of the bladder (in the presence of pathogenic microflora).

Symptoms

Since acute cholecystitis mainly occurs in patients with cholelithiasis, its symptoms are superimposed on the symptoms of this disease.

Acute pain in the right hypochondrium is the main symptom of the disease. In localization and strength, it is similar to biliary colic. However, the pain is more severe and lasts more than 6 hours.

Nausea and vomiting are characteristic of an attack.

Some time after the onset of the disease, Murphy's symptom appears, in which a deep breath increases pain in the gallbladder when it is probed. There is also a protective muscle tension on the right in the upper abdomen.

Many patients have a mild fever.

In elderly patients, the only or first symptoms may be:

• Weakness.
• Lack of appetite.
• Vomit.
• Increased temperature.

Manifestations of acalculous acute cholecystitis are similar to those in the presence of stones in the bile ducts. Sometimes the manifestations of the disease can be acute fever or bloating.

Differentiation from other diseases

Most often, acute cholecystitis has to be differentiated from acute pancreatitis, renal colic, acute appendicitis, and perforated duodenal or gastric ulcer.

Acute appendicitis

If the appendix is ​​located high, it (with exacerbation) can simulate acute cholecystitis. However, acute cholecystitis occurs with irradiation of pain in the shoulder, right shoulder blade and repeated vomiting of bile.

Acute appendicitis has a more severe course, with it the rapid development of peritonitis is possible.

Renal colic

Renal colic is characterized by the development of acute pain in the lumbar region, which radiates to the genitals. Leukocytosis and fever are absent. There are no symptoms of peritoneal irritation.

Acute pancreatitis

Acute pancreatitis occurs with rapidly developing signs of intoxication, intestinal paresis, tachycardia. The pain is girdle in nature, and is localized in the left hypochondrium. Accompanied by indomitable vomiting.

Diagnosis (differential) of acute pancreatitis and acute cholecystitis is extremely difficult. It is carried out only in a hospital setting.

Diagnostics

The patient is examined of the sclera (to detect the onset of jaundice), the temperature is measured, and the abdomen is palpated.

One of the main signs of the disease is Murphy's syndrome. To check it, the doctor puts his hand under the right hypochondrium, asks him to take a deep breath and hold his breath. The gallbladder is pushed out towards the doctor's hand. When it becomes inflamed, it causes severe pain. This is Murphy's positive symptom.

Also carry out diagnostic procedures:

Treatment

• In the first 2 days of an exacerbation of the disease, a strict diet must be observed; on the following days, mineral water, fruit and vegetable puree, meat (low-fat varieties), sour-milk products, compote, cereals are allowed.
• Twice a day for 2 hours put an ice pack on the stomach.
• Antispasmodics: papaverine or no-shpa (twice a day, 2 ml intramuscularly) for a week.
• Antibiotics (to suppress infection). In the acute form of the disease, they are administered intravenously or intramuscularly (metronidazole 500 mg plus ceftriaxone 2 g every 8 hours).
• To get rid of pain, opioid analgesics (morphine, omnopon) are prescribed. Complement with ketorolac to suppress inflammation.
• If medical treatment fails, a cholecystectomy (removal of the gallbladder) is prescribed. The operation prevents the development of complications, prevents inflammation and eliminates pain. Cholecystectomy, which is performed during the first 2 days, is preferable in elderly patients, diabetics.
• Endoscopic surgery is an alternative to conventional surgery for patients with high surgical risk (elderly patients with acalculous cholecystitis, for those in the intensive care unit with respiratory failure, burns, injuries).
• If patients have severe comorbidities that increase the risk of surgical interventions, cholecystectomy is postponed until the condition stabilizes. If the attack passes, the operation can be performed after 6 weeks and even later.

Consequences and prognosis

With proper and timely treatment, the prognosis is favorable. In the absence of medical assistance, the development of perforations and gangrene is possible, which is fraught with a fatal outcome.

With inadequate treatment, the disease can become chronic.

Removal of the gallbladder usually does not impair quality of life. The liver continues to produce bile, which flows directly into the duodenum. But in some cases, postcholecystectomy syndrome may develop. After surgery (at first), patients may develop soft and frequent stools, but this will resolve with time. Only in 1% of cases, operated patients report persistent diarrhea. In this case, you need to limit yourself to spicy and fatty foods and exclude dairy products from the diet. But vegetables and foods rich in fiber, it is desirable to consume more.

We must not forget that in chronic cholecystitis it is necessary to observe a special way of life. Its violation leads to an exacerbation of the disease, which, of course, worsens the prognosis.

If surgery was performed according to emergency indications, the prognosis is worse.

Traditional medicine

• Pour three large leaves of celandine with a glass of boiling water. Half an hour to insist and strain. Take 1 teaspoon 3 times a day (20 minutes before meals).
• A combination of a daily enema (water temperature - 30 degrees) and fasting gives an excellent effect.
• Mix 1 glass of honey, 1 glass of carrot juice, 1 glass of cognac, 1 glass of beetroot juice (keep in a cool place). Take ½ cup a day 3 times 20 minutes before meals.
• Crush (in ceramic or glassware) 20 g of anise seeds and pour 500 g of white wine. Insist for a day. Take 3-4 tablespoons 3 times a day after meals. Course - 10 days.
• Mix a quarter cup of grapefruit juice with the same amount of olive oil. Drink in the evening (before going to bed) no earlier than 60 minutes after eating. Before use, it is advisable to make a cleansing enema.

Diet

You can eat:

• Cereals (except millet), casseroles, puddings.
• Berries and fruits (boiled, baked, fresh).
• Sauces (sour cream, milk).
• Sweet dishes (honey, jelly, kissels, compotes).
• Useful dairy products.

• Smoked meats, sausages, heavy fats.
• Sour vegetables and fruits.
• Legumes.
• Alcohol.
• Fish and meat broths.
• Fried meals.

You need to eat 5 times a day. Food temperature 15 - 60 degrees. More about nutrition.

Prevention

Prevention is prompt timely treatment of gallstone disease.

If you suspect that you have cholecystitis, be sure to consult a hepatologist. He will prescribe an examination and treatment of the disease.

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With untimely diagnosis or treatment, acute cholecystitis leads to the development of a number of serious complications, which in some cases can lead to life-threatening consequences. Specialists classify them, taking into account the form of the course of the disease.

In this article, we will introduce you to the possible complications of acute cholecystitis. You will be able to understand what this ailment sometimes leads to and make the right decision about the need for a timely visit to the doctor with the development of this disease.

Why Complications Develop

The untimely appeal of the patient to the doctor is one of the most common causes of the development of complications of acute cholecystitis.

The following factors can lead to the development of complications arising from acute cholecystitis:

• untimely visit to the doctor;
• unprofessionalism of a specialist;
• the root cause of the development of acute cholecystitis is an infectious agent;
• development of peritonitis;
• the formation of an intestinal fistula;
• the presence of an inflammatory process in the pancreas.

With incorrect or untimely diagnosis of cholecystitis, the disease can become chronic. As a result, the patient may experience the following consequences of the disease:

• reactive hepatitis;
• reactive pancreatitis;
• pericholecystitis, etc.

Complications

Empyema of the gallbladder

With this consequence of the disease, purulent exudate accumulates in the cavity of the gallbladder due to blockage of the cystic duct and infection of bacterial origin. Due to such processes in the patient:

• the temperature rises to high levels;
• intense pain occurs;
• symptoms of intoxication develop.

Empyema of the gallbladder can be detected using the following studies:

• bacterial blood culture;
• Ultrasound of the liver and bile ducts.

To treat such a complication of acute cholecystitis, the patient is prescribed:

• antibacterial drugs before and after surgery for cholecystectomy, administered intravenously, and after stabilization of the condition - orally;
• detoxification therapy before surgery.

In some clinical cases, when the patient's condition is severe, the operation is postponed until the patient stabilizes, and as a temporary measure, decompression of the gallbladder is performed. This requires the installation of transhepatic drainage, which is performed under x-ray control.

Without timely surgical treatment, gallbladder empyema can be fatal. Such a prognosis largely depends on the presence of complications and the stage of the pathological process. In cases where this complication is detected on time and the patient does not show signs of perforation or blood poisoning, the outcome may be favorable.

To prevent the development of pleural empyema, timely treatment should be carried out or. Patients with immunodeficiency states, or hemoglobinopathies, should undergo regular preventive examinations, including studies such as ultrasound of the liver or abdominal organs.

Peripesical abscess

This complication of acute cholecystitis can develop 3-4 days after the onset of inflammation of the gallbladder. In a patient, an inflammatory infiltrate is formed around this organ, which at first looks like a conglomerate loosely adjacent to the tissues. At this stage of the pathological process, the abscess can be easily removed surgically. At more advanced stages, the formed infiltrate increases in size, grows into the surrounding tissues, and its treatment becomes more difficult.

When a perivesical abscess occurs, the patient experiences the following symptoms:

• stomach ache;
• vomiting and nausea;
• dry mouth;
• fever with chills;
• pain on movement.

If, against the background of the emerging complication, the patient takes antibacterial agents, then the abscess may not manifest itself with tangible symptoms. In such cases, a physical examination is not enough to identify the pathological process and a dynamic ultrasound examination is necessary.

Gallbladder perforation

With such a complication, a rupture of the organ wall occurs. The fluid contained in the gallbladder can enter the abdominal cavity. Subsequently, the patient may develop adhesions, subhepatic abscess and local peritonitis. In addition, intrahepatic abscesses and can develop.

The greatest likelihood of such a complication of acute cholecystitis is observed in elderly patients with gallstones with bouts of colic and patients with sickle cell and severe systemic diseases, diabetes mellitus.

With the development of perforation, the patient has the following symptoms:

• long-lasting pain syndrome in the right side, radiating to the scapula and right shoulder;
• the appearance of symptoms of an acute abdomen;
• high fever;
• vomiting of bile;
• nausea;
• signs of liver failure and hepatorenal syndrome;
• oppression of respiratory and cardiovascular activity;
• intestinal paresis and its obstruction.

If treatment is delayed, this complication can lead to death.

To detect perforation of the gallbladder, the doctor prescribes ultrasound studies to identify stones and effusion around the organ or the development of peritonitis, intrahepatic or interloop abscess. If it is necessary to obtain a more detailed clinical picture, CT or MSCT of the studied areas is performed.

For the treatment of perforation of the gallbladder, the patient is immediately transferred to the intensive care unit or operating room. At the stage of preparation for the upcoming surgical intervention, the patient is given antibacterial, infusion and analgesic therapy. Such measures are necessary to partially eliminate multiple organ failure, and after the stabilization of the patient's condition, the surgeon performs the operation.

Purulent diffuse peritonitis

With the initial development of this form of peritonitis, which occurs against the background of acute cholecystitis, serous-purulent exudate is formed in the abdominal cavity. Initially, almost all patients develop pain in the abdomen and vomiting and nausea occur. However, with a lightning-fast or uncharacteristic course of the disease, such patient complaints may be absent.

Due to severe pain, the patient has to take a forced position in bed, and some patients show signs of fever. On examination, the doctor may notice moderate tension in the abdomen and its non-participation in the breathing process. When probing the abdomen, a more active intestinal motility is initially determined, but over time it weakens.

After 1-3 days, the patient's condition worsens due to an increase in inflammation. He develops uncontrollable vomiting, leading to the appearance of fecal masses in the discharge from the oral cavity. The patient's breathing becomes superficial, the activity of blood vessels and the heart is disrupted, the abdomen swells, becomes moderately tense, the separation of gases and feces from the intestines stops.

At the irreversible stage of purulent peritonitis, the patient's skin acquires an earthy hue and becomes cold to the touch. Consciousness is disturbed to the manifestations of "travel fees" (the patient collects imaginary objects, does not react to the environment, catches midges in front of his eyes, etc.), and blood pressure and pulse indicators are almost not determined.

The transition to the stage of diffuse peritonitis can be lightning fast, and then it is impossible to separate one stage of the development of the pathological process from another.

To identify signs and symptoms of purulent peritonitis, the doctor prescribes blood tests, ultrasound, ECG and plain radiography. If difficulties arise in the diagnosis, the patient undergoes diagnostic laparoscopy. With such a study, the doctor can take an inflammatory exudate for seeding on the sensitivity of the pathogen to antibacterial drugs. If diagnostic laparoscopy is not performed, then the degree of intensity of inflammation is determined by the level of leukocytes in the blood.

To eliminate purulent peritonitis, only surgical treatment should be carried out. Before the intervention, medical preparation of the patient is carried out, aimed at eliminating anemia, electrolyte imbalance, detoxification and suppression of pathogenic flora.

To anesthetize operations, general anesthesia is performed, and the intervention itself can be performed according to classical methods or using video-laparoscopic surgery.

Gangrene of the gallbladder

With this complication, purulent contents accumulate in large quantities in the cavity of the gallbladder. This consequence of acute cholecystitis is caused by obstruction of the cystic lumen, which is provoked by an infectious process of a bacterial nature.

When such a complication occurs, pain occurs in the right hypochondrium, the temperature rises and intoxication develops. In addition, the patient may experience yellowness of the sclera.

When probing the abdomen, an enlarged gallbladder is determined, the size of which does not change with time. At any time, it can rupture and lead to peritonitis. In the future, if the infection has entered the bloodstream, then the patient develops sepsis, which can lead to severe outcomes.

To identify gangrene of the gallbladder, the doctor prescribes a series of examinations to the patient to assess the degree of the inflammatory process, intoxication of the body and obstruction of the organ. For this, the following studies are carried out: ultrasound, clinical tests and. In the future, to select the tactics of therapy after surgery, an analysis is prescribed to determine sensitivity to pathogenic microflora.

For the treatment of gangrene of the gallbladder, surgical treatment should be carried out, aimed at removing the organ affected by the purulent process. In addition, the patient is prescribed antibiotics that suppress bacterial inflammation. If in the next few hours the surgical intervention cannot be performed, then against the background of drug preparation, the patient is decompressed the gallbladder with a drain installed in the liver.

Pancreatitis

Acute cholecystitis can lead to the development of inflammation in the pancreatic tissue.

Arising against the background of acute cholecystitis can be provoked by the activation of pancreatic enzymes. This process leads to inflammation of the tissues of the gland. With a mild process, the affected organ can be cured, and with a severe one, pronounced destructive processes or local complications occur in the gland, consisting in necrosis, infection or encapsulation. In severe cases of the disease, the tissues surrounding the gland are necrotic and encapsulated by an abscess.

With the development of acute pancreatitis, the patient develops pains of an intense nature, they are constant and become stronger when trying to lie on his back. In addition, the pain syndrome is more intense after eating (especially fatty, fried or spicy) and alcohol.

The patient experiences nausea and may experience uncontrollable vomiting. The body temperature rises, and the sclera and skin become icteric. Also, with acute pancreatitis, the patient may show signs of indigestion:

• bloating;
• heartburn;
• hemorrhages on the skin in the navel;
• bluish spots on the body.

To identify an acute inflammatory process in the pancreas, the patient undergoes a study of blood and urine parameters. To identify structural changes, instrumental studies are performed: ultrasound, MRI and MSCT.

Treatment of acute pancreatitis is pain relief and bed rest. To eliminate inflammatory processes are prescribed:

• bed rest and rest;
• hunger;
• enzyme deactivators;
• antibiotic therapy.

Pain can be eliminated by performing novocaine blockades and antispasmodic drugs. In addition, detoxification therapy is carried out. If necessary - the appearance of stones, the accumulation of fluid, necrotization and abscess formation - the patient undergoes a surgical operation.

The success of the treatment of pancreatitis depends on the severity of pathological changes in the tissues of the gland. The duration of therapy also depends on these indicators.

In some cases, acute pancreatitis can cause the following complications:

• shock reaction;
• gland necrosis;
• the appearance of abscesses;
• pseudocysts and subsequent ascites.

Biliary fistulas

A fistula of the gallbladder in acute cholecystitis can form in rare cases with a long course of cholelithiasis. Such a pathology occurs when a surgical operation is not performed in time and is detected in approximately 1.5% of patients with calculous cholecystitis and stones in the gallbladder.

Preoperative detection of fistulas is often difficult due to the absence of obvious clinical manifestations. Sometimes the first sign of such a pathological process is the appearance of large stones in the feces or vomit. More often, getting a calculus into the digestive organs leads to intestinal obstruction.

The development of cholangitis can be caused by the movement of infection through the fistula. Clinically, this pathology is accompanied by the occurrence of weakness, chills, diarrhea and increased pain. In the long term, symptoms are manifested by jaundice and toxic cholangitis.

With an external fistula of the gallbladder, an open fistulous tract appears on the anterior abdominal wall, from which bile, mucous secretions and small stones flow. In the expiration, pus, dyspepsia and steatorrhea can be observed, leading to emaciation.

In some cases, biliary fistulas cause acute pain, shock, respiratory distress, bleeding, and a persistent cough. If it is impossible to perform a surgical operation, such changes can lead to serious consequences and death.

Detection of the fistula is possible with the help of plain radiography and fistulography. In some cases, choledochoscopy is performed. Sometimes obstructive obstruction that occurs can be determined using contrast-enhanced radiography (EGDS). To obtain a more detailed clinical picture, tests are performed to detect hypoproteinemia, hyperbilirubinemia, and hypocoagulation.

Getting rid of the biliary fistula can only be achieved through surgery. To do this, the fistula between the gallbladder and adjacent tissues is removed, thereby ensuring a normal outflow of bile into the lumen of the duodenum. In addition, the doctor performs a cholecystectomy.

Cholangitis

With nonspecific inflammation of the bile ducts against the background of acute cholecystitis,

chronic course implies repeated manifestations of inflammatory changes in the bladder and its degenerative changes, and each case of exacerbation is regarded as acute cholecystitis. In the presence of stones in the gallbladder, calculous is added to the name of the disease, in their absence they speak of acalculous (or non-calculous) cholecystitis. The reasons for the formation of stones and inflammation in the gallbladder are discussed here. According to the severity of inflammation, catarrhal, phlegmonous, gangrenous, perforated cholecystitis are distinguished. Acute cholecystitis can occur initially against the background of complete well-being, incl. and in the absence of stones. Chronic cholecystitis may also be asymptomatic or manifested by dyspeptic symptoms, heaviness in the epigastrium and right hypochondrium, a feeling of bitterness in the mouth, unstable stools (i.e., a sluggish inflammatory process) or have periodically recurring symptoms of acute cholecystitis.

Cholelithiasis is a generic name for the entire pathology associated with the formation of stones in the biliary system. This includes gallbladder calculosis and choledocholithiasis.

For acute cholecystitis the following main symptoms are characteristic: pain from short-term paroxysmal (colic) to constant intense in the right hypochondrium and in the epigastric region; nausea, vomiting, fever from low to 39.5 degrees. Irradiation of pain under the left shoulder blade, in the supraclavicular region on the left. With catarrhal, superficial inflammation of the mucosa only, there may be no other symptoms. In destructive forms of inflammation, when changes occur in the entire wall of the bladder - phlegmonous, gangrenous, perforative, symptoms of peritonitis, local or widespread, occur, which significantly worsens the patient's condition. Other concomitant diseases and complications of acute cholecystitis are choledocholithiasis, cholangitis, obstructive jaundice, pancreatitis. Currently, it is unacceptable to designate the simultaneous course of acute cholecystitis and acute pancreatitis as a diagnosis of cholecystopancreatitis. The diagnosis should be as follows (example): “acute phlegmonous cholecystitis, acute edematous pancreatitis” or “acute gangrenous cholecystitis, hemorrhagic pancreatic necrosis”, etc.

Tactics of assistance and treatment in acute cholecystitis.

Prehospital stage.

All patients with symptoms of acute cholecystitis, regardless of the presence or absence of stones, are subject to emergency hospitalization in the surgical department. If possible, a short-term examination on an outpatient basis is allowed - tests, ultrasound, endoscopy. Antispasmodics are used as first aid, analgesics are unacceptable until a final diagnosis is established.

hospital stage.

After the examination, a blood test / leukocyte count /, a urine test for diastasis is performed, in the presence of jaundice - bilirubin in the blood and bile pigments in the urine, the blood type and Rh factor are determined, the blood is examined for HIV, syphilis, hepatitis B and C. An ECG is taken, produce radiography of the lungs and survey radiography of the abdominal organs. According to indications and for persons over 50 years of age, consultation by a therapist, at present, by order of the Ministry of Health, the need for consultation is established for all persons with acute surgical pathology. If possible, a complex of laboratory studies is carried out - a clinical blood test, bilirubin, urea, AST, ALT, L-urine amylase, PTI, INR, APTT. Ultrasound of the abdominal organs is performed, if necessary, MRI, laparoscopy, RPCG.

Indications for emergency laparoscopy are: an unclear diagnosis in the presence of signs of inflammation in the abdominal cavity (peritonitis); the need to verify the form and prevalence of the inflammatory process with a clear clinical picture of acute cholecystitis; acute cholecystitis complicated by cholangitis and obstructive jaundice in the absence of an opportunity to perform RPCG with PST.

Conservative treatment of acute cholecystitis.

In the absence of signs of diffuse peritonitis, conservative treatment of acute cholecystitis is allowed within 12 hours. For conservative treatment, antispasmodic, analgesic, antibacterial therapy, infusion detoxification, correction of concomitant pathology are carried out. In the case of a positive effect - a decrease in pain and fever, a positive trend with a control ultrasound - the operation is performed either on a delayed basis (in 7-10 days) or in a planned manner. In the absence of positive dynamics from conservative treatment, surgery is indicated.

Upon admission of a patient with a long course of acute cholecystitis (not the first day) and a serious condition, short-term intensive therapy, hemodynamic stabilization and emergency surgery are indicated.

Surgical treatment of acute cholecystitis.

Emergency surgery is indicated for acute destructive cholecystitis with widespread peritonitis. Delayed surgery is indicated for progressive obstructive jaundice and cholangitis, if their endoscopic resolution is impossible, as well as in young people, in the absence of the effect of conservative therapy.

In acute cholecystitis, it is possible to perform minimally invasive interventions, laparoscopic manipulations and open operations.

To minimally invasive include percutaneous (transcutaneous) punctures and drainage of the gallbladder. They are performed under local anesthesia for people who cannot perform a full-fledged intervention. These are patients with severe comorbidities and in serious condition (usually elderly). Evacuation of the contents of the gallbladder with concomitant conservative treatment leads to subsidence of inflammation, but leaves the gallbladder and stones in the abdominal cavity. Its planned removal is possible in 7-10 days. Often, after external drainage, a “wrinkled” bubble forms in old people and never bothers them again. The technique is quite simple, under ultrasound control, the bottom of the bladder is punctured with a special needle with a conductor, the needle is removed, and a drainage tube with an inflated balloon or a “pig tail” at the inserted end is inserted through the remaining conductor into the bladder cavity.

Via laparoscopy it is possible to solve a number of problems: to carry out diagnostics, perform external drainage, contrast the bile ducts, remove the gallbladder. General anesthesia for laparoscopy is preferred. In acute surgical pathology, the transition from one method of anesthesia to another is unacceptable.

Laparoscopic cholecystostomy is indicated for phlegmonous cholecystitis /without widespread peritonitis/, with a high risk of surgery, in elderly and senile patients with a general serious condition; patients of any age group with severe concomitant diseases; with complications of cholelithiasis (cholangitis, obstructive jaundice, liver failure). After transcutaneous or laparoscopic drainage, it is necessary to perform an X-ray examination with contrasting of the gallbladder and ducts, a second examination is carried out after 5-7 days.

Laparoscopic cholecystectomy is performed for asymptomatic stone carriers, chronic cholecystitis and in emergency cases, performed under general anesthesia. Currently, the indications for surgery for acute cholecystitis have expanded. In any case, if there are doubts about the differentiation of structures, when performing laparoscopic cholecystectomy, it is better to switch to an open operation than to damage, for example, one single choledochus. In any case, this method has a number of undeniable advantages over open surgery - low trauma and blood loss, rapid activation of the patient, good cosmetic effect. Probably in pursuit of the latter, two-port and one-port operation are currently being developed and used.

Open Operations. Classical cholecystectomy involves a sufficient incision to access the abdominal cavity along the midline or in the right hypochondrium, removal of the gallbladder from the neck or from the bottom, isolation of the cystic duct and artery and their separate ligation and transection. Cholecystectomy is performed under endotracheal anesthesia. In elderly and senile patients with severe comorbidities, epidural anesthesia may be used. Popular before the active development of laparoscopic surgery, mini-access cholecystectomy differs from the classical operation practically only in the size of the incision and the use of special retractors, and is currently practically not used.

Operations for other localization of stones.

In case of choledocholithiasis or stenosis of the outlet section of the common bile duct, it is necessary to perform endoscopic papillotomy before the main operation.

The law of "old" surgeons dictates the need for intraoperative radiodiagnosis of extrahepatic bile duct calculi, except in cases of reliable preoperative diagnosis.

Choledochotomy is indicated in the presence of calculi in the common bile duct, cholangitis, and stenosis of the distal choledochus, and should be completed with drainage of the choledochus either through the stump of the cystic duct with single stones and complete patency of the major duodenal papilla, or with Kehr's T-shaped drainage with multiple small stones and patency of the large duodenal nipple, or choledochoduodenoanastomosis with wide choledochus and stenosis of its distal part over a considerable extent. Drainage from the choledoch is removed 10-14 days after the control radiopaque study of the choledoch.

final stages of the operation.

Currently, almost all surgeons agree that any operation on the gallbladder and bile ducts should be completed with drainage of the subhepatic space. Depending on the severity of the inflammatory process and the complexity of the operation, either thin or thick tubular /preferably double-lumen/ drainage, which is removed through a puncture of the abdominal wall outside the surgical wound. Drainage is removed after 1 to 5 days. The most ideally performed operations do not exclude the risk of bleeding or biliary peritonitis (for example), the diagnosis of which in the postoperative period presents certain difficulties. Control drainage will help in the diagnosis of complications.

The introduction of tampons is indicated only when capillary bleeding from the gallbladder bed has not been stopped or in order to delimit the perivesical abscess from the free abdominal cavity.

postoperative period.

The course of the postoperative period depends, again, on the severity of inflammation, the severity of the patient's condition and the presence of concomitant pathology, on the volume and complexity of the operation. The general task of the postoperative period is the early activation of the patient and the restoration of the functions of the gastrointestinal tract. After minimally invasive manipulations, laparoscopic cholecystectomy and removal of the gallbladder through a mini-access, activation of the patient is possible in the next 5-8 hours. The volume of traumatization during such interventions is small, the pain syndrome is weak or not expressed, the state of health can be satisfactory. Patients are allowed to sit down, get up to the toilet. Adequate anesthesia allows you to completely eliminate pain. After classical operations, the wound hurts more intensely, damage to the abdominal muscles is more extensive, and there is still a risk of suture failure on the wound. Such patients should not rush to be active, it may be necessary to wear a postoperative bandage to prevent the formation of postoperative hernias, the risk of which also exists after laparoscopy. The bandage is worn for 2 months, it is put on before getting out of bed and removed after taking a horizontal position. Heavy lifting, coughing and constipation should also be avoided. Wound care is well described here, sutures are removed after laparoscopy on days 5-7, after large incisions on days 10-12. For the first three days, diet 0 is prescribed, which includes only liquids - non-greasy broth, jelly and compote without berries. Gradually expands to diet No. 1 by adding solid components to the liquid - pasta, potatoes, mashed meat. Lactic acid foods and fresh fruits and vegetables should be avoided for 4-5 days. Further nutrition expands to diet number 5, gradually. It is important to change the diet - increase the frequency of meals (5-6 times) and reduce its volume per meal. This regimen should be followed for 2 months, gradually reducing the frequency, increasing the volume. After 2 months, irritants are introduced into the diet - salty, sour, smoked foods - quite a bit. By adhering to this regime, we achieve the adaptation of the alimentary tract to work without a gallbladder. After 6 months, the functions of digestion are almost completely restored.