Cholangitis

Cholangitis (synonym angiocholitis) is inflammation of the liver bile ducts. Cholangitis is often combined with cholecystitis (see) and cholelithiasis (see).
Cholangitis is usually caused by various bacteria, mainly Escherichia coli. The infection can enter the rising bile ducts by means of a gall bladder, gastrointestinal tract, pancreas, and lymphogenous and hematogenous route.
Of great importance in the development of cholangitis is a stagnation of bile in a gall ducts, resulting in the violation of their motor activity or formation of these stones.
The nature of pathological process distinguish catarrhal, purulent and necrotic (diparities) cholangitis. In catarrhal cholangitis there hyperemia and swelling of the mucosa of the bile ducts, infiltration their walls are white cells, desquamation of the epithelium. For purulent cholangitis is characterized by the fusion of the walls of the bile ducts
with the formation of small abscesses. In severe cases there are foci of necrosis of the mucous membrane with the formation of fibrinous films (difteriticheskoe cholangitis).
On clinical course cholangitis divided into acute and chronic.
Acute cholangitis characterized by chills, intermittent fever, profuse sweating, a feeling of bitterness in the mouth, vomiting, pain in the right hypochondrium, sometimes very intense, the increase in liver size, often jaundice, skin itch. In the blood by the neutrophilic leucocytosis. ROHE accelerated.
Chronic cholangitis develops as a consequence of acute cholangitis. The clinical picture of chronic cholangitis much in common with chronic cholecystitis (see). Cholangitis may appear counter subfebrile temperature, subikterichnost (light yellow) sclera, aching pain in the right hypochondrium, weakness, periodic poznaniyami, fatigue, weight loss. The liver and spleen, often increased. ROHE much faster.
Complications. Acute cholangitis may arise suppuration and necrosis in the walls of the bile ducts with their perforation (a perforation) and the development of peritonitis (see). Chronic cholangitis may lead to a hardening of the bile ducts and their subsequent stenosis; to the development of hepatitis C outcome in cirrhosis of the liver (see) and chronic pancreatitis (see).
The diagnosis is based on the above-described clinical symptoms, palpation (enlargement of the liver, and sometimes and spleen), laboratory and radiologic studies. A history of disease, gallbladder, pancreas, stomach, duodenum and colon.
When duodenal intubation in bile in the portions With detected a large number of leukocytes; chest x-ray - cholangiography (see) - revealed pathological changes in the bile ducts.
Treatment. In acute and chronic cholangitis the patient should be directed to the medical Department of the hospital. Given the severity of the disease, treatment should be initiated immediately upon diagnosis. It is necessary to apply treatment with broad-spectrum antibiotics, which are allocated through the bile ducts: tetracycline 200 000 IU 4 times a day or aureomycin (biomitsin) 200 000 IU 5-6 times a day for half an hour before meals, signalizing, oletetrina 250 000 IU 4 times a day. Health food - table 5-a and 5 (see clinical nutrition).
In chronic cholangitis, in addition to a course of treatment by the above antibiotics (course lasts 10-14 days), apply thermal procedures (paraffin, ozokerite and mud applications on the liver area), physiotherapy (UHF, diathermy), special complexes exercise therapy and health resort treatment (the resorts of Caucasian Mineral Waters, Truskavets, Arzni and others). Surgical treatment is indicated in chronic cholangitis, leading to a narrowing of the extrahepatic bile ducts (the common bile duct).
In the prevention of exacerbations of chronic cholangitis are crucial: 1) prevention of stagnation of bile, which is achieved regular, frequent (every 4 hours) eating, regular activity of the intestines, physical exercises (exercises, walking); 2) treatment of diseases such as cholecystitis, pancreatitis, colitis.

Cholangitis (cholangitis; from the Greek. chole - bile and angeion - vessel; synonym angiocholitis) - inflammation of the intrahepatic and extrahepatic bile ducts. Cholangitis in most cases occurs as a secondary disease. The usual cause of cholangitis are cholelithiasis and acalculous cholecystitis (angiocholitis), rarely - cancer of the biliary tract. With the defeat of the smallest intrahepatic bile ducts in the process inevitably involves the liver parenchyma (holangiogepatit).
The etiology and pathogenesis. The emergence of cholangitis due to the introduction of various microbial flora, mainly Escherichia coli. Possible cholangitis viral nature as a consequence of the epidemic hepatitis. However, cholangitis develops only when infection joins the stagnation of bile. In the occurrence of major defeats of extrahepatic bile ducts plays a big role duodenobiliary reflux. The infection can get into the bile ducts in two ways; rising (interagency) and hematogenous. Ascending by the infection spreads in chronic diseases of the gastrointestinal tract, calculous cholecystitis, narrowing and the compression of the final part of the common bile (zhelchevyvodjashchih) flow (scar sphincteroplasty, cancer of the pancreatic head). Hematogenous by the infection spreads by hepatic artery and portal vein. Place of formation of infection are lots of biliary system in the field of precapillaries. In old age, chronic cholangitis may be due to a massive fibro muscular hypertrophy of Vater's papilla with violation of bile outflow. The emergence of cholangitis may be associated with worm infestation and observed especially often in opisthorchiasis.
Pathological anatomy. Pathomorphological distinguish catarrhal, purulent, diparities cholangitis.
In catarrhal cholangitis macroscopically mucosa full-blooded, swollen, within the lumen of the ducts sticky, cloudy mucus. Microscopically determined plethora, edema, infiltration wall duct leukocytes, lymphocytes, macrophages, and significant desquamation of the epithelium of the mucosa. Catarrhal cholangitis intrahepatic bile ducts sometimes develops in intestinal infections typhoid fever, paratyphoid, dysentery. While the walls of the ducts infiltrated by leukocytes, macrophages and lymphoid cells in a lumen of many cells sladenkogo epithelium, leucocytes, mucus. Less of typhoid fever and paratyphoid developed purulent cholangitis and rarely cholangitis with granulomas of the so-called typhoid cells. If catarrhal cholangitis takes chronic, relapsing course, the wall of the duct sklerosiruta, mucous membrane exposed atrophy, sometimes grow adenomatous polyps.
Purulent cholangitis, as purulent cholecystitis, often with cholelithiasis. Intrahepatic ducts expanded, made with pus, painted bile; the serous membrane dull, with overlays of fibrin; wall ducts thickened, mucous membrane full with bleeding, sometimes with ulcers (peptic ulcer cholangitis). Microscopically, the wall of the duct swollen, heavily infiltrated segmented by leukocytes.
Sometimes mucous membrane ducts undergoes necrosis and richly saturated with fibrin (difteriticheskoe cholangitis).
At purulent cholangitis possible suppuration and necrosis in the walls of the bile ducts with perforation and their development gallbladder or bile-purulent peritonitis. The healing of festering ulcer cholangitis goes by granulation and epithelization of ulcers, followed sclerosis and deformation of the duct.
Purulent inflammation of the intrahepatic bile ducts accompanied by marked dystrophic changes in liver parenchyma. The liver is swollen, grabovica, on the surface of a cut under pressure from the biliary ducts are droplets of pus. Microscopically the walls of the ducts abundantly infiltrated by leukocytes may spread purulent process in the surrounding tissue (pericolosit), the formation of the so-called cholangitis abscesses.
Inflammation in chronic cholangitis is mostly productive with plasmocytomas and lymphocytic infiltration and sclerosis of the walls of the bile ducts. In chronic cholangitis intrahepatic ducts due to the spread of the inflammatory process on the interstitial tissue arise productive pericolosit, productive interstitial hepatitis, which in Exodus lead to the development of cirrhosis (see) - the so-called cholangitis biliary cirrhosis.
Cholangitis large ducts may be complicated by damage to the pancreas.
When throwing bile into the ductus pancreaticus develops acute necrosis of pancreatic cancer, when lymphogenous distribution of infecta - chronic productive pancreatitis. Helminthes, settling in bile ducts, causing chronic productive cholangitis and pericolosit with outcomes in cirrhosis. In opisthorchiasis there is hyperplasia of the epithelium biliary moves, against which sometimes develops cancer. When miliary tuberculosis, congenital syphilis specific granulomas are localized in the connective tissue in the course of the ducts, or sometimes in the wall of them (specific cholangitis).


The clinical picture and over. The clinical course cholangitis divided into acute and chronic septic, with acute period and protracted. Among chronic allocate stenozirutaya cholangitis, which in turn can be diffuse with defeatist main ducts (total plastic angiocholitis) and localized];: (in the field of hepatic duct, the terminal segment zhelchevyvodjashchih duct).
Complaints of patients with cholangitis: diarrhoea disorders, decreased appetite, nausea and sometimes vomiting, pain in the right hypochondrium, periodically take the character abdominal cramps, fever, which can sometimes reach high numbers, and be accompanied by chills. Jaundice is not a mandatory symptom and indicates to either inflammatory Genesis of holestaza, or the involvement of liver disease process (holangiogepatit). Sometimes there is an increase in the spleen. Enlarged liver moderate, the edge of her soft, painful on palpation. May be complaints about stabbing pain in the heart, sometimes attacks type of angina, symptoms of Meniere's, vegetative-vascular crises with high blood pressure.
Acute cholangitis is purulent lesion with intrahepatic bile ducts and catarrhal localized in large extra-hepatic ducts. Acute intrahepatic cholangitis may be benign or malignant, leading to the formation of abscesses of the liver. There are four phases of the course of acute intrahepatic cholangitis. The first to appear remittent fever, chills, excessive then followed beligradeanu period (pseudomusaria form), as well as colicky pain in the right hypochondrium, vomiting. The General condition of patients getting progressively worse, developed lethargy, apathy, diarrhoea disorders, diarrhea. In the second phase join the symptoms of liver damage - holangiogepatit. Appears istericeski skin and eyes, or in the urine, usually determined by the urobilin. The liver is enlarged, painful. Starts to increase spleen. ROHE accelerated appears leukocytosis (up to 18 000-20 000) with a pronounced shift leukocyte left. If you are unable to timely stop the growth of the pathological process, it is entering the third phase, which is manifested menacing signs of hepatic failure and significant increase in the level of urea in the blood (up to 200 mg%). The main symptom of the fourth, and final, phase is uremic coma on the soil of renal and hepatic failure (hepato-renal syndrome, heptneri).
Chronic cholangitis is the most common form of defeat bile ducts - arises as a consequence of acute cholangitis. In elderly and old people possible primary chronic cholangitis - the so-called age cholangitis. Non-specific clinical picture - long-term (months, years) : fever, weight loss, individual intolerance, especially fat, dishes, fatigue, weakness. There subikterichnost sclera; liver and often enlarged spleen. ROE slightly accelerated.
Critical to the diagnosis is detected in the portions With the bile of a significant number of white blood cells, epithelial cells of bile ducts, microbes. The course of chronic cholangitis slow - to 5 - 10 years.
Narrowing the final part zhelchevyvodjashchih duct - stenosing papilla is the most common form of chronic stenotic cholangitis. The clinic is reminiscent of choledocholithiasis and includes attacks of pain in the right upper quadrant of the abdomen, fever, jaundice. Correct diagnosis can only be installed cholangiographic when detected expansion zhelchevyvodjashchih duct over the site of the narrowing in the sphincter of Oddi.
Septic cholangitis is the most dangerous form of cholangitis. There are cholangitis acute, recurrent and slow (cholangitis septica lenta). The first two forms are characterized by severe, high temperature (up to 40 degrees), chills, bacteraemia and intermittently growing jaundice. The liver is enlarged, painful; spleen moderately increased soft (septic). For complicated by the thrombosis of the portal vein, metastatic abscesses in the lungs. Especially threatening form of anaerobic cholangitis.
Slow septic cholangitis develops mainly on the background of exhaustion in the result of infection with Streptococcus viridans small bile ducts. Beginning of the disease is slow. The temperature is subfebrile, sometimes the temperature of the "candle" (to 39-40E), weakness, pain in the joints. Jaundice is rare. The liver and spleen were enlarged. Most patients have a tendency to radiation. Lymph nodes are enlarged, possible osteomyelitis, periostitis (septic cancer), sometimes developing focal or diffuse jade. Possible complications abscesses of the liver, subphrenic abscess, biliary cirrhosis.
Diagnosis of cholangitis is often difficult, especially in the elderly, and should be based on a careful study of anamnesis, clinical picture, survey data bile, liver functioning, x-ray study (see), cholangiography (see), laparoscopy (see Peritoneoscope). Great importance is the presence of indications of a history of gallbladder disease (stone and acalculous cholecystitis), colon, pancreas. From laboratory studies of great importance is the study of bile (see Duodenal sounding), where portions, normally containing neither blood, nor of the bacteria that are sown E. coli, strepto-, stafilo - and enterococci are leikozita, signs desquamative Qatar in the form of a large number of cells high or nizkointensivnogo epithelium in various stages of decay. When intrahepatic cholangitis in the blood increases the activity of alkaline phosphatase (up to 300 IU at the rate of 8-10 IU).
The possibility of using laparoscopy and sighted liver biopsy for diagnosis of cholangitis not equally valued by different authors.
Treatment of acute and chronic cholangitis should be directed first of all to suppress the infection. Are the most effective broad-spectrum antibiotics [tetracycline, oxytetracycline (terramycin), aureomycin (biomitsin), signalizing (oletetrin)], which in high concentration of excreted via the bile ducts. The most appropriate use of the antibiotics to which most sensitive microbial flora (blood and bile). Anaerobic flora in the complex treatment of add protivomigrenoznoe serum. When holangiogepatit with severe biliary syndrome shows the inclusion of steroid hormones. Health food - Desk № 5-a, 5.
Of stenosing cholangitis only surgical treatment.
Mortality from cholangitis remains high, particularly poor prognosis when cholangitis septica lenta.