Prevention and treatment

In the prevention of cholecystitis significant importance should be given timely treatment of digestive apparatus diseases: duodenal ulcer, gastritis, duodenitis, colitis, chronic appendicitis.
The aim should be to eliminate stagnation of bile in a gall bladder. This determines the value of regular preventive nutrition, proper mode of the day, gymnastics, sports, tempering.
A. L. Myasnikov pays special attention to the need for medical examination of persons suffering from cholecystitis: nutritionally proper nutrition, permanent treatment, observance of hygiene rules.
It is necessary to conduct sanitary-hygienic measures aimed to combat parasitic diseases, first of all with giardiasis, preventive examinations for the early detection of infected and treatment.
Should be abolished foci of infection in the tonsils, sinuses, in the female sexual sphere.
Treatment of patients with cholecystitis should be built in accordance with the following tasks:
1) elimination of the inflammatory process. Given the complex Genesis of inflammation (first chemical, in subsequent microbial), the pathogenic significance of bile stasis, this task should be achieved by the use bacteriostatic drugs, ensuring a good flow of bile, the elimination of the biliary dyskinesia;
2) prevention and treatment of complications. In the acute period - gangrene, abscesses, peritonitis. Chronic cholecystitis - hepatitis, biliary cirrhosis, pancreatitis, gallbladder cancer, and others;
3) symptomatic treatment;
4) prevention of exacerbations of chronic cholecystitis.
Treatment should be individualized, taking into account the nature and
phase underlying disease, complications and comorbidities, individual characteristics of the patients, in particular constitutional and age.
In cases of acute cholecystitis should be hospitalized patients from the beginning of the disease in the surgical Department. The diagnosis of acute cholecystitis not in all cases entails the need for an urgent operation. When the lungs (catarrhal) forms is conservative treatment, which consists in the application of perirenal procaine blockade on Century A. Vishnevskaya, heaters on the area of the right hypochondrium, promedol with atropine, broad-spectrum antibiotics, liver diets small portions 4-5 times a day. If this therapy attack of acute cholecystitis subsides, then on the second or third day from the start of the attack, you can start the application of magnesium sulfate as choleretic method Demyanova or with the use of intelligent sensors with intervals of 3-5 days. The course of treatment - 8 - 10 washings.
If acute cholecystitis when conservative therapy does not abate, expectant therapy should not be delayed longer than three days and the patient must undergo surgery.
The surgery most patients is to remove the gallbladder - cholecystectomy. In severe changes infarction in the elderly more profitable to produce the operation of cholecystostomy, evacuation from the gallbladder purulent bile and stones and the drainage of the bladder. After both operations - cholecystectomy and holetsistektomii - shows the use of antibiotics. Stoma is released from the gallbladder drainage two weeks, and formed biliary fistula recovery outflow of bile into the duodenum close itself within 6-8 weeks. If biliary fistula to this term is not closed, it is necessary to make fistulabrazillian, which can show the presence of obstacles in the course of the biliary tract (stone, constriction of the throat). Under such conditions the inevitable second operation: cholecystectomy, descaling and narrowing.
Mortality after surgery for acute cholecystitis varies depending on the age of the patients: operation for patients under 50 years give 3.3% of mortality in the age of 50 - 11.2%and over 60 years of age - 18% (B. A. Petrov, 1956). If you compare two equal groups of patients treated for acute cholecystitis promptly or conservative, we can cite the following figures mortality; 3.7 percent after surgery and 6.3% among unoperated (Reinus, Kessler, 1957). All of this suggests that need to operate at the earliest possible age.
Mortality increases significantly after operations for health reasons, i.e. when it is necessary to operate at the onset of the perforation, when started peritonitis and other complications. In these conditions mortality reaches 37,7% (B. A. Petrov, 1961) or 22,5% (Century A. Gulyaev, 1961).
In the treatment of chronic cholecystitis and cholelithiasis there are two directions - conservative and surgical.
So far all activities proposed for dissolution, resorption of the stones were insufficient. By the very nature of the pathological process to expect from conservative therapy radical treatment is hardly possible.
Remote results of conservative treatment of a bile stone disease are: a good result - from 7,3 up to 16%, a satisfactory result - 12%, prolonged treatment, re-hospitalization, etc., - 72%, lethality - 5,7% (Century A. Smirnov, 1959).
For the treatment of chronic cholecystitis is a need to ensure good draining of the gallbladder, which is achieved by assigning liver diets, periodic choleretic drugs, mineral waters, systematic duodenal sounding.
In the period of exacerbation shown treatment with broad spectrum antibiotics.
Giardiasis with lesions of the biliary tract apply the specific therapy.
Patients with chronic cholecystitis out pronounced deterioration shown Spa treatment.
Use mineral water: carbon dioxide alkaline, alkaline or alkaline-saline. In the first place are domestic sources - Essentuki, Jermuk, Zheleznovodsk, Borjomi, Izhevsk source. Foreign mineral springs, the most famous Karlovy vary. Drinking mineral waters warmed reduce congestion in the gall bladder, improves the flow of bile.
Mud therapy is indicated when an inactive form of cholecystitis, with exacerbations of this method should not be used. Good effect can give paraffin applications. For elimination of the biliary dyskinesia, always expressed with cholecystitis, may apply antispasmodic: drugs belladonna, atropine. The favorable effect of some holinolitikov - ARMENAL, hexane, gangleronum, spazmolitina. The latter can be used for intradermal the paravertebral blockades in the segments D7 - D11.
In the cases giving rise to suggest the inclusion in the pathological process of the hepatic parenchyma, it is recommended parenteral vitamin B13, B6, ascorbic acid.

To the surgeon patients with cholelithiasis, are most often due to very frequent episodes of biliary colic, or because of certain complications of gallstones. The surgery technique should vary century, depending on the form of a bile stone disease, from opportunistic diseases, complications, and the age and condition of the cardiovascular activity of the patient, from the functional state of the liver, kidneys and other uncomplicated form of a bile stone disease is shown "keeping" operation, called the perfect cholecystotomy. When this operation is performed the autopsy of the gall bladder, the removal from it of stones, check the cholangiography on the operating table of a lack of stones in the bile ducts and stitching tightly section of the gallbladder wall. In cholelithiasis complicated by obstructive jaundice, shown surgery in the coming days from the onset of jaundice. The operation should be to remove the gallbladder, in the opening of the common bile duct and the removal of stones from it. With drainage of the common bile duct competes choledochoduodenostomy.
Testimony to this operation are stenosis in the field of Vater nipple, not udalenie for whatever reasons, the common bile duct stones, chronic cholangitis extension duct. After this operation should be carried out treatment of cholangitis antibiotics.
Contraindications to surgery for gallstones can be formulated as follows: in patients except cholelithiasis, myocarditis, arteriosclerosis, emphysema, chronic bronchitis, nephritis, a severe diabetes, and very obese patients should seriously weigh the chances for and against, before deciding on the operation. Age does not play a big role. When life indications for surgery are no contraindications.
After the expiration of three months after the operation, patients should be directed to one of the above resorts.
Death after operations performed in the advanced stages of the disease, reaches 20% or more.
The group of symptoms that remains after surgery to the gallbladder or bile duct, it was given the name "postcholecystectomy syndrome". None of the surgeons did not have 100% success in the surgical treatment of cholecystitis and cholelithiasis. On average, 80 to 90% of patients can be considered healthy, and 20-10% of the operated suffer pain, which occurred at different times after the operation - from one to several years. Naturally, the first assumption about the causes pain was associated with suspected relapse. Later they began to distinguish between the true and the false recurrence, i.e., the recurrences occurred in connection with the newly formed by the stones in the bile ducts, and relapses are caused by stones, the remaining bile ducts and viewed in the survey during operations. Viewing small stones in the bile ducts during operation is possible, even if it is used sensing of the bile ducts. The possibility to leave the small stones in the ducts began to decrease after the introduction of the operating cholangiography. But it during the operation does not warrant from the view of small stones. Singleton, and Coleman (1956) provide evidence about 15% of erroneous data cholangiography. Another reason "postcholecystectomy syndrome" is left long stump of the cystic duct, discovered in some cases with re-operation. However, this discovery, many is questioned, since it is difficult to explain the mechanisms of pain. It seems likely explanation pain if left long stump of the cystic duct development in it amputation of neuroma.
One of the causes of pain after cholecystectomy and choledochotomy are spikes and growths that arise in the area of the liver-duodenal sheaf. The fusion of these are the cause of circulatory disorders in the gate of the liver, duodenostasis. Inflammatory processes in the external biliary tract system gepathology may remain after surgery choledochotomy and associated cholangitis. These changes can lead to stricture gepathology. Apart from the pain, when they appear, and jaundice.
"Postcholecystectomy syndrome can be caused by flash existed before cholecystectomy pancreatitis. One of the causes of acute pancreatitis are biliary dyskinesia, spasm of the sphincter of Oddi and throwing bile in Virunga duct. Postcholecystectomy syndrome continues to draw the attention of both surgeons and therapists. A. N. Kravchuk (1969), having studied the remote results at 850 people undergoing cholecystectomy), 62 people have installed poor results and the reasons associated with the operation, were established in 37%, not associated with the operation - 63% of patients. This ratio, according to the author, "casts doubt on the accuracy adopted in medical practice of the term "postcholecystectomy syndrome". The term "postcholecystectomy syndrome" is less than successful, as this concept brings together a number of diseases, many of which are not associated with the performed operation (A. M. Nogales, 1969).
Thus, it should be recognized that causes "postcholecystectomy syndrome" not only diverse, but occur at different times after the surgery cholecystectomy and choledochotomy.