Cholecystitis

Cholecystitis is an inflammation of the gallbladder. Cholecystitis is a very common disease that is more common in women. Downstream cholecystitis divided into acute and chronic; calculous and acalculous.
The etiology and pathogenesis. In occurrence cholecystitis is set: various infection (virus, E. coli, cocci and others), worm infestation (roundworm), giardiasis, the defeat mucous membrane of the gallbladder to the abandonment of pancreatic juice. The infection can penetrate into the gallbladder hematogenous, interagency (from the intestines) and lymphogenous way.
However, one of infection is not enough for the emergence of cholecystitis. A factor contributing to its development, is a stagnation of bile in a gall bladder, arising from the presence of stones (calculous cholecystitis), impaired motor activity (dyskinesia), long interruptions in food intake and sedentary lifestyle. In addition, motor function of the gallbladder may change under the influence of numerous reflexes from other pathologically changed authorities (viscero-visceral reflexes).
Pathological anatomy. The nature of the inflammatory process in acute cholecystitis distinguish forms: catarrhal, purulent, phlegmonously and gangrenous. Chronic cholecystitis the gallbladder wall gradually sklerosiruta. Formed adhesions (pericholecystic) distort the gallbladder, and thus the conditions for the stagnation of bile and recurrent exacerbations of chronic inflammatory process. Usually inflammation of the gallbladder is combined with inflammation of the bile ducts (see Cholangitis).
The clinical picture. Acute cholecystitis. Main symptom is sudden threats pain in the right hypochondrium, epigastric region, at least around the navel. Iradionet pain in the right supraclavicular region, in the right shoulder and sometimes in the heart area. Attack of pain is usually accompanied by nausea, bitterness in the mouth, vomiting, mild fever (t 38-39 degrees); sometimes it jaundice is the result of increased pressure and stress of the gallbladder to the common bile duct or blockage him with a stone, or if a change occurs in the liver cells. The liver is enlarged, particularly in introducing cholecystitis. The gallbladder is palpated not always. In acute cholecystitis effleurage on the abdominal wall and palpation in the right hypochondrium sharply painful, here we usually include muscle tension, positive symptom Ortner - pain effleurage with the edge of the brush on the right costal arch.
Palpation between the legs right sternocleidomastoid muscles found sore point is a symptom of Mussi - St. George. If you are involved in the inflammatory process peritoneal appears symptom Shchetkina - Blomberg-the emergence of a sharp pain in the abdomen after a quick stop pressing your finger on the front wall of the abdomen. In the study of blood found neutrophilic leucocytosis (8000-10 000 cells per 1 mm3 blood) with a slight shift to the left. All patients with acute cholecystitis should hospitalized in the surgery Department, as, on the basis of the clinical picture cannot accurately judge the nature of the pathological changes of the gallbladder. Only a surgeon on the basis of the analysis of symptoms and their changes in the monitoring process defined indications for conservative or surgical treatment and the degree of urgency of the operation.
Acute cholecystitis may be complicated spilled or limited purulent peritonitis (see), perforation of the gallbladder with the development of biliary peritonitis, acute pancreatitis (see), mechanical jaundice and purulent cholangitis (see). Any of these complications can develop as for the first and each subsequent attack; when stone (calculous) cholecystitis, more acalculous cholecystitis - less.
Acute cholecystitis should be differentiated with acute appendicitis (see), hepatic colic (see Cholelithiasis), perforated duodenal ulcer (see peptic Ulcer disease), myocardial infarction (see), diaphragmatic pleurisy (see).
Chronic cholecystitis may develop after an acute, but more often develops gradually. Patients experience a dull aching pain in the right hypochondrium, under the right shoulder blade and in the right shoulder. Chronic cholecystitis may leak and without pain, manifesting itself only a feeling of heaviness in the epigastric region, bloating, nausea 1-3 hours after meals, especially fat, a feeling of bitterness in the mouth. When the feeling is determined by the pain in the right hypochondrium. Muscle tension is missing. Symptoms Ortner, Mussy-St. George can be negative. Enlargement of the liver occurs when complications of chronic cholecystitis, cholangitis. In portions In and duodenal contents signs of inflammation (see Duodenal intubation). The radiological examination of the gallbladder (see Cholecystography) finds a violation of its functional abilities form, and the presence in it of stones. For uncomplicated chronic cholecystitis often find low-grade fever, a few accelerated ROHE. Periodically may be acute, resembling the clinical picture of acute cholecystitis.
Chronic cholecystitis should be differentiated from a duodenal ulcer, gastritis, colitis, kidney-stone disease.
The prognosis for acute cholecystitis depends on the timely admission and early shows treatment. Chronic calculous cholecystitis requires surgical treatment, as with long-term conservative treatment may develop serious complications (acute cholecystitis and peritonitis, acute and chronic pancreatitis, mechanical jaundice and cholangitis, cancer of the gallbladder).

Cholecystitis (cholecystitis; from the Greek. chole - bile and kystis - bubble - is an inflammation of the gallbladder. Relatively frequent disease; women get sick more often than men.
Classification. In the USSR the most commonly used with some modifications classification S. P. Fedorova, a Discerner: 1) acute primary cholecystitis (catarrhal, phlegmonously, gangrenous); 2) chronic recurrent; 3) chronic complicated (purulent, ulcer); 4) sclerosis gallbladder; 5) the dropsy of the gallbladder.
The etiology and pathogenesis. In most cases the cause cholecystitis is the infection, most E. coli, precisely wand and coccal flora (strepto - and stafilokokkami), less anaerobes. In recent years, proved the possibility of viral nature of the disease (the virus that causes epidemic hepatitis). In some cases have a value toxicity, irritation of mucous membrane of the gallbladder throw him in pancreatic juice and infestation of worms (roundworm); etiological significance of Giardia controversial.
Etiological role of infection proves discovery in the result of bacteriological study the microbial flora in the gallbladder bile produced on the operating table, and in the bile, obtained with duodenal intubation patients with a chronic cholecystitis (normal bile sterile).
Penetration microbial flora or other pathogens viruses, helminthes, protozoa) in the gallbladder may occur in three ways: hematogenous, interagency and lymphogenous, of which, apparently, the first two are the most frequent. On this basis, cholecystitis may be referred to the group of autoinfection.
An indispensable condition for the development of cholecystitis is a stagnation of bile, without which the inflammation does not occur, despite already nesting in the gallbladder microflora. Also known role of gallstones. When acalculous cholecystitis stasis bile cause of biliary dyskinesia, long breaks in eating, sedentary lifestyle, as well as numerous and varied interoceptive effects on biliary excretion system of the pathologically changed abdominal organs. Known value in some cases has allergic factor.

Pathological anatomy. Cholecystitis on the nature of the inflammatory process is divided into catarrhal, purulent, diparities, gangrenous.
In acute catarrhal cholecystitis gallbladder slightly increased the mucosa of its redness, swollen, bile in the cavity bladder watery, muddy from impurities Muco-serous or mucous-purulent exudate. Microscopically the gallbladder wall full-blooded, edematous, in mucosal and submucosal shells infiltration by blood, lymphoid cells, macrophages, there is a desquamation of the epithelium cells. Acute cholecystitis may occur in acute infections (typhoid fever, paratyphoid), and jelchnokamenna disease, often results from autoinfection process (coli infection).
Catarrhal cholecystitis can take a chronic relapsing course. Thus the gallbladder wall thickens, sklerosiruta mucosa atrophy, places form polypous expansion. Under the epithelium, the number of macrophages containing cholesterol (santonij cells),a cholesterosis of a gall bladder (printing. table, Fig. 2 and 4). Microscopically in sklerozirovanie the gallbladder wall observed lymphocytic and plazmotsytome infiltrates; in the period of recurrence on the background of chronic changes develop redness, swelling, infiltration by leukocytes.

cholecystitis
Fig. 1. Acute hemorrhagic cholecystitis. Fig. 2. A cholesterosis of a gall bladder. Fig. 3. Purulent acute cholecystitis. Fig. 4. Chronic cholecystitis. Fig. 5. Purulent cholangitis, which emerged as a complication of cholecystitis.


Purulent cholecystitis often develops when gallstones (calculous cholecystitis). The gallbladder is thus increased, tense; serous covers dim, covered with fibrinous overlays (pericholecystic), the wall of the gallbladder sharply thicker (up to 0.5-1 cm). The mucous membrane is swollen, red-blooded, erosions, ulcerations. In the lumen of the gallbladder accumulates purulent exudate, painted bile. Purulent cholecystitis occurs more often by type flamanskogo, with abundant diffuse infiltration of the gallbladder wall segmented by leukocytes (phlegmonously cholecystitis). Acute cholecystitis may be accompanied by a massive hemorrhages in the wall and the lumen of the bubble, and then the process takes on the character of purulent-hemorrhagic inflammation - purulent acute cholecystitis (printing. table, Fig. 1 and 3). Often in introducing cholecystitis arise necrosis of the mucous membrane with the formation of more or less extensive ulcers (flegmonas ulcerative cholecystitis), sometimes the necrotic tissue mucous membranes swelling impregnated with fibrinous the exudate and get a kind of dirty-green films. These films are rejected, and in their place are formed deep ulcers (difteriticheskoe cholecystitis) or necrotic process covers the entire thickness of the gallbladder wall, which is black and brown, dull, flabby (gangrenous cholecystitis). In the pathogenesis of this form cholecystitis have a value of hemodynamic disorders associated with damage to the intramural blood vessels, which in acute purulent cholecystitis, as a rule, inflammatory changes - purulent vasculitis, thrombovascular and fibrinoid necrosis vessels.
Gangrenous process in the gallbladder may be due also the primary lesion of the blood vessels in hypertensive disease (see), nodular the nodosa (see Nodosa nadasny; R. A. Khurgina, G. A. Kirillov).
Chronic purulent cholecystitis morphologically characterized primarily by the deformation of the gallbladder. He reduced in size and coarse spikes spliced with neighbouring authorities - transverse colon rectum, gland, stomach. In places free from adhesions, the outer surface of the gallbladder "glazed". The wall is much thicker, denser due sclerosis, sometimes petrification. The inner surface of the gallbladder - with fibrous cords that Shine through atrophic mucosa. Meet ulcers of the mucous membrane of different depths, made granulation tissue. Microscopically against sclerosis in the gallbladder wall detected from lymphoid infiltrates and plasma cells, the small number of macrophages, eosinophilic white blood cells. Reparation processes in chronic cholecystitis expressed in the form of granulation ulcers with subsequent scarring and epithelization of them, the latter is due to the remaining cells moves Luske. Moves Luchki grow, branched, reach subserous layer; seats they cystic expanded and made a mucin; additional granulation tissue can see education adenomatous structures.
The most dangerous complications of acute purulent, flamanskogo with suppuration and gangrenous cholecystitis are perforation (sometimes of Microperforation) of the gallbladder wall and the subsequent development of the bile or chronic purulent of peritonitis; less encysted pericholecystic or subphrenic abscess. Purulent inflammation may spread to the retroperitoneal fat. When a protracted period of sometimes formed fistulous passages, opens into the lumen of the intestine, stomach or through the abdominal wall to the outside.
When closing the mouth of the cystic duct stone, thickening the exudate or obliteration him in patients with chronic cholecystitis in the gallbladder accumulates a large amount of pus, considerably stretching its cavity,the so - called empyema of the gall bladder. When the remission of inflammatory process leukocyte exudate replaced serous fluid, evolving dropsy of the gallbladder.
The inflammatory process, which arose primarily in the gall bladder, often extends along the biliary tract. Therefore, in some cases, cholecystitis combined with inflammation of intra - and extrahepatic bile ducts - cholangitis (printing. table, Fig. 5), pericolanti, which in turn can be complicated by abscess of the liver, in the long - biliary cirrhosis. In addition, inflammation of gallbladder wall on the contact in the field of bed it can go on the liver tissue, where is developing the focal fibrinous perihepatitis, interstitial hepatitis.
At cholecystitis sometimes develops the defeat of the pancreas in the form of acute hemorrhagic its necrosis when getting infected bile into the pancreatic duct or in the form of chronic pancreatitis (see) in the case of infection gland lymphogenous way. Occasionally specific inflammation in the gallbladder tuberculosis, syphilis; cholecystitis described giardiasis, ascariasis, opisthorchiasis and echinococcosis.