Internal use of mineral waters for chronic liver diseases and biliary tracts

Chronic diseases of liver and biliary tracts are diverse, as in etiology, pathogenesis and pathomorphology and its clinical manifestations and the nature of the flow. Resort therapy is indicated for many forms of pathology of liver and bilious ways, including chronic hepatitis of various severity, the residual phenomena of acute epidemic of hepatitis( Botkin's disease), chronic cholecystitis, mild cholecystoangiogram and diseases, developing after surgery to remove the gallbladder (so-called postcholecystomic syndrome). On the basis of long-term observations, conducted mostly in Yessentuki, a number of authors are tailored to resort workers classification of chronic diseases of liver and biliary tracts, be treated resort factors (I. C. savoshenko, 1957; A. S. Vishnevsky and Y. Svirzhevskaya, 1963).
On severity of symptoms distinguish between mild, moderate and severe forms of chronic hepatitis. In mild pain in the right hypochondrium and diarrhoeal phenomenon weak and unstable, the liver is not increased or is under a costal arch only 1-2 cm, its consistence is not changed less often slightly condensed, some patients also include blurred expressed cholecystitis without signs of angioholity. Functional disorders of the liver are weak and unstable. The body temperature and the picture peripheral blood remain within the normal range. The General condition of patients and health, as a rule, are not violated.
In chronic hepatitis moderate pain in the right hypochondrium and dyspeptic symptoms are almost permanent nature, but most of moderately intense, liver increased by 3 to 4 cm, moderately sealed; in some cases there is a slight increase in the spleen. Liver function in most cases violated, especially during periods of exacerbation. Very often there are complications - cholecystitis and less angiocholitis. Therefore, the disease usually alternating - on the background of relatively constant dull pain in the right hypochondrium arise periodically expressed moderate acute, sometimes accompanied
subfebrile temperature, light yellow eyes, by the appearance of small hyperbilirubinemia and urobilinemia, changes in peripheral blood. The General condition of the body is disturbed usually during exacerbations.
In severe chronic hepatitis pain in the right hypochondrium and diarrhoeal phenomenon are continuous and rather intensive, liver increased by 4-5 cm and more, in most cases has a dense consistence. Often marked increase, induration and tenderness of the spleen. Liver dysfunction has a pronounced and persistent. Typically, there are clinical and laboratory signs cholecystoangiogram. The disease in most cases, relapsing, i.e. characterised by rather severe exacerbations with fever, jaundice, changes in peripheral blood. Characterized by persistent violations of the General condition of the organism, in particular the decline of the power supply. When progressive course of severe hepatitis, cirrhosis of the liver, often with symptoms of portal hypertension.
In recent years the attention of clinicians increasingly attract patients with so-called residual effects of acute epidemic of hepatitis (post-hepatitis syndrome, hepatomegaly, functional hyperbilirubinemia and others). The considerable prevalence of this disease and a greater frequency of adverse outcomes give the problem of treatment of patients in the recovery period of the epidemic of hepatitis a special urgency. According to S. M. of Russa (1963), the treatment of patients in this period of disease should be preventive in the transition acute process in chronic. Stressing the value of such methods of complex therapy that enhance the immune forces of organism and maximum restore damaged liver, the author considers him clinical nutrition, the use of vitamins, steroid hormones, oxygen, neurotropic drugs, antibiotics.
In the clinic of the Pyatigorsk Institute of balneology and physiotherapy, Yu. S. Osipov in 1962 were undertaken search and surveillance, with the view of ascertaining the possibility and expediency of application of resort factors in the early stages posleratna period Botkin's disease. The results were very encouraging. In the next 3 years the staff of the clinic studied in detail indications, methods and efficiency of resort treatment of the patients with residual effects of the epidemic of hepatitis a in different terms after jaundice - from 1 to 12 months. On the basis of a comprehensive evaluation of the number of laboratory and clinical signs are three phases of the disease: inactive output activity and active.
When the residual phenomena of Botkin's disease in the active phase, as a rule, there are persistent and severe pains in the right hypochondrium, a significant increase in liver (3-4 cm), often enlargement of the spleen, yellowness of the skin and eyes, underweight, syndromic General asthenia, pathological deviations of the majority of laboratory indicators of the actual activity of defeat and liver dysfunction. Depending on the severity of these changes establish three levels of disease activity: low, medium and high. Of low activity of the process can talk in those cases, when the level of glutamine-pyruvic transaminases in the blood increased less than 2 times, the content of gamma-globulin is increased to 23%, diameter "papules" when intradermal administration of autofavorits does not exceed 10-20 mm
When the residual phenomena of Botkin's disease in the phase of a fading activity of the disease mostly favorable, but often have mild pain syndrome, increase in liver 1-2 cm, there are low or moderate deviations in laboratory parameters of activity of the pathological process in the liver without the expressed dysfunction or with slight changes of separate functions.
When the residual phenomena of Botkin's disease in the inactive phase pain syndrome in the most cases absent or poorly expressed, the liver has a normal size or increased by only 1 to 1.5 cm, not enlarged spleen, and laboratory indicators of activity of the process - level gamma-globulin, glutamine-pyruvic transaminases in the blood (G. F. Kulikov, 1965), the results of intracutaneous test with autosportas (Yu. S. Osipov, 1964)is not detect deviations from the norm (or there is a slight change in any one of these tests); basic functions of the liver, the synthesis of albumin, prothrombin, education and the provision of bilirubin is saved or slightly disturbed.
Treatment by drinking and balneological resorts recommended in patients with residual effects of Botkin's disease mainly in the inactive phase and at the phase of a fading activity at any time after jaundice, including within the first 1-3 months, when this treatment is most effective. When residual effects of the epidemic of hepatitis a in the active phase resort treatment are permissible only if low activity of the process and preferably at a later date after jaundice (4-6 months). With middle-and high-level epidemic of hepatitis regardless ago moved jaundice should be re-treatment in the hospital, and later to refer the patients to continue treatment mainly in the health resort of local type, which can be used is shown in such cases medical factors and first of all the internal use of bottled mineral water in combination with a sparing regime, diet therapy and medication.
In chronic diseases of the gallbladder and biliary tract - dyskinesia them, cholecystitis, cholecystoangiogram - the use of resort factors, including drinking mineral waters are widely shown and gives a good therapeutic effect.
In all diseases of liver and biliary tracts of drinking mineral water used in combination with other therapeutic agents. In the resort this diet therapy, therapeutic mud, mineral and gas baths, apparatus physiotherapy, therapeutic physical exercise, drugs, etc. the Role of internal intake of mineral water in the medical complex is very significant. First of all, mineral water act on the state of the liver and biliary tract. They increase zheleobrazovatel and excretory functions of liver, improve it carbohydrate and protein metabolism, activate detoxifying processes, etc. of Particular importance is the ability of mineral waters to change the physicochemical properties of bile. In the result of drinking treatment in patients with liver diseases and biliary tract decreases viscosity of bile, normalizes its reaction (pH), increases the amount of bile acids, etc. (I. C. savoshenko, 1957; A. M. Nogales, 1957; I. D. Frenkel and others, 1962).
All this creates conditions for the elimination of the inflammatory process in the biliary tract and prevents the deposition of cholesterol crystals, what is especially significant in the inclinations kamneobrazovaniu. An important factor therapeutic action of mineral waters in the pathology of the liver and biliary tract is their favorable effect on the digestive system - reducing inflammation in the mucous membranes of the gastrointestinal tract, restoration of violated secretory function of the stomach, increased motor activity of the stomach and intestines, activation of enzymatic functions of the main digestive glands.
Of great importance in liver pathology has normalizing effect of drinking mineral waters of different types of metabolism in the body - salt-water, carbohydrate, fat, and other (C. A. Aleksandrov, G. A. Smirnov, 1958). Finally, it should be emphasized recent evidence that some methods of the internal intake of mineral water influence the processes of humoral, including hormonal, regulation in the body. In particular, I. C. Nanazashvili (1962) found in patients with chronic infectious cholecystitis stimulating effect subaqueous baths on the function of the adrenal cortex.
Therapeutic action of mineral waters in the pathology of the liver and bile ducts due to their chemical composition. A. S. Vishnevsky (1959) and other authors attach great importance to the presence of mineral waters ions of sulphate, hydrocarbonate, chloride and magnesium. Sulfate water reinforce choleresis and bile, promote the excretion of cholesterol and bilirubin in bile and improve bowel movements and thereby reduce aterogennoe flow in the liver toxic substances and infectious agents. Choleretic effect bicarbonate and chloride waters is weaker than under the action of sulphate waters, but all the same it has medicinal value. Mineral water, having in its composition magnesium ions have a bile-expelling effect, reduce spasms of the muscles of the gallbladder, improve bowel movements.
Deserve attention and sulfide water (mostly poor concentration), as according to the available literature data, these increase the water content in the liver sulfgidrile connections playing, as you know, an important role for many metabolic processes, especially protein.
Particular caution is required in respect of the internal receive healing waters, having in its composition radon and other radioactive substances, as, according to literature data, these waters may sometimes have a negative impact on certain aspects of metabolic processes in the liver (C. A. Aleksandrov, G. A. Smirnov, 1958; C. N. Molchanov, 1960).
Along with the peculiarities of the chemical composition of mineral water in the effectiveness of their internal use at diseases of liver and biliary tracts play the role of other factors - temperature, dosage, method of application, etc. unfortunately, these issues are highlighted only some of the work.
Based on the experience of work in conditions of Karlovy vary, V. N. Donskaya, B. K. Luminezi M. I. Germanova (1957) emphasize the therapeutic value of high-temperature mineral waters (46-58 degrees). According to the authors, hot water, especially containing sulphate, have a constant gentle tonic effect on bile ducts, strengthen choleresis and bile. Significant and dose of drinking mineral waters, the multiplicity of its methods during the day. In everyday medical practice for treatment of patients with chronic liver diseases and biliary tracts most commonly used conventional method drinking - drinking of mineral water 200 ml 3 times a day for 30, 60 or 90 minutes before meals, depending on the nature of the secretory function of the stomach.
I. C. savoshenko (1957) was administered twice mineral water: the first at the usual time in view of the secretory function of the stomach (150-200 ml) and the second 20 minutes before a meal (even 150-200 ml) to enhance the flow of bile and its supply to the intestine at the beginning of the act of eating that, according to the author, improves digestion.
A. S. Vishnevsky (1958, 1959) recommends that, if necessary, strengthen zheleobrazovatel and excretory functions of liver, increase the dose of mineral water with 200-300 up to 400-500 ml and take her immediately, but in 2-3 reception for 30 to 40 - 60 minutes during the walk. The author believes that under these conditions, the first portion of mineral water stimulates mainly choleresis and the second bile secretion.
In the works of I. D. Frenkel and employees (1962) found that chronic infectious cholecystitis increasing single doses of mineral water promotes favorable shifts in respect of microflora of bile, content, leukocytes and especially physical-chemical properties, causes greater alkalization of bile and the increase of bilirubin, cholesterol and bile acids.


However, in chronic infectious hepatitis increasing doses of mineral water, seems inappropriate. This is evidenced by the work of G. M. Krasnici and B. N. Pereverzeva (1962) and Y. S. Vishnevskaya with employees (1963). The purpose of mineral water in a dose of 400 ml per reception (instead of 200 ml), according to the observations of the authors, reduces the overall efficiency of the resort complex therapy of patients with chronic hepatitis. This applies to both the clinical symptoms of the disease and the individual functions of the liver - belkovosvazavatei, excretion of cholesterol and other works marked beneficial effect of the increased doses of mineral water (400 ml) only on some features of the stomach, but at the same time underlines the negative effect of this method drinking treatment on the state of the intestine (flatulence, rumbling, tenderness to palpation). Therefore, chronic infectious hepatitis increasing single doses of mineral water to 400 ml can be recommended mainly with a concomitant gastritis, if there is no obvious violations of functional ability of the liver and intestines. Increasing doses of mineral water is also impractical in patients with chronic hepatitis and cholecystitis accompanying disorders of water-salt metabolism and obesity.
Along with drinking treatment in diseases of the liver and biliary tract widely used duodenal intubation with the subsequent introduction of mineral waters, tyubazhi (without probe),transduodenal of enema and rectal administration methods of mineral waters. Among the latter are of special importance subaqueous baths, which significantly increase the overall efficiency of the complex Spa treatment (I. C. savoshenko, 1957), contribute to the elimination of the inflammatory process in the bile ducts and liver dysfunction, reflex increase the gall bladder emptying, improve physical-chemical properties of bile and contribute to the changes of microflora in it.
A. S. Vishnevsky (1958, 1959) and Y. S. Vishnevskaya (1961) recommend the use of subaqueous baths in patients with hepatitis and cholecystitis signs of fermentation and putrefaction of indigestion and intestinal toxemia. In cholelithiasis subaqueous baths contribute to increased excretion of cholesterol from the body. With predominant lesion of the sigmoid and rectum authors prefer intestinal souls and irrigation. Widely used are also siphon washing, cleansing enema of mineral water and absorption microclysters.
Building the whole medical complex, in particular methods for internal use of mineral waters, should be differentiated depending on the features of disease. When chronic (mainly infectious) hepatitis medical complex is built taking into account the gravity of the disease, condition of the biliary tract, the presence of secondary or related lesions of the digestive tract (table. 8). In mild chronic hepatitis for internal use are recommended water medium and low mineralization. When the preferential pigmented lesion of liver function and pathology of the digestive system shows mineral water with a predominance of ions of hydrogen carbonate, sulfate, chlorine, sodium and calcium. The combination of these ions can be quite varied. Most suitable can be considered the following main types of medicinal waters.
1. The water is hydrocarbonate-chloride-sodium-hydrocarbonate-sulphate-sodium; the same waters with content of calcium ions.
2. The water is chloride-hydrocarbonate-sodium and chloride-sulphate-sodium.
3. Water is sulphate-chloride-sodium and sulphate-hydrocarbonate-sodium; the same waters with content of calcium ions.
4. Water is sulphate-sodium, sodium chloride and hydrocarbonate-sodium; the same waters with content of calcium ions.
5. Water with a more complex anion composition - hydro-carbonate-sodium-sulphate-chloride and chloride-hydrocarbonate-sulphate-sodium (or calcium).
At preferential violation of protein liver function tests may be recommended poorly sulphide water with small and medium mineralization.
For drinking treatment of mineral water in most cases prescribed at 200 ml 3 times a day for 30, 60 or 90 minutes before meals, depending on the state of the secretory function of the stomach. The increase in a single dose the water up to 300-400 ml shown in the accompanying pathology of the stomach, if not severe dysfunction of the liver and intestines. The water temperature 35-55 degrees. In inflammatory lesions of the biliary tract shown duodenal drainage and tyubazhi. In cases of concomitant pathology of the gastrointestinal tract should be widely used gastric lavage and various methods rectal insertion of mineral waters. Intestinal dyspepsia, constipation, aterogennoe intoxication most effective subaqueous baths.
Along with the mineral waters treatment in the medical complex consists of diet therapy (mainly diet 5 and 5A), physiotherapy, General gas and mineral baths, apparatus physiotherapy, climate, etc. In secondary inflammatory process in the biliary tract and the digestive tract pathology shown mud packs on the abdomen and waist temperature 42-44 degrees and in alternation with baths.
In chronic hepatitis moderate methods internal use of mineral waters are essentially the same. The increase of single doses of mineral water more than 200 ml) is not recommended. Widely shown mud packs on the area of the liver and the back is the temperature of 40-42 degrees in alternation with mineral and gas baths. Together with dieting 5 and 5A applies the so-called lipotropic diet.
In severe chronic hepatitis of the above mineral waters most shows water of low mineralization, with a predominance of ions of hydrogen, chlorine, sodium and calcium. The use of sulfide waters is not recommended. Water appoint a reduced dose - in the 100-150 ml 2-3 times a day when the temperature 35-45 degrees. In violation of the portal circulation drinking treatment is contraindicated.
Introduction of mineral waters through duodenal probe requires caution, it is preferable to restrict the appointment of tubage 1 time in 5-7 days. In testimony to the rectal introduction of mineral waters (flatulence, constipation) recommended more sparing methods - cleaning enema and microclysters. In violation of the portal circulation rectal introduction of mineral waters is not shown.
In the medical complex provides for the application lipotropic and hypochloride diet, lipokaina, methionine, choline chloride, vitamins C and group b, choleretic drugs; in more severe cases successfully used hormones napochechnikov crust. Mud treatment is carried out with caution, at the temperature not more than 38-40°, 2-3 times a week, alternating with the total mineral and gas baths.
Treatment of patients with residual effects of Botkin's disease is differentiated depending on the duration and degree of the process activity. When residual phenomena in the inactive phase and at the phase of a fading activity direction of patients on drinking and balneological resorts valid in any period of time after jaundice, including in the first 3 months. For internal use are listed above water of small and medium mineralization with a predominance of ions of hydrogen carbonate, sulfate, chlorine, sodium and calcium. Sulphide and radon waters are not recommended. Water appoint 200 ml 3 times a day at a temperature of 35-55 degrees. In inflammatory lesions of the biliary tract widely used duodenal drainage or tyubazhi at least 1-2 times a week.
In many cases, residual effects Botkin's disease is manifested not only by the defeat of a liver and bilious ways, and pathology of the gastrointestinal tract. This reparative processes in the liver occur less favourable residual effects Botkin's disease become protracted. From here follow the indications for the use of such methods internal use of mineral waters, as gastric lavage and rectal procedures; however, in the first 3 months, you should avoid prescribing subaqueous baths.
The great value has the correct use of other components of the medical complex. Motor mode must be at the beginning of the course sparing (especially in the first 3 months after jaundice), then toning with restriction walk to distant source of drinking water.
The duration of the adaptation period prior to the balneotherapy 3-4 days. The total mineral and gas baths are appointed in the first 3 months after jaundice no more than 3 times a week as 8-10 procedures for the course, in later periods - up to 4-5 times a week, only 12-14 procedures. Mud applications on the region of the liver in the first 3 months apply at the temperature of 38o later, at a temperature of 40-42 degrees in alternation with baths.
Patients with residual effects of Botkin's disease in the active phase of treatment in Spa resorts can be recommended only in low activity of the process and not earlier than 4-6 months after jaundice. For internal use are shown mainly water of low mineralization, mainly hydrocarbonate-chloride-sodium. Water appoint 150-200 ml 2-3 times a day. The water temperature 35-45 degrees. Intraduodenal introduction of mineral waters, tyubazhi and stomach spend for the same reasons as in residual phenomena Botkin's disease in the inactive phase and at the phase of a fading activity. From rectally methods of introduction of mineral waters shown more sparing - microclysters, cleansing enema, a siphon of enema.
Motor mode should be sparing no walk to distant source of drinking water. The period of adaptation to the beginning of balneotherapy should take not less than 5 days. Shared bath appoint at a temperature of 36-37° no more than 3 times a week as 8-10 procedures per course. Mud therapy is not used at all or designate at the temperature of 38o 2-3 times a week, alternating with baths. The use of resort factors must be combined with medication; widely used vitamins B1, B2, PP, B6, B12 (primarily parenteral), lipokain, methionine, choline, bile-expelling, insulin, glucose, antibiotics.
When the residual phenomena of Botkin's disease with medium and high activity of the process, as well as for persistent recurrent form of the disease (regardless of the length of posleratna period) a direction of patients for drinking and balneological resorts is not recommended. Shows the aftercare of patients in health resorts of local type using bottled mineral water, with the use of diet therapy, medical preparations and methods of restorative treatment. Treatment of patients with chronic diseases of the biliary tract is differentiated depending on the clinical form of the disease, the severity and nature of the functional and inflammatory components, stage or phase of the process, presence of complications, etc., (PL. 9).
When biliary dyskinesia should identify the predominant nature of musculoskeletal disorders of the gall bladder. When atopic form dyskinesia shows water medium and high salinity dominated ions of sulphate, sodium and magnesium - sulfate-sodium, sulphate-magnesium type batalinsky. Can be used sulfate water medium, and high mineralization (mainly from 8-10 to 20-25 g/l) number of other types:
1. Sulphate-sodium-chloride and chloride-sulphate-sodium.
2. Hydrocarbonate-chloride-sodium and chloride-hydrocarbonate-sodium.
3. Sodium chloride, sodium chloride-calcium chloride-sodium-calcium-magnesium.
If the mineral water resort only low mineralization, you can add bottle batalinsky water (50-100 ml per glass), Karlovy vary and Morshinska salt or sulphate of magnesia (1/4-1/2-1 teaspoon per glass of water).
In hypertensive form of a dyskinesia of the gallbladder shows water, small and medium-mineralized (up to 8-10 g/l) from previously recommended at diseases of a liver. Mineral water appoint 200 ml (less 300 ml) 3 times a day. When atopic form of biliary dyskinesia apply cold water and poorly thermal (17-35 degrees)in hypertensive form - thermal and high thermal (35-55 degrees). When atopic form, except drinking, widely shown duodenal drainage, tyubazhi, gastric lavage and when insufficient gastric emptying - rectally methods of introduction of mineral waters. Other methods of complex Spa therapy with biliary dyskinesia apply diet without significant restrictions chemical and mechanical stimuli, enriched with salts of magnesium and vitamins. Effective total mineral and gas baths indifferent temperature, therapeutic exercises, climatotherapy, etc., If necessary, apply medications - hypnotics, sedatives, antispastic, cortical stimulants and other Mud therapy should be used only when there are more indications-development dyskinetic cholecystitis, pathology of the digestive tract, etc. it is Preferable elektrogryazevye procedures or mud applications temperature of 38 degrees and in alternation with baths.
In chronic infectious cholecystitis apply the above water of small and medium mineralization with a predominance of ions of sulphate, hydrogen, chlorine, sodium and magnesium, mainly thermal and high thermal; shows calcium waters. The method of treatment by drinking plain. The increase of single doses of mineral water to 300-400 ml may be recommended when the abundance of inflammatory products in the bile and the presence in it of pathogenic microflora. This dose drink water in 2-3 reception at intervals of 20-30 minutes. Widely shown intraduodenal and rectal administration methods of mineral waters. Intestinal dyskinesia, dyspepsia and enterogeno intoxication without exacerbation, and in the absence of preprocess recommended subaqueous baths. Without exacerbation widely used mud packs on the area of the liver at a temperature 38-40-42°, preferably in alternation with baths. In the phase of exacerbation and decaying exacerbation antibiotics are used (preferably taking into account the sensitivity of microflora to them), anti-inflammatory and unloading diet, antispastic and cholagogue, etc.
For chronic calculous cholecystitis apply water of small and average mineralization, mostly listed above hydrocarbonate-chloride sodium (or chloride-hydrocarbonate-sodium), thermal (35-42 degrees). Sulfide water is not shown.
Drinking water treatment is the usual procedure, the increase of single doses of mineral water to 400-300 ml (2-3 receiving) may be recommended in the pathology of physico-chemical properties of bile - low values of pH and golato-cholesterol ratio.
Introduction of mineral waters through duodenal and rectal probe requires caution, as the heavy reflex stimulation of the motor function of the gallbladder may provoke migration stones. When combined calculous cholecystitis with hypercholesterolemia, obesity and gout, if there is no danger to cause an attack of biliary colic, shown subaqueous baths. Mud therapy is used with caution at a temperature of 38-40 degrees and in alternation with shared baths. Shown magnesium diet (A. M. Noveller and others, 1955), medical gymnastics in a gentle method, antispastic drugs, cholesterol and other
In chronic parasitic cholecystitis drinking treatment is carried out by a method similar to that described for patients with infectious cholecystitis. Rectal administration methods of mineral waters is shown mainly in the pathology of the intestine after a preliminary specific anti-parasitic treatment. Mud therapy is indicated for secondary hepatitis and concomitant pathology of the digestive tract.
Chronic cholecystitis complicated by angiocholitis, it is necessary first of all to ensure a good flow of bile. For this purpose sulphate-sodium and sulphate-magnesium water of small and medium mineralization. To reduce the inflammatory process in the biliary tract and the digestive system shows hydrocarbonate and calcium waters. In the absence of contraindications water is better to assign an increased dose is 300-400 ml (2-3 receiving) 3 times a day at temperature 35-45 degrees; for constipation is advisable to add magnesia sulfate or sodium sulfate. Widely shown stomach, duodenal drainage, tyubazhi, cleansing enema of mineral water, intestinal soul siphon of enema, without exacerbation, and in the absence of preprocess - subaqueous baths. Mud treatment is in remission for sparing method in the form electrographic procedures or applications in the area of the liver at a temperature 38-40-42 degrees and in alternation with baths. In the inclinations to frequent exacerbations, subfebrile temperature, changes in peripheral blood resort factors used in combination with antibiotics that are assigned taking into account the sensitivity of microflora of bile. Using special food rations - inflammatory, magnesium, lipotropic diet, antispastic, choleretic, vitamin, lipotropic drugs.