What is cholangitis symptoms and treatment. Chronic cholangitis: symptoms and treatment, nutritional advice

Cholangitis is an inflammatory process in the bile ducts, provoked by an infection that has penetrated through the lymph or blood that comes from the intestines or gallbladder. The syndrome rarely occurs on its own, more often it acts as a complication of viral hepatitis, inflammation of the pancreas, calculous cholecystitis.

Among the pathologies of the digestive tract, it is cholangitis that appears to be one of the most difficult pathologies in terms of diagnosis and therapy. There are several varieties of the disease, which differ clinical manifestations and etiological factors. Some of them have a latent treatment, the cause cannot be established.

Consider the etiology, pathology, varieties and forms of inflammation, features of the course and methods of conservative therapy of cholangitis.

Description of the disease and causes

A person in the body has a complex network of channels of various sizes through which bile flows.

The network starts from the liver and ends in the intestine, where lipids are digested and pathogenic microorganisms are destroyed.

Against the background of cholangitis in a patient, extra- and intrahepatic bile ducts are affected.

Pathology most often develops in women 50-60 years of age. In gastroenterological practice, the disease is often diagnosed together with cholelithiasis, inflammation of the pancreas, gastroduodenitis, viral hepatitis, cholecystitis (then they talk about cholecystocholangitis).

Etiology

The dominant role in the development of cholangitis (with the exception of the sclerosing form) is played by two provoking factors - the presence of pathogenic microorganisms that have penetrated the ascending path, and congestion.

Microbes that provoke inflammation can enter the channels from the gallbladder, intestines, blood vessels, or through the lymphatic pathway. For this reason, cholangitis is often a complication of inflammation of the gallbladder.

Stagnation is a consequence of a violation of the discharge of bile. The reason is the following factors:

  • Clogging of the ducts with calculi against the background of cholelithiasis.
  • The occurrence of an acute form of pancreatitis and subsequent swelling of the pancreatic head.
  • The presence of a tumor neoplasm that compresses the common bile duct or prevents the full discharge of bile.
  • Stenosis (pathological narrowing) of the bile ducts.
  • The defeat of Vater's papilla is the place where the lumen of the common bile duct and pancreatic canals opens.

The sclerosing form of cholangitis differs from all others. Until now, the exact causes of the development of pathology have not been established. Most doctors adhere to the theory of autoimmune occurrence.

Due to incorrect operation immune system, due to which the immune system begins to attack healthy cells, the tissues of the channel system are affected. Continuous chronic inflammation provokes pathological growth of connective tissues, stenosis of the lumen and a violation of the discharge of bile.

In autoimmune disorders, intrahepatic bile capillaries are affected, which contributes to the onset of cirrhosis.

Types and forms of pathology

Determining the type and form of pathology plays an important role in treatment.

The classification of cholangitis depends on the form, type and course of the disease.

Depending on the course, cholangitis is acute and sluggish (that is, chronic).

In turn, the acute course is divided into subtypes. They are presented in the table:

The chronic form of cholangitis is sclerosing (when connective tissues grow), latent, recurrent, prolonged septic and abscessing. Depending on the localization of the inflammatory focus, there are:

  1. Choledochitis (with inflammation of the common duct).
  2. Angiocholitis (inflammatory process affects the extra- and / or intrahepatic bile ducts).
  3. Papillitis (inflammation of the duodenal papilla).

Clinic of cholangitis

Acute and chronic cholangitis are difficult diseases to diagnose.

With the same disease, two patients may have a different clinic.

Sometimes inflammation is disguised as another ailment, it proceeds latently, which further complicates the diagnostic process.

acute form

Acute (reactive) cholangitis is a dangerous condition that requires immediate medical attention. Lack of therapy leads to blood poisoning, a high probability of death.

Triad of acute cholangitis:

  • Temperature increase. Usually a feverish state manifests itself suddenly, the temperature rises to 40 degrees. The patient complains of severe weakness, headache. There is increased sweating, which increases the risk of dehydration. In some patients, the temperature "jumps", does not always stay at the same level.
  • Jaundice, . These two symptoms have the same causes, due to an increase in the concentration of bilirubin in the blood. Bilirubin is a toxin that is formed after the breakdown of red blood cells and is excreted along with bile or urine. Since the normal process is disrupted due to inflammation, bilirubin accumulates. The patient's whites of the eyes, mucous membranes, integument turn yellow, the skin itchs.
  • Pain in the right hypochondrium. If you draw the edge of the palm along the edge of the costal arches on the right and left, then pain syndrome will be on the right. This indicates cholangitis and inflammation of the gallbladder.

The listed signs may be supplemented by other symptoms - a decrease in indicators blood pressure, rapid heartbeat and pulse.

Chronic form

It is difficult to suspect chronic cholangitis, because against the background of a sluggish course of the disease, a person’s well-being worsens slightly. Additionally, the variety of forms of the disease complicates the diagnosis. Each patient has chronic inflammation with its own symptoms.

A hint for making the correct diagnosis is the patient's history:

  1. Removal of the gallbladder (this operation is called cholecystectomy). According to statistics, after surgery, 1/3 of patients develop cholangitis.
  2. GSD is one of the risk factors.
  3. In the past, acute cholangitis that was not properly treated.

People with this history have a high risk of developing cholangitis. Chronic inflammation can also be suspected by the following complaints:

  • Disruption of the digestive tract.
  • Yellowing of the skin.
  • Pain in the upper abdomen on the right.
  • Constant weakness and lethargy, decreased ability to work.
  • Feverish state of idiopathic etiology.

Such complaints indicate a number of other gastroenterological diseases, therefore, complex differential diagnosis is required.

PSH

The primary sclerosing form of the disease in 55% of cases has an asymptomatic course. In 20-60% of patients, the disease is diagnosed when there is already cirrhosis of the liver. Up to 20% suffer from malignant liver disease resulting from PSC.

This suggests that PSC is very difficult to detect. On the one hand, patients rarely go to the doctor with mild symptoms, on the other hand, not every specialist will suspect a rare but insidious disease.

Diagnostic methods

To confirm the diagnosis, a complex of instrumental and laboratory research methods is carried out.

Definitely recommended clinical trial blood - evaluate the concentration of ESR, leukocytes and neutrophils. Urinalysis for the presence of bilirubin. Blood biochemistry - determine reactive protein, total and direct bilirubin, GGTP, AST, ALT, alkaline phosphatase.

In acute cholangitis, all of the above indicators are above the norm. And against the background of a chronic course within the normal range, with the exception of the rate of decay of erythrocytes. Normally, there should be no bilirubin in urine.

Magnetic resonance cholangiopancreatography is the "gold standard" for diagnosing cholangitis. A special medicine is injected into the patient's blood, which stains the ducts and gallbladder in a certain color. Further, their condition is studied on the MRI machine.

Other instrumental studies:

Type of studyDescription
ultrasoundAssess the condition of the gallbladder, choledochus. Advantages of the method - informative and safe, can be done during pregnancy, little child. Cons of echoscopic examination - you can not see the small bile ducts.
Endoscopic retrograde cholangiopancreatographyAcross oral cavity a special device is inserted, and upon reaching the final section of the choledochus, a contrast agent is injected. It is distributed throughout the channel system, which allows you to visualize it in the picture. The disadvantage of the study is the high risk of complications.
HHHThe bile ducts are filled with contrast, after which pictures are taken. The main difference from the previous technique is the method of delivery of the contrast component. It is injected directly into the canal through the skin or liver under the control of an ultrasound machine.

Medical therapy

If an acute course of cholangitis is suspected in a patient, then treatment in a hospital is required - the patient is assigned to the surgical department. This is due to the fact that the disease is characterized by unpredictable consequences; at any time, inflammation of the canal system can provoke sepsis or severe impairment of the functionality of other organs.

Surgery is potentially indicated for each patient in order to restore the full discharge of bile. Doctors are trying to choose minimally invasive techniques. If possible, the procedure is done with the help of an endoscope - it is carried out through the oral cavity to the final section of the common choledochus. Chronic forms are treated at home.

Treatment of an acute illness

The operation is carried out in 95% of cases. The time of its implementation is determined by the well-being of the patient. With a relatively mild course of the disease, intervention is carried out in the first 24 hours after hospitalization.

In severe cases or when sepsis has developed, it is required to prepare the body with medications.

The treatment course to improve the condition includes:

  1. Intravenous infusion of solutions that improve metabolic processes, reduce intoxication in the body (sodium chloride, glucose, Ringer's solution).
  2. Antibacterial therapy (combine several antibiotics of different groups).
  3. Hepatoprotectors - to support the functionality of hepatocytes.
  4. If the patient suffers from pain, the use of painkillers is required.

After surgical treatment conservative therapy continues. The treatment regimen is prescribed individually.

Treatment of a chronic illness

When chronic cholangitis is identified, medical professionals try to find the source of the problem. It is he who determines the subsequent tactics of therapy.

Specific treatment complemented general recommendations. A diet is recommended (table No. 5), smoking, alcohol, exclusion of excessive physical activity. Need to take vitamin complexes, including retinol, tocopherol, vitamins K and D.

Forecast

With timely treatment of acute cholangitis, which is not complicated by blood poisoning, liver failure, the prognosis is favorable. Adequate treatment for catarrhal cholangitis provides a positive result. And with a purulent and necrotic form, complications always develop. The prolonged course of the chronic form leads to disability.

Cholangitis is an inflammatory lesion of the biliary tract, which most often has a non-specific nature - that is, it is caused by non-specific pathogens that can cause other inflammatory diseases.

This is a common disease that quite often goes hand in hand with other disorders of the gastrointestinal tract. Cholangitis is a problem of gastroenterology, but in case of complications, it requires surgical intervention.

Table of contents:

common data

The bile ducts can equally often be affected by cholangitis along their entire length - both small intra- and large extrahepatic ones.

note

The disease is most often diagnosed in the older age group - from 50 to 60 years, but in recent years there has been a trend towards rejuvenation of cholangitis, and more and more 40-year-old patients are admitted to the clinic with signs of this disease. Mostly women of this age category suffer.

Isolated cholangitis is less common than combined - therefore, if it is detected, other diseases of the gastrointestinal tract should be diagnosed, which may or may not appear, or their symptoms may be lost against the background of signs of cholangitis. Most often, an inflammatory lesion of the bile ducts is combined with acute or chronic forms of such acute and chronic diseases of the digestive tract as:

  • gastroduodenitis;
  • in some cases - violations of the papilla of Vater (the place where the common bile duct and the pancreatic duct flow into the duodenum).

Causes

Inflammatory changes in the biliary tract are directly caused by an infectious agent that has entered them in different ways. Most often it is:

  • different forms;
  • enterococci;
  • anaerobic infection of the non-clostridial series.

The defeat of an infectious agent that causes specific infectious diseases is quite rare - but it should also be remembered (in particular, if typical cholangitis is not amenable to classical treatment). These can be the following pathogens:

  • bacillus Koch (mycobacteria);
  • pale spirochete (pathogen).

note

Often, the symptoms of such cholangitis, provoked by a specific infection, may not be noticed, as they are lost against the background of the main symptoms caused by this infectious agent. This is especially true of latent (hidden) and sluggish forms of inflammatory lesions of the biliary tract.

The infectious agent most often penetrates the bile ducts:

  • by normal migration, being nearby in the duodenum and getting out of it through the papilla of Vater;
  • hematogenously - with blood flow through the portal vein (central vein of the liver);
  • lymphogenous way - with lymph flow (mainly with inflammatory lesions of the gallbladder, pancreas or small intestine).

Also, a viral agent can play a role in the development of cholangitis - basically, with such a lesion, small bile ducts that pass inside the liver are involved (in particular, this is observed in viral hepatitis).

But inflammation biliary tract can develop without the participation of any pathogens. This so-called aseptic (literally - sterile) cholangitis. Basically it happens:

  • enzymatic nature, when activated pancreatic juice irritates the wall of the biliary tract from the inside (this is observed with the so-called pancreatobiliary reflux, when the secret of the pancreas is "poured" into the biliary tract, which should not normally be). At first, inflammation occurs without the participation of an infectious agent, but it can join later at different stages of the disease;
  • sclerosing cholangitis - occurs due to autoimmune inflammation of the bile ducts (when the body reacts to its own tissues as if they were foreign).

The suspicion that cholangitis is of an autoimmune nature should appear if, in parallel, the patient has signs of such immune diseases as:

  • (formation of ulceration of the mucous membrane of the large intestine throughout its entire length);
  • (formation of granulomas all over gastrointestinal tract);
  • (inflammation and subsequent destruction of the walls of blood vessels);
  • (connective tissue disease that goes away with joint deformity);
  • thyroiditis (inflammation of the thyroid gland)
  • and some other diseases.

The penetration of infection into the biliary tract is facilitated by cholestasis - stagnation of bile. It is mainly found in pathologies such as:

  • (violation of their motor skills);
  • congenital anomalies of the biliary tract (kinks, compression);
  • choledochal cyst;
  • cancer of the biliary tract;
  • choledocholithiasis (stones in the common bile duct);
  • stenosis (narrowing) of the papilla of Vater.

The trigger for the onset of cholangitis can also be damage to the walls of the bile ducts during endoscopic manipulations - most often such as:

  • retrograde cholangiopancreatography (injection of a contrast agent with a probe through the duodenum into the bile ducts);
  • stenting (installation of special frames that support the normal shape of the bile ducts);
  • sphincterotomy (dissection of the sphincter of Oddi - the muscle at the confluence of the common bile duct and the pancreatic duct into the duodenum);
  • surgical treatment of diseases of the biliary system of the liver.

Flow

Downstream cholangitis can be:

  • sharp;
  • chronic.

Depending on what pathological changes occur in the wall of the bile ducts, acute cholangitis is:

  • catarrhal;
  • purulent;
  • diphtheric;
  • necrotic.

At catarrhal cholangitis in the walls of the biliary tract, the usual uncomplicated inflammation is observed in its classical manifestation - this is redness and swelling of the mucous membrane, exfoliation of its surface layer.

Purulent form cholangitis is characterized by the formation of small multiple abscesses (limited abscesses) and further purulent fusion of the bile ducts.

At diphtheria cholangitis in the walls of the biliary tract, multiple ulcerations are formed, which lead to the gradual destruction of the walls. Also characteristic- the walls of the bile ducts are covered from the inside with a fibrous film.

For necrotic form characteristic is the formation of foci of necrosis (necrosis) of the wall of the biliary tract.

Chronic cholangitis is more common. It may develop:

  • as a primary process with a protracted course;
  • as a result of acute inflammation.

There are such forms of chronic cholangitis as:

  • latent - this is a latent form, during which there are morphological changes in the bile ducts, but symptoms do not appear;
  • recurrent - a form with alternating exacerbations and periods of calm;
  • long-term septic - a protracted form with an infectious lesion of the whole organism;
  • abscessing - with this form, abscesses form in the bile duct system;
  • sclerosing - in the walls of the bile ducts there is a pronounced proliferation of connective tissue, which causes their narrowing and deformation.

Cholangitis can occur in the form of such varieties as:

  • choledochitis - inflammation of the choledochus (common bile duct);
  • angiocholitis - damage to smaller bile ducts;
  • papillitis - an inflammatory lesion of the Vater papilla (the place where the common bile duct enters the duodenum);
  • total defeat of the entire biliary tract system.

Symptoms of cholangitis

Signs of cholangitis depend on its form.

Acute cholangitis always begins suddenly. Its symptoms are:

  • fever and hyperthermia;
  • signs of intoxication;
  • dyspeptic phenomena;

Hyperthermia and fever are symptoms that usually start acute cholangitis:

  • body temperature rises to 39-40 degrees Celsius;
  • observed;
  • sweating is pronounced.

Pain characteristics:

  • begin almost simultaneously with fever;
  • by localization - in;
  • by irradiation (spread) - give to the right arm, shoulder, right half of the neck;
  • by nature - cramping, reminiscent of hepatic colic;
  • intensity - strong.

Signs of intoxication are:

  • progressive weakness;
  • loss of appetite;
  • decrease in performance.

Soon, dyspeptic phenomena develop:

  • which does not bring relief;

Later, jaundice occurs - yellowing skin, sclera and visible mucous membranes. Due to the accumulation of bile pigments and their irritation of nerve endings, jaundice provokes itchy skin.

Characteristic is increased itching at night, which disturbs the patient's sleep.

The main signs of acute cholangitis are three symptoms that make up the so-called Charcot triad:

  • significant hyperthermia (rise in body temperature);

If the course of acute cholangitis is especially difficult, then disturbances in consciousness and manifestations of shock are added - these are the five most important symptoms this disease called the Reynolds pentad. We can say that this is the main landmark, thanks to which clinicians make the diagnosis of acute cholangitis.

Signs of the chronic form of cholangitis are similar to those of the acute form, but erased - on the other hand, as the disease progresses, they gradually increase . In this case, abdominal pain:

  • stupid;
  • weak;
  • in some cases, these are not pains, but a feeling of discomfort and fullness in the upper abdomen.

Jaundice is present in chronic cholangitis, but it occurs quite late, when inflammation has long arose and worsened in the bile ducts - in fact, these are far-reaching pathological changes.

Common signs in chronic cholangitis are also present, but they are not as pronounced as in acute. In particular, there are:

  • an increase in body temperature to subfebrile numbers;
  • fatigue, but not critically affecting performance;
  • feeling of weakness.

Complications

If cholecystitis is not diagnosed and stopped in time, the following complications may occur:


Diagnostics

Based on the clinical picture, in the diagnosis of acute cholangitis, one should focus on Charcot's triad or Reynolds' pentad. But in general, to make a diagnosis of this disease, it is also necessary to involve additional methods diagnostics - physical (examination, palpation, tapping and listening to the abdomen with a phonendoscope), instrumental and laboratory.

When examining such a patient, the following are revealed:

  • yellowness of the skin, sclera and visible mucous membranes;
  • tongue dry, coated with yellow coating;
  • traces of scratching are visible on the skin, sometimes quite pronounced, up to blood (with severe itching).

With the phenomena of jaundice, an examination of feces and urine will also be informative:

  • feces are characterized by a lighter shade than usual (but in general it is not white, as it can be with jaundice about);
  • due to the ingress of bile pigments into the bloodstream, and then into the kidneys, the urine may darken (a characteristic symptom of “beer color”).

On palpation at the peak of the pain attack, there is strong pain in the right hypochondrium.

With percussion (tapping with the edge of the palm on the right costal arch), the patient reacts very painfully.

Auscultation is not informative.

Instrumental methods that are used to diagnose cholangitis are:

In the diagnosis of cholangitis use such laboratory methods, how:

  • – its data are not specific, but are important for assessing the progression of inflammation. So, an increase in the number of leukocytes and an increase in ESR will be detected;
  • biochemical- determine the increase in the amount of alkaline phosphatase, as well as transaminases and alpha-amylase. Such data indirectly indicate cholestasis (stagnation of bile), which is observed in cholangitis;
  • bacteriological culture of bile obtained by duodenal sounding - thanks to him, the causative agent of cholangitis is identified;
  • - thanks to him, they confirm or exclude the presence in the body or protozoa that can cause inflammation of the biliary tract.

Differential Diagnosis

Differential (distinctive) diagnosis of cholangitis should be carried out with diseases such as:

Treatment of cholangitis

Cholangitis is treated with conservative or surgical method. The choice of method depends on:

  • causes of illness;
  • degree of manifestations;
  • complications.

The most important tasks that are pursued in the treatment of this disease are:

  • elimination of inflammation;
  • detoxification;
  • decompression (unloading) of the biliary tract.

At the core conservative treatment are the following appointments:

If acute phenomena were overcome, then during the period of remission, physiotherapeutic methods of treatment are successfully practiced, such as:

  • inductothermy;
  • microwave therapy;
  • electrophoresis;
  • diathermy;
  • mud applications (application of therapeutic mud);
  • ozokeritotherapy;
  • paraffin therapy;
  • salt baths (in particular, sodium chloride).

All these methods can be carried out in the physiotherapy room of the clinic or during the spa treatment, which is recommended to the patient at the stage of remission.

If necessary, they resort to surgical correction of disorders of the biliary tract - these are:

  • endoscopic papillosphincterotomy - dissection of the narrowed vater of the papilla;
  • endoscopic extraction of stones from the bile ducts;
  • endoscopic stenting of the common bile duct - the introduction of a framework into it, which will help maintain the normal lumen of the common bile duct;
  • percutaneous transhepatic drainage of the bile ducts - removal of bile from the duct system through a puncture of the skin and liver.

In the case of sclerosing cholangitis, the most effective way is a liver transplant.

Prevention

The basis of measures that will help prevent inflammatory lesions of the biliary tract are the following:

Forecast

The prognosis for cholangitis is different. With the catarrhal form of cholangitis, it is satisfactory, with purulent, diphtheritic and necrotic forms it is more serious: in this case, the outcome can be favorable for the patient only in the case of verified prescriptions and scrupulously adhered to treatment.

If the inflammation of the biliary tract passes with complications, then the prognosis is unsatisfactory. This is especially true in diseases such as:

  • the formation of abscesses in the biliary tract;
  • cirrhosis of the liver;
  • hepatic and renal insufficiency;
  • septic damage to the body.

Kovtonyuk Oksana Vladimirovna, medical commentator, surgeon, medical consultant

Nonspecific inflammation of the bile ducts, which occurs as a result of impaired patency of the biliary tract and infection of the bile. Most often, with cholangitis, E. coli is sown from bile. Most often combined with choledocholithiasis, cysts of the common bile duct, bile duct cancer. In most cases, cholangitis occurs when pathogens of a bacterial infection enter the bile ducts from the lumen. duodenum(ascending infection), hematogenous (through the portal vein system), or lymphogenous (in diseases of the gallbladder, pancreas, or colon) by. According to the nature of the course, acute and chronic cholangitis are distinguished. Acute cholangitis, depending on the severity of inflammatory changes in the wall of the bile ducts, can be catarrhal, purulent, diphtheritic and necrotic. Among the forms of chronic cholangitis, latent, recurrent, long-term septic, abscessing and sclerosing are distinguished. Symptoms, course. The clinical picture depends on the presence or absence of acute destructive cholecystitis, often complicated by cholangitis. The disease usually begins with a painful attack resembling hepatic colic (a manifestation of choledocholithiasis), after which obstructive jaundice, fever, and pruritus quickly appear. On examination, icterus of the skin, traces of scratching on the skin, the tongue is wet, lined, the abdomen is not swollen. On palpation of the abdomen, some stiffness of the muscles in the right hypochondrium, pain, with deep palpation, an increase in the size of the liver is determined, its edge is rounded. Temperature sometimes hectic type, chills. In the blood - leukocytosis with a shift to the left. Hyperbilirubinemia mainly due to direct bilirubin, an increase in alkaline phosphatase, a moderate increase in liver enzymes (ALT, ACT) due to toxic damage to the hepatic parenchyma. An ultrasound examination of the liver and biliary tract can provide significant assistance in establishing the diagnosis of cholangitis. In the absence of timely treatment, inflammation from the wall of the bile ducts passes to the surrounding tissues and can cause impregnation of the hepatoduodenal ligament with bile and peritonitis, the formation of intrahepatic abscesses, the development of sclerotic changes in the liver tissue and secondary biliary cirrhosis. Complications. Formation of multiple liver abscesses, sepsis, hepatic-renal insufficiency. Obstructive jaundice often develops in elderly and senile people, whose compensatory capabilities of the body are very limited, and surgery against the background of acute cholecystitis is a great risk. In this situation, urgent endoscopic papillotomy is promising. Through the biopsy channel of the duodenoscope, a thin cannula is inserted into the major duodenal papilla, after which its upper wall is cut using a special papillotome. In this case, the calculi from the ducts either move away on their own, or they are removed with special tweezers using a Dormia loop (basket) or a Fogarty probe. This manipulation allows you to eliminate biliary and pancreatic hypertension, reduce jaundice and intoxication. Subsequently, an operation on the gallbladder is performed in a planned manner. A patient with suspected cholangitis needs urgent hospitalization, since the treatment is predominantly surgical. At the pre-medical stage, antispasmodic and anti-inflammatory drugs, broad-spectrum antibiotics that do not have hepatotoxic properties are prescribed. The tactics of managing patients with cholangitis presents significant difficulties, they are due to the presence of a purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these moments requires an early resolution, however, patients with obstructive jaundice do not tolerate long-term and traumatic surgical interventions. Therefore, it is advisable first of all to ensure an adequate outflow of bile, which at the same time reduces the clinical manifestations of cholangitis, intoxication. The second stage is a radical intervention aimed at eliminating the cause of cholangitis. In the hospital, detoxification and antibiotic therapy and prepare the patient for surgery. The most widely used in acute cholangitis are endoscopic methods for draining the bile ducts, which ensures a normal outflow of bile. The prognosis of catarrhal cholangitis with timely treatment is favorable. With purulent, diphtheritic and necrotic cholangitis, the prognosis is more serious and depends on the severity of morfol. changes, the general condition of the patient, as well as the factor that caused cholangitis. Long-term chronic cholangitis may develop biliary cirrhosis liver or abscessed cholangitis, the prognosis of which is unfavorable. Prevention consists in the timely detection and treatment of diseases of the biliary tract and the region of the major duodenal papilla. In order to decompress the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual choledochal stones after papillosphincterotomy, the discharge of calculi from the biliary tract is sometimes noted, the phenomena of cholangitis are stopped and the question of the need for a second operation disappears. The prognosis is serious. Cholecystectomy is the main surgical intervention performed in acute cholecystitis. Removal of the gallbladder can present significant difficulties due to severe inflammatory changes in the surrounding tissues. Therefore, it is recommended to remove the bubble "from the bottom". Cholecystectomy, if indicated, should be supplemented by intraoperative examination of the extrahepatic bile ducts (cholangiography). When choledocholithiasis or stenosis of the terminal section of the common bile duct is detected, the same manipulations are performed that are customary to do in similar cases during planned operations in patients with chronic calculous cholecystitis (choledochectomy, T-shaped drainage, etc.). Drainage is left in the abdominal cavity to control blood and bile leakage. Mortality after cholecystectomy performed for acute cholecystitis is 6-8%, reaching the streets of elderly and senile age 15-20%. Tom and I with the removal of calculi and infected contents of the gallbladder is shown in rare cases, as a forced measure in the general serious condition of the patient and a massive inflammatory infiltrate around the gallbladder, especially in the elderly and senile. This operation allows only to eliminate acute inflammatory changes in the wall of the gallbladder. In the long term after the operation, as a rule, stones form again in the gallbladder and patients have to be operated on again.

Filtering toxins, storing vitamins, producing glycogen - these are the main tasks that the liver performs in the body of every person. If for some reason these functions cannot be fully executed, then . Yellowing of the skin or sclera of the eyes are clear signs that the liver is starting to fail.

What is it - cholangitis?

What is it - cholangitis? This is inflammation of the bile ducts. Their obstruction with the addition of infection is a sure sign of the disease.

Types and forms

Cholangitis has its own types and forms of development. The forms are divided into:

  1. Spicy. According to the inflammatory nature, acute cholangitis is divided into types:
  • Catarrhal - swelling of the bile ducts with their further scarring and narrowing.
  • Purulent - affects the liver and gallbladder, characterized by the accumulation of pus and bile in the bile ducts.
  • Necrotic - the formation of necrosis of sections of the bile duct after the ingestion of pancreatic enzymes.
  • Diphtheritic - manifestations and necrosis of the mucosa, destruction of the walls of the bile duct, purulent fusion of the surrounding tissue.
  1. Chronic. According to the inflammatory nature, they are divided into types:
    • Hidden (latent).
    • Septic.
    • Recurrent.
    • Abscessing.
  2. Sclerosing (autoimmune) cholangitis - it is assumed that it develops as a result of an autoimmune reaction of the body to itself. Hardening, narrowing and overgrowth of the bile ducts occurs, which leads to cirrhosis of the liver.
  3. Bacterial.

Causes

What could be the causes of such an unpleasant disease as cholangitis? Consider the most common:

  • Gallstone disease in the bile ducts (choledocholithiasis).
  • Scarring and narrowing of the bile duct due to removal of a cyst, tumor, or chronic cholecystitis.
  • Roundworm, helminthic invasion.
  • Hepatitis.
  • Penetration of infection from the intestines, through the flow of lymph or blood. A favorable environment for her becomes a violation of the outflow (stagnation) of bile.

Predisposing factors for these anomalies are:

  1. genetic predisposition.
  2. psychogenic factor.
  3. congenital anomalies.
  4. Giardiasis.
  5. Dyskenesia.
  6. endocrine disorders.
  7. immunological reactions.
  8. Pancreatobiliary reflux.
  9. Dyscholia, which develops for the following reasons:
    • Eating disorder.
    • Obesity.
    • Overweight.
    • Hormonal disruptions.
    • Taking hormonal medications.
    • Violation of the blood supply to the liver and gallbladder.
    • Dishormonal disorders.
    • Alcoholism, smoking.

Symptoms and signs of cholangitis of the bile ducts

Symptoms and signs of cholangitis of the bile ducts should be considered in the form of their course:

  1. Spicy:
    • Attack of pain in the right side chest(shoulder, shoulder blade) and abdomen.
    • Raising the temperature to 40ºС.
    • Nausea.
    • Lowering blood pressure.
    • Weakness.
    • Vomit.
    • Skin itching.
    • Chills.
    • Yellowness of the skin, mucous membranes, sclera.
    • Violation of consciousness.
    • Perhaps the development of hepatic coma.
  2. Chronic:
    • Pain is mild, but intense in the presence of stones.
    • Skin itching.
    • Bursting or squeezing in the right hypochondrium.
    • Weakness.
    • Intermittent high fever.
    • fatigue.
    • Thickening of the fingers, redness of the palms.
  3. Sclerosing:
  • Pain in the upper abdomen and right hypochondrium.
  • Violation of the stool, as in ulcerative colitis or Crohn's disease.
  • Jaundice and pruritus.
  • Temperature up to 38ºС.

Cholangitis in children

In children, cholangitis occurs mainly due to genetic or congenital causes. In other cases, the disease is not observed in children.

Cholangitis in adults

In adults, cholangitis develops due to genetic, congenital, and in women, it occurs with hormonal disruptions during pregnancy or childbirth. It occurs in men due to the presence bad habits or untreated diseases. An unhealthy lifestyle and poor-quality nutrition are the main factors of cholangitis in adults.

Diagnostics

Diagnosis of inflammation of the bile ducts begins with a general examination and collection of complaints. According to some external signs, the doctor has reasons for the following procedures:

  • Ultrasound of the liver.
  • Blood test.
  • Magnetic resonance cholangiography.
  • Analysis of feces for eggs of worms.
  • Endoscopic retrograde cholangipancreatography.
  • Analysis of urine.
  • duodenal sounding.
  • X-ray cholegraphy.
  • Cholangiomanometry.
  • Choledochoscopy.
  • Liver biopsy.
  • Radioisotope examination of the bile ducts.

Treatment

Treatment of cholangitis is carried out only in a hospital. Folk remedies, which a person wants to spend at home, do not contribute to recovery. This requires medical, therapeutic and sometimes surgical treatment.

What is the treatment for cholangitis? The doctor prescribes medications if there is a normal outflow of bile:

  • Antibiotics.
  • Antispasmodics.
  • Sulfonamides.
  • Drugs that reduce toxicity.
  • Medications that improve the outflow of bile.
  • Anthelmintic drugs.

In case of ineffectiveness of conservative treatment, surgical treatment is resorted to. Endoscopy is performed with drainage of the bile ducts, elimination of narrowing, removal of stones. With purulent inflammation, an abdominal operation is performed to remove purulent or necrotic areas. Sometimes a cholecystectomy is performed - the removal of the gallbladder or a complete liver transplant.

In the treatment of cholangitis, a rigid diet is actively used:

  1. Small meals at least 5 times.
  2. Avoid eating before bed.
  3. Exclusion from the menu of fresh bread, spicy, fried, spicy, onions, bacon, sour berries and fruits, garlic, strong tea, alcohol.
  4. Included in the menu are lean fish, cottage cheese, buckwheat, oatmeal, warm milk, egg whites, boiled meat, vegetables, milk soups, kefir, stale bread, honey, jam.
  5. Prohibition on hunger strike.
  6. Tea drinking special collections of herbs. Compotes, jelly, mineral waters.

Sclerosing cholangitis is treated as follows:

  • Vitamin therapy.
  • Antihistamines.
  • Ursodeoxysolic acid.
  • Sedative drugs.

Physiotherapy procedures are used:

  1. Amplipulse therapy.
  2. Diathermy.
  3. microwave therapy.
  4. Paraffin and mud applications.
  5. Sanatorium treatment.
  6. Physiotherapy.

Lifespan

How long do people live with cholangitis? The disease itself does not affect life expectancy, but provokes such complications that lead to death:

  • Peritonitis.
  • Abscess of the abdomen.
  • Liver failure.
  • Intrahepatic abscesses.
  • Sepsis.
  • biliary cirrhosis.
  • Cholangiocarcinoma.

Here you should not delay treatment and do not self-medicate. Seek medical attention at the first symptoms.

Cholangitis is a disease in which an inflammatory process develops in the intrahepatic and extrahepatic bile ducts. The disease rarely occurs on its own, and is often the result of diseases of the gallbladder ( cholelithiasis, cholecystitis, oncological diseases of the biliary tract and gallbladder). Cholangitis must be treated, because in the absence of adequate therapy, the disease can lead to severe complications, and even death.

Treatment of an exacerbation of the disease should be carried out in a hospital under the constant supervision of a doctor, since emergency surgery may be needed at any time. Depending on the degree of violation of the outflow of bile through the biliary tract, the doctor chooses a therapeutic tactic (conservative or surgical treatment).

Symptoms and signs

Usually, acute cholangitis begins suddenly and is accompanied by severe chills with a sharp rise in body temperature to 38-40 ° C. At the same time, pains of varying intensity appear in the right hypochondrium, somewhat reminiscent of biliary colic in nature. Periodically, they can spread to the region of the right shoulder and neck, and also radiate to the right shoulder blade, which is explained by the peculiarities of the innervation of the liver. In connection with the growing intoxication with cholangitis, general weakness and headache, loss of appetite, nausea, vomiting, etc.

A little later, jaundice, manifested by yellowing of the skin and sclera, joins these symptoms of acute cholangitis. It also contributes to the occurrence of itching, especially worse at night and thus preventing normal sleep. The presence of such itching may indicate scratching on the body of a patient with cholangitis.

Chronic cholangitis develops gradually, manifesting subtle signs. The patient is concerned about dull, low-intensity pain in the right hypochondrium, accompanied by a feeling of fullness and discomfort in the upper abdomen. As with acute cholangitis, the chronic process may be accompanied by yellowing of the sclera and skin. However, it should be noted that in this case, jaundice appears much later and only with a far advanced process. Less specific signs of chronic cholangitis are general weakness, fatigue and subfebrile body temperature.

Sclerosing cholangitis is enough rare disease, And his clinical picture differs little from that in an acute or chronic process. In some cases, cholangitis can be complicated by the development of sepsis and multiple liver abscesses, infectious-toxic shock and hepatitis, cholecystopancreatitis, biliary cirrhosis, etc.

Source medmir.by

Aseptic enzymatic cholangitis can develop as a result of irritation of the walls of the bile ducts by activated pancreatic juice, which occurs with pancreatobiliary reflux. In this case, aseptic inflammation occurs first, and the attachment of the infection occurs a second time, in a later period.

Sclerosing cholangitis, caused by autoimmune inflammation of the bile ducts, also proceeds according to the aseptic type. At the same time, along with sclerosing cholangitis, ulcerative colitis, Crohn's disease, vasculitis, rheumatoid arthritis, thyroiditis, etc.

Prerequisites for the development of cholangitis is cholestasis, which occurs with biliary dyskinesia, anomalies of the bile ducts, choledochal cyst, cancer of the biliary tract, choledocholithiasis, stenosis of the Vater papilla, etc. The onset of cholangitis may be preceded by iatrogenic damage to the walls of the ducts during endoscopic manipulations (retrograde pancreatocholangiography, installation stents, sphincterotomy), surgical interventions on the biliary tract.

Source krasotaimedicina.ru

Classification

Classification of cholangitis (Yu. I. Fishzon-Ryss, I. A. Postrelov, 1985)

1. By etiology:

1.1. Bacterial.
1.2. Helminthic.
1.3. Toxic and toxic-allergic.
1.4. Viral.
1.5. Autoimmune.

2. Downstream:

2.1. Spicy.
2.2. Chronic.

3. By pathogenesis:

3.1. Primary (bacterial, helminthic, autoimmune).

3.2. Secondary and symptomatic:

3.2.1. On the basis of subhepatic cholestasis:

3.2.1.1. Hepato-choledoch stones.

3.2.1.2. Cicatricial and inflammatory strictures of the main bile ducts and major duodenal papilla.

3.2.1.3. Malignant and benign tumors with occlusion of the hepatocholedochus or large duodenal papilla.

3.2.1.4. Pancreatitis with compression of the common bile duct.

3.2.2. On the basis of diseases without subhepatic cholestasis:

3.2.2.1. Biliodigestive anastomoses and fistulas.

3.2.2.2. Insufficiency of the sphincter of Oddi.

3.2.2.3. Postoperative cholangitis.

3.2.2.4. Cholestatic hepatitis and biliary cirrhosis.

4. By type of inflammation and morphological changes:

4.1. catarrhal.
4.2. Purulent.
4.3. Obstructive.
4.4. Destructive non-purulent.

5. By the nature of complications:

5.1. Abscesses of the liver.

5.2. Necrosis and perforation of the hepatocholedochus.

5.3. Sepsis with extrahepatic purulent foci.

5.4. Bacterial toxic shock.

5.5. Acute renal failure.

Most often, cholangitis is of a bacterial nature, the most common causative agents are E. coli, enterococci, Friedlander's bacillus, pneumococci, streptococci.

Source extremed.ru

Diagnostics

The diagnosis is made on the basis of the characteristic symptoms of cholangitis, a thorough examination and data from hardware and laboratory studies:

Ultrasound of the gallbladder, liver and bile ducts;

Radioisotope study of the biliary tract;

Intravenous cholangiography (fluoroscopy of the bile ducts with intravenous administration contrast medium, which allows you to see the intra- and extrahepatic ducts);

Retrograde pancreatocholangiography (fluoroscopy of the biliary tract and pancreas with endoscopic injection of a contrast agent);

Cholangiomanometry (measurement of pressure inside the bile ducts);

Choledochoscopy (endoscopic examination of the bile ducts);

General and biochemical analysis blood;

Laboratory study of bile.

Source neboleem.net

In children

Children rarely get sick with acute cholangitis. However, if it occurs as a secondary manifestation of another disease, often streptococcal etiology, then it proceeds very hard and is recognized with great difficulty.

Acute cholangitis can be complicated by liver abscess, subdiaphragmatic abscess, right-sided pleurisy, lung abscess, pericarditis, pancreatitis, peritonitis, sepsis. With ineffective treatment, it can also be complicated by toxic liver dystrophy and hepatorenal syndrome.

Chronic cholangitis may develop initially or be the outcome of acute cholangitis. With a latent form of chronic cholangitis, pain during palpation in the right hypochondrium is mild or absent, weakness, fever, chilling are observed, skin itching is occasionally noted, and a gradual increase in the liver occurs. The outcome of this form may be secondary biliary cirrhosis of the liver.

With a recurrent form of cholangitis, pain and local symptoms are mild (with severe pain in choledocholithiasis).

Source gastrolive.ru

Primary sclerosing

Primary sclerosing cholangitis (PSC) is a condition belonging to the group of autoimmune liver diseases, characterized by the production of antibodies to the bile ducts with a violation of the outflow of bile.

The cause of primary sclerosing cholangitis remains unknown. The most likely is the assumption of the presence of an infectious agent, which is a provoking factor in genetically and immune predisposed people.

Men get sick 2 times more often than women. The disease usually develops at the age of 25-45 years, although it is possible in young children.

In 70% of cases, patients have concomitant ulcerative colitis (a chronic autoimmune disease involving the mucous membrane of the large intestine), there may also be a combination with other autoimmune conditions (thyroiditis, diabetes I type).

Clinical picture of the disease. As a rule, the onset of the disease occurs without clear symptoms and the first manifestation of PSC is biochemical changes (increased activity of alkaline phosphatase, serum transaminases). Even with asymptomatic course, the disease can progress with the development of cirrhosis of the liver and portal hypertension.

Usually at the beginning of the disease there is weight loss, fatigue, pain in the right hypochondrium, skin itching, transient jaundice. The presence of symptoms indicates a far advanced process. Fever is usually uncommon, although there are cases where chills and fever come first and, accompanied by jaundice, itching, and pain in the hypochondrium, mimic acute bacterial cholangitis.

Diagnosis of the disease. In the study of blood serum, there is an increase in alkaline phosphatase, bilirubin, the level of γ-globulins, IgM, high titers of antibodies to smooth muscles and antinuclear antibodies appear.

Ultrasound examination reveals thickening of the walls of the bile ducts.

The method of choice for diagnosing PSC is cholangiography, which shows areas of narrowed and dilated hepatic ducts.

Forecast. Although some patients feel satisfactory, the majority progresses to jaundice and liver damage, which is manifested by the development of cirrhosis and hepatocellular insufficiency.

Treatment. There is no effective pathogenetic treatment for primary sclerosing cholangitis. Administration of ursodeoxycholic acid (UDCA) improves biochemical parameters and reduces disease activity according to liver biopsy. In some cases, it is necessary to prescribe drugs that suppress the activity of the immune system - corticosteroids and cytostatics. It is necessary to replenish the deficiency of calcium, vitamin D and other fat-soluble vitamins.

Source hepatocentre.ru

Chronic

Chronic cholangitis is the most common form of lesions of the bile ducts, occurs as an outcome of an acute or occurs immediately as chronic illness. Often chronic cholangitis joins chronic cholecystitis, cholelithiasis, may be the result of tumors and cicatricial inflammatory stenosis of the biliary tract. Primarily chronic cholangitis occurs most often in elderly, debilitated patients.

The clinical picture is uncharacteristic. There is a feeling of pressure or dull pain in the right hypochondrium, weakness, fatigue, often slight yellowness of the skin and mucous membranes, slight itching of the skin; a relatively common symptom is long periods of unmotivated subfebrile condition, accompanied by chills. In some cases, there is a recurrent course with repeated pain attacks in the epigastric region and the right hypochondrium with irradiation under the scapula, in the region of the heart and behind the sternum. On palpation, a somewhat enlarged, dense and painful liver is often determined, and the spleen may also be enlarged. Jaundice refers to late signs illness. The liver is always enlarged by the time jaundice appears. Often the course of chronic cholangitis is supported by an accompanying inflammatory process in the gallbladder or cholestasis. Complications are the development of cholangiogenic hepatitis, and then liver cirrhosis, pancreatitis, the occurrence of cicatricial-inflammatory stenosis of large ducts.

Differential diagnosis should be made with chronic cholecystitis, gallstone disease.

In the treatment of chronic cholangitis, a sparing diet is prescribed (table No. 5a) with frequent (4-6 times a day) meals. To enhance the outflow of bile, cholagogues are prescribed. In the period of exacerbation, antibiotics are indicated, when choosing which it is advisable to take into account the sensitivity of the microbial flora to them, as well as sulfanilamide preparations.

With stenosing cholangitis, the treatment is surgical. Spa treatment shown in the inactive stage of chronic cholangitis (Essentuki, Zheleznovodsk, Pyatigorsk, Borjomi, Jermuk, Truskavets, Morshin, Mirgorod, Arzni, Ankavan, Isti-Su, Berezovsky mineral waters).

The prognosis of chronic cholangitis depends on the cause of the cholangitis and the activity of the infection. With cholangitis on the basis of gallstones and cancer, the outcome is determined by the course of the underlying disease. Modern treatment v early stages cholangitis leads to a significant improvement, in some cases - to recovery. In the late stage, the prognosis is poor.

Prevention of chronic cholangitis is the correct and timely treatment of various forms of cholecystitis, especially calculous. Great importance have dispensary supervision.

Source lor.inventech.ru

Purulent

Purulent cholangitis is accompanied by the filling of the bile ducts with pus mixed with bile. Purulent cholangitis often involves the gallbladder and liver;

Source medresept.ru

Spicy

Etiology. Acute cholangitis develops with obstruction of the bile ducts. Most often it is caused by gallstone disease, less often - a tumor of the pancreas.

Also, cholestasis can develop with chronic pancreatitis(common bile duct stricture develops)

Charcot's triad is characteristic of acute ascending cholangitis:

one). Pain in the right hypochondrium.

2). Fever.

3). Jaundice.

Pain in the right hypochondrium should be distinguished from Murphy's symptom, which is characteristic of cholecystitis.

With progression, two more signs are added (Raynaud's pentad):

4). Confusion of consciousness.

5). Septic shock.

Diagnostics. The main method is ultrasound.

Conservative treatment:

Prescription of antibiotics

Fluid infusion

Surgery. Operation types:

Endoscopic papillosphincterotomy followed by laparoscopic cholecystectomy

Endoscopic papillosphincterotomy only (high risk)

Laparoscopic cholecystectomy

Open cholecystectomy

Decompression of the biliary tract

Source bgmustudents.narod.ru