Contents
Description of the disease
Calculous cholecystitis is a special form of cholecystitis that is characterized by the presence of stones (calculi) in the gallbladder. The disease is one of the manifestations of gallstone disease.
Calculous cholecystitis is characterized by inflammation of the gallbladder and the presence of stones in it. Calculi mainly have a mixed composition (calcium-pigment-cholesterol), homogeneous bilirubin (pigment) or cholesterol are less common. The size of the stones can reach the size of a chicken egg, and the number varies from units to hundreds, the shape is different.
They can be located in the cavity of the gallbladder, which is observed in 75% of cases, and support with their presence a weak inflammatory process leading to fibrosis, as well as the deposition of calcium salts (calcifications). But if the stones are in the bile duct, they can obstruct or block the outflow of bile, cause acute inflammation, characterized by the appearance of attacks of biliary colic.
The prevalence of the disease is quite high, reaching 10% of the total adult population, most often people who have crossed the 40-year mark suffer, but there are cases when calculous cholecystitis was diagnosed in children. Women are several times more likely to suffer from this disease, which is explained by the specifics of their hormonal levels.
The following population groups are at risk of developing the disease:
women and especially pregnant women;
people who are obese or who have lost weight drastically;
representatives of the Scandinavian and Indian peoples, their level of this disease is much higher than the rest;
older people;
those who take drugs and contraceptives that affect the hormonal background.
Factors leading to the formation of gallstones and the development of calculous cholecystitis:
dyscholia (change in the composition of bile);
cholestasis (stagnation of bile);
inflammatory component, in this case – primary cholecystitis.
In a healthy body, such components of bile as pigments, minerals, bile acids, lipids have a colloidal state. But when the ratio between the concentration of cholesterol and bile acids changes, the former precipitates and subsequently crystallizes. This situation can be provoked by malnutrition, diabetes, hepatitis, obesity, and infectious diseases.
Dyscholia contributes to the thickening of bile and its stagnation, which leads to various types of infection of the gallbladder with pathogens such as bacteroids, E. coli and others. The infection causes inflammatory changes in the walls of the gallbladder.
Fasting or overeating, a high content of animal fats in the diet, physical inactivity, heredity and long-term use of hormonal contraception can increase the lithogenicity (ability to stone formation) of bile.
Often, calculous cholecystitis is preceded by a normal, acalculous one, which leads to disruption of the dynamics of gallbladder emptying.
The risk of the onset of the disease is higher in patients with pancreatitis, biliary dyskinesia, duodenitis, chronic gastritis, liver cirrhosis, helminth infections and Crohn’s disease.
Features of the clinical picture make it possible to distinguish chronic and acute forms of calculous cholecystitis. The course of each of them can be complicated or uncomplicated. There are catarrhal, purulent, gangrenous and phlegmonous forms. Based on the symptoms, typical, atypical, cardialgic, intestinal, esophagalgic variants of the development of the disease can be distinguished.
Calculous cholecystitis has 4 stages:
prestone, initial, in most cases reversible stage – thick bile forms a stasis, there are microliths in the gallbladder;
the period of formation of stones;
development of the chronic stage of the disease;
complication of the disease.
Signs and symptoms of calculous cholecystitis
The presence of stones in the gallbladder may not affect the condition of a person, therefore, at the initial stage, the disease is often asymptomatic, latent.
Symptoms directly depend on the stage of development of the disease, so acute calculous cholecystitis is characterized by the following signs of biliary colic:
acute pain syndrome, localized in the right side and extending to the area of the shoulder or right shoulder blade, caused by dietary disorders, alcohol, physical activity or stress;
nausea, vomiting of gastric and bile contents;
elevated temperature, which is especially characteristic of purulent inflammation;
a sharp decrease in blood pressure;
the appearance of weakness and cold sweat;
individual manifestations of jaundice with a change in the color of the stool: the stool contains a lot of fat and has a discolored appearance, and the urine is darker than usual.
Manifestations of chronic calculous cholecystitis are more smoothed:
frequent aching pain in the region of the right hypochondrium;
the appearance of an acute pain syndrome caused by malnutrition, which gradually subsides on its own;
paroxysmal pain that occurs 3 hours after eating fatty, salty or fried foods;
nausea and belching with a bitter taste;
violation of the rules of nutrition can cause single bouts of vomiting with bile.
Chronic calculous cholecystitis
The chronic stage of development of calculous cholecystitis is characterized by the presence of stones in the gallbladder, a mild inflammatory process and periodic manifestations of the disease.
The chronic period can be almost asymptomatic or declare itself bouts of hepatic colic. With a latent form of the disease, a person experiences a feeling of heaviness on the right side of the hypochondrium. Suffering from flatulence, diarrhea, heartburn, belching, feels bitterness in the mouth. After overeating or fatty foods, unpleasant symptoms intensify.
Hepatic colic can occur suddenly, in most cases it is preceded by a violation of the diet, hard physical labor, psycho-emotional stress. An attack of colic is caused by spastic contractions of the gallbladder and its tracts, due to irritation of the mucous membranes by stones. There is an acute stabbing pain of varying intensity, localized in the right hypochondrium and radiating to the right side of the shoulder, shoulder blade and neck. The duration of an attack can vary from a few minutes to a couple of days.
Colic may be accompanied by fever, vomiting, which does not alleviate the patient’s condition. Patients are agitated, the dynamics of the pulse may be slow, rapid or arrhythmic. Arterial pressure changes insignificantly. Elderly patients may develop reflex angina.
At the time of the attack, the tongue becomes wet, plaque may be present, the abdomen is tense, swollen, painful in the region of the right hypochondrium, epigastrium. A blood test does not reveal any abnormalities, the gallbladder and liver are not enlarged, there are no symptoms of peritoneal irritation.
The attack of colic stops suddenly, the patient experiences relief, weakness and weakness.
Acute calculous cholecystitis
Acute calculous cholecystitis is understood as a pronounced inflammation of the gallbladder, which contains stones.
This form of the disease in terms of frequency of occurrence ranks second in the list of acute diseases of the abdominal organs. In most cases, it is complicated by concomitant ailments.
The development of an acute form of calculous cholecystitis leads to an infection that has entered the gallbladder, as well as a disturbed process of outflow of bile. Staphylococci, Pseudomonas aeruginosa and Escherichia coli, enterococci and other microbial flora can enter via ascending and descending routes (from the duodenum and liver, respectively), as well as lymphogenous and hematogenous. Obstruction of the outflow of bile leads to clogging of the cystic duct or neck of the gallbladder with stones, pathological processes in the periampullary zone. In addition, the development of the acute form of the disease is facilitated by changes in the vessels of the organ caused by atherosclerosis, damage to its mucosa by pancreatic enzymes, provoked by pancreatobiliary reflux.
Acute calculous cholecystitis is divided into three types:
catarrhal;
phlegmonous;
gangrenous.
All these forms of the disease are accompanied by pericholecystitis, which is characterized by a local or widespread adhesive process that limits the area of infection to the right hypochondrium only.
The acute form of the disease is manifested by a sharp pain that increases with any physical activity, nausea, repeated vomiting of a reflex nature.
On examination, dryness of the tongue, slight bloating, its limited participation in the breathing process, muscle tension and pain in the projection area of the gallbladder, which has an enlarged, tense structure, are revealed. Body temperature is elevated, a blood test shows neutrophilic leukocytosis and increased ESR.
The duration of the course of the acute form of the disease can reach several weeks. Gradually, it passes into a chronic stage or complications appear.
Phlegmonous calculous cholecystitis
In the case when calculous cholecystitis is complicated by purulent inflammation, accompanied by infiltration of the gallbladder and the appearance of ulcers on its mucosa, it means that the disease has entered phlegmonous stage. In this case, the wall of the organ is greatly thickened due to the abundant absorption of inflammatory exudate. The gallbladder is greatly enlarged, filled with pus. The mucosa is hyperemic, lined with fibrin.
The patient experiences severe pain, which increases from a change in position, breathing, coughing. The general condition of a person worsens, the temperature rises, nausea and repeated vomiting appear, the pulse reaches 120 beats per minute. The abdomen is slightly swollen due to intestinal paresis, palpation of the right hypochondrium is painful, reveals an enlarged gallbladder. If phlegmonous calculous cholecystitis is not treated in time, it can turn into a gangrenous form, which is dangerous with a fatal outcome.
Gangrenous calculous cholecystitis
This most dangerous stage of the disease is also called gangrene of the gallbladder. This form of cholecystitis is characterized by partial or total necrosis of the wall of the bile organ, which develops against the background of thrombosis of the cystic artery. The onset of gangrene is noted on the 3-4th day of illness. Perforation (through violation of the integrity) of the bladder wall may occur, followed by the outflow of bile into the peritoneal cavity and the appearance of biliary peritonitis. Openings are usually localized on the neck of the gallbladder or in the pocket of Hartmann, in places where stones accumulate.
Gangrenous calculous cholecystitis is more typical for elderly people, in whom the regenerative abilities are reduced and the blood supply to the gallbladder is weakened.
This form of the disease can be caused by infections coming from adjacent communicating organs, blood and lymph.
The gangrenous form of calculous cholecystitis is evidenced by a sharp increase in temperature against the background of the absence of complaints about well-being, which usually appears at night. The pain syndrome is pronounced, has a spasmodic character and can occupy not only the right area, but also spread to the entire abdomen. The pain is long and intense. The condition is complicated by nausea and vomiting, constipation or diarrhea, headaches, weakness, pallor and moisture of the skin, frequent breathing, drowsiness, faintness, bloating and its non-participation in the breathing process. There may be signs of jaundice.
Treatment of calculous cholecystitis
Therapy for this disease is aimed at solving the following problems:
stop an acute condition;
prevent complications;
eradicate factors that contribute to the formation of new stones.
Treatment of calculous cholecystitis can be carried out by conservative and surgical methods. The first includes diet therapy, taking painkillers and antispasmodics, antibacterial, detoxification therapy and antiemetics. The second is focused on the removal of the gallbladder and stones.
In most cases, surgery is the best way to get rid of the disease, because in this case the very source of stones is removed. Then conservative measures are used to stabilize the patient’s condition and prepare him for surgery.
There are several types of surgery for the treatment of calculous cholecystitis:
Laparoscopy. Several incisions are made on the abdomen, through which special instruments and an optical device, a laparoscope, are inserted, which transmits an image to the monitor. Extensive opening of the peritoneum is not required, therefore, the period of postoperative recovery is reduced and the appearance of the operated person does not suffer.
Open surgery. The gallbladder is removed through an incision in the abdominal wall. The method is used in severe cases, in case of infection of the gallbladder or the presence of cicatricial adhesions in the abdomen after previous operations. The postoperative period is longer and requires a stay in the hospital.
percutaneous cholecystostomy. A drainage tube is inserted into the gallbladder through a small incision in the abdomen. It is used for the course of elderly and severe patients who have complications of acute cholecystitis.
When removal of the gallbladder is impossible according to certain indicators, non-surgical crushing of stones with medications or using extracorporeal shock wave lithotripsy (ESWL) is prescribed. But when treating with such methods, there is a risk of re-formation of calculi.