The inflammatory process of the bile ducts caused by non-specific pathogens is called cholangitis. This is a fairly common ailment, and depending on the pathological changes that occur in the walls of the bile ducts, cholangitis is distinguished: purulent, necrotic, catarrhal and diphtheric. This article will focus on the purulent form of the disease.
General information
Previously, cholangitis was mainly diagnosed in the older age category, and in recent decades it has been increasingly diagnosed in forty-year-old individuals. Mostly women suffer from this pathology. The disease usually occurs against the background of other anomalies of the gastrointestinal tract - gastro- and duodenitis, cholelithiasis, gastritis, hepatitis, cholecystitis, pancreatitis. In this regard, the course of the disease is quite severe. In addition, concomitant diseases create some kind of obstacle to the effective prompt elimination of the cause of the disease. Acute purulent process of inflammation in the biliary tract, which is formed against the background of poor outflow of bile due to completeor partial blockage leads to a purulent form of cholangitis.
The disease is characterized by the following clinic: jaundice, which is rapidly growing, pain in the right side under the ribs, high fever, feeling cold. One of the complications of the disease is a combination of systemic inflammatory reactions to the process in the biliary tract with impaired consciousness, hemodynamics, kidney function and other organs. The diagnosis is made on the visualization of a mechanical obstruction detected by CT or ultrasound of the abdominal organs. Decompression of the biliary tract with the elimination of obstruction is carried out by surgical intervention, after which antibiotic therapy is prescribed. Further, other violations are subject to correction.
Causes for the development of pathology
Purulent cholangitis is bacterial in nature. It is characterized by the presence of wounds on the walls of the bile ducts, which fester after some time. This is a severe surgical pathology, which, if left untreated, leads to the death of the individual. About half of all patients with this diagnosis have a purulent inflammatory process in the ductal system.
Bile duct obstruction by hard formation stones is the main cause of purulent cholangitis. Other factors leading to a failure of the outflow of bile and causing inflammation include:
- narrowing of the ducts after injury;
- cicatricial changes;
- parasitic invasion;
- neoplasms in the region of the major papilla of the duodenum 12.
Pathogenic bacteria actively multiply in the biliary tract as a result of the cessation or incomplete outflow of bile. In a small amount, microbes are present in bile, having entered it from the jejunum hematogenously or with duodenobiliary reflux. With a normal outflow, inflammation does not develop, and the microflora maintains the immune system in good shape. If this process fails, the number of microorganisms in the bile increases. Provoke the development of purulent cholangitis mainly gram-negative microbes, in rare cases - streptococci, staphylococci, pseudomonads.
The increase in internal pressure in the ducts of the liver leads to the fact that the bile contained in them, due to changes in resistance, will enter the bloodstream. The result is bacteremia. Most often, Klebsiella or E. coli are detected. Leakage of pathogens into the bloodstream system provokes the occurrence of biliary septic shock. In addition, the development of sepsis occurs as a result of endotoxemia. Bacterial endotoxins, endowed with a pyrogenic effect, stimulate the blood coagulation system, which provokes intravascular clot formation. As a result of the humoral immune response, the work of the kidneys fails. In the development of toxemia, a special role is played by impaired functioning of both general and local intestinal immunity.
Other causes of the disease
After removal of the gallbladder, cholangitis develops in more than fifty percent of cases. In this case, the disease is accompanied by a strongduct inflammation. The following factors provoke pathology:
- worms in the bile ducts;
- hepatitis;
- postcholecystectomy syndrome;
- penetration of pathogenic microorganisms from the intestinal area to the digestive tract;
- untreated cholecystitis;
- cysts on the bile ducts.
Clinical picture
With partial or complete obstruction of the bile ducts, acute purulent cholangitis develops. Everything happens suddenly and begins with a rise in temperature to forty degrees, chills, nausea, a feeling of fullness and heaviness in the right hypochondrium. Jaundice in this case manifests itself quite quickly. With a non-obstructive purulent form, the icterus of the palate, dermis and sclera is absent or appears later.
The classic triad of the acute course of the disease, namely pain, fever, jaundice, with complete obstruction of the bile ducts is observed in fifty percent of individuals. Biliary sepsis is always present, a term used both in gastroenterology and in abdominal surgery to describe the very serious condition of an individual. With acute signs of bile stasis, sepsis develops within a few hours. Moreover, it can occur at lightning speed and be accompanied by multiple organ failure and multiple liver abscesses. The main signs of biliary sepsis are oliguria, impaired consciousness and low blood pressure.
Diagnostic measures
Initially, the physician evaluates the history and complaints of the individual. If inflammation of the gallbladder is suspectedducts, the patient is consulted by an abdominal surgeon. He makes a preliminary diagnosis. The following symptoms indicate the development of biliary sepsis: jaundice, fever and pressure, an increase in pain syndrome, tachypnea, and heart rhythm disturbance. In this case, the patient's body does not respond to intravenous administration of 500 ml of saline, there is confirmed bacteremia, there is thick pus in the biliary tract. Signs of acute inflammation are identified on the basis of laboratory tests:
- In the general clinical analysis of blood - an increase in the rate of sedimentation of red blood cells, neutrophilic leukocytosis.
- In liver samples - hyperphosphatemia, hyperbilirubinemia, high cholesterol. In some cases, transaminase activity is increased.
For the diagnosis of purulent cholangitis, an ultrasound of the abdominal organs is certainly performed. With this type of hardware research:
- reveal the basis that caused the disease;
- visualize a mechanical obstruction and expansion of the bile ducts above the level of the obstruction;
- detect modifications of the parenchyma in the event of the formation of a purulent-inflammatory process in the liver.
On CT, the results are clarified and confirmed. In addition, esophagogastroduodenoscopy is performed. If necessary, i.e. if the doctor does not have complete information, then endoscopic retrograde cholangiopancreatography is recommended. If it is not possible to do it, use percutaneous transhepaticcholangiography.
The contents of the biliary tract obtained during the study are sent for bacteriological analysis, where the sensitivity of the pathogenic microorganism to antibiotics is determined. Bile is assessed visually by the laboratory assistant. The purulent form of the disease is proved by the presence of pus in it.
Surgical methods
Treatment of cholangitis, the symptoms of the purulent form of which were described above, requires immediate medical intervention. When biliary sepsis has developed, emergency decompression of the biliary tract is necessary. If the cause of the pathology is cicatricial changes, then due to the installation of an endoprosthesis in the choledochus, adequate compression is achieved.
Due to the fact that open surgeries are traumatic for patients and have frequent complications, nowadays doctors prefer minimally invasive interventions:
- Percutaneous transhepatic cholangiostomy is the definitive treatment for severe comorbidities. In other cases, this is preoperative preparation, during which bile is drained until the interference is promptly eliminated.
- Mechanical lithotripsy.
- Endoscopic papillosphincterotomy - completely removes bile stasis and obstructive jaundice. It is used for the etiology of a calculous-inflammatory nature.
- and some others.
Depending on the signs of bile stagnation, the stage of violation of its outflow, the level of mechanical obstruction, the choice of method is assigned. After emergency decompression, radical treatment is performed - cholecystectomy, cholangioduodenostomy orrecanalization, if the purulent form is caused by cicatricial narrowing of the biliodigestive anastomosis.
Conservative treatment
After urgent decompression, antibiotic therapy is indicated, it plays an auxiliary role. Difficulties at this stage of healing are due to the fact that the identification of a pathogenic microorganism takes a long period, and in addition, after external drainage, the composition of the flora changes.
In practice, antibacterial agents are recommended to treat symptoms of cholangitis before the results of bacteriological examination are ready. This is necessary to prevent bacteremia and sepsis. Initially, ureidopenicillins and cephalosporins are used in combination with Metronidazole. Some doctors recommend tetracyclines, penicillins, aminoglycosides.
An important stage of treatment is detoxification, since one of the severe manifestations is endotoxemia in purulent cholangitis. Polymyxin B is a highly recommended endotoxin-binding drug. Reduces the plasma concentration of Lactulose lipopolysaccharide, which is highly effective. In addition, the use of plasmaphoresis makes it possible to remove cytokines, endotoxins and circulating immune complexes from the plasma. With the help of enterosorption, toxins are removed from the lumen of the gastrointestinal tract, preventing them from penetrating into the portal bloodstream. We also provide immunocorrection and nutritional support.
Forecast
Purulent cholangitis or an inflammatory process that affects the bile ducts indue to failure or complete blockage of the outflow of bile is considered a severe surgical anomaly. The prognosis for this disease is determined not only by the level of overlap of the bile ducts, but also by the timeliness of the provision of special special assistance. Unfortunately, the mortality rate for this disease is quite high. The danger of the purulent form of the disease is that the clinic is similar to other varieties of this pathology, and untimely and incorrect treatment leads to very serious consequences - purulent intoxication, liver failure, formation of abscesses in the liver.
Prevention
Severe complications can be prevented with endoscopic treatment of cholelithiasis. In addition, this is facilitated by the latest surgical equipment and high qualification of the abdominal surgeon. Individuals who underwent surgical treatment of purulent cholangitis, as well as patients with a history of obstructive jaundice, are under dispensary observation of a gastroenterologist. For them, routine examinations are carried out, which are aimed at identifying the presence of stones and cicatricial strictures of the biliary tract. They are on a diet for the rest of their lives. It helps to avoid violations of bile excretion and bile formation. If necessary, take medication recommended by the doctor.
Abdominal surgeon: who is it and what does it treat?
This is a doctor who performs surgical interventions using various innovative techniques and diagnostic equipment. He operates:
- injuries at industrial and domesticcharacter;
- inflammation of the appendix of the caecum;
- polyps, varicose veins of the peritoneal organs;
- penetrating wounds;
- new growths;
- hereditary and acquired diseases of the abdominal organs;
- retroperitoneal space.
In addition, it treats pancreatitis, gallstone disease, ulcerative lesions, and also deals with the prevention of complications and rehabilitation of individuals.
In modern conditions, abdominal surgeons perform emergency and planned complex operations:
- At a distance (video surgery) - when the patient is in a hard-to-reach area, the doctor directs the actions of doctors via video link.
- On transplantation of organs and tissues.
- Minimally invasive endoscopic operations (laparoscopy). In these cases, the surgeon is outside the surgical field and, using the 3D image on the monitor screen and the robot, operates with the highest precision.
For all surgical interventions, doctors use robotic technology and sophisticated diagnostic equipment. In multidisciplinary he althcare institutions, there are narrow specializations of abdominal surgeons - pediatric, hepatologist, oncologist, gastroenterologist, coloproctologist.
Now you know who an abdominal surgeon is and what he treats.
