Changes in duodenal contents in certain diseases of the biliary tract

Defeat biliary tract can be divided into three groups: dyskinesia, inflammation, cholelithiasis.

Most often, these diseases affect women.

Biliary dyskinesia

Dyskinesia zhelchnыh tract - a variety of violations of function of the gallbladder and bile ducts.

Pervichnaya dyskinesia It arises on the basis of disorders of neurohumoral regulation of the tone of the gall bladder and bile ducts. Secondary dyskinesia appear on the background of various diseases such as biliary tract, and other parts of the digestive system. There are also mixed forms of psoriasis.

When the flow of bile dyskinesia disturbed due to increased tone of the sphincter or atony of the gallbladder. Therefore clinically isolated hypertonic, hypotonic and atonic dyskinesia. Often when dyskinesia reveal an enlarged liver and gall bladder.

It is important fractional duodenal intubation. It allows us to differentiate the form of dyskinesia and assign effective treatment.

To hypotonic dyskinesia of the gallbladder, the most common, characterized by a delay start evacuation gallbladder bile, slow release of large amounts of dark (zastoynoy) bile, often incomplete emptying of the gallbladder. After the introduction of the second stimulus hypotonic gall bladder again reduced, while additionally allocated a significant amount of gallbladder bile. A portion of the bile B has a high density and high content of bilirubin.

On hypertonic dyskinesia of gall bubble indicates shortening or absence of cystic reflex, reducing the time reduction of the gall bladder (up to 10-15 minutes instead of 20-25 minutes in normal).

Gipertonicheskaya dyskinesia tsirkulyarnogo puchka gladkomыshechnыh volokon to shake zhelchnogo puzыrya (sphincter Lyutkensa) It is characterized by intermittent release of the gallbladder bile and lengthening the time of its evacuation. If this sphincter hypotension observed shortening of the phase A portion of the bile flow, and at atonii- simultaneous bile portions A and cystic.

At the tone of the sphincter of common bile duct duodenal intubation difficult, since the olive tree for a long time misses the spasm duodenum and returns from her stomach. Functional spasm of the sphincter is removed nitroglycerin or amyl nitrite. When fractional sounding second phase (reduction of hepatic, pancreatic sphincter ampoule) extended to 14-15 minutes.

The absence of bile or slow its release of a small amount of points to organic changes in the major duodenal papilla (cancer, inflammatory process, cholelithiasis).

Significant reduction of the period of contraction of the sphincter of pancreatic and hepatic ampoule indicates its hypotonic dyskinesia. The absence of the second phase of the fractional sensing characteristic of atony of the sphincter.

The most informative indicator of fractional duodenal intubation is the amount of bile secreted portion B and the concentration of bilirubin in it. The increase in this portion, and an increase in its levels of bilirubin indicate congestion and obstructions at the exit from the gallbladder. The absence of cystic reflex allows suspected cholelithiasis.

The absence of elements of inflammation on microscopic examination of bile in the case of biliary dyskinesia confirms the functional nature of the disease. Exceptions are secondary dyskinesia, emerged on the background of cholangitis or cholelithiasis.

Cholangitis (kholangit, cholecystitis) can be acute or chronic.

Kholangit

Kholangit (angiokholit) - Inflammation of the inside- and extrahepatic bile ducts. The disease is very common, sometimes combined with cholecystitis (holetsistoholangit) or cholelithiasis.

Etiological factors is often the ascending infection of the intestines. Less commonly observed or hematogenous route of infection lymphogenous. A role played by parasitic infestation. It contributes to the development of cholangitis bile stasis (resulting in stenosis of the large duodenal papilla, cholelithiasis, tumors of the biliary tract and piloroduodenalnoy area). In diseases of the abdominal cavity occurs secondary cholangitis.

Acute cholangitis It begins chills, significant increase of body temperature, toshnotoy, sometimes vomiting, the emergence of acute pain in the right upper quadrant. Sometimes it may occur subikterichnost, joins reactive hepatitis (enlarged liver, tenderness).

When a blood test revealed leukocytosis, sometimes up 17 T in 1 l (17*10⁹ in 1 l) with a moderate shift leukogram left to stab neutrophils. ESR increases, In more severe cases appear significant urobilinuria, C-reactive protein.

Duodenal intubation in acute cholangitis It reveals the various forms of dyskinesia. In portions of bile A and C are found especially turbidity, slizevidnye flakes. Microscopically, there was a significant number of epithelial cells of the bile ducts, a different number of leukocytes, sometimes helminth eggs, Giardia. Bacteriological examination of the bile can identify E. coli, rarely - Streptococcus pneumonia (pneumococci), streptokokki, staphylococci and anaerobic flora.

Chronic cholangitis - A common form of destruction of the bile ducts, than acute cholangitis. Perhaps the primary, a consequence of acute cholangitis or, It is the most frequent, combined with cholecystitis. Often, in the pathological process involved liver parenchyma (xolangiogepatit). In this case, laboratory research can reveal signs of disease of the liver.

Clinically, there are three basic forms of chronic cholangitis:

• latent;
• recurrent;
• duration of the current septic component.

At long current septic cholangitis component developing pericholangitis, which in some cases leads to biliary (holangioliticheskomu) cirrhosis.

When fractional duodenal sounding often found various forms of dyskinesia. In portions of bile from the common bile and hepatic ducts revealed signs of inflammation (slime, a significant number of epithelial cells of the bile ducts, sometimes eosinophilic granulocytes). During an exacerbation in the blood is determined expressed mild leukocytosis with a shift to the left leukogram, increased erythrocyte sedimentation rate. Often there urobilinuria.

Cholangitis latent flowing unable to diagnose a result of clinical observation and repeated duodenal intubation.

Cholecystitis

Cholecystitis - an inflammation of the gall bladder, a fairly common disease.

Acute cholecystitis Infection occurs by ingestion mainly by hematogenous (E. coli and parakishechnaya, strepto- and staphylococci, rarely - anaerobic microorganisms, Infectious hepatitis). In some cases, the infection is recorded in the gall bladder by ascending from the intestines or lymphogenous. Contribute to the development of the disease poor circulation, gallstones, bile stasis. Throwing pancreatic enzymes may cause enzymatic cholecystitis. Characterized by the appearance of leukocytosis with a shift to the left leukogram, increased erythrocyte sedimentation rate.

Distinguish catarrhal, purulent, flehmonoznыy and gangrenous cholecystitis.

Catarrhal cholecystitis proceeds more benign, but sometimes inflammation may become purulent.

Hnoynыy and flehmonoznыy cholecystitis characterized by the same initial signs, as catarrhal, but later is persistent temperature reaction, more severe and prolonged course. Leukocytosis dostyhaet 16 T in 1l (16*10⁹ in 1 l) leukogram shift to myelocytes.

Gangrenous cholecystitis often develops on the basis of the previous process, including abscess cholecystitis. Perhaps the development of bile peritonitis.

With duodenal intubation in patients with acute cholecystitis can reveal signs of different types of dyskinesia of the gallbladder. Physical properties of modified bile, It is cloudy, It contains a lot of mucus, its relative density is increased. Reaction bile deviates to the acid side, protein content therein increased.

Microscopic examination in the case of catarrhal cholecystitis can be found in a significant number of lumps of mucus epithelial cells of the gallbladder. When phlegmonous cholecystitis except mucus revealed a large amount of detritus in the destruction of white blood cells and epithelial. Bacteriological examination of the bile can detect the causative agent.

Chronic cholecystitis It develops under the influence of pathogenic microflora (E. coli, strepto- and Staphylococcus, rarely - Proteus, Pseudomonas aeruginosa, enterococcus). Sometimes, there are etiologic factor cholecystitis wand dysentery and typhoid. In the pathogenesis of chronic cholecystitis are important dyskinetic and congestion, as well as the sensitization of the organism to automikroflore. Meets aseptic inflammation of the gall bladder (in toxic effects or neurohormonal disorders). Clinically, the disease is characterized by long recurrent.

When duodenal sounding often can be detected dyskinetic disorders, often hypotonic or atopic type. Gallbladder bile dark, sometimes with a greenish tinge, cloudy, It contains a substantial amount of mucus. As a result of prolonged inflammation changes the structure of the epithelium of the mucous membrane of the gall bladder, as a result of its ability to disrupt the concentration. In such cases, gallbladder bile color component parts and does not differ from other portions of the bile.

For the detection of gallbladder bile is used chromatographic method study. Microscopic examination of the gallbladder bile revealed a considerable amount of mucus, epithelium of the gallbladder, detritus.

At cholecystitis allergic You can find eozivofilnye granulocytes. With concomitant bile duodenitis many white blood cells and epithelial cells of the duodenum.

To calculous cholecystitis characterized by the presence of calcium bilirubinate, bilimikrolitov, cholesterol crystals. Sowing bile helps clarify the etiology of cholecystitis. Often found in bile giardia or helminth eggs.

In chronic cholecystitis often vary the colloidal properties of bile, thus there is a decrease in its concentration of cholic acid, bilirubin, Calcium, disturbed lipid complex, holatoholesterinovy ​​factor. As a result of such bile (modified because of inflammation) precipitates as crystals bilirubin calcium and other ingredients bilirubinate. Thus, nekalkuleznыy cholecystitis, substantially, It is the initial stage of calculous cholecystitis and cholelithiasis.

Determination of the biochemical composition of bile (Lipid Complex, cholic acid, cholesterol, holatoholesterinovy ​​factor, bilirubin, phospholipids) to diagnose prekalkulezny period cholecystitis. A characteristic feature of inflammation is a high protein content, increasing its fractions krupnomolekulyarnyh, appearance in the gallbladder bile of C-reactive protein.

Cholelithiasis

Cholelithiasis (cholelithiasis) - Disease, characterized by the formation of stones in the liver, gallbladder, bile ducts.

Contributing factors of gallstone disease are diseases, due to metabolic disorders (obesity, atherosclerosis, gout), genetic predisposition, bile stasis (when dyskinesia, irregular meals, sedentary lifestyle, enhanced hemolysis). Excessive food intake, lipid rich and cholesterol, It contributes to a violation of cholesterol metabolism. Postponed disease of the liver and biliary tract - infectious hepatitis, chronic cholecystitis - also contribute to stone formation.

An important role in the process of stone formation is played changes in the biochemical composition of bile, in particular the total amount of bile acids, fosfolypydov, Lecithin. The solubility of cholesterol, bilirubin and calcium decreases, they precipitate. Hypersecretion psevdomutsina and proteins, and bakterioholiya (chtoimeet place with cholecystitis) contribute to the disruption of the lipid composition of the complex of protein and cause the formation of nuclei of future stones. The development of this process contribute to the reduction of pH and bile, increasing its content of coarse protein.

Distinguish cholesterol, pigment and mixed gallstones. The most common mixed stones, the center of which is a protein-based; of the stones are cholesterol, bilirubin and calcium.

The clinic consists of gallstone disease symptoms, associated with the movement of gall stones paths, and signs of cholecystitis or cholangitis companion, Sometimes hepatitis.

At uncomplicated gallstone disease (very rare) Clinical manifestations in the interictal period no. Sometimes there is a leukocytosis. Stones with a diameter of less than 15 mm can go to the duodenum, and 1-2 days to show up in the stool. Identification of the larger stones indicates that an intestinal bile-fistula. Sometimes clogs biliary tract stone. Blockage neck of the gallbladder It causes a violation of the outflow of bile, gall bladder increases in volume, its walls are stretched, and the mucous membrane loses its ability to concentrate bile and releases mucoid fluid. This leads to the development of gallbladder hydrops (in the bubble liquid soderzhitsyasvetlaya).

When duodenal sounding (outside the period of biliary colic) get the gallbladder bile fails, bile portions A and C contains mucus, detritus and lots of cholesterol crystals, calcium bilirubinate, microlites. When you join an infection develops gallbladder empyema. At the same time the patient's condition worsens, increased body temperature, there is a large amount of neutrophilic granulocytes, increased erythrocyte sedimentation rate. There is a risk of sepsis. When complete blockage of the gall bladder in the case of chromatographic studies do not get the gallbladder bile.

Obstruction of the common bile duct It leads to the development of obstructive jaundice. When duodenal sounding out an attack of colic bile in the duodenum is not found. In the blood increases the level of direct bilirubin, observed a small leukocytosis, a moderate increase in ESR. Sometimes, there are signs of progressive anemia, thrombocytopenia.

Blockage of the intrahepatic bile ducts accompanied by pain is not as sharp, as in the common bile duct blockage, and a slight increase in the corresponding lobe of the liver. Obstruction of the common hepatic duct gives a picture, similar to the occlusion of the common bile duct. When duodenal sounding in such cases there are no clear data, therefore applied for the diagnosis of contrast cholangiography.